A patient or family member may notice a mass on the neck or perhaps the primary care physician notes this during a routine examination. A neck mass may be painless or painful depending on the cause. Frequently, when the neck mass is painless, a longer duration may persist between the time that the neck mass arose and the time that it was detected and diagnosed.
The most common cause of neck masses in younger patients included reactive lymphadenitis, primary bacterial infection of the lymph nodes, and systemic infections. This will be covered in detail under the pediatric ENT pages on the Dallas ENT Group website, evaluation and treatment of neck masses.
Neck masses are best evaluated by an otolaryngologist (ear, nose, and throat surgeon) because of their experience in dealing with common and very uncommon presentations of neck mass and sometimes difficult treatment protocols. Otolaryngologists have the ability to examine the airway fully to determine the cause of the neck mass.
Evaluation includes a history of the neck mass, including how long the mass has been present; and whether or not it is painful with associated symptoms of sore throat, ear pain, tooth pain, and ear ache. Evaluation and history also focuses on any underlying factors that could cause a neck mass such as infection, previous chest or esophageal surgery, or a history of smoking.
Physical examination includes palpation of the mass to determine whether it is soft or fluctuant, rubbery or hard, and the degree of tenderness. The evaluation also includes endoscopy placement of a fiber optic lighted scope (through the nose into the throat). In addition, a full physical evaluation is performed to rule out any other enlargement of the spleen or lymph nodes in the axilla (armpit) or groin.
Further testing includes a contrasted CT scan of the neck and possibly the chest as well as an MRI in indicated patients. General blood work and a chest x-ray are also obtained. If the patient does not have a distinct primary cause for the neck mass, other testing may be necessary.
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Thyroid: One of the common midline neck masses involves the thyroid gland.
Patients frequently present to the office under referral of their primary care physician or endocrinologist (hormone) physician. The thyroid gland presents as either diffuse enlargement of a mass in the lower midline of the neck or a specific firm nodule.
The patient is evaluated in a similar fashion as any neck mass. Additional studies may include thyroid function test and possibly an ultrasound of the thyroid. A needle biopsy is frequently performed.
Drs. Tom Hung and Andy Chung have a distinct expertise in thyroid surgery. Thyroid surgery is performed under general anesthesia with the use of a nerve monitor that helps identify and prevent injury to the laryngeal nerve. One of the most common yet avoidable complications of thyroid surgery are injury to the laryngeal nerve and postoperative hoarseness. With the expertise of the surgeon and the nerve monitor; this complication is significantly minimized.
Postoperatively, the patient remains overnight in the hospital with a small drain tube in place.
A new state-of-the-art technique using an approach through the axilla (armpit) avoiding a neck scar is currently being performed by the surgeons. This uses the da Vinci surgery robot. The website can be accessed through this link.
The parotid gland is the largest of the salivary gland. There are 2 glands, one on each side of the face; just in front of the ear and extending down below the ear lobe. The salivary gland secretes saliva into the mouth. The gland is arbitrarily designated into a superficial and a deep lobe by the course of the facial nerve.
A mass in the parotid gland is evaluated as described in the section on “neck masses”.
A surgical procedure is performed under general anesthesia with a procedure time of an hour and half. An incision is made just in front of the ear, sweeping down below the ear lobe and then back for a very short distance on the upper neck. The scar becomes minimal within 4-6 months. The surgeon does elevate tissue off of the parotid gland and locates the several branches of the facial nerve that pass through the gland. A facial nerve monitor is used to help identify and avoid injury to the facial nerve. After completion of the procedure, the tumor is sent to the pathologist for evaluation. The determination of the type of tumor is made within the first 2-3 days after surgery.
Patients remain hospitalized overnight with a small tube drain or possibly return home for follow-up the next day to remove the drain. Removal of the parotid gland does not affect salivation or dryness of the mouth. Within the first few days, the patient is seen in follow-up for review of the pathology report determining the type of tumor in the gland and if other therapy is needed.
A mass just under the jaw is also a common finding in the neck. The majority of the masses are related to chronic infection and inflammation in the salivary gland. The small tube or duct that drains saliva into the floor of the mouth becomes obstructed and scarred with calcification. This results in enlargement and sometimes tenderness of the mass.
Masses in the submandibular area can also be either benign or malignant. Masses that have persisted for over 2 months certainly need to be evaluated as noted in the “evaluation of a neck mass”. After a CT scan and needle biopsy, a decision will be made by the surgeon to follow up or surgically remove the mass.
The surgical procedure is relatively straightforward requiring only a 2-1/2 to 3-inch incision transversely below the mandible. The mass is removed within 45 minutes and a small drain tube is place. Frequently, the patient may return home through the outpatient surgery unit. The drain tube will be removed the following day. The patient will be treated with antibiotics and postoperative pain medication. The complications for this procedure only include a collection of fluid or blood in the area where the mass was removed.
The surgeon evaluates the patient 2-3 days postoperatively to review the results of the pathology report.
There are several other types of neck masses that occur besides thyroid, parotid, submandibular, and malignant neck masses. These are usually inflammatory and diagnosed as noted in the “evaluation of the neck mass”. In addition, the CT scan as well as fine-needle biopsy leads to the diagnosis. Frequently, these neck masses are cystic, that are congenital in nature, but do not become apparent until childhood or later in life. These are usually easily excised without complication or deformity.
Tonsil and adenoid tissues are masses of immune cells commonly called lymphoid tissue. The tonsils are located along the wall of the upper throat just at the level of the soft palate. The adenoids are not easily seen, and in fact are located directly behind the nose above the soft palate. The images revealed the tonsils and the diagram shows the location of the adenoid tissue in the back and upper throat.
The tonsil and adenoid lymphoid tissues are important in the first several months of life. However, what is initially a benefit in the production of antibodies can become a detriment and causes upper airway obstruction as well as recurrent tonsillitis.
Parents are frequently concerned that removal of the tonsils and adenoids will decrease the child’s immunity. Studies have shown that children who have a chronic tonsillitis and airway obstruction have fewer problems after removal of the inflamed lymphoid tissue than those that do not undergo the procedure.
The primary care physician or pediatrician will usually refer the child for evaluation. In the past, the majority of tonsillectomies and adenoidectomies were performed because of recurrent strep throat, usually 4-5 episodes a year. Antibiotics have helped to decrease and control the recurrent “strep” tonsillitis. However, some children continued to experience recurrent tonsillitis requiring tonsil and adenoid removal.
Frequently, the child will experience mouth breathing and snoring and occasional apnea (obstruction of breathing) as a result of the tonsil and adenoid tissue partially obstructing the airway. The long-term problems with airway obstruction may not be readily apparent. Children with mouth breathing and snoring frequently experience what is known as the “sleep disorder breathing.” Sleep disorder breathing results in poor sleep quality and an increase incidence in daytime fatigue with a lack of attention and focus. In addition, significant obstruction with the resultant mouth breathing leads to the development of an “open bite” and malocclusion apparent when the child is 6 or 7 years of age.
Removal of the tonsils and adenoids (tonsillectomy and adenoidectomy) is a very commonly performed procedure that is typically an outpatient procedure in those children over 3-4 years of age. Some children that are younger require an overnight stay in the hospital. The child is evaluated in the office by one of the surgeons of the Dallas ENT Group. A history of the child’s infections and airways problems are documented and an exam of the tonsils is easily performed. Again, the adenoids are not seen because of the location in the back of the nose and upper throat.
The child is evaluated by a pediatric anesthesiologist and usually given an oral medication that is very pleasant tasting. These results in mild sedation and easily controls the anxiety the child experiences. Frequently, the child is amnestic (lack of awareness or memory of the procedure).
The procedure requires less than 10 minutes of surgical time with minimal-to-no bleeding.
Your child will be taken to the post anesthesia care unit. During recovery, you will be at the bedside. From the post anesthesia care unit, your child will be transported back to the pediatric preoperative area after full recovery from anesthesia. Once your child is fully awake and taking fluids, then you will be discharged from the unit. A follow-up will occur within 3-4 weeks. Postoperative medications including antibiotics and pain medicine will be called in to your pharmacy.
Complications include postoperative bleeding, usually at 7-10 days when the scab separates from the back of the throat. If this occurs, then call the surgeon on-call for the Dallas ENT Group. We are readily accessible to evaluate your child in the emergency room if the bleeding persists. In addition, some children have difficulty in tolerating liquids and soft foods and become volume depleted (dehydrated). A small percentage will require re-hospitalization with IV fluids for 24 hours along with pain control.
Adults experience chronic tonsil problems that differ from childhood tonsillitis. Childhood tonsillitis is associated with recurrent strep infections and mouth breathing and snoring. Adults with tonsil issues complain more of a chronic discomfort in the throat in large tonsils with the frequent complaint of debris that becomes a lodge in pits or crypts (a hidden place) in the tonsils. The food debris undergoes decay as a result of the common bacteria in the oral cavity. This results in the mild to moderate enlargement, intermittent throat discomfort, and a frequent foul taste and breath that the patient experiences.
Adult patients usually have had a history of tonsil problems when they were younger, but not to the extent that would indicate a tonsillectomy. Adults frequently are under the misconception that they are “too old to have a tonsillectomy,” or a physician has told them that “a tonsillectomy is dangerous in an adult”. Tonsillectomy is an entirely safe procedure in adults. The distinction is that adults are very aware of the postoperative pain; while children that have undergone tonsillectomies frequently do not remember the discomfort or period of recovery.
An adult tonsillectomy is performed under general anesthesia and requires less than 10 minutes to perform with minimal-to-no blood loss. The adult is almost always discharged from the outpatient surgical unit on antibiotics and pain medication. The surgeon discusses pain control with the adult patient at length and encourages maintaining an adequate fluid intake.
Complications of an adult tonsillectomy are unrelieved pain requiring an increase in pain medication and bleeding occurring at 7-10 days of when the scabs separates from the healing area of the throat.
The surgeon with the Dallas ENT group is readily accessible to handle any problems that occur postoperatively.