Neck masses differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Neck masses must be differentiated from congenital abnormalities, inflammatory, and malignant lesions.

Differentiating neck masses from other Diseases

Neck masses must be differentiated from congenital abnormalities, inflammatory, and malignant lesions.

Category	Diseases		Benign/ Malignant	Clinical manifestation						Paraclinical findings			Gold standard diagnosis	Associated findings
				Demography	History	Symptoms		Signs		Lab findings	Histopathology	Imaging
						Pain	Dysphagia	Mass exam	Others
Congenital	Branchial cleft cyst		Benign	Age: 1-15 years old Familial occurrence	Lateral neck mass	−	±	Solitary Smooth Mobile Well-defined Non-pulsatile Fluctuant	A pit at the opening of the cyst	−	Squamous or ciliated epithelial lining Lymphoid tissue with germinal centers and subcapsular sinuses	CT: Well defined fluid attenuation with slight enhancement of the capsule Ultrasound: Typical features of a cyst are seen	−	Brachio-oto-renal syndrome Sinus or fistula
	Thyroglossal duct cyst		Benign	Age: 1-10 years old	Midline neck mass	−	−	Mobile Moves upwards with tongue protrusion and swallowing	−	−	Squamous or ciliated pseudostratified columnar lining Foci of thyroid gland tissue Granulation tissue or giant cells if it gets infected	Ultrasound: Anechoic, thin walls, and heterogeneous with internal septa CT with contrast: Well circumscribed, homogeneous fluid attenuation, & thin enhancing rim MRI: T1-dark, T2-bright images	−	−
	Hemangioma		Benign	Age: Birth−2 years old Female>male	Presents with a flat red or purple patch Regress gradually with age	−	−	Firm Rubbery Well-demarcated	Blanching Telangiectasias Erythematous patch	GLUT-1 VEGF	Lined by non-atypical endothelial cells Vascular structures with RBC	Ultrasound: High flow with vascular channels	MRI with or without gadolinium (Gd)	POEMS Castleman's disease
	Vascular malformation		Benign	Incidence: 1 in 2000 to 5000 births Gender: No predilection	Venous: Present with a bluish swelling Arteriovenous: Present with purple/red swelling	±	−	Soft Compressible Non-tender Venous: No thrill, ↑ in size on valsalva AVM: Thrill, warm, pulsatile	Grow proportionally with age	Elevated D-dimer level in venous malfomations	Lined by single endothelial layer	Doppler ultrasound: Slow hypoechoic flow in Venous malformations - High flow in AVM MRI with gadolinium (Gd): Diffuse enhancement	MRI	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Congenital	Lymphatic malformation		Benign	Age: Birth-5 years old Gender: No predilection	Presents with a large swelling mainly in the neck	−	+	Soft Non-compressible Non-pulsatile Fluctuant Positive transillumination	Never regress, expand/contract based on inflammation	−	Dilated lymphatic channels lined by endothelial cells Positive D2-40 stain	Ultrasound: Hypo/anechoic with thick septa and fluid CT: Homogeneous and cystic mass MRI: Hyperintense on T2 & peripheral wall enhancement on T1	−	Down syndrome Turner syndrome
	Laryngocele		Benign	More common in adults Male/female = 5:1	Presents with a neck swelling, hoarseness, stridor and globus sensation Episodic in nature	−	+	Soft Reducible Increase in size on valsalva	Common in glass blowers and trumpet players	−	Lined by pseudostratified ciliated columnar epithelium	X-ray & CT: Fluid and air containing cystic masses Direct laryngoscopy	CT scan	−
	Ranula		Benign	Age: 1st and 2nd decade Female/male = 1:1.4	Presents with a blue colored swelling in the floor of the mouth	−	−	Well circumscribed Fluctuant Soft	−	−	H&E: Mucin surrounded by inflammatory cells & fibrosis	CT: Cystic mass with tail sign	−	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Congenital	Teratoma		Benign or malignant	Incidence: 1:4000 births Gender: No predilection	Presents as a firm lateral neck mass	−	−	Firm Non-tender	−	High ALP levels	Shows ectodermal, mesodermal, and endodermal tissues	CT & MRI: Shows calcification	−	−
	Dermoid cyst		Benign	Incidence: 3 in 10000 population Age: Birth-5 years old	Presents as a slow growing mass or a sinus	−	−	Freely mobile Solitary Rubbery Nonpulsatile Noncompressible	Usually normal Sometimes a pit or sinus A tuft of hair at the center of the pit for nasal dermoid cyst	−	Keratinizing squamous epithelium Occasional remnants of hair follicles, adipose tissue, and sweat glands	Ultrasound: Thin walled, unilocular CT with contrast: Well circumscribed, unilocular, sac-of-marbles appearance due to fatty tissue	−	−
	Thymic cyst		Benign	Age: 1-10 years old Males>Females	Presents as a soft mass, gradually enlarging, on left side of the neck (usual)	−	−	Soft Compressible	−	−	Squamous epithelium or cuboidal epithelium Lymphoid tissue in the cyst wall contains hassall's corpuscles	Ultrasound: Unilocular cystic mass CT: Uni/multilocular, well circumscribed and nonenhancing	−	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Inflammatory	Acute sialadenitis		Benign	Age: Occurs in all age groups Gender: No predilection	Presents with an unilateral erythematous swelling Bad breath Fever with chills	+	-	Tender Firm Purulent discharge expressed from the duct Smooth	Redness More common in people with bad oral hygiene	Elevated ESR Leukocytosis	Inflammatory infiltrate with microabscess formation	Ultrasound: Hypoechoic with ductal dilatation CT: Diffuse homogeneous enlargement	CT scan	−
	Chronic sialadenitis		Benign	Age: Occurs in all age groups Gender: No predilection	Presents with an unilateral swelling Recurrent episodes common	+	−	Non-tender Firm Smooth	Mostly due to obstruction by a stone or stricture	Elevated ESR Leukocytosis	Hyperplastic lymphoid infiltrates with loss of salivary gland acini Fibrosis	X-ray: Shows radiopaque stones CT: Reduced parenchymal volume	CT scan	−
	Reactive viral lymphadenopathy	CMV	Benign	Age: 10-35 years old Gender: No predilection	Flu-like illness	−	−	Non-tender Soft	Generalized or cervical lymphadenopathy	Elevated ESR Elevated SGOT/SGPT	H&E stain: Typical owl-eye inclusions (nuclear) Basophilic cytoplasmic inclusions	Usually not necessary	Fine needle aspiration cytology	−
		EBV	Benign	Age: Mainly adolescents Gender: No predilection	Sore throat Fever Malaise	−	−	Non-tender Firm	Bilateral posterior cervical, axillary, inguinal lymphadenopathy Ulcer or rash Redness	Atypical lymphocytosis Positive monospot test IgM & IgG antibodies against EBV ↑↑SGOT/SGPT	CD8+ lymphocytes Necrosis B lymphocyte blasts	Usually not necessary	Fine needle aspiration cytology	−
		HIV	Benign	Prevalence: 1.1 million in U.S Gender: Males>females	Flu-like illness Rash	−	−	Non-tender mass	Generalized lymphadenopathy	Leukopenia Thrombocytopenia Anemia Elevated AST/ALT Elevated CRP Elevated ESR	Lymphoid hyperplasia	Usually not necessary	Western blot & P24 antigen assay	−
		Viral URI	Benign	Incidence: More in fall & winter Age: Common in elderly and infants	Sore throat Cough Runny nose Sneezing	−	−	Non-tender	Mild cervical lymphadenopathy	Lymphocytosis Elevated ESR & C-reactive protein	Inflammatory infiltrate	No specific findings	−	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Inflammatory	Bacterial lymphadenopathy	Tularemia	Benign	Age: Affects all age groups Gender: No predilection	Fever Chills Swelling Joint pains	+	−	Tender Edematous	Regional lymphadenopathy	Elevated ESR Elevated C-reactive protein	Caseating granuloma +/- multinucleated giant cells	No specific findings	PCR & serology	−
		Brucellosis	Benign	Incidence: 100-200 cases anually in USA Gender: Males>females	Flu-like illness	+	−	Tender	Cervical lymphadenopathy	Elevated ESR	Non-caseating granuloma + giant cells, epitheloid cells	No specific findings	Serology	−
		Cat-scratch disease	Benign	More common in the Southern of U.S among children and young adults	Cat exposure Fever Fatigue Headache	+	−	Tender cervical nodes	Vesicular Erythema Papule at site of inoculation Lymphadenopathy	Elevated ESR Serology: Positive antibody to Bartonella Henselae	Satellite micro-abscess with granuloma	−	−	Bacillary angiomatosis Bacillary peliosis
		Actinomycosis	Benign	No predilection in race, age [[Male] to female ratio : 1.5 to 3:1	History of dental procedure or trauma Poor oral hygiene Swelling mandible	−	−	Tender at the beginning Painless Fluctuant Non-tender at late stage	Red or blue skin rash	Elevated ESR Elevated CRP Gram positive filamentous rods	Sulfur granules Filamentous organism	−	Histological examination Bacterial culture of the abscess	Mandible osteomyelitis
		Mycobacterial infections	Benign	More common in adults and children in endemic continent such as Africa	Recent travel to endemic regions Exposure to TB patients	−	−	Matted cervical nodes Firm Non-tender	Lymphadenopathy	Positive PPD Presence of acid fast bacilli on Sputum smear	Chronic necrotizing caseating calcified granuloma	Neck Ultrasound: Multiple lymph nodes Fusion tendency Internal echoes	Culture for mycobacteria	−
		Streptococcal infection	Benign	More common in children and adolescents	Fever Absence of cough Difficulty swallowing Swollen pharynx	+	+	Tender anterior cervical nodes Tonsillar exudates	Lymphadenopathy	Rapid antigen detection tests: ±	Follicular hyperplasia Infiltration of polymorphonuclear cells	−	Throat culture	Acute rheumatic fever Post-streptoccocal glomerulonephritis
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Inflammatory	Parasitic lymphadenopathy	Toxoplasma gondii	Benign	6 years old and older adults are more affected in U.S. Seen in hot climates	Cats or birds feces exposure Drinking unpasteurized milk Undercooked food Organ transplant recipients	+	−	Bilateral Non-tender Symmetrical Non-fluctuant	Lymphadenopathy	Serology: Positive IgG and IgM antibodies	Follicular hyperplasia	MRI: Multiple rings enhanced lesions	Serology Immunofluorescence MRI CT scan	−
	Sarcoidosis		Benign	More common in African American women aged 20-40 years	Family history of sarcoidosis Fatigue Swelling and pain in the joints	−	−	Swollen Non-tender parotid glands	Erythema nodosum Lupus pernios Bilateral lymphadenopathy	Elevated ESR Elevated ACE	Non-necrotizing epithelioid granuloma	CXR: B/L hilar adenopathy MRI: B/L multiples enlarged cervical lymph nodes	Biopsy	Heerfordt's syndrome: uveitis, facial nerve paralysis, parotitis
	Sjögren syndrome		Benign	Female to male ratio: 9 to 1 May happen at any age Mean age: 40-50	History of RA, SLE, and non-hodgkin B-cell lymphoma Dry mouth, dry eyes	−	+	Firm mass B/L enlarged parotid glands	Pruritis Rashes Lymphadenopathy	Elevated ESR Anti-SSA/Ro: + Anti-SSB/La: + Cytopenia Wetting <5 mm on Schirmer's test	Hyperactivity of B-cells and lymphocytes which lead to infiltration of the exocrine glands	US: Hypoechoic and inhomogeneous salivary glands	Biopsy	−
	Castleman disease (angiofollicular lymphoproliferative disease)		Benign	Mean age: 30-40 years	Asymptomatic at early onset B-symptoms	−	−	Non tender cervical node	Lymphadenopathy Papule Cherry hemangioma	Elevated ESR Elevated CRP Anemia Polyclonal hypergammaglobulinemia	Hyaline vascular variant Plasma cell variant Mixed variant	CT scan: Matted lymphadenopathy Solitary, noninvasive mass	Biopsy	HHV-8 Kaposi sarcoma Non-hodgkin lymphoma POEMS syndrome
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Inflammatory	Kikuchi disease (histiocytic necrotizing lymphadenitis)		Benign	High prevalence in Japan More common in young adults < 30 years old	Fever Flu-like prodrome	+	−	Tender cervical nodes	Skin rash Lymphadenopathy	Elevated ESR Abnormal liver enzymes Leukopenia	Irregular paracortical areas of coagulative necrosis with abundant karyorrhectic debris	−	Biopsy	Hashimoto's thyroiditis
	Kimura disease		Benign	More common in Asian males	History of painless cervical lump	−	−	Large Non-tender cervical node	Itching Lymphadenopathy	Elevated Eosinophils	Conserved lymph node structure Eosinophilic infiltration High postcapillary venules	−	Biopsy	Nephrotic syndrome Hypercoagulable state
	Rosai-Dorfman disease		Benign	More common in children	Fever	−	−	Non-tender enlarged cervical lymph nodes	Erythema Lymphadenopathy	Elevated ESR Polyclonal hypergammaglobulinemia	−	−	−	−
	Kawasaki disease		Benign	More common in children < 5 years old Highest incidence in Japan Most leading cause of acquired heart disease in U.S	High fever B/L conjunctivitis Rash Swelling of hands and feet Inflammation of lips Strawberry tongue	−	−	Large, single palpable cervical node	−	Elevated ESR Elevated CRP	Inflammation of medium sized arteries and organs	Echocardiography: Coronary artery dilation Coronary artery aneurysm	Clinical findings	−
Category	Diseases		Benign or Malignant	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Neoplasm	Salivary gland neoplasm	Pleomorphic adenoma	Benign	More common in females Incidence increase with age Incidence: 2-3.5 cases per 100,000 population	History of swelling Dysphagia Hoarseness	−	+	Palpable mass of deep lobe of parotid gland Firm Mobile	−	−	Proliferation of epithelial cells and stromal matrix in the ducts	MRI: Homogenous on T1 Abundant myxochondroid stroma on T2	Biopsy	−
		Warthin's tumor	Benign	Male to female ratio: 4:1 More common in people aged 60-70 years old	History of swollen salivary gland Jaw pain Tinnitus	−	+	Non tender Mobile Firm Solitary	−	−	Papillae Fibrous capsule Cystic spaces	Neck CT: Cystic lesion posteriorly within the parotid gland MRI: B/L heterogeneous lesions	Biopsy	−
		Oncocytoma	Benign	Race: Caucasian patients predilection Gender: No gender preference Age: 50–70 years	Growing palpable painless mass Facial swelling Lymphadenopathy (if transformed to malignant)	±	±	Firm, multilobulated Mobile mass	Normal Redness Swelling Skin ulceration	Normal Anemia	Epithelial cells with eosinophilic Granular cytoplasm Rich in mitochondria	CT: Isodense expansive mass Enhancement after intravenous contrast Hypodense areas MRI: Isodensties on T1 Mass is hyperintense on T2 Enhancement on contrast	Incisional biopsy and histopathological examination	-
		Monomorphic adenoma	Benign or malignant	Age: 26-76 years Rare in children Gender: No predilection	Growing palpable painless mass on jaw or in oral cavity Facial swelling Lymphadenopathy (if transformed to malignant) Pain and ulceration (in later stage)	±	±	Nodular Fluctuant swelling	Normal Redness Skin ulceration May have lymphadenopathy	Normal	Straw colored fluid on aspiration	Ultrasound: Used to biopsy the lesion May show cystic an solid components CT: useful for lesions with calcification and venous phleboliths MRI: Test of choice Differentiate benign from malignant Defines tumor extent Shows perineural spread	Incisional biopsy and histopathological examination	-
		Mucoepidermoid carcinoma	Malignant	Age: Mean age of 59 Female predilection	Painlesss mass Swelling in oral cavity Lymphadenopathy	±	±	Cystic and solid mass	May have lymphadenopathy	−	Gross findings: Firm Tan-white to yellow Bosselated Cystic Microscopic findings: Encapsulated squamous and glandular components	Cystic and solid component with variable appearance on CT and MRI	Incisional biopsy and histopathological examination	Association with CMV
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Neoplasm	Salivary gland neoplasm	Adenoid cystic carcinoma	Malignant	Age: 40s-60s Gender: Female predominance	Slow growing rare tumor with low recurrence	±	±	Solid mass	Normal to ulcerated lesions May have lymphadenopathy	−	Gross findings: Tubular Cribriform Solid pattern of growth Microscopic findings: Components of large cells with pleomorphic nuclei Increased mitotic activity Focal necrosis	Imaging reveal dimensions of the tumor, local spread, and distant metastasis	Biopsy and histopathological examination	−
		Adenocarcinoma	Malignant	Age: young age predilection	Its a tumor of minor salivary glands May present as small ulceration or nodules in oral cavity	−	−	Small nodules in oral cavity With or without lymphadenopathy	Normal to ulcerated lesions May have lymphadenopathy	May be normal Or may show anemia and blood cell disorders with distant bone invasion	On histology it is confused with Adeocyctic carcinoma Components of gland and cyst formations More perineural invasion	CT and MRI MRI being more accurate for adjacent tissue involvement and lymphadenopathy	Biopsy and histopathological examination	−
		Salivary duct cancer	Malignant (Highly aggressive)	Incidence: 1-3% Gender: Male predilection Mean age: 55-61 years old	Rapidly growing mass with jaw involvement	±	±	Painless Hard Non-compressible mass	Ulceration of mucosa and skin May have lymphadenopathy facial paralysis in case of facial nerve involvement	Pathomorphologically tumor of salivary ducts resembles tumor of breast ducts	Gross findings: Firm mass Cystic component of variable size and dimension Microscopic finding: Resembling ductal carcinoma of breast Intraductal components invading surrounding tissue in several forms: cribriform papillary Solid with comedo-like central necrosis	Non-specific features on CT and MRI Shows neural and jaw involvement	Biopsy and histopathological examination	−
		Squamous cell carcinoma	Malignant	Incidence: rare Age: Old age , 61-68 years Male predilection	Present as painful growing mass on jaw	+	−	Teneder Firm Solitary swelling on jaw	Submandibular gland predilection Thinning and discoloration of skin	Past radiation exposure is a strong risk factor	Gross findings: Thinning of skin Microscopically findings: Nest and solid sheets of tumor cells arranged in glandular pattern Immunohistochemical staining can be used to mark the squamous and keratin component	Tumor dimension can be delineated using both CT and MRI	Biopsy and histopathological examination	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Neoplasm	Hypopharyngeal cancer		Malignant	More common in males Age: 55-65 years old Incidence: < 1/100,000 in U.S. More common in Japan, India, Iran	Tobacco use Abuse alcohol consumption HPV infection Lump in the neck Odynophagia Hoarseness	−	+	Non tender cervical node	Lymphadenopathy	−	Spindle cells Nuclear atypia Basaloid cells Abundant chromatin	Neck CT scan: Soft tissue mass Irregular thickening of mucosa Necrotic region MRI: Tumors are hypointense on T1 and hyperintense on T2	Biopsy	−
	Parathyroid cancer		Malignant	Incidence: Rare Mean age : 44-54 years old Gender: Female predilection	Presents with the hyperparathyroidism Bone pains Abdominal pain Nausea and vomiting Fatigue Confusion	+	+	Lower neck mass	Tachycardia Weight loss Sweating Neck swelling	Low TSH Increased T4 and T3 Hypercalcemia	Microscopic findings: Trabecular growth pattern High mitosis Surrounding thick fibrotic bands Capsular involvement Vascular invasion is common	CT and MRI shows more frequent lower lobe involvement, vascular involvement , lymph node metastasis, and perineural involvement Bone scan may show decreasing bone density	Biopsy and histopathological examination	−
	Carotid body tumors		Benign	Age: 26-55 years Male predominance	A slow growing neck mass	+	−	Mobile Non-tender neck mass (horizontally more than vertically) Pulsatile Bruit may be present	Change in voice Dizziness Tinnitus Headache	Rasised catecholamine levels	Microscopically they are extra-adrenal paragangliomas	Doppler ultrasound, CT, MRI and angiography is used to visualize the tumor Metaiodobenzylguanidine (MIBG) testing	Histopathology analysis and catecholamine levels	−
	Paraganglioma		Benign (Majority) Malignant (rare)	Age 50-70 years More in females	May be an accidental finding depending on their secretory nature or present with following symptoms: Palpitation Tremor Pulse-like vibratory sense Headache Change in voice Vertigo Catecholamine secreting paragangliomas presents with : Hypertension Headache Sweating Tachycardia	−	−	No visible mass Located deep in the the neck along the glossopharyngeal and vagal nerves	−	Biochemical testing may show catecholamine metabolites in serum or urine samples	These are highly vascular tumors that involves nerves around vessels Gross findings: Fleshy tumors Pink to red-brown to gray in color Associated with hemorrhage or fibrosis Microscopic findings: Round or polygonal cells Aranged inside capsule In the form of nests or forming trabecular structures Differentiation between benign or malignancy is done depending on: microscopic features invasion and high mitotic index	Following imaging techniques can be used to diagnose the tumor: Ultrasound Computed tomography Magnetic resonance imaging As these are secretory tumors further testing with following techniques can confirm diagnoses: Angiography metaiodobenzylguanidine (MIBG) 18F-fluoro-2-deoxyglucose Positron emission tomography (FDG-PET)	Imaging and serum catecholamine analysis	-
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Neoplasm	Schwannoma		Benign	Rare tumor Incidence: 1% to 10%	Slow growing mass localized neural deficit depending on the site of peripheral nerve involved. Vagal involvement: Hoarseness Dysphagia Sympathetic nerve involvement may present as Horner's syndrome: Dilated pupil Decrease sweating Dropping eye lid Vestibular Schwannoma (most common): Hearing impairment	+	±	Multiple Slow growing nodules on the skin	Associated with neurofibromatosis type II. Most common nerve involved in vestibular nerve	May be normal	It is a peripheral nerve tumor vagus nerve or superior cervical sympathetic chain being most common locations. Histology shows encapsulated neural tissue growth.	Imaging can diagnose the tumor. Its hard to discriminate Carotid body tumor from Schwannoma on CT. MRI and MRI angiography can confirm the diagnoses.	Imaging is used for diagnoses	−
	Lymphoma		Benign/ malignant	Age: Predilection for older age Mean age: 55	Insidious onset slow growing lymph nodes Non-specific systemic B symptoms fever night sweats weight loss) Rash Waxing and waning lymphadenopathy Abdominal fullness hepatomegaly and splenomegaly Infections due tocytopenias	−	±	Multiple chain lymphadenopathy Hepatomegaly Splenomegaly Mesenteric lymphadenopathy Ascites Chest auscultation may show crackles and fibrosis	With acquired form of C1 inhibitor deficiency patients may develop angioedema Rash and pruritus	Anemia Thrombocytopenia Leukopenia Hypercalcemia Hyperuricemia (increased cell turnover) Monoclonal immunoglobulin (M-spike) Raised LDH levels	Fine needle aspiration (FNA) with cytometry is used for screening. Tissue biopsy is used for diagnose. On complete node analysis four patterns are described: Nodular/follicular Diffuse pattern Transition from a nodular to a diffuse pattern in adjacent nodes Transition from a lower to a higher grade of involvement within a single node	Imaging is used to stage the disease. Positron emission tomography with computed tomography (PET/CT) is preferred over MRI.	Lymph node biopsy coupled with cytometry	−
	Liposarcoma		Malignant	Rare tumors Age: Relatively in older age Gender: No gender predilection	Mobile mass Few symptoms until they grow enough to compress the surrounding structures Symptoms of neural deficit, pain, tingling or skin changes.	±	−	Mobile soft mass Intact overlying skin Blue discoloration due to intra-lesion hemorrhage	Intact skin and normal color	Normal	Gross findings: Bulk of yellow colored fat tissue Microscopic features: Adipose tissue containing lipoblasts Atypical nucleus pushed to side by intracytoplasmic vacuoles. Tissue biopsy may show histological sub-groups: Well-differentiated Myxoid/round cell Pleomorphic liposarcomas	Imaging is not usually used for diagnoses Except to look for deeper invasion. Ultrasound shows homogeneous hyperechoic mass.	Biopsy and histopathology analysis	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Neoplasm	Lipoma		Benign	Genetic predisposition Unspecific gender or age association	One or multiple soft, painless skin nodules. May causes pain or compressive symptoms	±	−	Mobile soft nodule Intact overlying skin	Intact skin and normal color	Normal	Diagnoses is usually clinical Tissue biopsy may show Bundle of well-demarcated lipocytes Single nuclei aligned to the side Intra-cytoplasimic fat granules.	Diagnoses is usually clinical ultrasound is used to differentiate lipoma from other benign lesions such as: epidermoid cyst or a ganglion.	Clinical evaluation and tissue biopsy	Multiple lipomas Associated with familial multiple lipomatosis
	Glomus vagale, glomus jugulare tumors		Benign	Rare tumor	Painless slowly enlarging mass in the neck May have compressive symptoms such as: Dysphagia Hoarseness Cranial nerves deficits Horner's syndrome	−	±	Non-compressible Firm Non-tender swelling Absent thrill or bruitdifferentiates it from carotid aneurysm Normal overlying skin.	Secretory tumors Diagnosed by biochemical testing: Metaiodobenzylguanidine (MIBG) Followed by imaging to locate the tumor	Normal	Glomus tumors arise from Non Chromaffin cells histopathology reveals "salt and pepper" chromatin which is typical of tumor. On immunohistochemistry tumor cells show chromogranin and S-100 positivisty	Imaging of choice is MRI MRI: Show typical appearance of the tumor along Vagus nerve. USG : Used to see the tumor in early stage of diagnoses. US shows isoechoic to hypoechoic well defined tumor CT: To see vascularity of tumor. Biochemical testing to see secretary nature of tumor	Imaging and MIBG testing	−
	Metastatic head and neck cancer		Malignant	Depends on the nature of metastatic tumor	Asymptomatic Painless lymphadenopathy Supra clavicular fullness in case of stomach cancer metastasis	−	±	Non-tender mass in the neck Non-tender lymphadenopathy	Majority of metastatic head and neck cancer Metastatise from GIT and lungs Are squamous cell caners by type	Vary depending on the underlying cancer	Histology of primary cancer	CT and MRI: To see extent of tumor And regions of metastasis	Biopsy and histopathology of the primary site of tumor	-
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Other	Laryngeal cancer		Benign/Malignant	Older males Younger patients with HPV infection or smoking history	Neck mass Hoarseness Throat pain Snoring Obstructive sleep apnea	±	±	Examination of neck and oral cavity may show : mass lymphadenopathy Examination of laryngeal cancer is done using flexible laryngoscopy under anesthesia.	Smoking is the most common risk factor Smoking with alcohol increases the risk Oropharyngeal cancers presenting with neck masses are associated with human papillomavirus (HPV) infection	HPV testing may show HPV infection	FNA of neck mass Followed by biopsy of laryngeal cancer Show type cancer cells	CT, MRI and PET are used to see local infiltration by cancer Also to see distant metastases. Panendoscopy is done to see extent of the tumor.	Laryngoscopy and biopsy	−
	Arteriovenous fistula		Benign/Malignant	Depends on the risk factors	Expanding neck mass Headaches Dizziness Neurological sequels	−	−	Pulsating neck mass Bruit	May be associated with vasculopathies metastatic invasion of vessels and neck surgery		Varies depending on the etiology	MR angiography	MR angiography	−
	Thyroid nodule/ Goiter		Benign/ Malignant	Female predominance Young age (benign causes) Old age (malignant etiology)	Growing painless neck mass in front of neck Weight loss Palpitation Hoarseness Irritability	±	±	Painless Non-tender Asymmetrical neck mass in front of neck With smooth overlying skin Nodular surface Depending on the type: May be mobile Adherent to the underlying structure Lymphadenopathy in case of malignant features	Goiter is most commonly associated with iodine deficiency	Normal to low TSH levels in case of malignancy High TSH levels in case of goiter	FNA is done in case of goiter Core biopsy is performed if malignancy is suspected	USG: Shows nodular or non- nodular lesions in Thyroid US is better than CT. Thyroid radionuclide imaging: Shows radioiodine uptake Cold in case of malignancy Cold or hot in case of goiter.	Biopsy and histopathology of nodules	−
Category	Diseases		Benign	Demography	History	Pain	Dysphagia	Mass exam	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings