Origi na l A r tic le

Evaluation of Neck Mass with Computed

Tomography: An Observational Study
Ishwar Charan1, 1
Assistant Professor, Department of Surgery, Sardar Patel Medical College, Bikaner, Rajasthan,
India, 2Resident, Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment &
Akhil Kapoor2,
Research Institute, Bikaner, Rajasthan, India, 3MBBS Internee, Sardar Patel Medical College, Bikaner,
Narender Kumar3, Rajasthan, India, 4Resident, Department of Radiology, BJ Medical College, Ahmedabad, Gujarat,
Namrata Jagawat4, India, 5Medical Officer, Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment
Mukesh Kumar Singhal5, & Research Institute, Bikaner, Rajasthan, India, 6Senior Professor, Department of Radiation Oncology,
Acharya Tulsi Regional Cancer Treatment & Research Institute, Bikaner, Rajasthan, India
Harvindra Singh Kumar6
Corresponding Author: Dr. Akhil Kapoor, Department of Radiation Oncology, Acharya Tulsi Regional
Cancer Treatment & Research Institute, Bikaner, Rajasthan, India. Phone: +91-9950482121.
E-mail: [email protected]

Abstract
Background: Introduction of cross-sectional imaging provides a new dimension in evaluation structural anatomy of the tissue.
This study was designed to assess the role of contrast enhanced computed tomography (CT) in the evaluation of neck masses
in respect of characterization based on location, morphological characteristics and enhancement pattern; outlining the extent in
terms of involvement of adjacent structures, vessels and possible lymphadenopathy; surgical and histopathological correlation
whereever possible.
Materials and Methods: An observational prospective study was conducted in 100 patients with clinically suspected neck
lesions or patients who were referred for CT scan for further characterization. A standard proforma was maintained in reporting
CT scan to allow documentation and comparison with histopathological reports. The site of lesion, the size of primary disease,
the extent of involvement, enhancement pattern, calcification, necrosis, local extension and distant metastasis were recorded
by CT scan.
Results: Mean age of the patients who had undergone CT scan for the neck was 44.5 ± 1.9 years ranging from 4 to 86 years
normally. Higher incidence of malignant lesions between 46 and 60 years of age was observed, and the higher incidence of
malignant cases was noted among males, with a male to female ratio of 2.5:1. Most common clinical presentation was neck
swelling in both benign (92%) and malignant lesions (93%). Visceral space was the most common space to be involved in both
benign (19%) and malignant (30%) lesions. Necrosis was the most common feature in malignant lesions. The sensitivity and
specificity of the study are 95.7% and 77.5% respectively, with positive predictive value and negative predictive value of 90.4%
and 88.9% respectively. Accuracy was found to be 90% (P < 0.001).
Conclusions: Contrast enhanced CT scans for the neck has improved the localization and characterization of neck lesions.
Since CT is fast, well tolerated, and readily available; it can be used for initial evaluation, preoperative planning, biopsy targeting,
and post-operative follow-up. However, histopathology remains the gold standard as CT has the accuracy of 90% only.

Keywords: Benign lesions, Computed tomography, Lymphadenopathy, Malignancy, Neck mass

INTRODUCTION the horizontal plane in the evaluation of these structures.

The transaxial orientation of CT planes is particularly useful
The development of computed tomography (CT) has the in certain locations such as pterygopalatine fossa. The ease
most important contribution in the medical diagnostic of obtaining CT scans and rapid scan acquisition are its
techniques by the continuation of application of X-rays since advantages. The recent trends in the technological use of CT
it is discovered by Roentgen in early 1895. The introduction increases the application of head and neck lesions.
of cross-sectional imaging provides a new dimension in the
evaluation structural anatomy of the tissue. CT is useful in The neck is divided into twelve spaces by the superficial
the evaluation of head and neck lesions such as lesions of and deep cervical fascia by the CT scan process.1 CT with
base of skull, nasopharynx, larynx and neck areas. CT added its unique capacity to display osseous and soft tissue details

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 Charan, et al.: CT Scan for Neck Mass

has become an indispensible tool in the evaluation of MATERIALS AND METHODS

patients with a neck mass.2 Nowadays spiral CT scanning
overtakes the conventional dynamic CT scanning (slice- An observational prospective study was conducted in
by-slice acquisition) in various medical centers and is been patients with clinically suspected neck lesions or patients
rapidly replacing it. Spiral CT permits the rapid scanning who were diagnosed to have neck lesion on ultrasound
of large volumes of tissue during quiet respiration and it and were referred to CT for further characterization from
is less susceptible to patient motion when compared to peripheral centers. The patients with a history of trauma
the conventional CT.3 Volumetric helical data permits the or contraindications to contrast administration were
optimal multiplanar and 3D reconstructions. Spiral-CT is excluded from the study. Study was conducted during
standard one for imaging neck tumours. Secondary coronal the period of August 2011 to October 2013. All patients
reconstructions of axial scans are very helpful in the were scanned by the Siemens Emotion 6, a six slice CT
evaluation of the crossing of the midline by small tumors scanner. A provisional diagnosis was made after CT scan,
of the palate or tongue base. Multislicespiral CT allows and these findings were correlated with histopathology/
almost isotropic imaging of the head and neck region and surgical findings as applicable.
also improves the assessment of tumor spread and lymph
node metastases in arbitrary oblique planes. Multislice A total of 100 patients with neck lesions were subjected
CT scan has a special feature in defining the critical to CT examination. After taking proper history, clinical
relationships of tumor and lymph node metastases and examination and laboratory investigations, the patients were
for functional imaging of the hypopharynx and larynx, not prepared for CT scanning. Informed consent of patient/
only in the transverse plane but also in the coronal plane. attendant was taken for IV contrast examination. The
patient was kept with an empty stomach for 4-6 h prior
Although CT and Magnetic Resonance Imaging (MRI) are to performing the scan. And 80 ml of 300 mg/ml non-
well suited in the evaluation of deep spaces and sub-mucosal ionic contrast was used. Monophasic injection protocol
spaces of the head and neck; both have its own limitations. was followed, and contrast injection was done at 3.5 ml/s
MRI has the advantages of higher soft tissue contrast by manual or a pressure injector when phasic scans
resolution, lack of iodine-based contrast agents, and high required. All scans obtained by the above mentioned
sensitivity for perineural and intracranial disease. There protocol were assessed by the team of radiologist with
are some disadvantages include lower patient tolerance, experience of reporting head and neck CT scans. The
contraindications with pacemakers, some other implanted images were evaluated on a networked workstation with
metallic devices, artifacts related to multiple causes, and not facility for multiplanar reconstruction (MPR). A standard
the least of which is motion. CT is fast, well-tolerated, and proforma was maintained in reporting CT scan to allow
readily available however, has lower contrast resolution and documentation and comparison with histopathological
requires iodinated contrast and ionizing radiations.4 reports. The site of the lesion, the size of primary
disease, the extent of involvement, enhancement pattern,
The main purpose of the head and neck imaging is calcification, necrosis, local extension and distant metastasis
to evaluate the true extent of disease to determine were recorded.
the best surgical and therapeutic needs. This process
includes evaluation of the size, location, and extent of
tumor infiltration into surrounding vascular and visceral RESULTS
structures; second nodal staging should be assessed in an
effort to increase the number of abnormal nodes detected Mean age of the patients who underwent CT scan of the
by physical examination and, more important to precisely neck was 44.5 ± 1.9 years ranging from 4-86 years. Most
define their location by a standard classification system of the patients were in the age group of 46-60 years (29%)
that can be understood and consistently applied by the followed by 31-45 years (24%). Male preponderance with
radiologist, surgeon, radiation oncologist, and pathologist. male to female ratio of 2.1:1 was seen. A total of 68%
cases were malignant, and 27% cases were benign in nature
This study was designed to assess the role of contrast diagnosed after pathological examination. Figure 1 shows
enhanced CT in the evaluation of neck masses in respect the characterization of neck masses. Higher incidence of
of characterization based on location, morphological malignant lesions between 46 and 60 years of age was
characteristics and enhancement pattern; Outlining the observed. Higher incidence of malignant cases was noted
extent in terms of involvement of adjacent structures, among males, with a male to female ratio of 2.5:1. Most
vessels and possible lymphadenopathy; surgical and common clinical presentation was neck swelling in both
histopathological correlation whereever possible. benign (92%) and malignant lesions (93%). Next common

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Fig: Nodal Status

Table 1: Anatomical location of primary disease
50% Anatomical location Number of cases (%)
40% Larynx 4 (5)
Hypopharynx 6 (8)
30%
Oropharynx 11 (15)
20% Benign Lymph node 16 (22)
Malignant Submandibular gland 3 (4)
10% Thyroid 9 (12)
0% Parotid 5 (7)
None (0) LN (1) Primary (2) Inflammation Nasopharynx 5 (7)
(3)
Benign 26% 0% 0% 1%
Oral cavity 6 (8)
Malignant 21% 46% 6% 0% Osteosarcoma of mandible 3 (4)
Other 5 (7)
Figure 1: Characterization of the neck mass

presentation in malignant lesions was hoarseness of voice Table 2: Location of mass in relation to neck spaces
(18%), followed by dysphagia (11%). In 8.3% (n = 6) of Location of neck space Benign (n=27) (%) Malignant (n=73) (%)
the cases, lymph node itself was suspected as a primary VS 5 (19) 22 (30)
site of the malignancy while in nodal metastasis from BS 0 (0) 4 (5)
unknown primary was identified in 13.7% (n = 10) of the MS 2 (7) 6 (8)
PMS 2 (7) 14 (19)
malignant cases (Table 1). Next most common lesion was
PCS 3 (11) 17 (23)
seen involving oropharynx (n = 11, 15%), in which base SM space 1 (4) 3 (4)
of tongue was most common site (72%, n = 8). Metastatic SSSB 1 (4) 0 (0)
nodes from known malignancies in the neck region were PEVS 4 (15) 0 (0)
CS 2 (7) 1 (1)
found in 35 (47%) patients. PPS 2 (7) 1 (1)
PS 5 (19) 5 (7)
Distribution of the lesions was noted according to neck VS: Visceral space, BS: Buccal space, MS: Masticator space, PMS: Pharyngeal
spaces (n = 100) as depicted in Table 2. Visceral space mucosal space, PCS: Posterior cervical space, SM: Submandibular,
SSSB: Suprasternal space, PEVS: Perivertebral space, CS: Carotid space,
was the most common space to be involved in both PPS: Parapharyngeal space, PS: Parotid space
benign (19%) and malignant (30%) lesions. The next
most common space involved was parotid space (19%)
for benign lesions and posterior cervical space (23%) Table 3: Enhancement pattern in CT
for malignant lesions. Solid nature of lesion was most Enhancement pattern Benign (%) Malignant (%)
common in the malignant lesions (88%), followed by HET 7 (26) 59 (81)
solid cystic type, which was seen in thyroid gland lesions HOMO 2 (7) 5 (7)
INTE 4 (15) 2 (3)
and salivary gland tumors (7%) and lytic sclerotic type ME 7 (26) 4 (5)
(7%), which was seen in bone tumors. Benign lesions NON EN 3 (11) 1 (1)
also showed solid lesions most commonly (44%), RIM 4 (15) 2 (3)
followed by cystic (19%) lesions. Most of the benign HET: Heterogonous, HOMO: Homogenous, INTE: Intense, ME: Mild enhancement,
NON EN: Non enhancing, RIM: Rim enhancement, CT: Computed tomography
lesions showed either mild enhancement (26%) or
heterogenous type (26%) while the malignant lesions was most common type of histopathological pattern
mostly showed heterogenous type of enhancement seen in malignant lesions followed by lymphoma. Most
pattern (81%), followed by homogenous type (7%) as
common histopathological pattern in benign lesions was
shown in Table 3. Calcification was found in 22% of
diffuse nonspecific inflammation.
benign and 19% of the malignant lesions. Necrosis was
most common feature in malignant lesions, 30% of Number of true positive +
malignant lesions showed necrosis & 7% of malignant Number of true negativves
lesions showed cystic areas. Cystic areas were most Accuracy =
commonly seen in benign lesions, 33% of the benign Number of true positive + False positive +
lesions showed cystic areas. Bone erosion was seen in Number of trrue negatives + False negatives
19% and cartilage erosion is seen in 7% of malignant
66+24 90
lesions. 15% of benign lesions showed bone erosion Accuracy = = = 0.90 = 90%
that was in case of ameloblastoma, which was primary 66+3+24+7 100
benign bone tumor caused lytic erosion of the mandible Out of 100 cases studied with CT scan total lesions
and two cases of angiofibroma. Squamous cell carcinoma distinguished as benign 69 and malignant 31. After

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correlation with histopathological examination malignant

Table 4: Diagnosis of cases based on CT and HPE
lesions turned out to be 73 and benign lesions were 27. The
sensitivity and specificity of the study are 95.7% and 77.5% CT HPE diagnosis Total %
diagnosis Malignant Benign
respectively, with positive predictive value and negative
predictive value (NPV) of 90.4% and 88.9% respectively Malignant 66 3 69 95.7 Sensitivity
Benign 7 24 31 77.5 Specificity
(Table 4). Accuracy was found to be 90% (P < 0.001). Total 73 27 100
90.4% 88.9% P<0.001
PPV NPV
DISCUSSION PPV: Positive predictive value, NPV: Negative predictive value, CT: Computed
tomography, HPE: Histopathological examination
Lymph nodes are most common solid neck masses.5
Oropharyngeal malignancies were most common followed hemangiomas (n = 2, 7%) among the benign lesions,
by oral cavity and larynx.6 Lymph nodes were found to be attributing to the presence of phleboliths. Calcified thyroid
the most common site to be involved in my study followed nodule has a high risk of malignancy8 and osteoid matrix
by oropharynx. There were total of 17 lymph node lesions mineralization is the most common pattern of calcification
with both benign and malignant etiology, lesions with in osteosarcoma.9
primary lymphoma (8%, out of n = 73) or metastasis
involving lymph node with primary elsewhere other than Useful fullness of computed tomography in oropharyngeal
the neck region (13%, of n = 73). One case of reactive cancers they found that sensitivity of CT for tumor
lymph node hyperplasia was seen. extension is more than 82%,10 evaluation of paraganglioma
from other mimicking lesions, where multidetector CT
Second most common site to be involved was oropharynx, (MDCT) sensitivity shows 83.33% and the NPV was 80%
15% of cases (of n = 73). Most of the malignant (81%)
sensitivity.11 Diagnostic accuracy of computed tomography
and benign (26%) lesions showed heterogenous type of
in the detection of necrosis in metastatic cervical nodes
enhancement pattern. Exceptions are noted in four cases
from patients with head and neck squamous cell carcinoma
of lymphoma and a case of nasopharyngeal carcinoma
showed an accuracy, sensitivity, and specificity of 92%,
which showed homogenous enhancement pattern, two
cases of osteosarcoma showing mild enhancement, 91%, and 93%, respectively.12
a case of anaplastic lymphoma and a case of metastatic
adenocarcinoma had rim enhancement pattern. A case CONCLUSIONS
of carcinoma nasopharynx and malignant paraganglioma
showed intense enhancement pattern. Two case of Contrast-enhanced CT scans of the neck has improved
osteosarcoma, a case of malignant peripheral nerve sheath the localization and characterization of the neck lesions.
tumor and a case of carcinoma nasopharynx showed If there is an accurate delineation of disease by CT
mild enhancement. Of the benign lesions, 26% showed scan provides a reliable pre-operative diagnosis, plan for
mild enhancement pattern. Cystic lesions.a case of radiotherapy ports and post-treatment follow-up. The
dermoid cyst, thyroglossal cyst, abscess and metastatic most important advantage lies in it, is ability to detect
germ cell tumor) showed central fluid attenuation with bony lesions (erosions and expansion). Recently developed
rim enhancement. There were 3 cases of lipoma, which MDCT enables for thinner collimation with use of MPR,
showed no post contrast enhancement. Four cases showed maximum intensity projection and shaded surface display
rim enhancement a case of thyroglossal cyst, dermoid cyst,
images which improve the localization of the neck lesions.
a case of thyroid gland abscess and a case of abscess in
The faster scan acquisitions, less susceptibility to deleterious
the posterior triangle of the neck. Intense enhancement
artifacts from patient motion, ability to be performed in
pattern is noted in benign hypervascular lesions like carotid
patients with implanted electrical devices are its advantages.
body tumor at carotid artery bifurcation (7%, n = 2) and
nasopharyngeal angiofibroma (8%, n = 2). CT is a more practical imaging modality due to its relatively
lower cost, making it more accessible to patients of lower
Most of the malignant (70%) lesions would show socioeconomic strata. Since CT is fast, well tolerated,
heterogenous enhancement, hypervascular lesions showed and readily available; it can be used for initial evaluation,
marked contrast enhancement and sclerotic lesions showed preoperative planning, biopsy targeting, and post-operative
lack of enhancement.7 Of malignant lesions calcification follow-up and reserve MRI as a complimentary imaging
most common lesions was thyroid malignancies (n = 6, 8%) modality or for those tumors that have higher chance of
followed by malignant bone tumor (n = 4, 6%). Most perineural spread. However, histopathology remains the
common benign lesions that showed calcification are gold standard as CT has only 90% accuracy.

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How to cite this article: Charan I, Kapoor A, Kumar N, Jagawat N, Singhal MK, Kumar HS. Evaluation of Neck Mass with Computed
Tomography: An Observational Study. Int J Sci Stud 2014;2(7):118-122.

Source of Support: Nil, Conflict of Interest: None declared.

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