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Background Neck masses are found in all age groups from many causes, ranging from congenital to acquired pathology. There is paucity of data on neck masses in Tanzania and at Muhimbili National Hospital, prevalence of neck masses is not yet known. The aim of this study was thus to address this gap. Methods Descriptive cross sectional study was done from July to December 2016 involving patients who were admitted in surgical wards. Structured questionnaires were filled after thorough head and neck evaluation of patients. Data analysis by SPSS version 20 and p-value <0.05 was considered to be statistically significant. Results The overall prevalence of neck masses was found to be 14.1% and proportion of neck masses was found to increase as the age increase. Anterior triangle was the commonest anatomical site (53.8%). Most of the neck masses (65.7%) were malignant and the age group most involved was >60 years (P-value 0.000). Among the malignant neck masses squamous cell carcinoma was the leading variant (54.1%) and most of the malignant neck masses were metastatic nodes from primary cancers in the upper aerodigestive tract (67.21%). Conclusion This study has unveiled neck masses at MNH to be prevalent and the proportion of neck masses increase age increase. Anterior triangle was the leading anatomical site. Most of the neck masses were malignant and majority of them were metastatic nodes from upper aerodigestive tract. Any neck mass especially in adults needs thorough evaluation including upper aerodigestive assessment to rule out the possibility of malignancy.
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Original Article
54
Medical Journal of Zambia, Vol. 46 (1): 54 - 60 (2019)
Prevalence and Aetiology of Neck Masses among
Patients Receiving Surgical Services at Muhimbili
National Hospital, Tanzania
Keywords: Prevalence, Aetiology, Neck masses,
Muhimbili, Tanzania.
1 2 3 3
Zephania Saitabau Abraham, Mary Mathias, Kassim Babu Mapondella, Aveline Aloyce Kahinga,
3 3
Daudi Ntunaguzi, Enica Richard Massawe
1 Department of Surgery, University of Dodoma College of Health and Allied Sciences
Box 259, Dodoma, Tanzania
2 Department of Otorhinolaryngology-Temeke Municipal Hospital
Box 45232 Dar es Salaam
3 Department of Otorhinolaryngology-Muhimbili University of Health and Allied Sciences
Box 65001- Dar es Salaam
ABSTRACT
Background: Neck masses are found in all age
groups from many causes, ranging from congenital
to acquired pathology. There is paucity of data on
neck masses in Tanzania and at Muhimbili National
Hospital, prevalence of neck masses is not yet
known. The aim of this study was thus to address this
gap.
Methods: Descriptive cross sectional study was
done from July to December 2016 involving
patients who were admitted in surgical wards.
Structured questionnaires were filled after thorough
head and neck evaluation of patients. Data analys is
by SPSS version 20 and p-value<0.05 was
considered to be statistically significant.
Results: The overall prevalence of neck masses was
found to be 14.1% and proportion of neck masses
was found to increase as the age increase. Anterior
triangle was the commonest anatomical site
(53.8%). Most of the neck masses (65.7%) were
malignant and the age group most involved was >60
years (P-value 0.000). Among the malignant neck
masses squamous cell carcinoma was the leading
variant (54.1%) and most of themalignant neck
masses were metastatic nodes from primary cancers
in the upper aerodigestive tract (67.21%).
Conclusion: This study has unveiled neck masses at
MNH to be prevalent and the proportion of neck
masses increase age increase. Anterior triangle was
the leading anatomical site. Most of the neck masses
were malignant and majority of them were
metastatic nodes from upper aerodigestive tract.
Any neck mass especially in adults needs thorough
evaluation i n c lu d i n g upper aerodigestive
assessment to rule out the possibility of malignancy.
INTRODUCTION
Neck masses can present in all age groups from
many causes, ranging from congenital to acquired
pathology. The occurrence of neck masses during
childhood creates anxiety to both parents and family
physicians because of fear for possibility of
malignancy even though majority of paediatric neck
masses are benign lesions. Despite this fact, special
concern should be given for the possibility of
malignancy. Regarding aetiology, neck masses can
be classified into three main groups: inflammatory
1,2,3
or infectious, congenital and neoplastic.
One of the most important considerations in an adult
presenting with a lump in the neck is that the mass
may represent a metastatic deposit from a primary
cancer, often but not always in the upper respiratory
or alimentary tract. This is particularly so for middle
aged or elderly patients, especially those who have
smoked. In this group of patients, it's important that
the primarytumor is found quickly so that correct
management of the disease can be instituted. Neck
node metastases from an unknown primary site are
part of the “Cancer of Unknown Primary” origin,
where the primary tumor may remain unknown for a
patient's lifetime despite thorough diagnostic work-
up. Over 90% of neck metastases comprise
squamous cell carcinoma (SCC) whereas other
4,5,6
malignancies are less common.
Studies show that proportion of neck masses
increase as the age increases and also the incidence
of neoplastic cervicaladenopathy increases as the
age of the patients increases. Anterior triangle has
been found to be the leading anatomical site with
neck masses in some studies while others show that
posterior triangle is the leading site with neck
3,4,7,8,9
masses.
Inflammatory neck masses have been reported as
most common, especially in paediatric population,
while malignant neck masses are found more in
adult population. Most malignant neck masses are
metastatic nodes from primary cancers in the upper
3,7,8,10,11,12,13,14,15,16
aerodigestive tract.
Despite the significant number of patients referred
lately to us at MNH and neck masses as the advanced
manifestation of certain malignant neoplasms in the
upper aerodigestivetract, their prevalence is not yet
known thus the aim of the study was to address this
available gap.
METHODS
Study design and participants
This was a hospital based descriptive cross-sectional
study carried out from July to December 2016 at
MNH involving patients admitted in surgical wards
which were ENT, Oral and Maxillofacial Surgery,
General surgery and Paediatric surgery.
Sampling method
Convenience sampling technique was utilized to
patients who consented for the study.
Sample size estimation
Sample size was calculated using Fisher's formula
2) 2
for prevalence studies as follows:n= (Z p(1-p)/£
Where
n = minimum sample size required, Z= statistic for
the level of confidence (1.96)
p= expected prevalence. (50% was used since no
prevalence found in previous studies)
£= maximum tolerable error, which is 4%
Thus the minimum sample size required was 600.
The adjusted for non-response (10%) was 60
Hence the adjusted minimum required sample size
was 660
Data collection methods
Detailed clinical examination of the patients with
neck masses including evaluation of nasopharynx,
oropharynx, hypopharynx and larynx was done
usi n g i n d ire c t l a r yngo s c opy or fl e x ibl e
lar y n gos c o py ( fib e r o p tic nas o phar y n go
laryngoscopy) and findings were filled in the
questionnaires. Primary site of malignant neck
masses was determined by collaboration with
general surgeons and ENT specialists through fiber
optic nasopharyngolaryngoscopy, oesophagoscopy,
and OGD. FNAC of the neck masses wasdone by
histopathologists. Open biopsy was done to neck
masses which were ulcerated and in which FNAC
had given inconclusive results.
Data analysis
Data analysis was done using the Statistical Package
for Social Sciences (SPSS) version 20.Chi-square
test was used to compare proportions. P value of
<0.05 was considered statistically significant.
55
Medical Journal of Zambia, Vol. 46 (1): 54 - 60 (2019)
Ethical considerations
Patients were provided with an informed consent
and then asked to provide written consent to
participate in the study. For patients younger than 18
years, informed consent was obtained from their
parents or guardians. Ethical approval was provided
by Research and Publication Committee of the
Muhimbili University of Health and Allied Sciences
(MUHAS).
RESULTS
Demographic characteristics of the study
population and overall prevalence of neck
masses.
A total of 660 participants were recruited from July
to December 2016 in which males were 48.6% and
females were 51.4%. Most of the study participants
were in the age group of £10 years (50.3%).
The overall prevalence of neck masses was found to
be 14.1%, and the prevalence of neck masses among
males was 15.9% while that among females was
12.4% (p-value was 0.197).
Moreover, the prevalence of neck masses was found
to increase as the age increase where it was found to
be higher in the age group of >60years (p-value
0.000) (table 1)
Table 1: Prevalence of neck masses according to
age
Anatomical sites for neck masses
Anterior triangle was the leading anatomical site
with neck masses (53.8%) and 22.6% of the neck
masses occupied more than 1 site. However, there
was no statistically significant difference in
anatomical sites forneck masses in relation to age
and sex (Figure 1)
Figure 1: Anatomical site of neck masses in
relation to sex
Histocytopathology of neck masses
Most of the neck masses (65.6%) were malignant
and the leading age group was > 60 years (p-value of
0.000). Inflammatory neck masses were the least
and accounted for 14% of all neck masses. (Table 2)
Table 2: Histocytopathology of neck masses
HI S TO C YT O PAT HO L OG Y O F N E CK
MASSES
Further analysis revealed reveled squamous cell
c a r c i n om a ( S C C) t o b e t he l e a di ng
histocytopathological variant (54.1%) and was more
NECK MASSES
Age group
(Years )
Yes (%) No (%) Total (%)
£10 9 (2.7) 323 (97.3) 332 (50.3)
11-20
7 (10.9)
57 (89.1) 64 (9.70)
21-30
8 (13.3)
52 (86.7) 60 (9.1)
31-40
16 (23.5)
52 (76.5) 68 (10.30)
41-50
12 (24.0)
38 (76.0) 50 (7.57)
51-60
17 (38.6)
27 (61.4) 44 (6.67)
>60
24 (57.1)
18 (42.9) 42 (6.36)
TOTAL
93 (14.1)
567 (85.9) 660 (100)
Age group
Malignant
Benign Inflammatory Total
N (%)
N (%) N (%) N (%)
£10
1 (11.1)
5 (55.6) 3 (33.3) 9 (9.68)
11-20
6 (85.7)
0 (0)
1 (14.3) 7 (7.53)
21-30
4 (50.0)
1 (12.5) 3 (37.5) 8 (8.60)
31-40
11(68.8)
3 (18.8) 2 (12.5) 16 (17.20)
41-50
6(50.0)
6 (50.0) 0 (0) 12 (12.90)
51-60 12(70.0) 2 (11.8) 3 (17.6) 17 (18.28)
>60 21(87.5) 2 (8.3) 1 (4.2) 24 (25.81)
Total 61(65.6) 19 (20.4) 13 (14.0) 93 (100)
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Medical Journal of Zambia, Vol. 46 (1): 54 - 60 (2019)
in the age group > 60 years (P-value < 0.01). The
second leading variant was lymphoma. Goitre was
the leading benign subtype and was more common
in females than males (Table 3).
Table 3: Malignant neck masses in relation to age
Primary site of malignant neck masses
67.21% of the malignant neck masses had primaries
in the upper aerodigestive tract. (21.31% from
nas o p harynx, 21.31% o r opharynx, 13.2%
hypopharynx, 9.8% larynx and 1.6% mid
esophagus). The rest were from neck itself(11.1%),
thyroid gland (6.6%), parotid (9.8%) and
submandibular gland (4.9%).Nasopharynx was the
leading primary site for malignant neck masses in
age groups 11-20, 31-40 and 4-50 years, while
hypopharynx was the leading site in the age group
>60 years (Table 4)
Table 4: Primary site of malignant neck masses in
relation to age
MALIGNANT NECK MASSES
Age
(Years)
SCC
N (%)
Lymphoma
N (%)
Mucoepidermoid
carcinoma
N (%)
Others
N (%)
Total
N (%)
£10
0 (0)
1(100)
0(0) 0 (0) 1 (1.64)
11-20
3(50.0)
1 (16.67)
0(0) 2 (33.33) 6 (9.84)
21-30
0(0)
1(25.0)
1(25) 2(50.0) 4 (6.56)
31-40
7 (63.63)
3 (27.27)
1 (9.1) 0 (0) 11(18.03)
41-50
2 (33.33)
3 (50.0)
0( 0) 1(16.67) 6 (9.84)
51-60
7 (58.33)
1(8.33)
2 (16.67) 2(16.67) 12(19.67)
>60
14 (66.67)
3(14.29)
1(4.76) 3(14.28) 21(34.4)
Total 33 (54.1) 13(21.31) 5(8.20) 10 (16.39) 61 (100)
PRIMARY SITE FOR NECK MASSES
Age Neck
N (%)
Prtd
N (%)
Thyrd
N (%)
Nsphrx
N (%)
Ophyrx
N (%)
Hphyrx
N (%)
Lyrnx
N (%)
Esphg
N (%)
Sbmnd
N (%)
Total
N (%)
£10 1 (100) 0 0 0 0 0 0 0 0 1(1.6)
11-20 1(16.7) 0(0) 0(0) 3(50) 2(33.3) 0(0) 0(0) 0(0) 0(0) 6(9.8)
21-30 1(25) 1(25) 0(0) 0(0) 1(25)
0(0)
0(0)
0(0)
1(25) 4(6.6)
31-40 1(9.1) 1(9.1) 0(0) 5(45.4) 1(9.1)
2(18.2)
0(0)
0(0)
1(9.1) 11(18.1)
41-50 1(16.7) 0(0) 1(16.7) 2(33.2) 1(16.7)
0(0)
1(16.7)
0(0)
0(0)
6(9.8)
51-60 1(8.3) 3(25) 1(8.3) 2(16.7) 0(0)
2(16.7)
2(16.7)
1(8.3)
0(0)
12(19.7)
>60 1(4.8) 1(4.8) 2(9.5) 1(4.8) 8(38.1)
4(19)
3(14.2)
0(0)
1(4.8) 21(34.4)
Total 7(11.5) 6(9.8) 4(6.6) 13(21.3) 13(21.3)
8(13.2)
6(9.8)
1(1.6)
3(4.9) 61(100)
Key: Prtd: Parotid gland Thyrd: Thyroid gland Nsphrx: Nasopharynx
Ophyrx: OropharynxHphyrx: HypopharynxLyrnx: Larynx
Esphg: Esophagus Sbmnd: Submandibular gland
DISCUSSION
Neck masses are common worldwide and constitute
a major indication for surgical consultation in many
centres. The current study enrolled 660 participants
with ages ranging from 7 months to 90 years. The
male to female ratio was 1:1.06. Most of the study
participants were at the age group £10 years
(50.3%).
The overall prevalence of neck masses was found to
be 14.1% and there was no statistical significant
difference between males and females in which
prevalence among males was 15.9% and among
females was 12.4% (p-value of 0.197). The
prevalence of neck masses was found to increase as
the age increases ((p-value0.000). The study done
by Soussau et.al in Iran also showed that the
proportion of neck masses to increase as the age
increases where it was 2.7% in paediatric group,
18
38.6% in young adults and 58.7% in adults. The
incidence of neoplastic cervical adenopathy
continues to increase with age. This was
documented by Gleeson et.al in London following
review of a large series of 8500 patients with head
and neck neoplasms diagnosed over a 10 year
4
period.
In this study, most of the neck masses were found in
anterior triangle (53.8%) and 22.6% of the neck
masses occupied > 1 site. The anatomical location of
neck masses did not differ significantly between the
age groups or sex (p-value 0.065 and 0.123
respectively). Other studies also revealed anterior
triangle to be the leading anatomical site with neck
masses while others show the posterior triangle to be
the more leading anatomical site with neck
7,9,3,8
masses. These differences can be attributed to
differences in methodologies used in the studies.
Most of the neck masses (65.6%) were malignant
and age group most involved was >60 years (p-value
0.000). Inflammatory neck masses were the least
(14%). Among the malignant neck masses,
squamous cell carcinoma was the most malignant
subtype found in the neck masses (54.1%) followed
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Medical Journal of Zambia, Vol. 46 (1): 54 - 60 (2019)
by lymphoma (21.31%). The findings are similar to
the findings obtained by Atiqur et al in which lymph
nodes with metastatic carcinoma were the most
common malignant (61.9%) followed by lymphoma
11
(26.2%). In the current study, other malignant
subtypes were adenocarcinoma, sarcoma, adenoid
cystic carcinoma and papillary carcinoma which all
together accounted for 16.39% of all malignant neck
masses. Mucoepidermoid carcinoma accounted for
8.20%. SCC was more common in males while
lymphoma was more common in females. The
benign neck masses constituted of pleomorphic
adenoma, goiter and congenital neck masses which
were 3 cystic hygromas and 2 thyroglossal cysts.
The benign thyroid neck masses were more
common in females. These findings differ with other
studies since most of the neck masses were found to
3,18,19,14
be inflammatory and benign. The reason for
these differences can be due to different study
populations in which most of them were children in
these studies while in the current study few children
were found to have neck masses. The short study
duration and different methodologies can also
contribute to these differences. For example, this
study enrolled only inpatients who could be more ill
due to some malignant conditions compared to
outpatients in other studies who might have benign
or inflammatory conditions.
Th e ma jorit y of mal ignan t ne ck m asses ,
67.21%,were metastatic lymph nodes from primary
cancers in the upper aerodigestive tract, (21.31%
from nasopharynx, 21.31% oropharynx, 13.11%
hypopharynx, 9.84% larynx and 1.64% mid-
oesophagus). The rest of the neck masses had neck
itself as the primary site while others were from
thyroi d a nd s aliv ary glan ds (parotid and
submandibular glands). Most of the metastatic
nodes were squamous cell carcinoma. This
resemble the study done by Bagwanet.al in India,
where the most common tumor metastasizing to the
neck nodes had the primary somewhere else. In that
study, the primary cancers were from the tongue,
16
alveolus, buccal mucosa and palate.
Gleeson. et.al documented the management of
lateral neck masses in adults and concluded that the
lateral neck mass in adults should be considered
4
malignant unless proven otherwise. This study also
found that most of the neck masses in adults to be
malignant and they were predominantly metastatic
nodes from upper aerodigestive tract.
CONCLUSION
Neck masses are common worldwide affecting
children as well as adults. In this study, neck masses
were found to be prevalent among patients receiving
surgical services at MNH. The proportion of neck
masses was found to increase as the age increased.
The most common anatomical site involved with the
neck masses was anterior triangle and there was no
statistically significant difference in terms of age or
sex. Most of the neck masses were found to be
malignant and SCC was the leading histological
variant followed by lymphoma. Majority of the neck
masses were metastatic lymph nodes from primary
cancers in the upper aerodigestive tract. Hence neck
masses should be taken seriously. Early assessment
including upper aerodigestive evaluation and biopsy
is important to rule out possibilities of malignancies
and hence early intervention.
LIST OF ABBREVIATIONS
ENT - Ear, Nose and Throat
FNAC- Fine Needle Aspiration Cytology
MD - Doctor of Medicine
MNH - Muhimbili National Hospital
MUHAS- Muhimbili University of Health and
Allied Sciences
OGD - Oesophagogastroduodenoscopy
OMFS- Oral Maxillofacial Surgery
SCC - Squamous Cell Carcinoma
SPSS - Statistical Package of Social Science
DECLARATIONS
Ethics approval and consent to participate
The approval to conduct the study was granted by
Ethics and Research Committee for Muhimbili
University of Health and Allied Sciences
58
Medical Journal of Zambia, Vol. 46 (1): 54 - 60 (2019)
Availability of data and material
The detailed reported information can be obtained
from the corresponding authors when needed and
f r om a rc h i ve s o f t h e d e p a rt m e n t o f
Otorhinolaryngology-MUHAS
Competing interests
The authors declare that they have no competing
interests
Authors' contributions
MM participated in study design, data collection
and analysis. ZSA Participated in study design and
preparation of manuscript. ERM Participated in
design of the study and data analysis. KBM
participated in data analysis andpreparation of the
manuscript. AAK participated in study design and
data analysis. DNparticipated in study design and
data analysis
ACKNOWLEDGEMENTS
We would like to acknowledge member of staffs
from the departments in which the data was
collected (ENT, OMFS, General surgery and
Pediatric surgery) for provision of a conducive
environment for the study. Also the Department of
Histopathology department for their cooperation
during follow up of cytology/histology results of
participants with neck masses.
Members of staff from MUHAS and MNH in the
Department of Otorhinolaryngology for their
valuable comments during the phase of study
design, data collection and compilation of the
report.
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... The majority of the neck masses in this study were located in the anterior triangle of the neck and this is consistent with the finding of Abraham et al. [2] and Osifo and Ugiagbe [18] where 53.85 and 40% of the masses, respectively, were located in the anterior triangle. Conversely, Lucumay et al. [19] reported 79.7% of the masses were located in the posterior triangle of the neck. ...
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Neck swelling due to various causes is common across age groups, and invasive methods are usually done in its management. An inflammatory swelling is considered in Ayurveda as Vidradhi (~abscess) or Vranasopha (~inflammatory swelling). A 27-year-old male patient with a solitary inflammatory neck swelling was successfully treated in 21 days with noninvasive methods like internal medicines and external therapies. Internal medicine like Trayanthyadikwatha, Gopichandanadi tablet, Sudarsanam tablet, Septilin syrup, Varanadikwatha, and Abhayarista were given as per the disease progression. Therapies like medicated lukewarm gargles, Murivena, and egg white external application were also done as per the stage of inflammation. The patient had a complete recession of the swelling without any discoloration or any other complication. The results of the present case report suggested that proper evaluation of Dosha and intervention at the right time key in managing such types of swellings from suppuration and avoid surgical intervention. Keywords: Ayurveda, Idradhichikitsa, inflammatory neck swelling, noninvasive management, Vrana Sopha
... This finding was like the study by Abraham et al, 67.2% were metastatic lymph nodes, and the primary cancers occurs commonly from the nasopharynx (21.31%) and oropharynx (21.31%). 20 Benign neck lumps are less common in adults. 2,6 However, benign tumours arising from the thyroid and salivary glands, are relatively commonly seen in adults. ...
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The importance of clinical assessment and its contribution to the diagnosis of neck masses was investigated in patients presenting with a neck mass. In our study, we collected the medical history of a total of 127 patients, including 66 males and 61 females, who presented with a neck mass. Physical exams, endoscopic examinations, laboratory tests, a variety of imaging studies, and fine-needle aspiration biopsies were performed. The relationship between age, duration and location of the neck mass, FNAB results, and definitive histopathological diagnosis were investigated as well as the correlation between the consensus diagnosis reached after the evaluation of the medical history, physical examination and imaging studies, and definitive histopathological diagnosis. A strong and positive relationship (p < 0.01) was found between patients’ ages and the definitive diagnosis established by histopathological examination. There was no statistically significant relationship (p > 0.05) between the duration and location of the neck mass and definitive diagnosis established by histopathological examination. And no statistically significant relationship (p > 0.05) was found between FNAB results and definitive histopathological diagnosis. Although no statistically significant relationship was found between the characteristics of neck masses and age, duration and location of masses and FNAB results, there was a statistically significant correlation between the pre-diagnosis estimated by ENT specialists and definitive diagnosis established by histopathological examination. A strong and positive relationship (p < 0.01) was found between clinical pre-diagnosis and definitive diagnosis established by histopathological examination. In patients presenting with a neck mass, the diagnosis should be made based on the medical history, physical examination, radiologic imaging and FNAB results, treatment decisions should be based on those findings.
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