What is Surgery for a Neck Mass?
Neck masses can occur for a number of reasons. Most are benign (non-cancerous) and self-limited and do not require surgery. However, there are several types of neck masses may be surgically removed. This includes congenital (present since birth) cysts such as branchial cleft cysts and thyroglossal duct cyst, suspicious lymph nodes that cannot be diagnosed through other methods, and various cysts or masses that a patient prefers to have removed (such as sebaceous cysts and lipomas).
When the thyroid gland forms during fetal development, it begins at the base of the tongue and moves down the neck through a canal called the thyroglossal duct. This duct normally disappears once the thyroid reaches its final position in the neck below the Adam’s apple. If the duct does not fully disappear, the duct can create a cyst. These cysts may not be apparent for years and often not until they become infected. Removal is recommended to prevent recurrent infections and to prevent infections from causing more serious problems.
Branchial cleft cysts are also congenital cysts. During early development there are gill-like structures that ultimately turn into the structures of the head and neck (such as the ear bones, jaw, muscles). Normally these gills disappear during development but in some cases, they fail to disappear completely. This can result in a cyst being formed. This fluid filled cyst may not be noticeable for years, and often not until they become infected. Removal is recommended to prevent recurrent infections and from other serious problems developing as a result of the cyst growing and pressing on surrounding structures.
Lymph nodes are small bean-shaped glands that are located throughout your body. They are part of your immune system and help fight off infections. Lymph nodes most commonly become enlarged due to an infection or inflammation in the structures nearby. However sometimes they can be enlarged due to a cancer or lymphoma. In lymph nodes that have been enlarged for over a month, or those that have become enlarged for no other reason your doctor may order a biopsy. The most common type of biopsy is a fine needle aspiration (FNA) where a small needle is inserted into the lymph node and a small amount of tissue is sampled. Rarely an FNA does not provide enough information and an open biopsy will be recommended where part or all of the lymph node will be removed.
What to do BEFORE surgery
Here are a few things you can do before surgery to help things go more smoothly:
- Eliminate ALL medications that thin your blood for two (2) weeks before surgery, unless directed otherwise by your surgeon. Please see this list--Medications to Avoid Prior to Surgery
- Stop smoking at least 3 weeks before your surgery date.
- If you get a chest cold or fever during the 5 days before the surgery, please notify us. A cold may increase the risk from anesthesia.
- Blood counts and clotting is checked before surgery to make sure you are not at risk of increased bleeding. Labs need to be drawn the week prior to surgery. Your insurance carrier may dictate the lab where the blood is drawn.
- No food 8 hours prior to surgery. No liquids for 4 hours prior to surgery.
- Arrange for a ride home after the procedure
What to expect during Surgery
Surgery is performed under general anesthesia. With general anesthesia, you will be asleep for the entire surgery.
The surgery to remove a thyroglossal duct cyst is called a Sistrunk procedure. During surgery an incision is made in the middle of the neck. The cyst and the tract, as well as a small portion of the middle of the hyoid bone (a small bone that sits underneath your chin) is removed. The entire tract must be removed to prevent the cyst from coming back. Surgery typically takes 1.5 hours. After surgery you will be monitored in the recovery area and then go home.
For a branchial cleft cyst, an incision is made in the neck in a neck crease. The exact location and size of the incision varies based on the size and position of the cyst. Infrequently, more than one incision is made, known as a stepladder incision. The cyst is carefully dissected free from the surrounding tissue—this includes the carotid arteries and it’s branches and the nerves in the neck. Any tract is followed and removed as well. Sometimes the tract extends into the throat and the tonsil may need to be removed as well. Often times a drain is place in the neck and the incision is closed. Surgery typically takes 1-2 hours. After surgery you will be monitored in the recovery area and then go home.
During a lymph node biopsy, a small incision is made in a crease in your neck overlying the lymph node. A portion or all of the lymph node is then removed and given to a pathologist to examine under a microscope. Surgery takes 30-60 minutes. After surgery you will be monitored in the recovery area and then go home.
What to expect AFTER Surgery
- You can expect some swelling and discoloration around your incision.
- After any surgery, some pain is normal, but if pain does not decrease or worsens, it may be abnormal and indicate infection or bleeding. Please notify us for worsening pain or increasing swelling of the incision.
- You will have some numbness around your incision. The sensation around your incision will return within a few weeks to months.
- Most patients can return to work/school within 7 days.
- Avoid any strenuous activity, exercise, lifting more than 10 pounds, excessive bending or straining for 2 weeks following surgery to prevent bleeding.
- Use mild non-aspirin pain relievers (Tylenol) as first line treatment for pain and prescription pain medication as directed by your doctor for breakthrough pain.
- A drain may be placed prevent build-up of blood or fluid under your incision. The nursing staff will teach you how to care for your drain and measure its output. We recommend every 8 hours emptying the drain and recording the output. At the end of each 24-hour period total the output. The drain must remain in place for a MINIMUM of 24 hours after surgery. You will be given instructions about when the drain will be removed
- You may not shower until the drain is removed. If you do not have a drain the incision must remain dry for 72 hours.
- You will have an appointment one (1) week after surgery to check your incision site and remove sutures. If this has not been made please contact our office to schedule
What are the risks of Surgery?
As with any surgical procedure, surgery to remove a neck mass has associated risks. Although the chance of a complication occurring is small, it is important that you understand the potential complications and ask your surgeon about any concerns you may have.
Bleeding: There is a very low risk of bleeding during and after surgery. The large vessels of the neck-- the carotid artery and internal jugular vein, are usually intimately associated with the wall of the branchial cleft cyst. Great care is taken to dissect those away from the cyst. Injury to these vessels is very rare.
Infection: This is possible with any surgery, although the risk is low. If an infection occurs antibiotics may be needed. Rarely the infection needs to be drained. Please notify us of increasing redness around the incision or drainage from the incision.
Recurrence: Every effort is made to remove the entire cyst and tract associated with either a branchial cleft cyst or thyroglossal duct cyst, however sometimes there are tracts that are not easily identifiable. Most patients do not have any problems with recurrence. If it does recur, then further treatment would be needed.
Scarring/Poor Cosmetic result: Despite careful planning and closing of the incision it is possible to have undesirable scarring. If you are dissatisfied with your incision after it has completely healed, it is possible to have a scar revision.
Nerve damage: The nerves that move the tongue (hypoglossal nerve), shoulder (spinal accessory), and vocal cords (recurrent laryngeal) all may travel near the cyst. The risk of injury to these nerves is very rare.
Need for further treatment: While unlikely if a cyst were to recur, further treatment may be needed. In addition, lymph node biopsies could diagnose a condition such as cancer or lymphoma that would need further treatment.
Anesthesia complication: Your operation will be carried out under a general anesthetic. There are rare but serious risks of anesthesia. Please feel free to discuss any specifics of the anesthesia with your anesthesiologist.