Differential Diagnosis for Pulsatile Neck Mass

The patient's symptoms of a pulsatile feeling in the right side of his neck, which sometimes worsens with movement, suggest a vascular origin. Given the results of the CBC, CMP, CTA head and neck, and CTA neck showing no acute abnormalities, the differential diagnosis can be organized as follows:

• Single Most Likely Diagnosis
  • Carotid Artery Stenosis or Kinking: This condition could cause a pulsatile sensation due to turbulent blood flow. The fact that the symptom sometimes worsens with movement supports this possibility, as certain positions could exacerbate the stenosis or kinking effect.
• Other Likely Diagnoses
  • Thyroid or Parathyroid Adenoma: Although less directly related to pulsatile sensations, large adenomas could potentially cause a sensation of pulsation due to their proximity to major vessels and the potential for compressive effects.
  • Cervical Vertebral Osteophyte: Bony spurs from the cervical spine could compress or irritate nearby vessels, potentially leading to a pulsatile feeling, especially with certain movements.
• Do Not Miss Diagnoses
  • Carotid Artery Dissection: Although the CTA neck showed no acute abnormality, dissections can sometimes be subtle and require careful examination. A dissection could lead to a pulsatile mass or sensation and is a critical diagnosis not to miss due to its potential for severe complications, including stroke.
  • Aortic Arch Atherosclerosis: While the primary concern is with the carotid arteries, significant atherosclerosis in the aortic arch could lead to similar symptoms and has important implications for management and risk of future vascular events.
• Rare Diagnoses
  • Carotid Body Tumor (Paraganglioma): These are rare, usually benign tumors located at the bifurcation of the carotid artery, which could cause a pulsatile neck mass. They are less common but should be considered in the differential diagnosis, especially if other causes are ruled out.
  • Arteriovenous Malformation (AVM) or Fistula: An AVM or arteriovenous fistula in the neck could cause a pulsatile sensation due to abnormal blood flow. These are rare and might not be immediately suspected but are important to consider for comprehensive evaluation.