COMMONCOMMONNECK SWELLINGSNECK SWELLINGS

M K ALAMM K ALAM

ALMAAREFA COLLEGEALMAAREFA COLLEGE

ILOsILOs

At the end of this presentation students will be able to: Describe the triangles and the lymph node distribution in

the neck. Name common neck swellings according to its location in

the triangles. Outline in brief the infection, stone disease and tumors of

salivary glands. Describe aetiology, clinical presentation, investigations and

management of lymph adenopathies. Name the congenital neck swellings, its clinical features and

management. Describe the presenting feature, investigation and

management of carotid body tumor.

Neck SwellingsNeck Swellings Often a diagnostic challengeOften a diagnostic challenge

Anatomy of the neckAnatomy of the neck

History & examinationHistory & examination

InvestigationsInvestigations

HistoryHistory LocalLocal:: Onset Onset DurationDuration PainPain Difficulty in swallowing/ masticationDifficulty in swallowing/ mastication Dyspnea/ nasal obstructionDyspnea/ nasal obstruction Change of voiceChange of voice

SystemicSystemic:: Weight loss Weight loss Night sweatingNight sweating FeverFever

PMHPMH:: Surgery, liver disease, smoking etc Surgery, liver disease, smoking etc

Family historyFamily history: MTC: MTC

ExaminationExamination

LocalLocal: Solitary/ multiple: Solitary/ multiple

Solid/ cysticSolid/ cystic

Effect of swallowing/ tongue protrusionEffect of swallowing/ tongue protrusion

Complete exam: head/neck/ oral and Complete exam: head/neck/ oral and upper aero-digestive tractupper aero-digestive tract

Systemic examinationSystemic examination::

InvestigationsInvestigations

CBC, Serology, TuberculinCBC, Serology, Tuberculin

CXR, U/S, CT scan, MRI, Angio.CXR, U/S, CT scan, MRI, Angio.

FNACFNAC

Laryngoscopy, EndoscopyLaryngoscopy, Endoscopy

Open biopsyOpen biopsy

Common Neck SwellingsCommon Neck Swellings

CongenitalCongenital

Vascular/ lymphatic malformation- Vascular/ lymphatic malformation- Cystic hygromaCystic hygroma

Branchial apparatus abnormality- Branchial apparatus abnormality- Branchial cystBranchial cyst

Thyroglossal cystThyroglossal cyst

Epidermoid cystEpidermoid cyst

Dermoid cystDermoid cyst

Cervical ribCervical rib

Common Neck SwellingsCommon Neck Swellings

AcquiredAcquired

Inflammatory:Inflammatory: Acute lymphadenitis Acute lymphadenitis ( bacterial, viral)( bacterial, viral) Granulamatous- Granulamatous- TBTB, Sarcoidosis, Sarcoidosis Salivary gland infections- viral, bacterialSalivary gland infections- viral, bacterial

Traumatic:Traumatic: HematomaHematoma PseudoaneusysmPseudoaneusysm

Common Neck SwellingsCommon Neck Swellings

AcquiredAcquired

Non-neoplasticNon-neoplastic SiallithiasisSiallithiasis GoitreGoitre AneurysmAneurysm Neoplasms:Neoplasms: Benign- Benign- salivarysalivary, thyroid, , thyroid,

fibroma, fibroma, carotid body tumourcarotid body tumour Malignant- Malignant- salivarysalivary, thyroid, lymphoma, , thyroid, lymphoma,

sarcoma, sarcoma, secondary depositssecondary deposits

Location of common neck swellings

• Mid-line: Dermoid cyst, thyroglossal cyst

• Anterior triangle: Thyroid, lymph nodes, branchial

cyst, carotid body tumour, submandibular salivary gland

enlargement

• Posterior triangle: Lymph nodes, cystic hygroma

lymphadenopathy

• Throat infection: Upper deep cervical, usually discrete, size 1-2 cm, mildly tender, inflamed tonsil

• Tuberculous: Upper & middle cervical, discrete or matted, mildly tender, firm to cystic, overlying skin- normal temp., purplish or normal color

• Primary neoplasms: Ant./post. triangles, smooth, discrete, non-tender, rubbery, not fixed

• Metastatic: Discrete, hard, non-tender, tethered,

Acute lymphadenitisAcute lymphadenitis

Usually follow tonsillitis, throat infection, Usually follow tonsillitis, throat infection,

scalp or face infection, dental abscess scalp or face infection, dental abscess

Lymph node enlarged and tenderLymph node enlarged and tender

Pyrexia, general malaisePyrexia, general malaise

Antibiotic and treatment of primary sourceAntibiotic and treatment of primary source

TB lymphadenitisTB lymphadenitis

Human & bovine TB bacillusHuman & bovine TB bacillus

Upper deep cervical groups commonly affectedUpper deep cervical groups commonly affected

Painless, initially firm swelling, later may become soft (cold Painless, initially firm swelling, later may become soft (cold

abscess), matted, discharging sinusabscess), matted, discharging sinus

Evening temperature, night sweats, weight loss, anorexiaEvening temperature, night sweats, weight loss, anorexia

Diagnosis: FNA, aspirate for AFB, culture, PCR, biopsyDiagnosis: FNA, aspirate for AFB, culture, PCR, biopsy

Treatment: Anti-tuberculous drugsTreatment: Anti-tuberculous drugs

Primary malignant tumours of lymph nodesPrimary malignant tumours of lymph nodes

Hodgkin's disease, Hodgkin's disease,

lymphosarcomalymphosarcoma

Secondary deposits in lymph Secondary deposits in lymph nodesnodes

Primary tumour sitePrimary tumour site: Nasopharyngeal area, : Nasopharyngeal area,

tongue, oral cavity, thyroidtongue, oral cavity, thyroid

Affected lymph nodes are hard and fixedAffected lymph nodes are hard and fixed

Diagnosis: Diagnosis: Assessment of primary, FNA & biopsyAssessment of primary, FNA & biopsy

Treatment: Block dissection of the neckTreatment: Block dissection of the neck

Inflammatory disorders (Salivary)

Viral infections (Mumps)

• Common among children.• Usually affects parotid, submandibular

occasionally• Painful swelling, fever and headache. • Resolves in 5-10 days.• Treatment- symptomatic

Bacterial infections (Salivary)

• Common in elderly, also seen in fit and young

• Dehydration results in ascending infection via parotid duct

• Painful, more on eating/ drinking,

• tender parotid swelling with fever and malaise

• Pus exuding from duct papilla

• Staph. aureus, Strep. viridans

• Early cases: antibiotics, oral hygiene

• Late cases: abscess drainage

Calcular disease (Sialothiasis)• Painful swelling of submandibular gland during

eating

• Swelling resolves/ reduces 1-2 hours after meals

• Enlarged submandibular gland on bimanual examination

• Stone in the duct- palpable in the floor of mouth

• Treatment: Stone in the duct- extraction by direct incision over the

duct Stone in the gland- excision of the gland

Salivary GlandsSalivary Glands

Neoplasms (Benign)

Pleomorphic adenoma

Warthins tumour

Oncocytoma,

Basal cell adenoma,

Intraductal papilloma

Pleomorphic AdenomaPleomorphic Adenoma

• Most common neoplasm, parotid most common site

• M=F, 3-5 decade

• Slow growing, painless mass/ mild discomfort

• Risk of malignant change- 1.5% in 5 years

• FNA- most helpful

• CT, MRI rarely needed

• Treatment: Superficial parotidectomy / Total parotidectomy

Enucleation not recommended Submandibular: Total gland excision

Salivary glandsSalivary glands

Neoplasms (Malignant) Mucoepidermoid carcinoma* Acinic cell carcinoma Adenoid cystic carcinoma Basal cell carcinoma Low grade adenocarcinoma Mucinous adenocarcinoma Malignant pleomorphic tumour Lymphoma Secondary deposits

Malignant tumoursMalignant tumours

• Swelling of the affected gland

• Rapid growth

• Painful

• Lymphadenopathy

• Fixity, skin attachment

• Nerve palsy, paresthesia

• No particular feature of histological subtype

Malignant tumoursMalignant tumours

• FNA

• CT, MRI

• Staging:

T1: Tumour less than 2 cm

T2: Tumour 2-4 cm T3: Tumour more than 4 cm T4: Any size with evidence of extension

Treatment- malignant salivary tumours

• Parotid: En-bloc excision. Preserve facial if not involved

• Submandibular/Sublingual: En-bloc excision• Post-op radiotherapy: High grade, local extension, perineural extension

• Neck dissection: High grade mucoepidemoid tumours

Thyroglossal cystThyroglossal cyst

• Persistent of part of thyroglossal ductPersistent of part of thyroglossal duct

• Midline swelling just above thyroid cartilageMidline swelling just above thyroid cartilage

• Moves up on tongue protrusionMoves up on tongue protrusion

• Cyst contains mucoid materialCyst contains mucoid material

• Cyst is in intimate relation with hyoid boneCyst is in intimate relation with hyoid bone

• Surgical excision (Sistrunk operation)- Excising whole Surgical excision (Sistrunk operation)- Excising whole

cyst, wedge of hyoid and duct up to the base of tonguecyst, wedge of hyoid and duct up to the base of tongue

Branchial cyst

• Remnant of 2nd branchial cleft

• Painless

• Site: Behind the anterior edge of upper 1/3rd of

sternomastoid muscle bulging forward

• Ovoid shape, size 5-10 cm, smooth surface

• Cystic (fluctuates)

• Transillumination: opaque

• Tender and red if infected

• Treatment; Surgical excision

Carotid body tumour

• Tumour of chemoreceptor tissue in carotid body• Painless, slow growing • Site: Anterior triangle, within carotid bifurcation, at the level

of hyoid bone• Spherical, non-tender, firm/hard• Pulsatile, moving in horizontal plane• Investigation: CT (splaying of carotid vessels), MRI, Investigation: CT (splaying of carotid vessels), MRI,

angiography angiography• No FNANo FNA• Treatment: Surgical excisionTreatment: Surgical excision

Cystic hygroma

• Collection of lymphatic sacs• Congenital• From birth to within few years• Site: base of the neck in post. triangle• Subcutaneous• Variable size• Soft, cystic , brilliantly trans illuminates