NECK SWELLINGSDr Manpreet Singh Nanda

Associate Professor ENTMMMC&H Solan

CLASSIFICATION BENIGN – CHILD 80 ADULT 20 MALIGNANT – CHILD 20 ADULT 80 MIDLINE Thyroglossal cyst, dermoid cyst LATERAL Ranula (submental/submandibular) Branchial cyst (carotid) Cystic hygroma, TB lymphadenitis,

Cervical rib (posterior)

THYROGLOSSAL CYST Cystic swelling in the remnant of

thyroglossal tract from foramen caecum to thyroid isthmus

Age – younger children (MC), but can occur at any age

Midline swelling (90%) Site – infra hyoid (mc..... 85%), other –

supra hyoid, lower neck, base of tongue Tract passes through, behind or front of

hyoid bone

C/F Painless, rounded (2-4 cm), soft swelling,

moves with deglutition, protrusion of tongue and sideways

URTI – infected – fever, painful and tender, sudden increase in size, ruptures to form thyroglossal fistula

Thyroglossal fistula- mucoid, watery or milky discharge. If infected becomes purulent

Hood’s sign – skin above fistula opening pulled upwards

Pathology – clear fluid Diagnosis USG Thyroid scan – diff from lingual thyroid Fistulogram Prognosis – can lead to papillary ca,

hurthle cell ca Treatment – Sistrunk’s operation –

surgical excision of cyst along with its tract and middle portion of hyoid bone

Only cyst removal - recurrence

BRANCHIAL CYST, SINUS, FISTULA Etiology – abnormal development of

branchial apparatus Age – late childhood/ early adulthood, 20-25

yrs, appears late though congenital as fluid within it takes time to accumulate

C/F Painless, oval/rounded swelling, soft, non

transilluminated, non compressible Becomes painful and tender if infected after

URTI Site – anterior triangle ( carotid) Pathology – cholesterol crystals

Types 2nd branchial cleft cyst (mc) Deep to and along ant border of SCM If infected – sinus Tract b/w 2nd arch structures (ECA, post

digastric, SCM) and 3rd arch structures (ICA) If fistula – 2 openings, external along ant

border of SCM at lower 1/3rd , internal – perforates pharyngeal wall and opens in tonsillar fossa (ant border of post pillar behind the tonsil)

3rd branchial cleft cyst Uncommon, deep to both ECA and ICA,

sup to hypoglossal nerve and vagus nerve

Opens into pyriform fossa 1st branchial cleft cyst Less common Along ant border of mandible, angle of

mandible, below ear lobe Opens into EAC

Diagnosis USG FNAC – cholesterol crystals, lymphoid

tissue Contrast X Ray (Fistulogram) Treatment Surgical excision along with its tract

LYMPHANGIOMA CYSTIC HYGROMA Etiology Congenital cystic lesion due to

incomplete development, obstruction or sequestration of normal lymphatic system ( jugular lymphatic sac)

Associated with chromosomal anomaly Age - < 2 yrs (90%), can be present at

birth Site – lower part of posterior triangle

(mc), base of tongue, cheeks, supraglottis

C/F Painless, slow growing, fluctuant, soft

swelling, with indiscrete margins, partially reducible, varies in size, transilluminated, increase in size on coughing or crying

If infected – painful and increase in size Pathology – contains multiple loculi of

clear lymph

Complications Stridor – if involve larynx, pharynx Respiratory difficulty Feeding problem Difficult labour Diagnosis Antenatal USG CT, MRI

Treatment Tracheostomy if stridor Complete excision Sclerotherapy - Injection sclerosing

agents like absolute alcohol, bleomycin, TCA

DERMOID CYST Head and neck – 7% of dermoid cyst MC site – floor of mouth post or lateral to

frenulum, midline (submental) C/F Slow growing, painless cystic swelling,

non transilluminated, can lead to difficulty in swallowing, speech and respiration

Children and young adults, 10-15 yrs Pathology – contains epidermoid

appendages like hair, hair follicles, sweat glands, sebaceous glands

Types Sublingual – MC Floor of mouth, above myelohyoid Cervical At submental triangle, below

myelohyoid, double chin appearance Diagnosis – USG Neck D/D – sebaceous cyst – skin mobile in

dermoid cyst over swelling Treatment – complete surgical excision

RANULA Etiology Mucous retention cyst of sublingual

salivary glands due to obstruction of their secretory ducts

Types Intra oral Cystic translucent bluish mass in lateral

part of floor of mouth, pushes tongue up Plunging ranula – neck swelling in

submental/ submandibular region, painless, transilluminated

Complications Difficulty in swallowing Difficulty in chewing Difficulty in speaking Treatment Excision along with sublingual gland Marsupialization if large (as thin walled so

grows into various structures If ruptures – recurrence Plunging ranula – trans cervical approach

ACUTE CERVICAL LYMPHADENITIS U/L MC – young children (1-8 yrs) Etiology – due to focus of infection in

tonsils, adenoids, dental, oral cavity JD lymph nodes C/F – fever, malaise, ln enlarged and

tender Diagnosis – WBC count, USG Treatment – antibiotic therapy, surgical

drainage of abscess

TUBERCULAR CERVICAL LYMPHADENITIS Chronic infection of lymph nodes due to

Mycobacterium tuberculosis Route of infection – I/L tonsil, secondary to

pulmonary TB, hematogenous C/F Painless, unilateral, gradual increase in size

most common seen in posterior triangle Evening rise of temp, night sweats, weight

loss Stages Adenitis – enlarged ln Periadenitis – matted ln (2-3 ln)

Cold abscess – central caseation within ln Collar stud abscess (dumb bell shaped) –

rupture of cold abscess, pus enters sup fascia below the skin

Discharging sinus – pus ruptures through skin

Diagnosis Mantoux test/ tuberculin skin test –

positive (> 10 mm) USG – matted ln with central necrosis Chest X Ray PA view – pulmonary TB

FNAC – granulomas, acid fast bacilli Excision biopsy C/S CBC Treatment ATT Complete excision along with surrounding

fibrous capsule – if residual ln after ATT If active pulmonary TB – excision not

done

NON TUBERCULAR MYCOBACTERIUM LYMPHADENITIS M avium complex (avium and

intercellulare) M fortuitum M kansassi M scrofulaceum Age – children < 6 yrs Site – pre auricular, submental, upper

jugular Diagnosis – tuberculin test positive (10-

15 mm) Treatment – coplete surgical excision

CERVICAL RIB Extra rib arising from C7 vertebra attached

to 1st rib Right side mc but can be left side or bilateral C/F Bony hard lump in supra clavicular region Compression of branchial plexus and

subclavian artery Branchial plexus compression – tingling,

numbness, pain along upper forearm and fingers

Loss of power of hand

Subclavian artery compression –excessive sweating of hands, cold and numb hands, pale and blue hands due to cyanosis, pain in forearm worsens on exercise

Diagnosis Adson’s test – positive – weak pulse on

turning neck on same side X Ray Treatment Asymptomatic – no treatment Symptomatic – excision by supraclavicular,

transaxillary approach

CAROTID BODY TUMOURS Carotid bodies – chemoreceptor

organs containing cells situated at bifurcation of CCA contain acetylcholine and catecholamine stimulated by increase pco2, decrease po2, increase H+ (higher altitudes)

Site – carotid triangle at CCA bifurcation Age – mc 5th decade Region – high altitude areas like Tibet,

Peru Etiology – chronic hyperplasia in high

altitude areas -> carotid body hyperplasia

Familial – 10% autosomal dominant

C/F Painless slow growing swelling of many

years duration in carotid triangle Pulastile Compressible – size decreases with carotid

compression and increases on release of pressure

Mobility from side to side and not up and down

Bruit, thrill + Can extend to parapharyngeal space and

oropharynx pushing the tonsil medially

If large can cause pressure symptoms like dysphagia, change in voice

Pressure on swelling can lead to faintness (carotid body syncope)

Rare regional and distant metastasis Diagnosis Serum catecholamines 24 hrs urine vanellyl mandelic acid CECT MRI with gadolinum MRI angiography/ DSA

Lyre’s sign – widening of angle/ splaying between ICA and ECA on angiography

Avoid FNAC, open biopsy as highly vascular

Treatment Younger age/ no metastasis/ fit –

surgical resection by trans cervical approach

Large tumours – do arterial embolization first to decrease bleeding

Elderly > 50 yrs/ metastasis/ unfit - RT

LYMPHOMA Children and young adults 55% of paediatric ca Hodgkin’s/ non hodgkin’s C/F Painless, mobile, non tender, discrete, rubbery,

progressively enlarging lymph nodes in the neck

Other sites of ln enlargement – axilla, groin and abdomen

Hypertrophy of spleen and liver Hypertrophy of waldeyer’s ring including tonsils Fever

Pressure symptoms like dysphagia, respiratory obstruction

Serous otitis media Diagnosis FNAC Needle biopsy Open biopsy Treatment Early stage – RT Advanced stage – CT, CT+RT.....

PARAPHARYNGEAL TUMOURS Types Pre styloid Mainly salivary gland tumours Pleomorphic adenoma Warthin’s tumour Mucoepidermoid ca Site – deep lobe of parotid C/F – mass or bulge on tonsillar fossa, soft

palate, lateral pharyngeal wall Displace the above structures mediallty Painless swelling

Post styloid Neurogenic tumours Schwannomas/ neurilemmomas Neurofibroma Paraganglioma Malignant schwannoma C/F Firm neck mass showing bulge in lateral

pharyngeal wall Can displace the lateral pharyngeal wall

medially

Pressure symptoms of hoarseness of voice, dysphagia, trismus

Painless Nasal obstruction and aural fullness Diagnosis CT/MRI DSA Rigid endoscopy 24 hrs VMA FNAC

Treatment Surgical resection Lower neck – trans cervical approach Upper neck – trans cervical trans

mandibular approach Parotid – cervico parotid approach

STERNOMASTOID TUMOUR Congenital torticolis Age – at birth Etiology Birth trauma – venous obstruction or

haematoma formation during..... Labour..... Leads to infarction of central portion of SCM which leads to fibrosis

Fibrosis causes contraction or shortening of SCM

Swelling in the SCM

C/F Circumscribed firm mass palpable in

middle 1/3rd of SCM Torticolis – face turned to opposite side,

head fixed on shoulder on same side Asymmetry of head and face Treatment Conservative – regular active and

passive neck movements to avoid contraction

Surgery – division of SCM at its lower end

METASTATIC LYMPH NODES Age - > 50 yrs M>F Can be occult primary – unknown primary Painless hard swelling non tender fixed to

skin or deeper structures Sites for primary tumour Tongue base – vallecula, pyriform sinus,

tonsil, RMT, nasopharynx – fossa of rosenmuller

For supraclavicular ln – primasry can be lungs, breasts, colon, kidney, ovary, testis, abdomen

Diagnosis Complete examination of digestive tract,

tracheo bronchial tree, breasts, thyroid, genito urinary tract

Pan endoscopy Imaging – X Rays, USG neck and abdomen,

CT, MRI....., PET scan FNAC If FNAC shows malignancy biopsy Biopsy Punch biopsy of hidden areas Excision biopsy of tonsils

Treatment Depends on primary site Occult primary – RND Post op RT to nasopharynx, I/L tonsil, C/L

neck....., base of tongue Need to do regular follow up

NECK DISSECTION Defination – en block removal of lymph

nodes, other lymph bearing and non lymphatic structures including surrounding fibrofatty tissue from various compartments of neck to eradicate metastatic cervical lymph nodes

Types RND Radical Neck Dissection Removal of structures related to

malignancy from mandible to clavicle, midline to trapezius

Indications Unknown primary Nodes fixed to underlying structures Contraindications Unresectable tumours Distant metastasis Life expectance < 3 months Major systemic illness Neck nodes fixed to branchial plexus,

cervical plexus, trachea

Incisions Mac Fee Crile’s Schobinger Hockey stick Structures removed LN I – V along with its fibrofatty tissue Muscles – SCM, Omohyoid IJV, EJV XI CN Glands – submandibular, tail of parotid

Structures preserved LN VI, VII, post auricular, sub occipital X, XII CN CCA, ICA, ECA Branchial plexus, phrenic nerve, mandibular

branch of facial nerve, lingual nerve, cervical sympathetic chain

Parotid except tip Complications Haemorrhage, airway obstruction, air

embolism, chylous fistula, wound infection, injury to nerves – X, XI, XII

MRND Modified Radical Neck Dissection Preservation of one or more of following

non lymphatic structures in RND – XI CN, IJV, SCM

Types I – Preservation of XI CN II – Preservation of IJV and XI CN III – Preservation of IJV, XI CN and SCM.

Also known as functional neck dissection

Extended Neck Dissection/ Selective Neck Dissection/ Staging Neck Dissection

Preservation of all three non lymphatic structures – XI CN, IJV, SCM along with one or more levels of cervical ln

Types Supra omohyoid Removal of level I, II, III Ca oral cavity, oropharynx with N0 Neck Lateral Removal of level II, III, IV Ca larynx, pharynx, cervical oesophagus with N0

Neck

Posterolateral Removal of level II, III, IV, V along with sub

occipital and posterior auricular ln Ca larynx, cervical oesophagus with N0 Neck Anterior Removal of level VI Papillary thyroid ca, ca trachea with N0 Neck..... Superior Mediastinal Removal of level VII Ca upper oesophagus, post cricoid When one or two levels of lymph nodes

are removed – Limited Neck Dissection

Extended Neck Dissection Indications Disease extension superiorly to skull base and

inferiorly to mediastinum RND along with removal of following as

needed – Retropharyngeal ln, parotid ln, level VI, VII XII CN ECA Parotid gland Mastoid tip Levator Scapulae muscle

NECK SPACE INFECTIONSPERITONSILLAR ABSCESS (QUINSY) Collection of pus in peritonsillar space (b/w

capsule of tonsil and sup constrictor muscle) Etiololgy Micro organisms – strept pyogenes, staph

aureus, anaerobes, pneumococci Age 20-40 yrs M>F Infection of weber’s glands (minor salivary

glands in soft palate near sup pole of tonsil) Recurrent attacks of acute tonsillitis Tonsillolith

FB tonsil Penetrating injury Dental infection Infectious mononucleosis Pathology Infection of crypts (crypta magna) ->

obstruction -> intratonsillar abscess -> peritonsillitis (acute inflammation with cellulitis) -> abscess

C/F U/L

Severe sore throat I/L referred otalgia Odynophagia Drooling of saliva – cant swallow saliva Muffled and thick hot potato voice Halitosis – foul breath due to sepsis Trismus – due to spasm of pterygoid muscles Fever high grade, chills, rigors, general

malaise, body pain, headache, nausea Torticolis – neck turned towards side of

abscess

Oedema and swelling ant and sup to tonsil Ant pillar and soft palate congested Tonsil enlarged and covered by oedematous

swelling, tonsil pushed medially and downwards

Uvula swollen and pushed to opposite side Enlarged and tender JD ln Diagnosis Throat swab for c/s CBC RBS CT/MRI

Complications Airway obstruction Laryngeal oedema Septicaemia Aspiration of pus due to spontaneous rupture

leading to pneumonia and lung abscess Jugular vein thrombosis Carotid rupture Treatment Medical surgical

Medical Hospitalization IV fluids IV antibiotics – 3rd gen cephalosporins,

clindamycin, pencillin, metronidazole Steroids Analgesics and antipyretics Oral hygiene – H2O2 gargles, saline mouth

wash Surgical Wide bore needle aspiration – small abscess

I&D of abscess Throat spray or infiltration with Xylocaine Use of peritonsillar knife or guarded knife

with only 1 cm of knife exposed to prevent deeper penetration

Give a stab incision at the point of maximum bulge above the upper pole of tonsil or at the junction of base of uvula and ant pillar where they meet (imaginary line)

Use a sinus or artery forceps to open and drain the abscess

Drain any recurrence next day

Interval tonsillectomy After 4-6 weeks Hot (abscess) tonsillectomy Done during acute abscess stage only,

after draining the abscess under same sitting

Complications – rupture of abscess, bleeding, dissemination of infection, thromboembolism

LUDWIG’S ANGINA Spreading cellulitis (mainly B/L) involving

submandibular, submental and sublingual spaces

Myelohyoid divides the submandibular space into lower submaxillary and upper sublingual space

Etiology Age 20-50 yrs Organisms – streptococci, staphylococci, H

influenzae, E coli, pseudomonas MC – dental infections, lower premolar and

molar

Dental extraction Tonsillar infection Fracture mandible Injury to oral mucosa – tongue, floor of

mouth Submandibular sialadenitis Post radiotherapy osteoradionecrosis of

mandible ONLY LOCAL SPREAD NO LYMPHATIC

SPREAD

C/F Marked progressively painful odynophagia Trismus Tongue pushed upwards and backwards Swollen tender woody hard swelling in

submandibular and submental region Marked rapidly increasing cellulitis Drooling of saliva Diagnosis Clinical features, increased leucocyte count X Ray/ CT/ MRI

Complications Spread to retropharyngeal space,

parapharyngeal space and mediastinum Airway obstruction due to laryngeal

oedema, tongue push up, swelling Septicaemia Tongue necrosis Aspiration leading to pneumonia and lung

abscess Treatment Medical – antibiotics, fluids, analgesics

Surgical Tracheostomy if airway compromised I&D of abscess Intra oral – if localised to sublingual space External/cervical – if involves

submandibular region Steps Transverse incision between angles of

mandible two finger breaths below margin of mandible

Vertical incision in midline

Serous fluid drained Incision not closed. Antibiotic soaked

ribbon gauze placed and dressing done daily

Wound allowed to heal by secondary intention

Extraction of infected teeth

RETROPHARYNGEAL ABSCESS ACUTE R P ABSCESS Etiology Age Mc children < 3-4 yrs Boys Adults Suppuration of RP ln due to infections of

adenoids, nasopharynx, PNS, nasal cavity and tonsils

Petrositis due to acute mastoiditis Penetrating injury to post pharyngeal wall due

to trauma or iatrogenic

FB impaction at cricopharynx and upper oesophagus

Organisms – streptococci, staphylococci C/F Dysphagia and odynophagia Airway obstruction leading to stridor/stertor Croupy cough Torticolis – stiff rigid neck Hot potato voice Rapidly increasing sore throat Drooling of saliva

Fever, malaise Lymphadenopathy U/L bulge in post pharyngeal wall, cant

cross midline due to median raphe Diagnosis X Ray soft tissue neck lateral view Air shadow in prevertebral space/

widening of prevertebral space (normal width 3.5 mm, > 50% width)/ presence of gas

CT Scan/ MRI

Complications Spread to mediastinum and danger space

(most dangerous) Septicaemia Meningitis Airway obstruction Treatment Hospitalization IV antibiotics IV fluids steroids

Tracheostomy – if stridor I&D of abscess Intra oral No GA – chance of rupture Position – supine with head low/ rose

position Vertical incision at most fluctuant area

on lat part of post pharyngeal wall Do suction to prevent aspiration

CHRONIC R P ABSCESS PRE VERTEBRAL SPACE ABSCESS Etiology Adults TB cervical spine and prevertebral space Types TB retropharyngeal ln Seen in children aged 8-10 yrs Lateral type/ U/L Cant cross midline TB cervical spine/ caries of cervical spine Any age, infection in prevertebral space Can cross midline B/L/ midline swelling

C/F Slow in onset/ insidious Less severe symptoms Dysphagia Throat discomfort Fluctuant swelling in midline or lateral Non tender enlarged JD ln Painless lump in throat Dyspnoea Chronic cough, evening rise of temp, night

sweats, loss of appetite, loss of weight

Diagnosis X Ray cervical spine Caries Loss of normal curvature/ straightening of

cervical spine Bony destruction of vertebra X Ray Neck – prevertebral widening X Ray Chest – TB, mediastinitis CT/MRI FNAC Mantoux test

Complications Can extend to danger space, mediatinum and

parapharyngeal space Airway obstruction and laryngeal oedema Pus can extend to coccyx Spontaneous rupture leading to pneumonia,

lung abscess Septicaemia Treatment ATT IV fluids Tracheostomy

I&D of abscess Transcervical approach Vertical incision at anterior or posterior

border of SCM Orthopaedics treatment for caries spine

PARAPHARYNGEAL ABSCESS PHARYNGO MAXILLARY ABSCESS/ LATERAL

PHARYNGEAL ABSCESS Etiology Any age but common in young adults Organisms – staphylococci, streptococci,

bacteroides, E coli Infection from peritonsillar space (mc),

retropharyngeal space, parotid space Tonsillitis, adenoiditis, pharyngitis,sialadenitis Dental infections – last molar, infected cysts, fistulas CSOM/ASOM – bezold’s abscess Penetrating injuries to neck Iatrogenic – during procedures, inj

C/F High fever, odynophagia, sore throat, torticolis Anterior compartment Prolapse of tonsils and tonsillar fossa Trismus due to spasm of pterygoid muscles Swelling at angle of mandible Odynophagia and dysphagia Bulging of tonsil, soft palate Posterior compartment Pharyngeal bulging behind posterior pillar Swelling in parotid region

CN palsy – IX, X, XI, XII CN I/L palsy of palate, larynx, tongue Horner’s syndrome – involvement of

sympathetic chain – I/L anhidrosis, ptosis, enophthalmos, constricted pupil

Diagnosis CT/ FNAC/ USG/ X Ray Complications Airway obstruction/ laryngeal oedema Thrombophlebitis of jugular vein Carotid artery rupture Mediastinitis/ RP abscess

Pneumonia/ emphysema Meningitis Septicaemia Treatment IV antibiotics – cephalosporins,

aminoglycosides Fluids Analgesics Tracheostomy – if airway obstruction Surgical drainage

I&D of abscess Transcervical approach GA Horizontal incision 2-3 cm below angle

of mandible (level of hyoid) Abscess is aspirated Drain placed for 2-3 days

AVOID TRANS ORAL APPROACH – chance of damage to greater vessels