COMMON NECK SWELLINGS

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COMMONNECK SWELLINGS

• M K ALAM
• ALMAAREFA COLLEGE

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ILOs

• 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.

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Neck Swellings

• Often a diagnostic challenge
• Anatomy of the neck
• History examination
• Investigations

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History

• Local Onset
• Duration
• Pain
• Difficulty in swallowing/
  mastication
• Dyspnea/ nasal
  obstruction
• Change of voice
• Systemic Weight loss
• Night sweating
• Fever
• PMH Surgery, liver disease, smoking etc
• Family history MTC

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Examination

• Local Solitary/ multiple
• Solid/ cystic
• Effect of swallowing/ tongue
  protrusion
• Complete exam head/neck/ oral and
  upper aero-digestive tract
• Systemic examination

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Investigations

• CBC, Serology, Tuberculin
• CXR, U/S, CT scan, MRI, Angio.
• FNAC
• Laryngoscopy, Endoscopy
• Open biopsy

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Common Neck Swellings(Congenital)

• Vascular/ lymphatic malformation- Cystic
  hygroma
• Branchial apparatus abnormality-
  Branchial cyst
• Thyroglossal cyst
• Epidermoid cyst
• Dermoid cyst
• Cervical rib

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Common Neck Swellings(Acquired)

• Inflammatory
• Acute lymphadenitis ( bacterial, viral)
• Granulamatous- TB, Sarcoidosis
• Salivary gland infections- viral,
  bacterial
• Traumatic
• Hematoma
• Pseudoaneusysm

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Common Neck Swellings(Acquired)

• Non-neoplastic
• Siallithiasis
• Goitre
• Aneurysm
• Neoplasms
• Benign- salivary, thyroid,
  fibroma, carotid body tumour
• Malignant- salivary, thyroid,
  lymphoma, sarcoma, secondary deposits

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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

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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,

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Acute lymphadenitis

• Usually follow tonsillitis, throat infection,
  scalp or face infection, dental abscess
• Lymph node enlarged and tender
• Pyrexia, general malaise
• Antibiotic and treatment of primary source

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TB lymphadenitis

• Human bovine TB bacillus
• Upper deep cervical groups commonly affected
• Painless, initially firm swelling, later may
  become soft (cold abscess), matted, discharging
  sinus
• Evening temperature, night sweats, weight loss,
  anorexia
• Diagnosis FNA, aspirate for AFB, culture, PCR,
  biopsy
• Treatment Antituberculous drug

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• Primary malignant tumours of lymph nodes-
• Hodgkins disease,
• lymphosarcoma

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Secondary deposits in lymph nodes

• Primary- nasopharyngeal area, tongue, oral
  cavity, thyroid
• Affected lymph nodes are hard and fixed
• Diagnosis Assessment of primary, FNA and biopsy
• Treatment Block dissection of the neck

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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

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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

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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

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Salivary Glands

• Neoplasms (Benign)
• Pleomorphic adenoma
• Warthins tumour
• Oncocytoma,
• Basal cell adenoma,
• Intraductal papilloma

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Pleomorphic Adenoma

• Most common neoplasm, parotid most common site
• MF, 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

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Salivary 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

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Malignant tumours

• Swelling of the affected gland
• Rapid growth
• Painful
• Lymphadenopathy
• Fixity, skin attachment
• Nerve palsy, paresthesia
• No particular feature of histological subtype

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Malignant 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

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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

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Thyroglossal cyst

• Persistent of part of thyroglossal duct
• Midline swelling just above thyroid cartilage
• Moves up on tongue protrusion
• Cyst contains mucoid material
• Cyst is in intimate relation with hyoid bone
• Surgical excision (Sistrunk operation)- Excising
  whole cyst, wedge of hyoid and duct up to the
  base of tongue

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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

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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, angiography
• No FNA
• Treatment Surgical excision

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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

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THANK YOU!