AP. Dr. ALI MOHSIN ALKHAYAT DGS FICS CABS MRCS FRCS NECK SWELLINGS AP. Dr. ALI MOHSIN ALKHAYAT DGS FICS CABS MRCS FRCS

OBJECTIVES 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 Swellings USUALLY ,,diagnostic challenge Anatomy of the neck History & examination Investigations

Lymph Node Identification Level 1 contains the submental and submandibular nodes. Level 2 is the upper third of the jugular nodes medial to the SCM, and the inferior boundary is the plane of the hyoid bone (clinical) or the bifurcation of the carotid artery (surgical). Level 3 describes the middle jugular nodes and is bounded inferiorly by the plane of the cricoid cartilage (clinical) or the omohyoid (surgical). Level 4 is defined superiorly by the omohyoid muscle and inferiorly by the clavicle. Level 5 contains the posterior cervical triangle nodes. Level 6 includes the paratracheal and pretracheal nodes.

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

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

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

Common Neck Swellings Divided into two groups 1-Congenital Vascular/ lymphatic malformation- Cystic hygroma Branchial apparatus abnormality- Branchial cyst Thyroglossal cyst Epidermoid cyst Dermoid cyst Cervical rib

Common Neck Swellings 2-Acquired Inflammatory: Acute lymphadenitis ( bacterial, viral) Granulamatous- TB, Sarcoidosis Salivary gland infections- viral, bacterial leudvig angina. Traumatic: Hematoma Pseudoaneusysm

Common Neck Swellings Acquired Non-neoplastic Siallithiasis Goitre Aneurysm Neoplasms: Benign- salivary, thyroid, fibroma, carotid body tumour some tumors of the mandible Malignant- salivary, thyroid, lymphoma, sarcoma, secondary deposits

Locations of common neck swellings Mid-line: Dermoid cyst, thyroglossal cyst, ranula and subhyoid bursa and sebaceous cysts Anterior triangle: Thyroid, lymph nodes, branchial cyst, carotid body tumour, submandibular salivary gland enlargement, laryngeocele and pharyngeal pouch(Zenker diverticulum) 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 tumors: Ant./post. triangles, smooth, discrete, non-tender, rubbery, not fixed Metastatic: Discrete, hard, non-tender, tethered,

Acute lymphadenitis Following tonsillitis, throat infection, scalp or face infection, dental abscess Lymph node enlarged and tender !!! Pyrexia, general and malaise Antibiotic and treatment of primary source

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: Anti-tuberculous drugs

Primary malignant tumours of lymph nodes Hodgkin's disease, non hodgkins lymphoma. lymphosarcoma

Secondary deposits in lymph nodes Primary tumour site: Nasopharyngeal area, tongue, oral cavity, thyroid Affected lymph nodes are hard and fixed Diagnosis: Assessment of primary, FNA & biopsy Treatment: Block dissection of the neck

Inflammatory disorders (Salivary) Viral infections (Mumps) usually among children. Usually affects parotid, submandibular occasionally Painful swelling, fever and headache. Resolves in 5-10 days. Treatment- antipyritic.....and supportive lines

Bacterial infections sailadinitis (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

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

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

Malignant tumours FNA CT, MRI Staging:local extension of the tumor locally and distally 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. scarfise the nerve if involved Submandibular/Sublingual: En-bloc excision Post-op radiotherapy: High grade, local extension, perineural extension Neck dissection: High grade mucoepidemoid tumours

Thyroglossal cyst Persistent of part of thyroglossal tract Midline swelling just above thyroid cartilage sometimes towards the left side Moves up on tongue protrusion Cyst contains mucoid material Cyst is in intimate relation with hyoid bone Surgical excision (Sistrunks operation)- Excising whole cyst, 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 chemodectoma 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 POTATO TUMOR Pulsatile, moving in horizontal plane only ... Investigation: CT (splaying of carotid vessels), MRI, angiography No FNA Treatment: 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

THANK YOU any question