1. Case scenarios- Neck Swelling
Abdulaziz Alsaigh
FRCS, FACS
Professor of Surgery

2. Case scenario 1
A 60- year old female presented with neck swelling for 4 months, dyspnea and hoarseness of voice for 1 month.
She is in your clinic.
? What to do.

3. History History of neck swelling: How noticed? Often noticed by others
Duration? Acute or chronic
Painful- acute lymphadenitis, thyroiditis, bleeding in goitre, submandibular salivary gland stone
*Painless- chronic lymphadenopathy, goitre, branchial cyst
*Change in size: Rapid increase- infection, bleeding, malignant change. Slow increase in neoplasms
Single or multiple? Multiple- lymph nodes

4. Other symptoms *Voice change ( malignant invasion)
Dysphagia ( pressure on esophagus)
*Dyspnea (pressure on trachea)
Eye symptoms
Throat pain , Oral ulcer ,
Nasal symptoms, Scalp lesion

5. Systemic symptoms
Lymphadenopathy: Fever, night sweating, contact with infectious disease, weight loss, change in appetite, respiratory/ gastrointestinal symptoms. Goitre: Nervousness, tremor, weight loss/ gain, palpitation, preference to cold/ warm weather, muscle fatigue, sweating

6. Systemic inquiry GI – appetite, wt. change, bowel habit (thyroid, LN)
RS- dyspnea on exertion, (retrosternal extension)
CVS- palpitation, ankle swelling
GU- amenorrhea
CNS- nervousness, irritability, insomnia (thyrotoxicosis)
Endocrines- preference to warm or cold weather

7. This patient PMH- Nil significant, no neck radiation
Neck swelling
Painless
Slow increase
Dyspnea
Voice change
PMH- Nil significant, no neck radiation
FH of neck /thyroid malignancies- NAD
Medication/allergies- nil

8. General Examination Appearance- NAD Eye- NAD Hand tremors- NAD
Tachycardia- NAD

9. Local Examination
Inspection- solitary mass, left anterior triangle, moving up on deglutition
Palpation: Left lobe- 3x3 cm hard mass , non-tender.
Rt. Lobe- normal
Multiple ipsilateral LAP,
Trachea shifted to right side
Percussion - NAD
Auscultation- NAD

10. Differential Diagnosis
Clinical: Goitre, Thyroid mass
Functional- ?Hyper, hypo, Normothyroid
? Pathological- Diff. diagnosis
MNG, Thyroiditis, Cyst
Thyroid neoplasms
? Which type

11. Thyroid malignancy Papillary Follicular Hurthle cell
MTC (sporadic / familial
MEN 2 A (Sipple syndrome- MTC, pheo, HPT, lichen planus amyloidosis, Hirschsprung's dis.) MEN2B (MTC, pheo, marfanoid, mucosal neuromas, ganglioneuroma of GIT)
Anaplastic
Lymphoma

12. Differential diagnosis
Papillary carcinoma
Anaplastic carcinoma
MTC
Lymphoma

13. Investigations US FNA- PC (malignant, non-diagnostic, benign) TFT CXRCT
Indirect laryngoscopy: Lt RL nerve palsy
Surgery

14. Inconclusive FNA Non-diagnostic/ cellular – repeat
Repeat FNA- inconclusive
TSH level- normal/high- surgery
TSH low- nuclear scan
Low uptake- surgery,
High uptake- FU or therapy)

15. Thyroidectomy for thyroid nodule (Indications)
Malignant nodule
Progressively enlarging nodule
Pressure symptoms
Suspicious nodule (FNA failed to establish a benign nature)
Thyrotoxic nodule

16. Total thyroidectomy Malignant tumours ? Neck lymph node dissection
RIA (Radio iodine ablation)- large tumour, metastasis, local tumour extension
Complications: Bleeding, hypoparathyroidism, recurrent laryngeal nerve injury

17. Case 2: 12-year old boy presented with a neck swelling

18. Thyroglossal cyst Midline swelling
Moves upwards with protrusion of the tongue
Aetiology- persistence of part of thyroglossal duct
Treatment: Excision with a central wedge of hyoid bone ( tract run either superficial of deep to hyoid)

19. Case 3 A 35-year old female presented with multiple neck swellings for 3 months
?History

20. The patient History of lump: multiple, painless
Systemic inquiry: Fever, loss of weight, night sweat, no cough
Examination: multiple, some discrete, some matted, firm swellings
ENT, chest, abdomen- NAD
Diagnosis / DD : ?
Investigation

21. TB lymphadenitis Painless, initially firm swelling,
later may become soft (cold abscess),
Matted, discharging sinus
Evening fever, night sweats, wt. loss, anorexia
Diagnosis: FNA, aspirate for AFB, culture, PCR, biopsy
Treatment: Anti-tuberculous drugs

22. Case 4 Presented with a painful swelling

23. Parotid abscess 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

24. Case 5 Painless swelling for 1 year

25. Salivary gland neoplasms
BENIGN:
Pleomorphic adenoma
Warthin’s tumour
Oncocytoma,
Basal cell adenoma,
Intraductal papilloma
MALIGNANT:
Mucoepidermoid carcinoma*
Acinic cell carcinoma
Adenoid cystic carcinoma
Basal cell carcinoma
Low grade adenocarcinoma
Mucinous adenocarcinoma
Malignant pleomorphic tumour
Lymphoma

26. 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

27. Thank you!