1. M K ALAM ALMAAREFA COLLEGE
COMMON NECK SWELLINGS
M K ALAM
ALMAAREFA COLLEGE

2. 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.

3. Neck Swellings Often a diagnostic challenge Anatomy of the neck
History & examination
Investigations

6. 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

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

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

9. Common Neck Swellings Congenital
Vascular/ lymphatic malformation- Cystic hygroma
Branchial apparatus abnormality- Branchial cyst
Thyroglossal cyst
Epidermoid cyst
Dermoid cyst
Cervical rib

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

11. Common Neck Swellings Acquired
Non-neoplastic
Siallithiasis
Goitre
Aneurysm
Neoplasms:
Benign- salivary, thyroid, fibroma, carotid body tumour
Malignant- salivary, thyroid, lymphoma, sarcoma, secondary deposits

12. 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

13. 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,

14. 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

15. 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

19. Primary malignant tumours of lymph nodes
Hodgkin's disease,
lymphosarcoma

22. 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

25. 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

26. 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

28. 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

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

31. 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

35. 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

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

37. 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

38. 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

39. 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

41. 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

44. 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

46. 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

50. THANK YOU!