APPROACH TO PATIENT WITH NECK SWELLING

2.  TRIANGLES OF
NECK:-
Neck can be divided into
anterior & posterior
triangle by
STERNOCLIDOMASTOID
MUSCLE

7.  In pediatric age group - 90% benign.
 50% out of which may be congenital.
 In adult population – 80% non- thyroid
masses

9.  MID LINE ANTREIOR TRIANGLE POSTERIOR TRIANGLE
 CONGENITAL
 Thyroglossal cyst
 Dermoid cyst
 INFLAMMATORY
 Lymphadenitis
 TUMOUR
 Thyroid
 Lymphoma
 OTHERS
 Sternoclidomastoid
 Hematoma/fibroma
 CONGENITAL
 Brachial cyst
 Thymic cyst
 INFLAMMATORY
 Adenitis
 Sialadenitis
 TUMOUR
 Metastatic
 Lymphoma
 Vascular
CONGENITAL
Lymphangioma
INFLAMMATION
Adenitis
TUMOUR
Lymphoma
Metastaic
Supraclavicular
OTHERS
neuroma

10.  AGE:-
 < 20 yrs
20 – 40 yrs
> 40yrs
congenital
inflammatory
Inflammatory, salivary gland.
lymphoma
metastatic

11.  SEX :-
 Male preponderance- hodgkins lymphoma,
nasopharyngeal carcinoma, thyroid mass in
pediatric age group.
 Female preponderance – Thyroid swelling in
adult age group.

12.  DURATION:-
 Acute
 Chronic
Mode of onset?
 Progressive/non progressive?
 Site?
 Painful/painless?
 Associated systemic symptoms
 Personal habits
 Previous irradiation or surgery


13. SITE OF THE SWELLING:-
-tells about the organ of origin
-certain swellings are site specific
-dermoid cyst
-thyroid swelling

14.  *Size
 *Number :- .
 - solitary ( dermoid cyst & lipoma)
 - multiple ( NFM & hodgkin’s lymphoma)
*Shape:-
 -Spherical
 -irregular

15. *Surface:-
 - smooth ( cystic & benign)
 - irregular.
*Margins:-
 - Well defined
 - diffuse

16. *Colour
* Overlying skin
Special signs :-
- -Pulsation
- - movement with swallowing
- - movement with protusion of tounge

17. PALPATION:-
Temp
tenderness
Site
Size
Surface – smooth , irregular, lobulated
Margins – well defined, ill defined
Extension
Consistency – solid, soft , firm , hard , rubbery.
Mobility
Tense/fluctuation
Transillumination
Pulsation
Relation to surrounding structures
Draining lymph node

18. Fluctuation test
pulsation
Relation to muscle

19. BLOOD:-
CBC, ESR, TFT, CRP,
IMAGING:-
Xray, USG, CT scan, MRI , Radionuclitide scan, PET
Sialography
CYTOLOGY
TISSUE:-
Incisional/excisional biopsy

20. Standard for diagnosis.
Indications:-
- Any neck mass that is not an obvious abscess
- Persistent after 2 wks of antibiotics

22. Inexpensive
easily available
Non invasive
Not associated with radiation
Solid versus cystic masses
Congenital cyst from solid nodes/ Tm.
calcification
Extent & vascularity.
Guided FNAC

23.  Distinguish cystic from solid
 Extent of lesion
 Anatomical relations
 Vascularity with contrast
 Pathological node( lucent, > 1.5 cm, loss of
shape, rim
enhancement)
 Detection of unknown primary

24.  Similar information as CT

 Better soft tissue contrast
 Better for upper neck and skull base

25.  Uses flourine labelled deoxyglucose
 Valuable tool – evaluation of regional LN
 - detect distant metastasis
 - synchronous primary lesion
 - unknown primary

26. Any solid assymetric mass MUST be considered
a metastatic neoplastic lesion until proved
otherwise.
Asymptomatic cervical mass ~ 12% cancer
 80% are SCCS

27.  Asymptomatic neck swelling
 Associated symptoms – otalgia, dysphagia,
voice change, difficult breathing, weight loss,
loss of appetite, bone pain , chest pain.
 Fever & night sweats.
 Ipsilateral otalgia with normal otoscopy-
direct attention to tounge base, tonsil,
supraglottis & hypopharynx.
 U/L serous otitis media- direct attention to
nasopharynx.

28. Directed biopsy- primary is known.
 All suspicious mucosal lesions
 Areas of concern on CT/MRI
FNAC

29. Metastatic neck LAP withou the development of
primary lesion with a subsequent 5 yr period.
Head & neck cancer with unknown primary 3-
7% patients.
Most common – level LN II & III.
Supraclavicular nodal involement – below
clavicle
SCC thyroid, lung, breast, GI tract

30.  High risk nasopharynx, pyriform sinus &
base of tongue & tonsil.
 Full ENT examination.
 Level I – lip , anterior tongue, buccal mucosa.

31. Level II,III,V- tonsil or tounge base
nasopharyngeal examination,
tounge base biopsy from
concerned areas.
 Level IV,V – hypopharynx & larynx
 DL scopy, esophagoscopy, chest
abdomen CT, PET Scan.

32.  PET- CT negative & no primary on
endoscopy.
 -Tonsillectomy
 - tongue base biopsy & biopsies of postnasal
space & pyriform fossa
 -25% found at tonsil
 - clinical examination, panendoscopy, CT and
MRI with biopsy reveal primary in 40% cases.
 - definitive MND in all patients after FNAC
or biopsy.

33. Cystic remnant of the TGD between foramen
caecum of tounge base & thyroid bed in
infrahyoid neck.

34.  70% - congenital neck mass
 65% - between hyoid & thyroid
 50% - hyoid
 20% - suprahyoid
 1-2% - lingual
 1-2% - malignancy

35. A small, round, soft mass in
the midline of neck( 90%)
Infected cyst(5%) – enlarge
neck mass, fever, draining
sinus(15%) & dysphagia.
Moves with protrusion of
tounge.
Pre school age children or mid
adolescence.(5yr)

36.  History & examination
 Investigation -
 FNAC
 USG- location, cystic, normal thyroid.
 CT & MRI – large cyst, suspected malignancy,
lingual thyroid

37.  Surgical excision- T/t of
choice
 Sistrunk’s operation –
 Removal of cyst, the tract
, the central portion
of hyoid bone, as well
as core of tissue including
tissue tract or raphe
between mylohyoid
muscles, portion of
geinoglossus muscle and
up to foramen caecum

38.  4th- 6th week IUL.
 6 paired branchial
arches.
 Persistent cleft-
external sinus.
 Persistent pouch –
internal sinus
 Fistula.
 17% pediatric neck
masses.

39. 5% of brachial cleft anamolies
M = F
Cyst ( adult> children),
fistula/sinus(children>
adult).
Line from tragus to hyoid
bone.
Left predominance.
2 types.

40. Type 1 Type 2

41.  Discharging ear with intact TM.
 Cyst or opening in preauricular area.
 May present as abscess.
 HISTOPATHOLOGY:-
 Lined by stratified squamous epithelium.
 Cyst may have lymphoid tissue with germinal
centers.

42. INVESTIGATION:-
Imaging usually not required.
Sinogram – extent & confirm the position of
upper end.
TREATMENT:-
Surgical excision.

43. Most common.
95% of the anomalies.
M =F
3RD n 4th decade
15% < 10yrs
Left predominance
Cysts> sinus/fistula

45.  Cysts > sinus/fistula
 Cyst- smooth , soft mass in the lateral neck &
located anterior and deep to SCM.
 Fistula/sinus- congenital opening on the
lower neck , ant to SCM.
 Recurrent neck infection
 Can present as pain , dyspnoea & dysphagia.

46. INVESTIGATION :-
 FNAC – epithelial elements & cholesterol
crystals.
 Radiological usually not required.
 Contrast sinogram to define track.
 USG.

47. Complete surgical excision.
Stepladder technique for sinus & fistula.
Delay until 2-3yrs of age.
Intraoral approach for isolated pharyngeal cysts.

48.  Rarely seen
 2 – 8 % all anomalies
 Left predominance.

51. Cutaneous opening along anterior border of
SCM
Neck abscess, retropharyngeal abscess or
hypoglossal nerve palsy

52. INVESTIGATION:-
As for 2nd arch anomaly
Laryngoscopy-opening in pyriform sinus
TREATMENT:-
Surgical excision.

53.  Lymphangiomas & hemangiomas
 Usually 1st yr of life.
 Hemangiomas often resolve spontaneously,
while lymphangiomas unchanged.

54.  75% head & neck region
 Left predliction
 Posterior triangle of neck
 50- 65% at birth, 80- 90% by 2 yrs age.
 Karyotypic abnormality in 25-70% children.
 Macrocystic – cystic hygroma.
 Microcystic.

55. Location:-
 Microcystic- oral cavity as clusters of clear,
red or balck vesicles.
 Cystic hygroma – soft, painless , compressible
mass.
 Typically transilluminates.
 Airway compromise.

56.  INVESTIGATION:-
 FNAC- little or no value.
 Plain xray
 USG – cystic nature, relationship to
surrounding structures & differentiate btw
micro and macrocystic.
 CT & MRI.

57. Medical T/t :-
 Sclerosant agent- bleomycin, pure
ethanol,doxycycline, sodium tetradecyl
sulfate & OK -432( inactive group a
streptococcus pyogene).
Surgical excision- mainstay of T/t.
Laser- microcystic lesion.

58. 20% in neck.
28% all midline cyst
M = F
TYPES:- Epidermoid cyst
true dermoid cyst
teratoid cysts
ETIOLOGY:- ectodermal differentiation of
mulitpotent cells trapped along the lines of
tissue fusion.

59.  2ND & 3RD decade.
 Cystic or solid painless mass .
 Submental region , above or below
mylohyoid muscle.
 Inflammatory swelling.

60.  INVESTIGATION:-
 Clinical diagnosis
 FNAC
 TREATMENT:-
 Complete surgical excision.

61.  Lymphadenopathy:-
 Most common clinical problem in children.
 38-45%
 90% are benign in children
 Cervical lymph nodes- infectious pathology.
 reactive.
 infection(most common)
 proliferation – lymphomas
 Infiltration- metastatic
 metabolic

62.  Newborn – any palpable mass
 Children – cervical LN size 2cm, axillary 1cm &
inguinal 1.5 cm is normal.
 Symptoms of URI.
 Fever, irritability, anorexia
 Poor dental health
 Contacts with animals
 Tender lymph node
 GRANULOMATOUS :- weeks to months
 Minimal systemic c/o
 Firm realtivly fixed node

63. empirical antibiotics for 2 weeks
Blood investigations – CBC, ESR, CRP
Serology
Chest xray
FNAC - no response
Progressively enlarging
Solitary & assymetric node
Supraclavicular mass
Firm, rubbery consistency
biopsy

64.  Expectant - <3cm , non tender, no skin
changes & present for 2 wks or less.
 Antimicrobial therapy- > 2-3 cm, overlying
erythema & tender.
 ATT
 Chemotherapy & radiotherapy.

65. LUDWIG’S ANGINA:-
 Rapidly progressive
cellulitis of soft tissue
of neck & floor of
mouth.
 Submandibular space –
sublingual

Submaxillary space
 Dental infection – 80%
cases
 Aerobes & anaerobes

66. 95% cases have B/L submandibular swelling.
Brawny and tense with overlying erythema.
Neck pain, dysphagia, respiratory distress.
Elevated or protuded tounge.
Complications:-
airway obstruction
Retropharyngeal & parapharyngeal infection
Septicemia
Aspiration pneumonia

67.  Systemic antibiotics
 Incision & drainage :- intraoral
 external
 Tracheostomy

68. Base of skull to
bifurcation of
trachea.
Retropharyngeal lymph
nodes.
Parapharyngeal space
communicates.

69.  Common in children <3 yrs
 Suppuration of retropharyngeal LN – infection of
adenoid, nasopharynx, PNS or nasal cavity.
 Adults- injury to PPW, cevical esophagus.
 Clinical features:-
 -Dysphagia
 - Difficult breathing
 - Stridor
 -Torticollis
 - Bulge in PPW

70.  INVESTIGATIONS:-
 Xray STN – lateral view
 TREATMENT:-
 Systemic antibiotics
 Incision & drainage
 Tracheostomy

72.  Infection :- pharynx( tonsil, adenoid,
peritonsillar abscess)
 Teeth(lower last molar)
 Ear( bezold abscess)
 Parotid, retropharyngeal & submaxillary
 External trauma

73. anterior compartment- triad( prolapse of tonsil &
tonsilar fossa, trismus & external swelling behind the
angle of jaw)
Odynophagia
Posterior compartment – bulge of pharynx, palsy of CN
9,10,11,12& sympathetic chain and swelling of parotid
area.
Complications:-
Respiratory obstruction
Septicimea
Retropharyngeal space infection
Mediastinum infection
Mycotic aneurysm of carotid

74. Systemic antibiotics
Drainage of abscess
tacheostomy

75. THYROID MASS :-
Leading cause of anterior neck masses.
CHILDREN- most common neoplastic condition
Male predominance
Higher incidence of malignancy
ADULTS –
Female predominance
Mainly benign

76. Goitre
Thyroid nodule
Cancer benign
Thyroid nodule
MNG
Simple cyst
Follicular adenoma
Hashimotos
thyroiditis
Malignant
Papillary Ca
Follicular Ca
Hurthel ce ll Ca
Medullary Ca
Anaplastic CA

77.  Thyroid mass
Associated symptoms of hyper/hypothyroidism
Associate compressive symptoms
Features suggestive of increase risk of malignancy:-
h/o irradiation
Family h/o MCT or men2
<20YRS > 70YRS
Male
Growing nodule
Firm & hard
Fixed
Cx adenopathy
Persistent hoarsness, dysphagia, dysphagia.

78.  TFT
 FNAC
 USG
 TREATMENT:- etiology

79.  Most common in children & young adult.
 Male predominance
 Hodgkin’s lymphoma & non- hogkin’s
lymphoma.
 80% children with hodgkin’s have neck mass.

80.  Lateral neck mass only – discrete , rubbery &
non tender
 Fever, night sweats & weight loss
 Hepatosplenomegaly
 Diffuse lymphadenopathy.

81. FNAC- first line diagnostic test.
If suggestive of lymphoma – open
biopsy.
Full work up- CT scan chest,
abdomen pelvis, head & neck &
bone marrow biopsy
PET scan

82.  Age
 Disease stage
 Potential T/t sequeale
 Chenotherapy- chemosensitive.(NHL)
 Radiotherapy- limited role (NHL)
 Advanced stage – combined
chemoradiotherapy.

83.  Arise from neural crest derivative
 Include schwannoma, neurofibroma,&
malignant pheripheral cell Tm.
 Increase incidence in NF syndrome
 Schwannoma most common in head & neck
region.

84.  Mostly sporadic cases
 25 – 45% neck when extracranial
 20 – 50yrs
 Benign < 1% malignant
 Signs & symptoms :-
Medial tonsillar enlargement
Hoarseness( vagus)
Horners syndrome

85.  INVESTIGATION:-
 Diagnosis- biopsy
 CT Scan & MRI
 TREATMENT :- surgical removal,
chemotherapy or radiotherapy.

86. Swelling :- reactive lesion
Infectious sialadenitis
Benign neoplasm
Malignant neoplasm
Rare lesion
Symptoms:- limited & non specific – swelling,
pain, xerostomia, foul taste & excessive
salivation.

87.  Signs :-
 Swelling of the gland
 Mucosal dryness
 Intraoral examination
 Facial nerve function.
INVESTIGATION :-
FNAC
Plain Xray ( occlusal view)
Sialography
sialendoscopy
USG
CT , MRI

88.  Acute infection – antibiotic .
 Stones-sumbandibular glad duct excision.
 - lithotrpsy
 Tumour- gland excision.

89.  Dealing with a mass in the neck may seem
daunting, but a systemic approach is all that is
needed.