Neck swellings

other than thyroid

Neck Mass

 Any abnormal enlargement, swelling or growth from the

base of skull to clavicles
 Clinically neck masses can be divided into
-Midline masses
-Lateral masses(according to the triangles)
Structures involved in neck

 Lymph nodes
 Thyroid gland*
 Remnants of congenital structures
 Carotid body and Vagal Body
 Parotid gland
 Parathyroid gland
Examination

 Exposure: Entire neck such that both clavicles are

exposed
 Position: sitting
 Mobility: Does it move with tongue protrusion/swallowing
Investigations

 Fine needle biopsy is indicated for non pulsatile

masses
 If cytology is not definitive then ultrasound core
biopsy maybe indicated if imaging suggests it
 Definitive investigation is MRI
 Patients over 45 years of age, assume a neck lump is
metastatic malignant disease until proven otherwise
SUPERFICIAL Sebaceous cyst
Lipoma
Dermoid cyst
Abscess
LYMPH NODES
DEEP
Anterior triangle Move on swallowing
Thyroid
Thyroglossal cyst
Lymph node
Don’t move on swallowing
Salivary glands
Branchial cyst
Carotid body tumor
Carotid aneurysm
Sternocleidomastoid
tumor
Posterior triangle Cervical rib
Subclavian artery
aneurysm
Pharyngeal pouch
Cystic hygroma
Superficial

 LIPOMA
-slow growing benign tumor of fatty tissue
-soft, lobulated and overlying skin appears normal
-commmon site: midline posteriorly at the level of collar
line
Treatment: surgical excision if symptomatic
case

 7 years old child who has h/o of cough and fever since the
last 3 days presented to you with a tender swelling on the
lateral aspect of her neck
Lymphadenopathy

 Causes of cervical lymphadenopathy

INFECTION
Local lesion in head and neck
URTI
Tonsillitis
Glandular fever
Toxoplasmosis
Tuberculosis
HIV
Cat-scratch disease
• MALIGNANCY
Primary: lymphoma
lymphosarcoma
leukemia
Secondary: almost everywhere in the body e.g. breast,
lung, testis

• SARCOIDOSIS
Acute lymphadenitis

 Enlarged and tender nodes

 May be associated with pyrexia, anorexia and generalized
malaise
 Dental abscess or tonsillitis are common causes
 Management includes treatment of primary focus of
infection
Acute Lymphadenitis
Chronic lymphadenitis

 Long standing and usually painless

 May be secondary to malignancy or tuberculosis
Chronic lymphadenitis

 Affected nodes are usually non tender

 Treatment
Antibiotics and pain killers (if infection is a cause)
 If pain continues or abscess formation occurs in lymph
nodes, parapharyngeal or retropharyngeal space then
surgical drainage is required
 Extensive workup should be done to find the primary
cause of lymph node enlargement
 case

 A previously healthy young man from slums of Rawalpindi

presented with a left neck lump that increased gradually in
size over the past 10 weeks, associated with a low-grade
fever and night sweats (up to 37.9 degrees Celsius) for the
past one month. He also complains of cough with blood in
mucus. One week prior to his medical appointment, a little
pustule developed over the lump which discharged
seropurulent (yellowish) fluid spontaneously.
complications

 Caseated node may liquefy and form a cold abscess in the

neck
 The pus is first restricted by the deep fascia but overtime may
erode and enter the space beneath superficial fascia.
 Process is known as the collar stud abscess.
case

 A 10 year old boy with a 1 month h/o fever which occurs

especially in the evening ,night sweats and a painless
lump in his neck. He doesn’t eat that much now a days &
his mother is worried that he’s gotten a bit skinny
 O/E, there is pallor, generalized lymphadenopathy and
hepatosplenomegaly is present.
Lymphoma
Lymphoma

 Primary malignancies are known as

lymphomas
 Two broad categories
-Hodgkin’s
-Non Hodgkin’s
Investigations and Treatment

 Fine Needle Aspiration Cytology

 Flow Cytometry
 Ultrasound/CT scan

 Chemotherapy and Radiation

case

 45 year old man with a h/o recent tooth

infection shows up with huge, hot, red, tender,
fluctuant mass occupying the left lower side of
face and upper neck including underside of
mouth. Mass pushes up the floor of mouth on
that side. He is febrile
Ludwig’s Angina
Ludwigs angina
Ludwig’s Angina

 Massive swelling on neck, often extends close

to clavicle
 Involvement of sublingual space results in
elevation
posterior enlargement
protrusion of tongue
Treatment

 Broad spectrum IV antibiotics with additional

anaerobic coverage are instituted

 If swelling does not get resolved, a curved

submental incision is used to drain both
submandibular triangles
DEEP SWELLINGS OF ANTERIOR
TRIANGLE
 Thyroglossal duct cyst

 A remnant of diverticulum formed by

migration of thyroid tissue from
foramen cecum at the base of
tongue through hyoid bone to its final
position around the tracheal cartilage
 Failure of subsequent closure and
obliteration of this tract predisposes to
cyst formation.
 Almost always in the midline and is
painful when infected or increases in
size
Thyroglossal duct cyst

 CONSISTENCY:
firm to hard
 MOVEMENT:
Upward by deglutition and protrusion of tongue
 DIAGNOSIS
made clinically
Investigation

 Blood test : blood testing of thyroid function

 Ultrasound: degree of mass and its surrounding tissues
 FNA
Treatment

 If infected: antibiotics+/- needle aspiration followed by

excision after an interval

 SISTRUNK OPERATION
surgical excision of cyst + tract including body of hyoid
bone
Branchial cyst

 Congenital epithelial cyst

 Failure of obliteration of 2nd branchial cleft in embryonic
development
 Swelling arises in the early or middle adulthood
 Found at the junction of the upper and middle third of
sternocleidomastoid
 Lined by squamous epithelium
 Clinical picture

 Slow growing
 Painless
 Soft cystic swelling
 Not translucent
(sometimes the fluid is golden yellow & shimmers with fat globules &
cholesterol crystals secreted by the sebaceous glands in the epithelial lining.
Such cysts transilluminate)
 Does not move on swallowing
 Cannot be reduced or compressed
Branchial Abscess

 When the branchial cyst gets infected

Symptoms
 Pain
 Swelling size can increase
 Occasionally pressure symptoms like difficulty in
swallowing or breathing
Branchial Fistula

 Tract running from neck skin to the posterior pillar of

fauces
 Represents a persistent 2nd branchial cleft
 Lined by ciliated columnar epithelium
 Contains small amounts of mucopurulent discharge
 Swallowing accentuates the opening on the skin
Branchial fistula
Diagnosis & Investigation

 For branchial cyst and abscess

1.Ultrasound (investigation of choice)
CT/MRI for complex cases
2. Fine needle aspiration biopsy:
Cysts: straw colored fluid containing cholesterol crystals
Abscesses: Purulent fluid is obtained that may culture
organisms.
Treatment

 Treated by complete excision

structures to identify to avoid damage:
-hypoglossal nerve
-glossopharyngeal nerve
-spinal accessory nerve
case

 45 year old male presented with hoarseness,dysphagia

and symptoms of Horner syndrome(ptosis, miosis,
anhydrosis etc). On examination there is a palpable neck
mass in anterior triangle of neck. According to the patient
the mass has been there for many years but for the past
few months it has increased in size and now he has
developed all these symptoms. Initially he was
asymptomatic
Chemodectoma (carotid body
tumor)
Chemodectoma (carotid body
tumor)

 Rare
 Develops within the adventitia of medial aspect of
carotid bifurcation.
 Slow growing, remains asymptomatic for many years
 Usually present in the anterior triangle of neck
 Commonly occurs between 40-60 years of age
Carotid Body Tumor
Carotid Body Tumor

 Tumor can enlarge & compresses the carotid artery and

the surrounding nerves
Symptoms
pain, hoarseness, dysphagia, Horner syndrome
Examination

 On examination, the mass is typically vertically fixed

because of its attachment to the bifurcation of the
common carotid (Fontaine sign)
 Bruit maybe present
Investigations

 Carotid angiogram
 MRI
 Tumor should NOT be biopsied
 FNAC is also contraindicated
Treatment

 Tumor is slow growing so the need for surgery should be

considered carefully
 Surgery is best avoided in elderly patients
 If tumor is large and inseparable from vessels, resection is
necessary
 Salivary Gland Swelling

 Acute Infection
-Viral (mumps)
-Bacterial (Staph aureus)
 Duct Obstruction
 Sialectasis (chronic infection)
 Tumor
 Sarcoidosis
 Sjogren’s Syndrome
Parotid gland tumors

 Parotid gland tumors may involve the angle of the

jaw, that is the lower end of the mandible and
thus may appear as neck swellings.
 Two most common examples are Pleomorphic
adenoma and Warthin’s tumor
Pleomorphic adenoma

 Located anterior and superior to the angle of the jaw

 Males are affected more
 Have a mixed histological pattern
 Mass is unilateral
 Mass has a rubbery hard consistency
 Is painless
 Biopsy, MRI,CT Scan done
 No cervical lymph node is enlarged
 Treatment is complete excision with a cuff of normal
tissue.
Warthin’s Tumor (Adenolymphoma)
 Warthin’s Tumor

-slow growing tumor of the parotid gland.

-tumor is firm, non tender, painless and usually appears in the tail of
parotid gland near the angle of mandible.
-painless until super infected

INVESTIGATION
Biopsy
MRI, CT
Sialogram show displacement of glandular
tissue

TREATMENT
Surgical excision
 case

 A normal vaginal delivery was prolonged because the baby had a

large swelling on the neck. The swelling increased in size when the
child cried. On examination, there is a swelling in the subcutaneous
tissue of posterior triangle which transilluminates.
Cystic Hygroma

 Also known as cystic lymphangioma

 Congenital mostly in the posterior triangle of neck
 Benign, but disfiguring
 Cyst like cavities containing lymph
Pathophysiology

 Failure of lymphatics to connect to venous system

 A portion of jugular lymph sac gets sequestered from
lymphatic systems
 These sequestered lymphatics retain their growth potential
 Can penetrate adjacent structures
 Retain their secretions
Clinical picture

 Soft
 Easily compressible
 Brilliant translucence
 Fluctuant
 Cannot be reduced
 Mostly in the posterior neck
INVESTIGATION
-CT scan with contrast
Treatment

 Treatments for removal of cystic hygroma are surgery

or sclerosing agents which include:
 Bleomycin
 Doxycycline
 Ethanol (pure)
 Picibanil (OK-432)
 Sodium tetradecyl sulfate
case

 A 45 year old woman presented with complaints of

lethargy, bone pain, haematuria. She says she’s not
been feeling so well and is depressed for the past few
months. She has occasional episodes of nausea and
vomiting. Labs show an elevated serum calcium and
PTH levels .
 Parathyroid swellings

 Parathyroid adenoma
It is extremely rare to be able to palpate an abnormally enlarged
parathyroid gland
 Very rarely a large carcinoma may be felt, which is in itself a vary
rare condition
 Physical signs noted may relate to functional abnormalities of the
gland itself
 Biochemical test may show raised calcium and parathyroid
hormone levels, radiographs may show changes in bone and
renal calculi.
Hyperparathyroidism

 Stones, bones, abdominal groans and psychic

moans are effects of the resultant hypercalcaemia
that follows the enlargement of the gland.
 Treatment is removal of the gland through a
conventional thyroidectomy incision
Thank You