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 challengeAnatomy of the neckHistory & examinationInvestigations
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 voiceSystemic: Weight loss Night sweating FeverPMH: Surgery, liver disease, smoking etcFamily history: MTC
Examination Local: Solitary/ multiple Solid/ cystic Effect of swallowing/ tongue protrusion Complete exam: head/neck/ oral and upper aero-digestive tractSystemic examination:
Investigations CBC, Serology, TuberculinCXR, U/S, CT scan, MRI, Angio.FNACLaryngoscopy, EndoscopyOpen biopsy
Common Neck SwellingsDivided 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 Swellings2-Acquired Inflammatory: Acute lymphadenitis ( bacterial, viral) Granulamatous- TB, Sarcoidosis Salivary gland infections- viral, bacterialleudvig angina.Traumatic: Hematoma Pseudoaneusysm
Common Neck SwellingsAcquired Non-neoplastic Siallithiasis Goitre AneurysmNeoplasms: Benign- salivary, thyroid, fibroma, carotid body tumoursome 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 cystsAnterior 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 tonsilTuberculous: Upper & middle cervical, discrete or matted, mildly tender, firm to cystic, overlying skin- normal temp., purplish or normal colorPrimary tumors: Ant./post. triangles, smooth, discrete, non-tender, rubbery, not fixedMetastatic: 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 malaiseAntibiotic and treatment of primary source
TB lymphadenitis Human & bovine TB bacillusUpper deep cervical groups commonly affectedPainless, initially firm swelling, later may become soft (cold abscess), matted, discharging sinusEvening temperature, night sweats, weight loss, anorexiaDiagnosis: FNA, aspirate for AFB, culture, PCR, biopsyTreatment: Anti-tuberculous drugs
Primary malignant tumours of lymph nodesHodgkin'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 fixedDiagnosis: Assessment of primary, FNA & biopsyTreatment: 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 youngDehydration results in ascending infection via parotid ductPainful, more on eating/ drinking, tender parotid swelling with fever and malaisePus exuding from duct papillaStaph. aureus, Strep. viridansEarly cases: antibiotics, oral hygieneLate cases: abscess drainage
Calcular disease (Sialothiasis) Painful swelling of submandibular gland during eatingSwelling resolves/ reduces 1-2 hours after mealsEnlarged submandibular gland on bimanual examinationStone in the duct- palpable in the floor of mouthTreatment: 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 siteM=F, 3-5 decadeSlow growing, painless mass/ mild discomfortRisk of malignant change- 1.5% in 5 yearsFNA- most helpfulCT, MRI rarely neededTreatment: 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 glandRapid growthPainfulLymphadenopathyFixity, skin attachmentNerve palsy, paresthesiaNo particular feature of histological subtype
Malignant tumours FNACT, MRIStaging: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 involvedSubmandibular/Sublingual: En-bloc excisionPost-op radiotherapy: High grade, local extension, perineural extensionNeck dissection: High grade mucoepidemoid tumours
Thyroglossal cyst Persistent of part of thyroglossal tractMidline swelling just above thyroid cartilage sometimes towards the left side Moves up on tongue protrusionCyst contains mucoid materialCyst is in intimate relation with hyoid boneSurgical excision (Sistrunks operation)- Excising whole cyst, wedge of hyoid and duct up to the base of tongue
Branchial cyst Remnant of 2nd branchial cleftPainlessSite: Behind the anterior edge of upper 1/3rd of sternomastoid muscle bulging forwardOvoid shape, size 5-10 cm, smooth surfaceCystic (fluctuates)Transillumination: opaqueTender and red if infectedTreatment; Surgical excision
Carotid body tumourchemodectoma Tumour of chemoreceptor tissue in carotid bodyPainless, slow growing Site: Anterior triangle, within carotid bifurcation, at the level of hyoid boneSpherical, non-tender, firm/hard POTATO TUMORPulsatile, moving in horizontal plane only ...Investigation: CT (splaying of carotid vessels), MRI, angiographyNo FNATreatment: Surgical excision
Cystic hygroma Collection of lymphatic sacsCongenitalFrom birth to within few yearsSite: base of the neck in post. triangleSubcutaneousVariable sizeSoft, cystic , brilliantly trans illuminates