1. COMMON NECK SWELLINGS M K ALAM ALMAAREFA COLLEGE

2. ILOs   At the end of this presentation students will be able to:   Describe neck triangles and the lymph node distribution.   Name common neck swellings & its location in the triangles.   Outline in brief diseases of salivary glands.   Describe causes & management of lymph adenopathies.   Name the congenital neck swellings & management.   Describe management of carotid body tumor.

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

6. History  Local : Onset- sudden/ gradual Duration- acute/ chronic Duration- acute/ chronic Pain/ painless Pain/ painless Difficulty in swallowing/ mastication Difficulty in swallowing/ mastication Dyspnea/ nasal obstruction Dyspnea/ nasal obstruction Change of voice Change of voice  Systemic : Weight loss Night sweating Night sweating Fever Fever  PMH : Surgery, smoking  Family history : MTC

7. Examination  Local: Solitary/ multiple Solid/ cystic Solid/ cystic Effect of swallowing / tongue protrusion Effect of swallowing / tongue protrusion Complete exam: head/neck/ oral & upper aero-digestive tract. Complete exam: head/neck/ oral & 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  Acquired Infections Infections Trauma Trauma Non-neoplastic Non-neoplastic Neoplasms Neoplasms  Location Anterior triangle Anterior triangle Posterior triangle Posterior triangle

10. Congenital Neck Swellings  Lymphatic malformation- Cystic hygroma  Branchial apparatus abnormality- Branchial cyst  Thyroglossal cyst  Epidermoid cyst  Dermoid cyst  Cervical rib

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

12. Acquired Neck Swellings  Non-neoplastic Sialolithiasis Sialolithiasis Goitre Goitre Aneurysm Aneurysm  Neoplasms: Benign- salivary gland tumours, thyroid tumours, carotid body tumour Benign- salivary gland tumours, thyroid tumours, carotid body tumour Malignant- salivary, thyroid, lymphoma, sarcoma, secondary deposits Malignant- salivary, thyroid, lymphoma, sarcoma, secondary deposits

13. 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

15. 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,

16. 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

17. 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

20. Primary malignant tumours of lymph nodes:  Hodgkin’s disease,  Lymphosarcoma

23. Secondary deposits in lymph nodes  Primary- nasopharyngeal area, tongue, oral cavity, thyroid  Lymph nodes are hard and fixed  Diagnosis: Assessment of primary, FNA & biopsy  Treatment: Block dissection of the neck

25. Salivary gland swellings- Inflammatory disorders Viral infections (Mumps) Common among children. Usually affects parotid, submandibular occasionally Painful swelling, fever and headache. Resolves in 5-10 days. Treatment- symptomatic

26. Salivary Gland swellings- Bacterial infections Common in elderly, also seen in fit and young 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. Salivary gland swellings- Calcular disease (Sialolithiasis) 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 Neoplasm Benign: Pleomorphic adenoma Warthin’s 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

34. Salivary glands Neoplasm Malignant: Mucoepidermoid carcinoma* Acinic cell carcinoma Adenoid cystic carcinoma Basal cell carcinoma Low grade adenocarcinoma Mucinous adenocarcinoma Malignant pleomorphic tumour Lymphoma Secondary deposits

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

37. Malignant salivary gland 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 Persistent of part of thyroglossal duct Midline swelling just above thyroid cartilage Midline swelling just above thyroid cartilage Moves up on tongue protrusion Moves up on tongue protrusion Cyst contains mucoid material Cyst contains mucoid material Cyst is in intimate relation with hyoid bone 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 Surgical excision (Sistrunk operation)- Excising whole cyst, wedge of hyoid and duct up to the base of tongue

41. Branchial cyst Remnant of 2 nd branchial cleft Painless Site: Behind the anterior edge of upper 1/3 rd 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 Investigation: CT (splaying of carotid vessels), MRI, Angiography No FNA No FNA Treatment: Surgical excision 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