1. AP. Dr. ALI MOHSIN ALKHAYAT DGS FICS CABS MRCS FRCS
NECK SWELLINGS
AP. Dr. ALI MOHSIN ALKHAYAT
DGS FICS CABS MRCS FRCS

2. 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.

3. Neck Swellings USUALLY ,,diagnostic challenge Anatomy of the neck
History & examination
Investigations

5. 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.

7. 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

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

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

10. Common Neck Swellings Divided into two groups 1-Congenital
Vascular/ lymphatic malformation- Cystic hygroma
Branchial apparatus abnormality- Branchial cyst
Thyroglossal cyst
Epidermoid cyst
Dermoid cyst
Cervical rib

11. Common Neck Swellings 2-Acquired
Inflammatory:
Acute lymphadenitis ( bacterial, viral)
Granulamatous- TB, Sarcoidosis
Salivary gland infections- viral, bacterial
leudvig angina.
Traumatic:
Hematoma
Pseudoaneusysm

12. Common Neck Swellings Acquired
Non-neoplastic
Siallithiasis
Goitre
Aneurysm
Neoplasms:
Benign- salivary, thyroid, fibroma, carotid body tumour
some tumors of the mandible
Malignant- salivary, thyroid, lymphoma, sarcoma, secondary deposits

13. Locations of common neck swellings
Mid-line: Dermoid cyst, thyroglossal cyst, ranula and subhyoid bursa and sebaceous cysts
Anterior 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

14. 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 tumors: Ant./post. triangles, smooth, discrete, non-tender, rubbery, not fixed
Metastatic: Discrete, hard, non-tender, tethered,

15. Acute lymphadenitis
Following tonsillitis, throat infection, scalp or face infection, dental abscess
Lymph node enlarged and tender !!!
Pyrexia, general and malaise
Antibiotic and treatment of primary source

16. 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, non hodgkins lymphoma.
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)
usually among children.
Usually affects parotid, submandibular occasionally
Painful swelling, fever and headache.
Resolves in 5-10 days.
Treatment- antipyritic.....and supportive lines

26. Bacterial infections sailadinitis (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

29. ''

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

33. 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

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

35. Malignant tumours FNA CT, MRI
Staging: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

36. Treatment- malignant salivary tumours
Parotid: En-bloc excision.
Preserve facial if not involved.
scarfise the nerve if involved
Submandibular/Sublingual:
En-bloc excision
Post-op radiotherapy:
High grade, local extension,
perineural extension
Neck dissection:
High grade mucoepidemoid tumours

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

39. 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

42. Carotid body tumour chemodectoma
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 POTATO TUMOR
Pulsatile, moving in horizontal plane only ...
Investigation: CT (splaying of carotid vessels), MRI, angiography
No FNA
Treatment: Surgical excision

44. 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

47. THANK
YOU
any question