DIFFERENTIAL DIAGNOSIS OF NECK SWELLINGS.

ANATOMY OF THE NECK REGION

Anatomists use the term triangles of the neck to describe the divisions created by the major muscles in the region.

The side of the neck presents a somewhat quadrilateral outline, limited, * above, by the lower border of the body of the mandible, and an imaginary line extending from the angle of the mandible to the mastoid process; * below, by the upper border of the clavicle; * in front, by the middle line of the neck; * behind, by the anterior margin of the Trapezius.

This space is subdivided into two large triangles by Sternocleidomastoid, which passes obliquely across the neck, from the sternum and clavicle below, to the mastoid process and occipital bone above

The triangular space in front of this muscle is called the Anterior triangle of the neck; and that behind it, the Posterior triangle of the neck.

Anterior Triangle of Neck

Bounded by anterior border of sternocleidomastoid, lower edge of jaw and the midline

The upper part of the triangle is also known as digastric triangle or submandibular triangle; as it lies above the digastric muscle.The structures deep to the sternocleidomastoid are considered to be inside the anterior triangle.

Posterior triangle Of Neck

Bounded by the posterior border of the sternocleidomastoid, anterior edge of the Trapezius muscle and clavicle

Midline Lumps

Ludwig,s angina Enlarged submental lymph nodes Dermoid cyst Thyroglossal cyst Subhyoid bursitis Pretracheal and prelaryngeal lymph nodes Thymic swelling Enlarged lymph nodes or lipoma in the

suprasternal space of burns Thyroid swelling

Swellings in Anterior Triangle Branchial Cyst Brachial fistula/sinus Parotid tumour Laryngocoele Enlarged submandibular lymph

nodes Submandibular salivary gland

enlargement Plunging ranula

Swellings in Anterior Triangle

Carotid artery aneurysm Cold abcess (Lymph node swelling) Neurofibroma vagus Carotid body tumour-rare Sternomastoid tumour-rare Tumours of the mandible-rare

Swellings in Posterior Triangle

SOLID:* Lymphoma* Lipoma* Cervical Rib* Metastatic Lymph Nodes* Tuberculous Lymph nodes* Pharyngeal Pouch* Pancoast Tumour

Cystic* Lymphangioma (Cystic Hygroma or Hydrocele of the neck)* Haemangioma

- Arterial-Venous-Capillary ( Salmon Patch,

Port Wine StainStrawberry angioma)

Pulsatile

* Subclavian Artery Aneurysm* Vertebral Artery Aneurysm

Symptoms Associated with Neck Lumps

Lump in the neck persisting for more than two weeks, especially if it is not associated with a cold, flu, or other infection.

Cancers of the mouth, throat, voice box (larynx), thyroid, and some lymphomas can appear first as a painless, growing neck lump.

Symptoms Associated with Neck Lumps

Change in the voice including hoarseness that persists for more than two weeks

Growth in the mouth

Swollen tongue

Blood in the saliva or phlegm

  Swallowing problems

MANAGEMENT

Detailed history of the patient.* Systemic illness- general malaise, fever and rigors, contact with people with infectious diseases, loss of appetite, loss of weight, irritation of the skin.

* Head and Neck Symptoms

Diagnosing Neck Masses

Examination of some masses / swelling may allow a physician to determine their cause based on location, size, and consistency.

In other cases, however, additional tests may be required.

EXAMINATION

1) Number of lumps – single/multiple.2) Site of lump – anterior/posterior

triangle.3) Consistency of the lump –

solid/cystic.4) Movement of the lump – with

swallowing/protrusion of tongue.5) Examination of Head, Neck and

Eyes.

MEDICAL HISTORY INCLUDES

Is it a hard lump? Is it a relatively soft, pliable, bag-like

(cystic) mass? Is it a painless bag-like (cystic)

mass? Is the entire neck swollen? Where is the lump located?

Has it been growing bigger? Over how many months?

What other symptoms are present? Is there a rash? Do you have difficulty breathing?

Diagnosing Neck Masses

Changes in the skin – It is important to examine changes in the skin that could indicate basal cell carcinoma, squamous cell cancer, and malignant melanoma.

Persistent Ear Pain or ear pain while swallowing may be a symptom of infection or a growth in the throat.

INVESTIGATIONS

Baseline investigations CBC, LFT, RFT, Serum Electrolytes, Viral Markers.

Blood culture and sensitivity (TB) Chest X-ray (cervical rib, malignancy, bilateral

hilar lymphadenopathy) Mycodot/Mantoux test Virology ( HIV, EBV) Ultrasound (reveals lump consistency) FNAC CT (defines masses)

Radiographic Investigation of the Neck Masses

MRI – Magnetic Resonance Imaging can clearly highlight soft tissue pathologies better than the C.T. Scan.

It uses a magnetic field rather than x-rays (radiation).

Diagnosing Neck Masses

F.N.A.C – Fine Needle Aspiration Biopsy is

Safe

Rapid

Inexpensive

Presurgical planning

Avoids open biopsy

Definitive Treatment

Depends as the case may be……