Neck swellings
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Transcript of Neck swellings
NECK SWELLINGSDr Manpreet Singh Nanda
Associate Professor ENTMMMC&H Solan
CLASSIFICATION BENIGN – CHILD 80 ADULT 20 MALIGNANT – CHILD 20 ADULT 80 MIDLINE Thyroglossal cyst, dermoid cyst LATERAL Ranula (submental/submandibular) Branchial cyst (carotid) Cystic hygroma, TB lymphadenitis,
Cervical rib (posterior)
THYROGLOSSAL CYST Cystic swelling in the remnant of
thyroglossal tract from foramen caecum to thyroid isthmus
Age – younger children (MC), but can occur at any age
Midline swelling (90%) Site – infra hyoid (mc..... 85%), other –
supra hyoid, lower neck, base of tongue Tract passes through, behind or front of
hyoid bone
C/F Painless, rounded (2-4 cm), soft swelling,
moves with deglutition, protrusion of tongue and sideways
URTI – infected – fever, painful and tender, sudden increase in size, ruptures to form thyroglossal fistula
Thyroglossal fistula- mucoid, watery or milky discharge. If infected becomes purulent
Hood’s sign – skin above fistula opening pulled upwards
Pathology – clear fluid Diagnosis USG Thyroid scan – diff from lingual thyroid Fistulogram Prognosis – can lead to papillary ca,
hurthle cell ca Treatment – Sistrunk’s operation –
surgical excision of cyst along with its tract and middle portion of hyoid bone
Only cyst removal - recurrence
BRANCHIAL CYST, SINUS, FISTULA Etiology – abnormal development of
branchial apparatus Age – late childhood/ early adulthood, 20-25
yrs, appears late though congenital as fluid within it takes time to accumulate
C/F Painless, oval/rounded swelling, soft, non
transilluminated, non compressible Becomes painful and tender if infected after
URTI Site – anterior triangle ( carotid) Pathology – cholesterol crystals
Types 2nd branchial cleft cyst (mc) Deep to and along ant border of SCM If infected – sinus Tract b/w 2nd arch structures (ECA, post
digastric, SCM) and 3rd arch structures (ICA) If fistula – 2 openings, external along ant
border of SCM at lower 1/3rd , internal – perforates pharyngeal wall and opens in tonsillar fossa (ant border of post pillar behind the tonsil)
3rd branchial cleft cyst Uncommon, deep to both ECA and ICA,
sup to hypoglossal nerve and vagus nerve
Opens into pyriform fossa 1st branchial cleft cyst Less common Along ant border of mandible, angle of
mandible, below ear lobe Opens into EAC
Diagnosis USG FNAC – cholesterol crystals, lymphoid
tissue Contrast X Ray (Fistulogram) Treatment Surgical excision along with its tract
LYMPHANGIOMA CYSTIC HYGROMA Etiology Congenital cystic lesion due to
incomplete development, obstruction or sequestration of normal lymphatic system ( jugular lymphatic sac)
Associated with chromosomal anomaly Age - < 2 yrs (90%), can be present at
birth Site – lower part of posterior triangle
(mc), base of tongue, cheeks, supraglottis
C/F Painless, slow growing, fluctuant, soft
swelling, with indiscrete margins, partially reducible, varies in size, transilluminated, increase in size on coughing or crying
If infected – painful and increase in size Pathology – contains multiple loculi of
clear lymph
Complications Stridor – if involve larynx, pharynx Respiratory difficulty Feeding problem Difficult labour Diagnosis Antenatal USG CT, MRI
Treatment Tracheostomy if stridor Complete excision Sclerotherapy - Injection sclerosing
agents like absolute alcohol, bleomycin, TCA
DERMOID CYST Head and neck – 7% of dermoid cyst MC site – floor of mouth post or lateral to
frenulum, midline (submental) C/F Slow growing, painless cystic swelling,
non transilluminated, can lead to difficulty in swallowing, speech and respiration
Children and young adults, 10-15 yrs Pathology – contains epidermoid
appendages like hair, hair follicles, sweat glands, sebaceous glands
Types Sublingual – MC Floor of mouth, above myelohyoid Cervical At submental triangle, below
myelohyoid, double chin appearance Diagnosis – USG Neck D/D – sebaceous cyst – skin mobile in
dermoid cyst over swelling Treatment – complete surgical excision
RANULA Etiology Mucous retention cyst of sublingual
salivary glands due to obstruction of their secretory ducts
Types Intra oral Cystic translucent bluish mass in lateral
part of floor of mouth, pushes tongue up Plunging ranula – neck swelling in
submental/ submandibular region, painless, transilluminated
Complications Difficulty in swallowing Difficulty in chewing Difficulty in speaking Treatment Excision along with sublingual gland Marsupialization if large (as thin walled so
grows into various structures If ruptures – recurrence Plunging ranula – trans cervical approach
ACUTE CERVICAL LYMPHADENITIS U/L MC – young children (1-8 yrs) Etiology – due to focus of infection in
tonsils, adenoids, dental, oral cavity JD lymph nodes C/F – fever, malaise, ln enlarged and
tender Diagnosis – WBC count, USG Treatment – antibiotic therapy, surgical
drainage of abscess
TUBERCULAR CERVICAL LYMPHADENITIS Chronic infection of lymph nodes due to
Mycobacterium tuberculosis Route of infection – I/L tonsil, secondary to
pulmonary TB, hematogenous C/F Painless, unilateral, gradual increase in size
most common seen in posterior triangle Evening rise of temp, night sweats, weight
loss Stages Adenitis – enlarged ln Periadenitis – matted ln (2-3 ln)
Cold abscess – central caseation within ln Collar stud abscess (dumb bell shaped) –
rupture of cold abscess, pus enters sup fascia below the skin
Discharging sinus – pus ruptures through skin
Diagnosis Mantoux test/ tuberculin skin test –
positive (> 10 mm) USG – matted ln with central necrosis Chest X Ray PA view – pulmonary TB
FNAC – granulomas, acid fast bacilli Excision biopsy C/S CBC Treatment ATT Complete excision along with surrounding
fibrous capsule – if residual ln after ATT If active pulmonary TB – excision not
done
NON TUBERCULAR MYCOBACTERIUM LYMPHADENITIS M avium complex (avium and
intercellulare) M fortuitum M kansassi M scrofulaceum Age – children < 6 yrs Site – pre auricular, submental, upper
jugular Diagnosis – tuberculin test positive (10-
15 mm) Treatment – coplete surgical excision
CERVICAL RIB Extra rib arising from C7 vertebra attached
to 1st rib Right side mc but can be left side or bilateral C/F Bony hard lump in supra clavicular region Compression of branchial plexus and
subclavian artery Branchial plexus compression – tingling,
numbness, pain along upper forearm and fingers
Loss of power of hand
Subclavian artery compression –excessive sweating of hands, cold and numb hands, pale and blue hands due to cyanosis, pain in forearm worsens on exercise
Diagnosis Adson’s test – positive – weak pulse on
turning neck on same side X Ray Treatment Asymptomatic – no treatment Symptomatic – excision by supraclavicular,
transaxillary approach
CAROTID BODY TUMOURS Carotid bodies – chemoreceptor
organs containing cells situated at bifurcation of CCA contain acetylcholine and catecholamine stimulated by increase pco2, decrease po2, increase H+ (higher altitudes)
Site – carotid triangle at CCA bifurcation Age – mc 5th decade Region – high altitude areas like Tibet,
Peru Etiology – chronic hyperplasia in high
altitude areas -> carotid body hyperplasia
Familial – 10% autosomal dominant
C/F Painless slow growing swelling of many
years duration in carotid triangle Pulastile Compressible – size decreases with carotid
compression and increases on release of pressure
Mobility from side to side and not up and down
Bruit, thrill + Can extend to parapharyngeal space and
oropharynx pushing the tonsil medially
If large can cause pressure symptoms like dysphagia, change in voice
Pressure on swelling can lead to faintness (carotid body syncope)
Rare regional and distant metastasis Diagnosis Serum catecholamines 24 hrs urine vanellyl mandelic acid CECT MRI with gadolinum MRI angiography/ DSA
Lyre’s sign – widening of angle/ splaying between ICA and ECA on angiography
Avoid FNAC, open biopsy as highly vascular
Treatment Younger age/ no metastasis/ fit –
surgical resection by trans cervical approach
Large tumours – do arterial embolization first to decrease bleeding
Elderly > 50 yrs/ metastasis/ unfit - RT
LYMPHOMA Children and young adults 55% of paediatric ca Hodgkin’s/ non hodgkin’s C/F Painless, mobile, non tender, discrete, rubbery,
progressively enlarging lymph nodes in the neck
Other sites of ln enlargement – axilla, groin and abdomen
Hypertrophy of spleen and liver Hypertrophy of waldeyer’s ring including tonsils Fever
Pressure symptoms like dysphagia, respiratory obstruction
Serous otitis media Diagnosis FNAC Needle biopsy Open biopsy Treatment Early stage – RT Advanced stage – CT, CT+RT.....
PARAPHARYNGEAL TUMOURS Types Pre styloid Mainly salivary gland tumours Pleomorphic adenoma Warthin’s tumour Mucoepidermoid ca Site – deep lobe of parotid C/F – mass or bulge on tonsillar fossa, soft
palate, lateral pharyngeal wall Displace the above structures mediallty Painless swelling
Post styloid Neurogenic tumours Schwannomas/ neurilemmomas Neurofibroma Paraganglioma Malignant schwannoma C/F Firm neck mass showing bulge in lateral
pharyngeal wall Can displace the lateral pharyngeal wall
medially
Pressure symptoms of hoarseness of voice, dysphagia, trismus
Painless Nasal obstruction and aural fullness Diagnosis CT/MRI DSA Rigid endoscopy 24 hrs VMA FNAC
Treatment Surgical resection Lower neck – trans cervical approach Upper neck – trans cervical trans
mandibular approach Parotid – cervico parotid approach
STERNOMASTOID TUMOUR Congenital torticolis Age – at birth Etiology Birth trauma – venous obstruction or
haematoma formation during..... Labour..... Leads to infarction of central portion of SCM which leads to fibrosis
Fibrosis causes contraction or shortening of SCM
Swelling in the SCM
C/F Circumscribed firm mass palpable in
middle 1/3rd of SCM Torticolis – face turned to opposite side,
head fixed on shoulder on same side Asymmetry of head and face Treatment Conservative – regular active and
passive neck movements to avoid contraction
Surgery – division of SCM at its lower end
METASTATIC LYMPH NODES Age - > 50 yrs M>F Can be occult primary – unknown primary Painless hard swelling non tender fixed to
skin or deeper structures Sites for primary tumour Tongue base – vallecula, pyriform sinus,
tonsil, RMT, nasopharynx – fossa of rosenmuller
For supraclavicular ln – primasry can be lungs, breasts, colon, kidney, ovary, testis, abdomen
Diagnosis Complete examination of digestive tract,
tracheo bronchial tree, breasts, thyroid, genito urinary tract
Pan endoscopy Imaging – X Rays, USG neck and abdomen,
CT, MRI....., PET scan FNAC If FNAC shows malignancy biopsy Biopsy Punch biopsy of hidden areas Excision biopsy of tonsils
Treatment Depends on primary site Occult primary – RND Post op RT to nasopharynx, I/L tonsil, C/L
neck....., base of tongue Need to do regular follow up
NECK DISSECTION Defination – en block removal of lymph
nodes, other lymph bearing and non lymphatic structures including surrounding fibrofatty tissue from various compartments of neck to eradicate metastatic cervical lymph nodes
Types RND Radical Neck Dissection Removal of structures related to
malignancy from mandible to clavicle, midline to trapezius
Indications Unknown primary Nodes fixed to underlying structures Contraindications Unresectable tumours Distant metastasis Life expectance < 3 months Major systemic illness Neck nodes fixed to branchial plexus,
cervical plexus, trachea
Incisions Mac Fee Crile’s Schobinger Hockey stick Structures removed LN I – V along with its fibrofatty tissue Muscles – SCM, Omohyoid IJV, EJV XI CN Glands – submandibular, tail of parotid
Structures preserved LN VI, VII, post auricular, sub occipital X, XII CN CCA, ICA, ECA Branchial plexus, phrenic nerve, mandibular
branch of facial nerve, lingual nerve, cervical sympathetic chain
Parotid except tip Complications Haemorrhage, airway obstruction, air
embolism, chylous fistula, wound infection, injury to nerves – X, XI, XII
MRND Modified Radical Neck Dissection Preservation of one or more of following
non lymphatic structures in RND – XI CN, IJV, SCM
Types I – Preservation of XI CN II – Preservation of IJV and XI CN III – Preservation of IJV, XI CN and SCM.
Also known as functional neck dissection
Extended Neck Dissection/ Selective Neck Dissection/ Staging Neck Dissection
Preservation of all three non lymphatic structures – XI CN, IJV, SCM along with one or more levels of cervical ln
Types Supra omohyoid Removal of level I, II, III Ca oral cavity, oropharynx with N0 Neck Lateral Removal of level II, III, IV Ca larynx, pharynx, cervical oesophagus with N0
Neck
Posterolateral Removal of level II, III, IV, V along with sub
occipital and posterior auricular ln Ca larynx, cervical oesophagus with N0 Neck Anterior Removal of level VI Papillary thyroid ca, ca trachea with N0 Neck..... Superior Mediastinal Removal of level VII Ca upper oesophagus, post cricoid When one or two levels of lymph nodes
are removed – Limited Neck Dissection
Extended Neck Dissection Indications Disease extension superiorly to skull base and
inferiorly to mediastinum RND along with removal of following as
needed – Retropharyngeal ln, parotid ln, level VI, VII XII CN ECA Parotid gland Mastoid tip Levator Scapulae muscle
NECK SPACE INFECTIONSPERITONSILLAR ABSCESS (QUINSY) Collection of pus in peritonsillar space (b/w
capsule of tonsil and sup constrictor muscle) Etiololgy Micro organisms – strept pyogenes, staph
aureus, anaerobes, pneumococci Age 20-40 yrs M>F Infection of weber’s glands (minor salivary
glands in soft palate near sup pole of tonsil) Recurrent attacks of acute tonsillitis Tonsillolith
FB tonsil Penetrating injury Dental infection Infectious mononucleosis Pathology Infection of crypts (crypta magna) ->
obstruction -> intratonsillar abscess -> peritonsillitis (acute inflammation with cellulitis) -> abscess
C/F U/L
Severe sore throat I/L referred otalgia Odynophagia Drooling of saliva – cant swallow saliva Muffled and thick hot potato voice Halitosis – foul breath due to sepsis Trismus – due to spasm of pterygoid muscles Fever high grade, chills, rigors, general
malaise, body pain, headache, nausea Torticolis – neck turned towards side of
abscess
Oedema and swelling ant and sup to tonsil Ant pillar and soft palate congested Tonsil enlarged and covered by oedematous
swelling, tonsil pushed medially and downwards
Uvula swollen and pushed to opposite side Enlarged and tender JD ln Diagnosis Throat swab for c/s CBC RBS CT/MRI
Complications Airway obstruction Laryngeal oedema Septicaemia Aspiration of pus due to spontaneous rupture
leading to pneumonia and lung abscess Jugular vein thrombosis Carotid rupture Treatment Medical surgical
Medical Hospitalization IV fluids IV antibiotics – 3rd gen cephalosporins,
clindamycin, pencillin, metronidazole Steroids Analgesics and antipyretics Oral hygiene – H2O2 gargles, saline mouth
wash Surgical Wide bore needle aspiration – small abscess
I&D of abscess Throat spray or infiltration with Xylocaine Use of peritonsillar knife or guarded knife
with only 1 cm of knife exposed to prevent deeper penetration
Give a stab incision at the point of maximum bulge above the upper pole of tonsil or at the junction of base of uvula and ant pillar where they meet (imaginary line)
Use a sinus or artery forceps to open and drain the abscess
Drain any recurrence next day
Interval tonsillectomy After 4-6 weeks Hot (abscess) tonsillectomy Done during acute abscess stage only,
after draining the abscess under same sitting
Complications – rupture of abscess, bleeding, dissemination of infection, thromboembolism
LUDWIG’S ANGINA Spreading cellulitis (mainly B/L) involving
submandibular, submental and sublingual spaces
Myelohyoid divides the submandibular space into lower submaxillary and upper sublingual space
Etiology Age 20-50 yrs Organisms – streptococci, staphylococci, H
influenzae, E coli, pseudomonas MC – dental infections, lower premolar and
molar
Dental extraction Tonsillar infection Fracture mandible Injury to oral mucosa – tongue, floor of
mouth Submandibular sialadenitis Post radiotherapy osteoradionecrosis of
mandible ONLY LOCAL SPREAD NO LYMPHATIC
SPREAD
C/F Marked progressively painful odynophagia Trismus Tongue pushed upwards and backwards Swollen tender woody hard swelling in
submandibular and submental region Marked rapidly increasing cellulitis Drooling of saliva Diagnosis Clinical features, increased leucocyte count X Ray/ CT/ MRI
Complications Spread to retropharyngeal space,
parapharyngeal space and mediastinum Airway obstruction due to laryngeal
oedema, tongue push up, swelling Septicaemia Tongue necrosis Aspiration leading to pneumonia and lung
abscess Treatment Medical – antibiotics, fluids, analgesics
Surgical Tracheostomy if airway compromised I&D of abscess Intra oral – if localised to sublingual space External/cervical – if involves
submandibular region Steps Transverse incision between angles of
mandible two finger breaths below margin of mandible
Vertical incision in midline
Serous fluid drained Incision not closed. Antibiotic soaked
ribbon gauze placed and dressing done daily
Wound allowed to heal by secondary intention
Extraction of infected teeth
RETROPHARYNGEAL ABSCESS ACUTE R P ABSCESS Etiology Age Mc children < 3-4 yrs Boys Adults Suppuration of RP ln due to infections of
adenoids, nasopharynx, PNS, nasal cavity and tonsils
Petrositis due to acute mastoiditis Penetrating injury to post pharyngeal wall due
to trauma or iatrogenic
FB impaction at cricopharynx and upper oesophagus
Organisms – streptococci, staphylococci C/F Dysphagia and odynophagia Airway obstruction leading to stridor/stertor Croupy cough Torticolis – stiff rigid neck Hot potato voice Rapidly increasing sore throat Drooling of saliva
Fever, malaise Lymphadenopathy U/L bulge in post pharyngeal wall, cant
cross midline due to median raphe Diagnosis X Ray soft tissue neck lateral view Air shadow in prevertebral space/
widening of prevertebral space (normal width 3.5 mm, > 50% width)/ presence of gas
CT Scan/ MRI
Complications Spread to mediastinum and danger space
(most dangerous) Septicaemia Meningitis Airway obstruction Treatment Hospitalization IV antibiotics IV fluids steroids
Tracheostomy – if stridor I&D of abscess Intra oral No GA – chance of rupture Position – supine with head low/ rose
position Vertical incision at most fluctuant area
on lat part of post pharyngeal wall Do suction to prevent aspiration
CHRONIC R P ABSCESS PRE VERTEBRAL SPACE ABSCESS Etiology Adults TB cervical spine and prevertebral space Types TB retropharyngeal ln Seen in children aged 8-10 yrs Lateral type/ U/L Cant cross midline TB cervical spine/ caries of cervical spine Any age, infection in prevertebral space Can cross midline B/L/ midline swelling
C/F Slow in onset/ insidious Less severe symptoms Dysphagia Throat discomfort Fluctuant swelling in midline or lateral Non tender enlarged JD ln Painless lump in throat Dyspnoea Chronic cough, evening rise of temp, night
sweats, loss of appetite, loss of weight
Diagnosis X Ray cervical spine Caries Loss of normal curvature/ straightening of
cervical spine Bony destruction of vertebra X Ray Neck – prevertebral widening X Ray Chest – TB, mediastinitis CT/MRI FNAC Mantoux test
Complications Can extend to danger space, mediatinum and
parapharyngeal space Airway obstruction and laryngeal oedema Pus can extend to coccyx Spontaneous rupture leading to pneumonia,
lung abscess Septicaemia Treatment ATT IV fluids Tracheostomy
I&D of abscess Transcervical approach Vertical incision at anterior or posterior
border of SCM Orthopaedics treatment for caries spine
PARAPHARYNGEAL ABSCESS PHARYNGO MAXILLARY ABSCESS/ LATERAL
PHARYNGEAL ABSCESS Etiology Any age but common in young adults Organisms – staphylococci, streptococci,
bacteroides, E coli Infection from peritonsillar space (mc),
retropharyngeal space, parotid space Tonsillitis, adenoiditis, pharyngitis,sialadenitis Dental infections – last molar, infected cysts, fistulas CSOM/ASOM – bezold’s abscess Penetrating injuries to neck Iatrogenic – during procedures, inj
C/F High fever, odynophagia, sore throat, torticolis Anterior compartment Prolapse of tonsils and tonsillar fossa Trismus due to spasm of pterygoid muscles Swelling at angle of mandible Odynophagia and dysphagia Bulging of tonsil, soft palate Posterior compartment Pharyngeal bulging behind posterior pillar Swelling in parotid region
CN palsy – IX, X, XI, XII CN I/L palsy of palate, larynx, tongue Horner’s syndrome – involvement of
sympathetic chain – I/L anhidrosis, ptosis, enophthalmos, constricted pupil
Diagnosis CT/ FNAC/ USG/ X Ray Complications Airway obstruction/ laryngeal oedema Thrombophlebitis of jugular vein Carotid artery rupture Mediastinitis/ RP abscess
Pneumonia/ emphysema Meningitis Septicaemia Treatment IV antibiotics – cephalosporins,
aminoglycosides Fluids Analgesics Tracheostomy – if airway obstruction Surgical drainage
I&D of abscess Transcervical approach GA Horizontal incision 2-3 cm below angle
of mandible (level of hyoid) Abscess is aspirated Drain placed for 2-3 days
AVOID TRANS ORAL APPROACH – chance of damage to greater vessels