Neck Swellings

Dr. Vishal Sharma

Neck Triangles

Anterior Triangle

Boundaries: Anterior = midline of neck

Posterior = S.C.M. anterior border

Superior = lower border of mandible

Floor = deep layer of deep cervical fascia

Roof = Superficial layer of deep cervical fascia

Subdivision: by digastric & omohyoid muscles into

submental, submandibular, carotid, muscular

Contents: carotid arteries, internal jugular vein, vagus,

recurrent laryngeal nerves, submandibular gland,

Levels I, II, III, IV & VI lymph nodes

Posterior Triangle

Boundaries:

Posterior: Trapezius anterior border

Anterior: S.C.M. posterior border

Inferior: Middle 1/3rd of clavicle

Floor: deep layer of deep cervical fascia

Roof: Superficial layer of deep cervical fascia

Subdivision: occipital & supra-clavicular by omohyoid

Contents: subclavian artery, brachial plexus, spinal

accessory nerve, level V lymph nodes

Neck Lymph Nodes

Sloan Kettering ClassificationLevel I: Submental + submandibular nodes

Level II: Upper jugular nodes (upper 1/3 of IJV)

Level III: Middle jugular nodes (middle 1/3 of IJV)

Level IV: Lower jugular nodes (lower 1/3 of IJV)

Level V: Posterior triangle nodes

Level VI: Anterior compartment nodes

Level VII: Superior mediastinal nodes

Submental Lymph nodes (Level Ia):

Lateral: Anterior digastric belly (both sides)

Inferior: Body of hyoid

Submandibular Lymph nodes (Level Ib)

Posterior: Posterior digastric belly

Anterior: Anterior digastric belly

Superior: Body of mandible

Anterior Posterior Superior Inferior

II Lateral

border of

sterno-

hyoid

Posterior

border of

sterno-

cleido-

mastoid

Skull base Carotid

bifurcation

or hyoid

III Carotid

bifurcation

or hyoid

Cricoid

IV Cricoid Clavicle

Level V: Posterior triangle nodes

Posterior: Trapezius anterior border

Anterior: S.C.M. posterior border

Inferior: Middle 1/3rd of clavicle

Level VI: Anterior compartment nodes

Superior: Body of hyoid bone

Inferior: Supra-sternal notch

Lateral: Lateral border of sterno-hyoid

Level VII: Superior mediastinal nodes

Classification of neck swelling according to position

• Ubiquitous neck swellings

• Midline neck swellings

• Anterior triangle neck swellings

• Posterior triangle neck swellings

Ubiquitous neck swellings• Sebaceous cyst

• Lipoma

• Neurofibroma, schwannoma

• Hemangioma

• Dermoid cyst

• Teratoma

• Hydatid cyst

Midline swellings

Lymph node (submental, Delphian, suprasternal)

Ludwig’s angina Sublingual dermoid

Thyroglossal cyst Subhyoid bursitis

Thyroid swelling (isthmus & pyramidal lobe)

Laryngeal tumors Cold abscess

Sternal tumor Thymus tumors

Submandibular triangle swellings

• Lymph node (level 1b)

• Cold abscess

• Submandibular salivary gland enlargement (deep

lobe is bimanually

ballotable)

• Plunging ranula

• Mandibular tumor

Carotid + muscular triangle swellings

Branchial cyst Branchiogenic cancer

Laryngocoele (external) Thyroid lobe swelling

Lymph node (II, III, IV) Cold abscess

Carotid body tumour Carotid aneurysm

Sternomastoid tumor of newborn

Posterior triangle swellings

Cystic hygroma

Pharyngeal pouch (Zenker’s diverticulum)

Lymph node (level V)

Cold abscess

Cervical rib

Clavicular tumour

Subclavian artery aneurysm

Classification by etiology

• Congenital / Developmental

• Infectious / Inflammatory

• Neoplastic: Benign / Malignant

Congenital neck swellings

a. Cystic

Sebaceous cyst Dermoid cyst

Branchial cyst Thyroglossal cyst

Thymic cyst

b. Solid: Ectopic thyroid

c. Vascular

Hemangioma Lymphangioma

Inflammatory neck swellings• Lymphadenitis

– Viral

– Bacterial

– Granulomatous

• Sialadenitis

– Parotid

– Sub-mandibular

• Deep neck space abscess

Neoplastic neck swellings

• Skin: Squamous cell Ca, Malignant melanoma

• Soft tissue:

– Benign: Lipoma, Fibroma, Schwannoma

– Malignant: Rhabdomyosarcoma

• Lymph node: Lymphoma, Metastasis

• Thyroid: Benign / Malignancy

• Vascular: Carotid body tumor, Angioma

Hemangioma & lipoma

Cervical Lymphadenopathy

A. Inflammatory hyperplasia

1. Acute lymphadenitis 2. Chronic lymphadenitis

3. Granulomatous lymphadenitis

Bacterial: tuberculosis, secondary syphilis

Viral: infectious mononucleosis, AIDS

Parasitological: toxoplasmosis

Non-specific: sarcoidosis

B. Neoplastic: lymphoma, lymphosarcoma, metastatic

C. Lymphatic leukemia

D. Autoimmune: systemic lupus erythematosus

Lymph node consistency

• Firm, rubbery: lymphoma

• Soft : infection or cold abscess

• Multiple, firm, shotty: syphilis, viral

• Matted (connected): tuberculosis , sarcoidosis,

malignant

• Rock hard, immobile, fixed to skin: metastatic

Tuberculous lymphadenitis

• Involves upper deep cervical chain &

posterior triangle lymph nodes

• Development of peri-adenitis → matted

nodes

• Development of caseation → cold abscess

• Abscess tracking down to skin forms

subcutaneous collection → collar stud

abscess

• Abscess bursts spontaneously →

tuberculous sinus

Tuberculous lymphadenopathy

LymphomaMore common in children & young adults

60 - 80% children with Hodgkin’s have neck mass

Signs & symptoms:

• Fever + malaise

• Night sweats

• Weight loss

• Pruritus

• Rubbery lymph nodes

Metastatic lymph node

• Seen in older patients

• Level 1: oral cavity

• Level 2, 3, 4: larynx, oropharynx, hypopharynx,

thyroid

• Level 5: nasopharynx

• Left supraclavicular fossa: lung, stomach, testis

Unknown Primary Lesion (UPL)

Synonym: 1. metastasis of unknown origin

2. occult primary

Definition: metastatic lymph node with primary site

hidden or undetected

Primary malignancy sites (as per frequency):

1. Nasopharynx 2. Oropharynx (base of tongue)

3. Hypopharynx (pyriform fossa) 4. Larynx 5. Thyroid

Investigations for UPL

1. Fibreoptic nasopharyngoscopy + laryngoscopy

2. Rigid panendoscopy

3. Excision biopsy of I/L tonsil + blind biopsy of

tongue base, pyriform fossa, fossa of Rosenmuller,

tonsilo-lingual sulcus, retro molar trigone

4. CT scan from skull base to superior mediastinum

5. Excision biopsy of metastatic lymph node

Ranula

Introduction

• Rana means frog (blue translucent swelling in

floor of mouth looks like underbelly of frog)

• Simple ranula: Bluish cyst located in floor of

mouth. Painless mass, does not change in size in

response to chewing, eating or swallowing

• Plunging ranula: Sub-mandibular neck swelling

with or without cyst in floor of mouth

Simple Ranula

Plunging ranula

Plunging ranula

Etiology• Simple ranula: partial obstruction or severance of

sublingual duct leads to epithelial-lined retention

cyst. Commonly traumatic.

• Plunging ranula: 1. sublingual gland projects

through or behind mylohyoid muscle

2. ectopic sublingual gland on

cervical side of mylohyoid muscle

TreatmentMarsupialization: un-roofing of cyst & suturing of

cyst margin to adjacent tissue. Failure = 60-90%

Sclerosing agents: intra-lesional injection of

Bleomycin or OK-432

Intra-oral excision: of ranula alone (failure = 60%) or

ranula + sublingual gland (failure = 2 %)

Trans-cervical approach for plunging ranula:

complete removal of cyst + sublingual gland

Marsupialization

Intra-oral excision

Ranula specimen

Thyroglossal cyst

Embryology• Thyroid appears as epithelial proliferation in floor

of mouth. Thyroid descends in front of pharynx

as bi-lobed diverticulum, connected to tongue by

thyroglossal duct.

• The duct normally disappears later. Thyroglossal

cysts are cystic remnant of thyroglossal duct.

• Commonest congenital anomaly of thyroid

Location

• Cyst may lie at any point along migratory pathway

of thyroid gland

• Commonest site: sub-hyoid (50%)

• Second common site: supra-hyoid

• Other common sites: base of tongue, at level of

thyroid cartilage, sublingual

• Least common site: at level of cricoid cartilage

.

Location

1 = base of tongue

2 = sublingual

3 = supra-hyoid

4 = sub-hyoid

5 = in front of thyroid

cartilage

6 = in front of cricoid

cartilage

Clinical features• Commonly seen in early childhood

• Midline, round swelling, 2-4 cm in diameter

• Swelling moves up with swallowing

• Swelling moves up with protrusion of tongue

• Swelling mobile horizontally but not vertically

• Cyst increases in size with URTI

Neck swelling moving with swallowing

• Thyroid swelling

• Thyroglossal cyst (mobile horizontally)

• Subhyoid bursitis (oval, long axis horizontal)

• Pre-laryngeal & pre-tracheal lymph nodes

• Laryngocele

Midline neck swelling

Ultra-sonography

CT scan axial cut

MRI sagittal cut

Sistrunk’s operation

Consists of complete surgical excision of cyst &

its tract along with body of hyoid bone & core of

tongue tissue around suprahyoid tongue base up

to foramen caecum

Thyroid scan mandatory before cyst excision as

cyst may contain only functioning thyroid tissue

Patient position & incision

Exposure of cyst + tract

Exposure & cutting of hyoid bone

Removal of tongue tissue

Removal of cyst + tract

Complications1. Infection of cyst & abscess formation

2. Throglossal fistula 3. Malignancy (1%)

Infected cyst

Thyroglossal fistula

Branchial cleft cysts

Embryology

Branchial anomalies

• Cyst: remnant of branchial clefts or pouch without

internal or external opening

• Sinus: persistence of cleft with skin opening

• Fistula: persistence of both cleft + pouch with

openings in skin & pharynx

• Fistula tract lies caudal to structures derived from its

arch & dorsal to structures of following arch

Branchial anomalies

• In children, fistulas are more common than

sinuses, which are more common than cysts

• In adults, cysts predominate

• Branchial cleft anomalies + biliary atresia +

congenital cardiac anomalies = Goldenhar's

complex

First branchial cleft cyst

• Type I: Contains only ectodermal elements without

cartilage or adnexal structures. Present as

duplication of external auditory canal.

• Type II: Contains both ectoderm & mesoderm.

Present as abscess below angle of

mandible.

• Fistula ends internally around Eustachian tube

Second branchial cleft cyst• Commonest branchial anomaly

• Painless, fluctuant mass along anterior border of

middle 1/3rd of sternocleidomastoid muscle

• Fistula tract opens externally along lower 1/3rd of

SCM, passes deep to 2nd arch structures (external

carotid, stylohyoid muscle, posterior belly of

digastric); superficial to internal carotid (3rd arch);

ends internally in tonsillar fossa

Second branchial cleft cyst

Second branchial cleft cyst

• Painless, fluctuant mass along anterior border of

lower 1/3rd of sternocleidomastoid muscle

• Fistula tract opens externally along lower 1/3rd of

SCM, passes deep to 3rd arch structures (internal

carotid, glossopharyngeal nerve); superficial to

superior laryngeal nerve (4th arch): opening internally

in base of pyriform fossa

Third branchial cleft cyst

Fourth branchial cleft cyst

• Presents as mass along anterior border of lower

1/3rd of stenomastoid or as recurrent thyroiditis

• Fistula tract opens externally along lower 1/3rd of

SCM, passes deep to 4th arch structures (superior

laryngeal nerve ); superficial to recurrent laryngeal

nerve (6th arch); opening internally in apex of

pyriform fossa

CT scan 1st branchial cyst

CT scan 2nd branchial cyst

CT scan 3rd branchial cyst

Coronal MRI Sagittal MRI Axial MRI

Treatment

• Abscesses treated first with incision & drainage +

broad-spectrum antibiotics

• Elective surgical excision of cyst with its tract

traced up to its origin in pharyngeal wall done

after infection resolves

• Branchial fistula excised with 2 horizontally

placed incisions (stepladder incision)

Excision of branchial cyst

Branchial fistula excision

Laryngocoele

• Arises from expansion of saccule of laryngeal

ventricle due to ed intra-luminal pressure in

larynx or congenital large saccule

Causes of ed intra-luminal pressure in larynx:

• Occupational (?): trumpet players, glass blowers

• Coexistence of larynx cancer

• Male : female 5:1, Peak age = 6th decade,

Unilateral in 85 % cases, 1% contain carcinoma

Swelling enlarges on Valsalva

Types of laryngocoele• Internal (20%): contained entirely within endolarynx

with bulge in false vocal fold & aryepiglottic

fold

• External (30%): only neck swelling without visible

endolaryngeal swelling

• Combined (50%): Also extends into anterior triangle of

neck through foramen for superior laryngeal nerve &

vessels in thyrohyoid membrane. Dumbbell shaped.

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Types of laryngocoele

Internal External Combined

Clinical Features• Hoarseness

• Stridor in large endolaryngeal laryngocoele

• Neck swelling

• Manual compression of neck swelling results in

escape of fluid / gas into airway (Boyce’s sign)

• 10% cases are pyocele: sore throat, cough

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Flexible laryngoscopy

▪Swelling of false vocal

folds & ary-epiglottic fold

▪Swelling easily emptied

▪Escape of purulent fluid

into airway = pyocoele

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X-ray neck AP view

X-ray soft tissue neck AP

view during Valsalva

maneuver shows air-

filled radiolucent

swelling

CT scan: mixed laryngocoele

Treatment• No symptom: no treatment

• Infected laryngocoele: aspiration & antibiotics

• Internal laryngocoele: endoscopic marsupialization

• External laryngocoele: Excision by external

approach. Cyst exposed by removing upper half of

thyroid cartilage. Cyst incised at its neck & stitched.

Endoscopic marsupialization

External approach

Carotid body tumor• Pulsating, compressible mass in carotid triangle

• Mobile only horizontally not vertically

• Angiography: vascular mass b/w external &

internal carotid arteries (Lyre’s sign)

• Rx: Radiation or close observation in elderly.

Surgical resection for small tumors in young

patients with hypotensive anesthesia & pre-

operative measurement of catecholamines.

Lyre sign

Sternomastoid tumor of infancy

• Firm mass of SCM, becomes prominent when chin

turned away & head tilted towards the mass

• Due to birth trauma causing infarction / hematoma

with subsequent fibrotic replacement

• Rx: Physical therapy. Myoplasty of SCM for

refractory cases.

Hypopharyngeal pouch

Introduction• Hypopharyngeal pouch is an acquired pulsion

diverticulum caused by posterior protrusion of

mucosa through pre-existing weakness in

muscle layers of pharynx or esophagus

• In contrast, congenital diverticulum like Meckel's

diverticulum is covered by all muscle layers of

visceral wall

Weak spots b/w muscles

Origin of Zenker’s diverticulum

Etiology1. Tonic spasm of cricopharyngeal sphincter:

C.N.S. injury Gastro-esophageal reflux

2. Lack of inhibition of cricopharyngeal sphincter

3. Neuromuscular in-coordination between thyro-

pharyngeus & cricopharyngeus

4. Second swallow against closed cricopharynx

These lead to increased intra-luminal pressure in

hypopharynx & mucosa bulges out via weak areas

Clinical features1. Entrapment of food in pouch: sensation of food

sticking in throat & later dysphagia

2. Regurgitation of entrapped food: leads to foul taste

bad odor nocturnal coughing choking

3. Hoarseness: due to spillage laryngitis or sac

pressure on recurrent laryngeal nerve

4. Weight loss: due to malnutrition

5. Compressible neck swelling on left side: reduces with

a gurgling sound (Boyce sign)

Complications

1. Lung aspiration of sac contents

2. Bleeding from sac mucosa

3. Absolute oesophageal obstruction

4. Fistula formation into:

trachea major blood vessel

5. Squamous cell carcinoma within Zenker

diverticulum (0.3% cases)

Investigations

• Chest X-ray: may show sac + air - fluid level

• Barium swallow

• Barium swallow with video-fluoroscopy

• Rigid Oesophagoscopy

• Flexible Endoscopic Evaluation of Swallowing

Barium swallow

Barium swallow with Video-fluoroscopy

Rigid Esophagoscopy

Staging

Lahey system:

• Stage I: Small mucosal protrusion

• Stage II: Definite sac present, but hypo-pharynx

& esophagus are in line

• Stage III: Hypopharynx is in line with pouch

& esophagus pushed anteriorly

Stage 1

Stage 2

Stage 3

Surgical Treatment

1. Cricopharyngeal myotomy: combined with others

2. Diverticulum invagination: Keyart

3. Diverticulopexy: Sippy-Bevan

4. External or open Diverticulectomy: Wheeler

5. Rigid Endoscopic Diverticulotomy

Cautery (Dohlman) Laser Stapler

6. Flexible Endoscopic Diverticulotomy with Laser

Treatment Protocol

1. Small sac (< 2cm):

Cricopharyngeal (CP) myotomy + invagination

2. Large sac (2-6 cm):

Open Diverticulectomy with CP myotomy

or Endoscopic Diverticulotomy with CP myotomy

3. Very large sac (> 6 cm):

Open Diverticulectomy with CP myotomy

or Diverticulopexy with CP myotomy

Cricopharyngeal myotomy

Diverticulum invagination Diverticulum pushed into hypopharynx lumen &

muscle + adjacent tissue are oversewn.

CP myotomy is usually combined with this.

External diverticulectomy

Endoscopic diverticulotomy

Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum

View through diverticuloscope

Cautery, laser, or stapling device used to divide

common party wall between pouch & esophagus

View through diverticuloscope

Endoscopic diverticulotomy

Dohlman’s instruments

Diverticulopexy Sac mobilized & its fundus fixed to sternocleido-

mastoid muscle in a superior, non-dependent position. CP myotomy is also done.

Cystic hygroma

• Synonym: cystic lymphangioma

• Definition: congenital, benign, multi-loculated,

lymphatic lesion classically found in

posterior triangle of neck

• Other sites: axilla, mediastinum, groin & retro-

peritoneum

• Etiology: failure of lymphatics to connect to

venous system; abnormal budding of lymphatic

tissue; sequestered lymphatic cell rests

Clinical Features

• 50-65% cases present at birth, 80-90% by 2 years

• Soft, painless, compressible trans-illuminant mass

present in posterior triangle of neck. Overlying skin

can be bluish or normal . Sudden se in size due to

infection or intra-cystic bleeding.

• Look for tracheal deviation, airway obstruction,

cyanosis, feeding difficulty, failure to thrive

Stage Clinical Features Complication rate

Stage I U/L infrahyoid 20%

Stage II U/L suprahyoid 40%

Stage III U/L infrahyoid + suprahyoid 70%

Stage IV B/L suprahyoid 80%

Stage V B/L infrahyoid + suprahyoid 100%

Cystic hygroma

Investigations• USG: used to detect CH in utero

• CT scan: Contrast helps to enhance cyst wall

visualization & relationship to surrounding blood

vessels. CH appears isodense to CSF.

– Macrocystic: cystic spaces > 2 cm

– Microcystic: cystic spaces < 2 cm

• MRI: Best investigation. CH appears hyperintense

on T2 & hypointense on T1-weighted images.

MRI: CH causing airway compression

Treatment• Asymptomatic: 1. watchful waiting

2. sclerosing agents: OK-432 (Picibanil),

bleomycin, ethanol, doxycycline, Interferon, fibrin

sealant

• Infected cases: intravenous antibiotics & drainage;

definitive surgery after 3 months

• Surgical excision: mainstay of treatment. Done

with Cautery, Laser,

Radiofrequency

• Acute stridor: aspiration, emergency tracheostomy

Kawasaki syndrome• Etiology: idiopathic multisystem vasculitis

• Diagnosis (presence of any 5): 1. Fever > 5 days.

2. Conjunctival injection. 3. Red / desquamated

palm / sole. 4. Injected oral cavity 5.

Polymorphous rash. 6. Cervical lymph node

enlargement

• Permanent cardiac damage in 20% untreated cases

• Rx: high dose aspirin & immunoglobulin

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