A study on neck swellings

1. Dr Manpreet Singh Nanda
Associate Professor ENT
MMMC&H Solan

2.  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)

3.  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

4.  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

5.  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

6.  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

7.  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)

8.  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

9.  Diagnosis
 USG
 FNAC – cholesterol crystals, lymphoid tissue
 Contrast X Ray (Fistulogram)
 Treatment
 Surgical excision along with its tract

10.  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

11.  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

12.  Complications
 Stridor – if involve larynx, pharynx
 Respiratory difficulty
 Feeding problem
 Difficult labour
 Diagnosis
 Antenatal USG
 CT, MRI

13.  Treatment
 Tracheostomy if stridor
 Complete excision
 Sclerotherapy - Injection sclerosing agents
like absolute alcohol, bleomycin, TCA

14.  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

15.  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

16.  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

17.  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

18.  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

19.  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)

20.  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

21.  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

22.  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

23.  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

24.  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

25.  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

26.  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

27.  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

28.  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

29.  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

30.  Pressure symptoms like dysphagia,
respiratory obstruction
 Serous otitis media
 Diagnosis
 FNAC
 Needle biopsy
 Open biopsy
 Treatment
 Early stage – RT
 Advanced stage – CT, CT+RT.....

31.  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

32.  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

33.  Pressure symptoms of hoarseness of voice,
dysphagia, trismus
 Painless
 Nasal obstruction and aural fullness
 Diagnosis
 CT/MRI
 DSA
 Rigid endoscopy
 24 hrs VMA
 FNAC

34.  Treatment
 Surgical resection
 Lower neck – trans cervical approach
 Upper neck – trans cervical trans mandibular
approach
 Parotid – cervico parotid approach

35.  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

36.  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

37.  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

38.  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

39.  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

40.  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

41.  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

42.  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

43.  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

44.  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

45.  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

46.  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

47.  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

48.  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

49.  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

50.  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

51.  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

52.  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

53.  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

54.  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

55.  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

56.  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

57.  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

58.  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

59.  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

60.  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

61.  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

62.  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

63.  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

64.  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

65.  Complications
 Spread to mediastinum and danger space
(most dangerous)
 Septicaemia
 Meningitis
 Airway obstruction
 Treatment
 Hospitalization
 IV antibiotics
 IV fluids
 steroids

66.  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

67.  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

68.  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

69.  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

70.  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

71.  I&D of abscess
 Transcervical approach
 Vertical incision at anterior or posterior
border of SCM
 Orthopaedics treatment for caries spine

72.  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

73.  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

74.  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

75.  Pneumonia/ emphysema
 Meningitis
 Septicaemia
 Treatment
 IV antibiotics – cephalosporins,
aminoglycosides
 Fluids
 Analgesics
 Tracheostomy – if airway obstruction
 Surgical drainage

76.  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