Non thyroid neck swellings

1. Dr SUNDARPRAKASH SIVALINGAM
Associate Professor in Surgery
NON-THYROID NECK SWELLINGS
DR.SUNDARPRAKASH SIVALINGAM
ASSOCIATE PROFESSOR SURGERY

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. 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, sometimes transilluminated,
non compressible
Becomes painful and tender if infected after
URTI
Site – anterior triangle ( carotid)
Pathology – cholesterol crystals

4. 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)

5. 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

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

7. 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

8. 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

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

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

11. 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

12. 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

13. Etiology
Mucous retention cyst of
sublingual salivary glands due to
obstruction of their secretory
ducts
Types
Intra oral
Cystic translucent bluish mass in
lateral partof floor of mouth, pushes
tongue up
Plunging ranula – neck swelling in
submental/ submandibular
region, painless, transilluminated

14. 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

15. •It is a protrusion of mucosa through Killian’s dehiscence, a
weak area of the posterior pharyngeal wall between thyropharyngeus
(oblique fibres) and cricopharyngeus (transverse fibres) of the inferior
constrictor muscle of the pharynx.
• Thyropharyngeus is supplied by pharyngeal plexus from cranial accessory
nerve. Cricopharyngeus is supplied by external laryngeal nerve.
• Pharyngeal pouch is a pulsion diverticulum. It starts in the midline of
posterior pharyngeal wall. Once it expands and reaches the vertebra, it
deviates towards left side of the neck because of resistance of vertebra.
•The protrusion is usually towards left.

16. Stages
1. Small diverticulum pointing towards vertebra. It is asymptomatic
and incidentally diagnosed by barium meal X-ray. Foreign body
sensation in pharynx may be present.
2. Large, globular diverticulum with vertical mouth/opening causing
regurgitation, violent cough, dysphagia, respiratory infection.
Regurgitation is more after meals and while turning the neck.
Problems in pharyngeal pouch
• Progressive dysphagia
• Respiratory problems like pneumonia, lung abscess
• Abscess in the neck due to infection in the pouch
• Weight loss and cachexia

17. Differential Diagnosis
Branchial cyst.
Cold abscess in the neck.
Lymph cyst.
Haemangioma neck.
Clinical Features
• Pain, dysphagia, recurrent respiratory infection, swelling in the neck on
the left side which is smooth, soft and tender.
• Regurgitation during night while turning neck, smooth, soft, tender
swelling in the posterior triangle of the left side of the neck; typical
gurgling noise while swallowing—are typical features. It is common in
males.
• Swelling is deep to sternocleidomastoid muscle below the level of
thyroid cartilage; initially soft and emptying; impulse on coughing may
be evident unless opening of the pouch is blocked due to recurrent
inflammation.

18. Investigations
• Barium swallow—lateral view shows pharyngeal pouch.
• Chest X-ray shows pneumonia.
• CT neck is very useful.

19. Treatment
• Antibiotic is started to control infection.
• Pharyngeal pouch is excised by an oblique neck incision (approach from
neck). As there is cricopharyngeal spasm, cricopharyngeal myotomy (i.e.
cutting of cricopharyngeal circular muscle fibres without opening
mucosa) is done to
prevent the recurrence.
Indications for surgery
• Progressive symptoms.
• Recurrent respiratory complications.
• Dysphagia.
Complications of surgery
• Infection, either mediastinitis or lung infection (Pneumonia or lung
abscess)
• Pharyngeal fistula
• Abscess in the neck
• Oesophageal stenosis and recurrence

20. • It is a unilateral narrow necked, air containing diverticulum resulting
from herniation of laryngeal mucosa.
• It occurs in professional trumpet players, glass blowers and in people
with chronic cough.
Types
a. External: It is situated in the anterior third of the laryngeal
ventricle, between the false cords and thyroid cartilage, herniates
through the thyrohyoid membrane where it is pierced by superior
laryngeal nerve.
b. Internal: Confi ned within the larynx, presents as a distention
of false cords.
c. Combined.

21. Clinical Features
• Swelling in the neck in relation to larynx, adjacent to thyrohyoid
membrane which is smooth, soft, resonant and is more prominent while
blowing, coughing and Valsalva manoeuvre.
• It moves upwards during swallowing with expansile impulse on
coughing.
• Infection is quite common in the sac of laryngocele, leading to the
blockade of opening of the sac causing an abscess.
• Pus often may be discharged into the pharynx repeatedly.
• Hoarseness and cough.
• If large, causes obstruction to larynx.

22. Diagnosis
Clinical features, X-ray neck, laryngoscopy, CT scan.
Treatment
•External laryngocele: Excision through neck incision. Neck of the sac
should be ligated. Thyrohyoid membrane is repaired using 3 zero
nonabsorbable polypropylenes sutures.
•Internal laryngocele: Marsupialisation, with the help of laryngoscope.
Typical laryngocele in the neck which becomes
prominent after blowing. X-ray lateral show
radiolucent
air in the neck.

23. 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

24. 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 mostcommon seen
in posterior triangle
Evening rise of temp, night sweats,
weight loss
Stages
Adenitis – enlarged ln
Periadenitis – matted ln (2-3 ln)

26. 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 PAview – pulmonary TB

27. 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

28. 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

29. Extra rib arising from C7 vertebra
attached to1st rib
Right side is most common, but can be left side
or bilateral
Types
1. Complete bony: Cervical rib is radio-opaque,
anteriorly ends
over the first rib or manubrium.
2. Complete fibrous: Cannot be demonstrated
radio logically.
3. Combined: Partly bony partly fibrous.
4. Partial bony: With free end expanding as bony
mass, which
is felt in the neck.

30. 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

31. 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

32. 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 CCAbifurcation
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

33. 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

34. 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

35. Lyre’s sign – widening of
angle/ splaying between ICA
and ECA onangiography
Avoid FNAC, open biopsy as highly
vascular
Treatment
Younger age/ no metastasis/ fit
– surgical resection by trans
cervical approach
Large tumours – do arterial
embolization firstto decrease
bleeding
Elderly > 50 yrs/ metastasis/ unfit -
RT

36. 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

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

38. 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

39. 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

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

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

42. 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 ofSCM
Swelling in the SCM

43. 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

44. Age - > 50 yrs
M>F
Can be occult primary –
unknown primary
Painless hard swelling non
tender fixed toskin or
deeper structures.
Common sites of primary
Oral cavity, tongue, tonsils
Salivary glands
Pharynx—nasopharynx
Larynx
Oesophagus
Lungs
GIT
Thyroid

45. 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

46. 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

47. 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.influenza, E
coli, pseudomonas
MC – dental infections, lower
premolar andmolar

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

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

57. 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

58. PRE VERTEBRAL SPACEABSCESS
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

59. 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

60. 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

61. 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

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

63. PHARYNGO MAXILLARY ABSCESS/ LATERAL
PHARYNGEALABSCESS
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

64. 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

65. 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

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

67. 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