A 65-year-old man presented with a swelling on the left side of his neck for 20 days. On examination, the left upper jugular lymph nodes were enlarged and firm. He reported loss of appetite and weight. The doctor's diagnosis was neck secondaries of unknown primary, likely involving lymph nodes levels 2 and 3. Differential diagnoses included tuberculous lymphadenitis and lymphoma. Investigations such as blood tests, imaging of the neck and chest, and biopsies were planned. The proposed treatment was radiotherapy or radical neck dissection followed by chemotherapy.

1. CASE OF NECK
SECONDARIES
WITH UNKOWN
PRIMARY
HUMAID HABEEB

2. DEMOGRAPHICS:
Mr. Raju
65 yr old male,
Vannarpet,
Farmer.
Low socioeconomic status
CHEIF COMPLAINTS:
SWELLING IN LEFT SIDE
OF NECK – 20 DAYS

4. HISTORY OF PRESENTING
ILLNESS
Patient was apparently normal before 20 days
then he noticed
Swelling in the left side of the neck
which was insidious in onset
Initially it was small in size of
almost marble shape which progressed to
attain the current size .

5. PRESENTING ILLNESS
H/O Pain over the swelling for the past 15
days,
Dull aching type,
Intermittent in nature,
Radiating to ear,
No aggravating and relieving
factor.

6. PRESENTING ILLNESS
H/O difficulty in swallowing
H/O increased salivation
No H/O difficulty in chewing
 No H/O difficulty in opening mouth,
 No H/O oral ulcers,
 H/O dental caries,

7. No H/O aspiration.
No H/O deviation of angle of mouth or difficulty
in closing eyes
 No H/O slurred speech.
No H/O hoarseness of voice

8. No H/O ear discharge ,deafness
 No H/O nasal bleed
 No H/O dyspnea
 No H/O cough
No H/O altered bowel habits.
No h/o jaundice , haematemesis, malena .

9. No h/o Trauma
No h/o fever, evening rise of temperature,night
sweats,
H/O loss of weight,
H/O loss of appetite.
 No H/O any other swelling.

10. PAST HISTORY
• No H/O similar episodes in the past.
• Not a known diabetic , hypertensive , epileptic ,
asthma , tuberculosis.
• No H/O ischemic heart disease, chronic kidney
disease, thyroid disorder.
• No H/O radiation exposure.
• No H/O previous surgery

11. PERSONAL HISTORY
• Mixed diet
• Normal bowel and bladder habits
• H/O smoking for 40 yrs [5 beedies per day]
• Not an alcoholic,
• Not a tobacco chewer.
• NO H/O extra marital affairs

12. FAMILY HISTORY:
No H/O similar illness in the family member.
No h/o contact with open case of
tuberculosis
TREATMENT HISTORY:
 Not on any medical treatment.
ALLERGY HISTORY:
No h/o allergy

13. GENERAL EXAMINATION
• Patient conscious oriented moderately build and
nourished
• Afebrile
• No pallor
• No icterus
• No Cyanosis
• No pedal edema
• NO generalised lymphadenopathy

14. VITALS
• Pulse rate: 76 beats /min
• Respiratory rate:16, Abdominothoracic
• Blood pressure:120/70 mm/ hg

15. LOCAL EXAMINATION

16. INSPECTION
 Swelling in lateral aspect of the upper part of the
neck on the left side occupying upper
1/3 rd of sternocleidomastoid
 Size : 8*6 cm
 Shape : oval

17. INSPECTION
 Surface: smooth
 Skin over the swelling: stretched
 Margin: defined
 No scars.
 No sinuses
 No dilated veins
 No visible pulsation
 Retromandibular groove – not obliterated.
 Restriction of movement on turning neck to left
side
 Valsalva

18. PALPATION
 Not Warmth
 Tender
 Size:8*7 cm
 Shape : oval
 Extent :
• Upper border :1 cm below mastoid process
• Lower border :3cm below angle of mandible.
• Anterior :5.5cm from angle of mouth
• Posterior :5cm from midline of the back

19. PALPATION
 Surface : Nodular
 Consistency: Hard
 Margin: well defined
 Mobility: Restricted
 Skin not pinchable
 Plane of the swelling: deep to deep fascia.
 Carotid pulsation : Felt on both sides on normal
position
 Fluctuations

20. ORAL CAVITY
EXAMINATION
Oral hygeine : Poor.
Halitosis : Present.
Lips : Normal
Labial sulcus : Normal.
Gingivobuccal sulcus : Normal.
Gums: normal
Buccal mucosa : Nicotine stains present

21. ORAL CAVITY
 Dental caries : Present
 Floor of the mouth : Normal
 Anterior 2/3 rd of tongue : Normal
Mobility : Normal
No Deviation.
 Hard palate : Normal.
 Anterior tonsillar pillar : Normal.

22. ORAL CAVITY
 Posterior pharyngeal wall :Normal.
 Retromolar trigone : Free.
 Opening of mouth : Normal (admits 3 fingers)
 Bidigital palpation : No stricture or stone felt.
No discharge from Stensons duct

23. EAR:
• No Discharge
• No Perforation
• No Polyp
NOSE:
• No Discharge
• No Polyp
• No Nasal deviation
SCALP:
• No Ulcer
• No swelling
THYRIOD:
• Not palpable.

24. EXAMINATION OF LYMPH NODES:
 Preauricular ,postauricular,
occipital nodes : not felt
 Cervical node on opposite side : normal
 Left Supraclavicular fossa : Free
 Axillary area : Normal
 Inguinal region : Normal

25. OTHER SYSTEM
EXAMINATION
Respiratory system:
Normal vescicular breath sounds
Cardio-vascular system:
S1,S2 heard ,no murmurs
Central nervous system:
No focal neurological deficit
Abdomen:
Soft ,non tender , no organomegaly
Spine and cranium:
Normal
External Genitalia :
Normal
Per rectal examination: Normal

26. Summary
• A 65 years old gentleman presents to the out patient
department with chief complaints of swelling in the left
side of neck for past 20 days, With history of pain over
swelling, history of loss of appetite, loss of weight. On
examination the left upper jugular lymph nodes were
enlarged and firm.

27. DIAGNOSIS
A CASE OF NECK SECONDARIES
WITH UNKNOWN PRIMARY
PROBABLY INVOLVING LEVEL
2,3 NODES

28. DIFFERNTIAL
DIAGNOSIS
•TUBERCULOUS LYMPHADENITIS
•LYMPHOMA

29. INVESTIGATIONS
ROUTINE INVESTIGATION:
 Complete blood count
 Urine sugar ,albumin
 Blood sugar , Creatinine
 Chest Xray
 ECG

30. SPECIFIC
INVESTIGATIONS:
 USG neck
 CECT neck
 FNAC of Neck node.
 Triple endoscopy
 USG abdomen
 Blind biopsy
 PET scan

31. TREATMENT
NECK SECONDARIES WITH UNKNOWN PRIMARY:
• Radiotherapy
• Radical neck dissection followed by chemotherapy

32. THANK YOU