An approach to patient with neck swelling.

2. Musaddiq Hussain Bangash

3. Prominent landmarks
 Hyoid bone
 Thyroid cartilage (men)
 Cricoid cartilage (women)
 Trachea
 Sternocleidomastoid muscle

4.  Triangles of the neck
 Anterior
 Anterior border of the SCM, midline, lower border of the mandible
 Subdivisions: inferior carotid, superior carotid, submandibular, submental
 Posterior
 Posterior border of SCM, clavicle, anterior border of trapezius
 Subdivisions: subclavian, occipital

7.  In Pediatric age group: 90% benign.
 50% out of which may be congenital.
 In adult population: 80% non-thyroid masses.
(Rule of 80)

9.  <20 years…. Congenital or Inflammatory
 20-40 years…. Inflammatory or Lymphoma
 >40 years… Metastatic

10.  DURATION:
 Acute
 Chronic
 Mode of onset:
 Progressive/ Non-progressive
 Site
 Painful/Painless
 Associated symptoms
 Personal habits
 Previous irradiation or surgery

11.  Site of swelling
 Size
 Number
 Shape
 Surface
 Margins
 Colour
 Overlying skin

12.  Temperature
 Tenderness
 Surface
 Smooth
 Irregular
 Lobulated
 Consistency
 Solid
 soft
 Firm
 Hard
 Rubbery

13.  Mobility
 Fluctuation
 Transillumination
 Pulsation
 Relation to surrounding structures

14.  Blood:
 CBC
 ESR
 TFT
 CRP
 Imaging:
 Computed tomography (CT)
 Magnetic resonance imaging (MRI)
 Ultrasonography
 Radionucleotide scanning
 PET scan

15.  Cytology
 FNAB
 Tissue:
 Incisional/ Excisional Biopsy

16. Fine Needle Aspiration Biopsy (FNAB)
 Standard of care
 Indications
 Not obvious abscess
 Persists following antibiotics
 No contraindications

17.  Ultrasonography
 Inexpensive
 Easily available
 Non expensive
 Useful for solid versus cystic (congenital cyst vs. lymph node/glandular tumor)

18.  Uses Fluorine labelled deoxyglucose
 Used for:
 Evaluation of Regional LN
 Detect distant metastasis
 Synchronous primary lesion

19.  Thyroid Masses
 Lymphoma
 Salivary Tumors
 Lipoma

20.  A leading cause of anterior neck masses
 Children
 Most common neoplastic condition
 Male predominance
 Greater chance of malignancy
 Adults
 Mostly benign
 Female predominance

21.  Lymph node metastatic
 15% of papillary carcinomas
 40% with malignant nodules
 Histologically in >90% (microscopic)
 FNAB is standard of care
 Decreases number of patients with surgery
 Repeat negative aspiration in 1 month

23.  More common in pediatric & young adults
 80% of children with Hodgkin’s have neck mass
 Signs and symptoms
 Mass only, fever, hepatosplenomegaly, diffuse adenopathy
 FNAB - 1st line; open biopsy if suggestive
 CT scans (H&N, chest, abdomen) & bone marrow biopsy

24.  Any preauricular enlarging mass or at the angle of the mandible is suspicious
 Benign - asymptomatic
 Metastatic - rapid growth, skin fixation or cranial nerve palsies
 Open excisional biopsy preferred

25.  FNAB
 Reduces number of patients with surgery by 1/3
 Distinguishes intra-glandular lymph nodes, localized sialadenitis, benign cysts
 Accuracy >90% (better for benign)
 Sensitivity - 90%; Specificity - 80%
 May facilitate surgical planning or patient counseling
 Prepare for total parotidectomy & nerve sacrifice in unknown primaries

26.  Over age 35 usually
 Ill-defined, soft, mobile subcutaneous masses of variable sizes
 Excised only when infected or also for cosmetic reasons

27.  Very common
 Marked tenderness, torticollis, trismus, and dysphagia
 Systemic signs of infection
 Initial treatment - directed antibiotics
 Close follow up

28.  Failure of antibiotics necessitates biopsy after complete head and neck work-up
 FNAB indications
 Progressively enlarging nodes
 Solitary, asymmetric nodal mass
 Supraclavicular mass
 Persistent nodes without infectious signs

29.  Develop over weeks and months
 Minimal systemic complaints or findings
 Firm glands, fixation and injection of skin
 Common etiologies
 Typical Mycobacterium tuberculosis (adults)
 Atypical Mycobacterium tuberculosis (children)
 Cat-scratch fever (Bartonella henselae) (children)
 Actinomycosis, Sarcoidosis

30.  Atypical TB
 Anterior triangle lymph nodes
 Induration and pain
 Usually responds to complete surgical excision
 Cat-scratch fever
 Preauricular or submandibular lymph nodes
 Spontaneous resolution 1-2 months
 Typical TB (rarely seen, posterior nodes)