This document provides an overview of common neck swellings, including their classification, clinical features, investigations, and treatments. It discusses ubiquitous neck swellings such as sebaceous cysts and lipomas. It also covers midline neck swellings like lymph nodes and thyroid swellings, as well as lateral neck swellings including branchial cleft cysts, laryngoceles, and carotid body tumors. For each condition, the document describes location, symptoms, diagnostic tests, and surgical management approaches.

1. Evaluation of Common Neck
Swellings
Dr. Krishna Koirala, MS
2020-04-27@ 2:00PM

2. Classification of neck swelling
according to position
• Ubiquitous swellings
• Midline neck swellings
• Lateral neck swellings

3. Ubiquitous swellings
• Sebaceous cyst
• Lipoma
• Neurofibroma
• Hemangioma
• Dermoid cyst
• Teratoma
• Hydatid cyst

4. Midline Neck swellings
• Lymph nodes (submental, Delphian, suprasternal)
• Ludwig’s angina
• Sublingual dermoid
• Thyroglossal cyst
• Subhyoid bursitis
• Thyroid swelling (isthmus & pyramidal lobe)
• Laryngeal tumors
• Sternal and thymic tumors

5. Lateral Neck swellings
• Submandibular triangle:
– Level 1b lymph node, cold abscess, enlarged submandibular
salivary gland, plunging ranula, mandibular tumors
• Carotid and muscular triangle
– Branchial cyst, external laryngocele, thyroid swellings, lymph
nodes (II, III, IV), cold abscess, carotid body tumor, carotid
aneurysm, sternomastoid tumor of newborn
• Posterior triangle swellings:
– Cystic Hygroma, pharyngeal pouch (Zenker’s diverticulum),
lymph nodes (level V), cold abscess, clavicular tumor,
subclavian artery aneurysm

6. Classification of neck swelling
according to etiology
• Congenital / Developmental
• Infective / Inflammatory
• Neoplastic : Benign / Malignant

7. Congenital/developmental neck swellings
• Cystic:
– Sebaceous cyst, dermoid cyst , branchial cyst,
thyroglossal cyst, thymic cyst
• Solid
– Ectopic thyroid
• Vascular
– Hemangioma
– Lymphangioma

8. Infective/Inflammatory neck swellings
• Lymphadenitis
– Acute lymphadenitis
– Chronic lymphadenitis
– Granulomatous lymphadenitis
•Bacterial: tuberculosis, secondary syphilis
•Viral: infectious mononucleosis, AIDS
•Parasitological: toxoplasmosis
•Autoimmune: sarcoidosis, systemic lupus erythematosus
• Sialadenitis : Parotid and Sub-mandibular
• Deep neck space abscess

9. Neoplastic neck swellings
• Skin : Squamous cell ca, Malignant melanoma
• Soft tissue :
– Benign : Lipoma, Fibroma, Schwannoma
– Malignant : Rhabdomyosarcoma
• Lymph node : Lymphoma, Metastatic lymph node
• Thyroid : Benign / Malignant thyroid enlargement
• Vascular : Carotid body tumor, Angioma

10. Consistency of lymph nodes
• Firm, rubbery: lymphoma
• Soft : infection or cold abscess
• Multiple, firm, shotty: syphilis, viral , metastatic
• Matted : tuberculosis , sarcoidosis
• Rock hard, immobile, fixed to skin: metastatic

11. Natural history of Tubercular lymphadenitis

12. Thyroglossal duct cyst
• Thyroid appears as epithelial proliferation in floor of
mouth and descends in front of pharynx as bi-lobed
diverticulum, to reach its final position , connected to
tongue by thyroglossal duct
• The duct normally disappears later
• A cystic remnant might be trapped at any point of
descent and is termed as thyroglossal duct cyst

13. Location
• Base of tongue
• Sublingual
• Supra-hyoid
• Sub-hyoid (50%)
• Prelaryngeal
• Pretracheal

14. Clinical features
• Commonly seen in early
childhood
• Midline, round swelling, 2-4 cm
in diameter that moves with
swallowing and with
protrusion of tongue
• Swelling mobile horizontally but
not vertically
• Cyst increases in size with URTI
• Common Neck swellings
those move on swallowing
– Thyroid swelling
– Thyroglossal cyst
– Subhyoid bursitis
– Pre-laryngeal & pre-tracheal
lymph nodes
– Laryngocele

15. Investigations
• USG of Neck
– Size, site, extent, nature of the swelling and its relation to
hyoid bone, to look for the position of thyroid glands
• CT scan of neck ( plain/contrast)
– Cystic nature of swelling, walls, extent and relation to other
neck structures
• FNAC of neck swelling:
– To differentiate it from other neck swellings
• Thyroid scan: cyst may be the only functioning thyroid tissue

16. Treatment
• Surgical treatment (Sistrunk’s operation)
– Consists of complete surgical excision of cyst and
its tract along with body of hyoid bone and core
of tongue tissue around suprahyoid tongue base
up to foramen caecum

17. Dissection of cyst, following the tract & cutting the hyoid bone

19. Branchial cleft cysts

20. 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 and pouch with openings
in skin & pharynx
• Fistulous tract lies caudal to structures derived from its arch
and dorsal to structures of following arch
• Fistulae are more common in children and cysts
predominate in adults

21. Branchial arches, pouches and clefts

23. First branchial cleft cyst
• Type I
– Contains only ectodermal elements without cartilage or
adnexal structures
– Presents as duplication of external auditory canal
• Type II
– Contains both ectoderm and mesoderm and presents as
abscess below angle of mandible
• Fistula ends internally around Eustachian tube

24. Second branchial cleft cyst
• Commonest branchial anomaly
• Painless, fluctuant mass along anterior border of middle
1/3rd of sternocleidomastoid muscle
• Fistulous tract opens externally along the lower 1/3rd of SCM,
deeper to 2nd arch structures (external carotid, stylohyoid
muscle, posterior belly of digastric) passes superficial to
internal carotid (3rd arch) and opens internally in the tonsillar
fossa

25. • 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 internal carotid, glossopharyngeal nerve(3rd
arch structures) and superficial to superior laryngeal nerve
(4th arch structure)
• Opens internally in base of pyriform fossa
Third branchial cleft cyst

26. Fourth Branchial cleft cyst
• Presents as mass along anterior border of lower 1/3rd of
sternomastoid or as recurrent thyroiditis
• Fistulous tract opens externally along lower 1/3rd of SCM
• Passes deep to superior laryngeal nerve (4th arch structures)
and superficial to recurrent laryngeal nerve (6th arch structure)
• Opens internally in apex of pyriform fossa

27. Treatment
• Abscesses: incision & drainage,
broad-spectrum antibiotics to
control the infection
• Definitive treatment : excision of
cyst along with its tract traced
up to its origin in tonsillar fossa
• Fistula excised with 2
horizontally placed incisions
(step ladder incision)

28. Laryngocele

29. • Arises from expansion of saccule of laryngeal
ventricle due to increased intra-luminal pressure in
larynx or congenital large saccule
– Occupational (?): trumpet players, glass blowers
– Coexistence of larynx cancer
• Male : female 5:1, Peak age = 6th decade
• Unilateral in 85 % cases, 1% contain carcinoma

30. 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.

31. Types of laryngocoele
Internal External Combined

32. Clinical Features
• Hoarseness
• Stridor in large endolaryngeal
laryngocoele
• Neck swelling that enlarges
on Valsalva, crying, shouting
• Manual compression of neck
swelling results in escape of
fluid / gas into airway
(Boyce’s sign)
• 10% cases present with
pyocele: sore throat, cough

33. • Flexible Laryngoscopy
− Swelling of false vocal folds & ary
epiglottic fold
− Swelling easily emptied
− Escape of purulent fluid into airway
pyocele
• X-ray soft tissue neck AP view during
Valsalva maneuver
− Radiolucent area in the neck

34. CT scan of neck in mixed laryngocoele

35. Treatment
• No symptoms: 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, incised at
its neck & stitched

36. Carotid body tumor
• Pulsating, compressible mass in
carotid triangle
• Angiography: Splaying of external &
internal carotid arteries by a vascular
mass (Lyre sign)
• Rx:
– Radiation or close observation in elderly
– Surgical resection for small tumors in
young patients under hypotensive
anesthesia

37. 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

38. Cystic Hygroma

39. • Definition
– Congenital, benign, multi - loculated lymphatic
lesion classically found in posterior triangle of neck
(Cavernous Lymphangioma)
• Etiology
– Failure of lymphatics to connect to venous system
– Abnormal budding of lymphatic tissue
– Sequestered lymphatic cell rests

40. 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 increase in size due to
infection or intra-cystic bleeding
• Airway obstruction, cyanosis, feeding
difficulty, failure to thrive

41. 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%

42. Investigations
• USG : Used to detect cystic hygroma in utero
• CT scan: Contrast helps to enhance cyst wall visualization &
relationship to surrounding blood vessels
– Macrocystic : cystic spaces > 2 cm
– Microcystic : cystic spaces < 2 cm
• MRI : Investigation of choice
– Hyperintense on T2 and
– Hypointense on T1 weighted images

43. Treatment
• Asymptomatic
– Watchful waiting
– Sclerosing agents: OK-432 (picibanil), bleomycin, ethanol,
• Infected cases
– Intravenous antibiotics , Incision & drainage
• Surgical excision
– Mainstay of treatment
– Done with Cautery, Laser, Radiofrequency
• Acute stridor: aspiration, emergency tracheostomy

44. Occult primary with secondary neck node
• Any solid, hard and asymmetric lymph node MUST be
considered a metastatic neoplastic lesion until proven
otherwise (Unknown primary with secondary Neck node)
• Asymptomatic cervical mass carries ≈ 12% chance of cancer
and ≈ 80% of these are squamous cell carcinoma
– Ipsilateral otalgia with normal otoscopy – attention to
tonsil, tongue base, supraglottis and hypopharynx
– Unilateral serous otitis media – attention to nasopharynx

45. Investigations
• Panendoscopy
• Direct Biopsy: Synchronous primaries in 10 to 20%
– Suspicious mucosal lesions, areas of concern on CT/MRI
– None observed – Nasopharynx, tonsil, base of tongue and
pyriform fossa
• Open excisional biopsy of Lymph Node (if complete workup
negative)
– Complete neck dissection
– Frozen section results
•Inflammatory or granulomatous – culture
•Lymphoma or adenocarcinoma – close wound ,
definitive treatment