Mr. X, a 65-year-old male farmer, presented with a swelling in the left side of his neck for 20 days. On examination, a large oval swelling was found occupying the upper left side of his neck. Investigation revealed the swelling to be neck secondaries of an unknown primary cancer. The differential diagnoses included tuberculous lymphadenitis and lymphoma. Treatment would involve radiotherapy or radical neck dissection followed by chemotherapy.

1. CASE OF NECK
SECONDARIES

2. INTRODUCING MR.
DEMOGRAPHICS:
Mr.X
65 yr old male,
Arachalur,
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 variation in in size of the swelling or
pain during eating.
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 with hemoptysis.
No H/O altered bowel habits.
No h/o jaundice , haematemesis, malena .

9. PRESENTING ILLNESS
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
• Married -2 childrens
• H/O smoking for 40 yrs [5 beedies per day]
• Smoking index: 200
• 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
 Extent:
• Upper border : 1.5 cm below mastoid process
• Lower border : 2cm below angle of mandible
• Anterior :6cm from angle of mouth
• Posterior :5cm from midline of the back

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

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

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.
 Dental formula: 2 1 1 1 2 0 1 2
1 2 1 2 1 2 2 2

22. ORAL CAVITY
 Posterior pharyngeal wall :Normal.
 Retromolar trigone : Free.
 Opening of mouth : Normal (admits 3 fingers)
 Bimanual palpation: deep lobe is not palpable.
 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. DIAGNOSIS
A CASE OF NECK SECONDARIES
WITH UNKNOWN PRIMARY
PROBABLY INVOLVING LEVEL
2,3 NODES OF STAGING
TxN3M0.

27. DIFFERNTIAL
DIAGNOSIS
•TUBERCULOUS
LYMPHADENITIS
•LYMPHOMA

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

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

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

31. THANK YOU