🩺 MedAtlax

Neck swellings

7 min read

Case Scenarios - Neck Swelling

Dr. S. Ahmed Khan, MBBS, FCPS

Neck Swellings by Anatomical Location

Midline Neck Swelling

  • Thyroid mass
  • Thyroglossal cyst
  • Dermoid cyst

Anterior Triangle

  • Thyroid
  • Salivary glands
  • LN
  • Branchial cyst

Posterior Triangle

  • Cystic hygroma – transillumination test
  • LN – most common
  • Pharyngeal pouch

Case Scenario 1

A 60-year-old female presented with neck swelling for 4 months, dyspnea and hoarseness of voice for 1 month.

Involvement at Recurrent Laryngeal Nerve → so think about Cancer

  • She is in your clinic.
  • What to do?

Always Start with History

History of Neck Swelling

  • How noticed? Often noticed by others
  • Duration? Acute or chronic
  • Painful – acute lymphadenitis, thyroiditis, bleeding in goitre, submandibular salivary gland stone.
  • Painless – chronic lymphadenopathy, goitre, branchial cyst, TB
  • Change in size:
    • Rapid increase – infection, bleeding, malignant change.
    • Slow increase – in neoplasms
  • Single or multiple? Multiple – lymph nodes

Other Associated Symptoms

Specially in anterior triangle masses

  • Voice change (malignant invasion)
  • Dysphagia (pressure on esophagus)
  • Dyspnea (pressure on trachea)
  • Eye symptoms
  • Throat pain, Oral ulcer
  • Nasal symptoms, Scalp lesion

Goitre not moving with swallowing

Systemic Symptoms

Most common cause of neck swelling:

Lymphadenopathy

  • Fever, night sweating, contact with infectious disease, weight loss, change in appetite, respiratory/ gastrointestinal symptoms.
  • FNA is best investigation for lymph

Goitre

  • Nervousness, tremor, weight loss/ gain, palpitation, preference to cold/ warm weather, muscle fatigue, sweating.
  • Only enlargement – can be hypo or hyper

Systemic Inquiry

  • GI – appetite, wt. change, bowel habit (thyroid, LN)
  • RS – dyspnea on exertion, (retrosternal extension)
  • CVS – palpitation, ankle swelling
  • GU – amenorrhea
  • CNS – nervousness, irritability, insomnia (thyrotoxicosis)
  • Endocrines – preference to warm or cold weather

This Patient

  • Neck swelling
  • Painless
  • Slow increase → Neoplasm
  • Dyspnea
  • Voice change
  • PMH – Nil significant, no neck radiation
  • FH of neck /thyroid malignancies – NAD
  • Medication/allergies – nil

img-0.jpeg

General Examination

No endocrine symptoms

  • Appearance – NAD
  • Eye – NAD
  • Hand tremors – NAD
  • Tachycardia – NAD

Local Examination

  • Inspection – solitary mass, left anterior triangle, moving up on deglutition → thyroid
  • Palpation:
    • Left lobe – 3x3 cm hard mass, non-tender.
    • Rt. Lobe – normal
    • Multiple ipsilateral LAP, enlarged cervical lymph node → Papillary
    • Trachea shifted to right side
  • Percussion – NAD (significant in retrosternal goitre)
  • Auscultation – NAD (for bruit)

Differential Diagnosis

  • Clinical: Goitre, Thyroid mass
  • Functional – Hyper, hypo, Normothyroid?
  • Pathological – Diff. diagnosis?
    • MNG, Thyroiditis, Cyst
    • Thyroid neoplasms
  • Which type? Most likely papillary because of association of lymph nodes

Thyroid Malignancy

  • Papillary – most common thyroid tumor
  • Follicular → Hemogenous spread
  • Hurthle cell
  • MTC (sporadic / familial)
    • MEN 2 A (Sipple syndrome – MTC, pheo, HPT, lichen planus amyloidosis, Hirschsprung’s dis.)
    • MEN 2B (MTC, pheo, marfanoid, mucosal neuromas, ganglioneuroma of GIT)
  • Anaplastic
  • Lymphoma

Differential Diagnosis (Malignancy)

  • Papillary carcinoma
  • Anaplastic carcinoma
  • MTC
  • Lymphoma

Investigations

  • US
  • FNA – PC (malignant, non-diagnostic, benign) — best investigation
  • TFT – can’t differentiate between follicular adenoma and carcinoma
  • CXR
  • CT
  • Indirect laryngoscopy – Lt RL nerve palsy
  • Surgery

Inconclusive FNA

  • Non-diagnostic/ cellular – repeat
  • Repeat FNA – inconclusive if still → depend on other investigation
  • TSH level – normal/high → surgery (means that nodule is hypoactive)
  • TSH low – nuclear scan (hyperfunctioning nodule)
    • Low uptake – surgery, cold nodule ⇒ more malignancy
    • High uptake – follow up or therapy

Thyroidectomy for Thyroid Nodule

Surgery (indications):

  • Malignant nodule even if it’s small
  • Progressively enlarging nodule
  • Pressure symptoms
  • Suspicious nodule (FNA failed to establish a benign nature)
  • Thyrotoxic nodule

Total Thyroidectomy

  • Lobectomy in younger age
  • Subtotal → in benign
  • Total thyroidectomy → malignant
  • Malignant tumours
  • Neck lymph node dissection? in lymphadenopathy (papillary)
  • RIA (Radio iodine ablation) – large tumour, metastasis, local tumor extension
    • primary
    • secondary
  • Complications: Bleeding, hypoparathyroidism, recurrent laryngeal nerve injury.

If there’s hematoma after surgery this is an emergency case – often open the wound in the ward and relieve the bruise, then call the surgeon.

Case 2: Thyroglossal Cyst

A 12-year-old boy presented with a neck swelling.

img-1.jpeg

  • Midline swelling
  • Moves upwards with protrusion of the tongue
  • Aetiology – persistence of part of thyroglossal duct
  • Found in infrahyoid (more common than suprahyoid)
  • Treatment: Excision with a central wedge of hyoid bone (tract runs either superficial or deep to hyoid)

Case 3: TB Lymphadenitis

A 35-year-old female presented with multiple neck swellings for 3 months.

Posterior triangle

  • History?

img-2.jpeg

The Patient

  • History of lump: multiple, painless
  • Systemic inquiry: Fever, loss of weight, night sweat, no cough
  • Examination: multiple, some discrete, some matted, firm swellings – typical TB
  • ENT, chest, abdomen – NAD
  • Diagnosis / DD: ? lymphadenitis most probably
    • Cystic hygroma
    • Pharyngeal pouch
  • Investigation

TB → firm, painless, mattable, matted together

TB Lymphadenitis

  • Painless, initially firm swelling
  • Later may become soft (cold abscess) – because no classical symptoms of acute inflammation, in deep fascia
  • Matted, discharging sinus – may lead to fistula formation
  • Evening fever, night sweats, wt. loss, anorexia
  • Diagnosis: FNA, aspirate for AFB, culture, PCR, biopsy
  • CT in malignancy suspicion
  • Take one node and send it
  • Treatment: Anti-tuberculous drugs – if not treated will cause fistula

Case 4: Parotid Abscess

Presented with a Painful Swelling

  • Tender swelling
  • Fever

img-3.jpeg

Parotid Abscess

  • Tender parotid swelling with fever and malaise
  • Pus exuding from duct papilla
  • Staph. aureus, Strep. viridans
  • Early cases: antibiotics, oral hygiene before pus formation (-ve fluctuating test)
  • Late cases: abscess drainage (I/D) and antibiotic according to result.

Case 5: Pleomorphic Adenoma

Painless Swelling for 1 Year

Slow growing, most common benign → Pleomorphic adenoma

img-4.jpeg

Salivary Gland Neoplasms

BENIGN:

  • Pleomorphic adenoma – more common in superficial lobe of parotid gland
  • Warthin’s tumour
  • Oncocytoma
  • Basal cell adenoma
  • Intraductal papilloma

MALIGNANT:

  • Mucoepidermoid carcinoma*
  • Acinic cell carcinoma
  • Adenoid cystic carcinoma
  • Basal cell carcinoma
  • Low grade adenocarcinoma
  • Mucinous adenocarcinoma
  • Malignant pleomorphic tumour
  • Lymphoma

Pleomorphic Adenoma

  • Most common neoplasm, parotid most common site
  • F = M 2:1, 3–5 decade
  • Slow growing, painless mass / mild discomfort, not attached to skin
  • Risk of malignant change – 1.5% in 5 years
  • FNA – most helpful in all glands
  • CT, MRI rarely needed
  • Treatment:
    • Superficial parotidectomy / Total parotidectomy
    • Enucleation – not recommended
    • Submandibular: Total gland excision

Pain after eating → best option for treatment is surgery. If stone is in gland, best option is excision ⇒ most common in submandibular gland.

Common Neck Swellings

1. Jugular Venous Aneurysm

img-5.jpeg

  • Neck swelling lateral to the right sternomastoid muscle, made prominent on breath holding, straining, coughing, crying, Valsalva manoeuvre
  • Compressible
  • Investigations: best in any vascular disease – color doppler u/s, venography, CT angiography, MRI
  • Treatment: Surgery (cosmetic reason) – no complication

2. Cervical L.N

Anterior triangle

img-6.jpeg

3. Thyroid Mass

img-7.jpeg

  • Goitre could be diffuse or lobulated
  • Graves’ is the most common thyroid disease in female

4. Lipoma

img-8.jpeg

  • Soft, globular
  • Treatment: Excision

5. Acute Submandibular Sialoadenitis

salivary gland

img-9.jpeg

  • Severe pain
  • Relief after eating
  • In submandibular triangle
  • Treatment: Antibiotic, Excision

6. Goitre

img-10.jpeg

  • Hyper → use anti thyroid drugs
  • Hypo → use thyroxin
  • Rx: near total or total thyroidectomy

7. Dermoid Cyst

Midline

img-11.jpeg

  • Congenital at any midline
    • Cerebral
    • Coccygeal
    • Sublingual
  • If not moves with deglutition
  • Treatment: excision

8. T.B Lymphadenitis

img-12.jpeg

  • Shiny
  • Cold
  • Posterior triangle
  • Treatment: Anti TB
  • Don’t open the wound – may lead to fistula; if you want to drain pus, open it from an independent area

9. Thyroid Adenoma

Central

img-13.jpeg

  • Swallowing and protrusion tests are negative
  • Solitary nodule
  • Could be hypo or hyper functioning
  • Most of them benign
  • 15% malignant
  • We have to do FNA to make sure it’s not malignant; if not, we can leave it

10. Thyroglossal Cyst

img-14.jpeg

  • Globular
  • Moves with swallowing
  • Moves with protrusion of tongue
  • Treatment: Excision of cyst tract

11. Inflamed Thyroglossal Cyst

img-15.jpeg

  • Treatment: Antibiotics, then do cystectomy

12. Thyroglossal Abscess & Fistula

img-16.jpegimg-17.jpeg

  • A) Thyroglossal Abscess
  • B) Fistula

13. Parotid Adenoma

img-18.jpeg

  • Slow growing
  • Painless
  • Below ear lobe

14. Parotid Abscess

Pain, Fever & the swelling

img-19.jpeg

  • Incision & drainage
  • Antibiotic according to culture

Graph View

Backlinks