đź©ş MedAtlax

Neck swllings.backup

7 min read

Case Scenarios - Neck Swelling

Dr. S. Ahmed Khan

midline neck swelling

  • Thyroid mass
  • Thyroglossal cyst
  • Dermoid cyst

Ant. triangle

Thyroid

  • salivary glands
  • LN
  • Branchial cyst

Post. Triangle

  • cystic Hygroma

    • transillumination test

  • LN most common

  • Phanangean Poor

Case Scenarios - Neck Swelling

Dr. S. Ahmed Khan

MBBS, FCPS

Assoc.Prof of Surgery

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 assoc: 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

gaiter not moving with swallowing

Systemic Symptoms

most Common Cause of neck Swelling:

Lymphadenopathy: Fever, night sweating, contact

L FNA is best investigation for lymph with infectious disease, weight loss, change in appetite, respiratory/ gastrointestinal symptoms.

Goitre: Nervousness, tremor, weight loss/ gain,

only enlargement can be hypo or hyper

palpitation, preference to cold/ warm weather, muscle

fatigue, sweating.

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 goiter

Auscultation- NAD for Brue

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

  • most common thyroid tumor • Papillary
  • Follicular → Hemogenous spread
  • Hurthle cell
  • MTC (sporadic / familial

MEN 2 A (Sipple syndrome- MTC, pheo, HPT, lichen planus amyloidosis, Hirschsprung’s dis.)

MEN2B (MTC, pheo, marfanoid, mucosal neuromas, ganglioneuroma of GIT)

  • Anaplastic
  • Lymphoma

Differential Diagnosis

  • Papillary carcinoma
  • Anaplastic carcinoma
  • MTC
  • Lymphoma

Investigations

  • US

  • FNA- PC (malignant, non-diagnostic, benign)

  • TFT

Best investigation

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

so we will 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 the wound in the ward and relife the bruiser then call surgeon

Case 2:

12-year old boy presented with a neck swelling

img-1.jpeg

Thyroglossal Cyst

  • Midline swelling
  • Moves upwards with protrusion of the tongue
  • Aetiology- persistence of part of thyroglossal duct
  • Treatment: Excision with a central wedge of hyoid bone ( tract run either superficial of deep to hyoid)

found in Infrathyoid more common than supra

Case 3

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 clawed symptoms at acute inflammation

in deep facia

? 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 nose and send it

? Treatment: Anti-tuberculous drugs

if not treated will cause fistula.

Case 4

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

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 parietal 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

âś“ 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

Case pain after eating: Best option for treatment is surgery

if stone is no gland best option is excision ⇒ most common in Submandibular gland

Common Neck Swellings

1

img-5.jpeg

Jugular Venous Aneurysm

Neck swelling lateral to the right sternomastoid muscle made prominent on breath holding ,straining, coughing, crying, valsalva maouvre Compressible

  • Investigations: best in any vascular disease color doppler u/s, venography, CT angiography. MRI
  • Treatment: Surgery (cosmetic reason) not have any complication

2

Anterior triangle

img-6.jpeg

Cervical L.N

3

img-7.jpeg

Goiter Could be diffused or Loaize L. Graves is most common thyroid disease in female

Thyroid Mass

4

img-8.jpeg

Excision

Lipoma Soft, globular

Ht: excision

5

img-9.jpeg

. sever pain . reful after eating

in submandibular triangle

xiii: Antibiotic, Excision

Acute Submandibular Sialoadenitis

salivary gland

6

img-10.jpeg

Goiter

Hyper → use anti thyroid drugs

hypo → use thyroxin

***: near total or total thyroidectomy

7

midline

img-11.jpeg

Exhibition

Dermoid Cyst

Congenital at any midline Cerebral Corhead sublingual

if not moves with Dysputation

H.T.: excision

8

img-12.jpeg

Shiny Cold Pos. triangle

T.B Lymphadenitis

H4: Anti tB

don’t open the wound may lead
to fistula if you want to drain pus
open it from independent area

9

img-13.jpeg

Central

Swallowing and protracting test, are negative

Thyroid Adenoma

Solitary nodule

Could be hypo or hyper

Functioning

  • most of them benign

  • 15% malignant

we have to do FNA to make

Sure not malignant it

not we can leave it

10

img-14.jpeg

  • globule
  • Swallowing
  • Professional tongs
  • Ht: castrack

Thyroglossal Cyst

11

img-15.jpeg

Inflamed Thyroglossal Cyst

txt: Antibatic the do cistrunk

12

img-16.jpeg

A

img-17.jpeg

B

A) Thyroglossal Abscess

B) Fistula

13

img-18.jpeg

  • Slow growing
  • Painless
  • below ear lobe

Parotid Adenoma

14

Pain, Fever & the Hunting

img-19.jpeg

incision as draige

Antibiotic according to culture

Parotid Abscess

Thank You!

img-20.jpeg

Graph View