Neck swellings

By: Prof. Dr. Ayman Sameh Nabawi

Neck swellings can be classified into midline and lateral neck swellings.

Midline Neck swellings:

Anatomical Region Causes
a) submental region 1- submental LNs
2- sublingual dermoid cyst
3- hourglass ranula (plunging)
4- mandibular abscess
b) hyoid bone region 1- thyroglossal cyst
2- median ectopic thyroid tissue
3- sub-hyoid bursitis
4-tumors of the hyoid bone
c) laryngeal region 1- Laryngeal LNs ( delphian LN)
2- Laryngeal tumors
d)tracheal region 1- Pretracheal LNs
2- Isthmic thyroid nodule
e) supra-sternal space 1- enlarged LNs
2- Lipoma
3- Teratoma
4- Thymoma
5-High aortic arch

A) Dermoid cyst :
 It may present anywhere along the midline (below or above mylohyoid
muscle)
 It can be sub divided into epidermoid, true dermoid or teratoid type.
 It usually presents between 10-25 years of age.
 Incidence: Male = female
 Clinically: smooth, spherical, opaque, fluctuant, and clearly defined
if infected  Painful
 Treatment: Surgical Excision
B) Sub-Hyoid bursitis:
 Affecting old age group
 Presents at the lower border of the hyoid bone.
 Mobile with tongue protrusion
 Translucent

C) Median ectopic thyroid tissue:

 Usually mistaken for a thyroglossal cyst
 Presents in the upper 2/3 of the neck.
 Diagnosed by thyroid scanning.
 May be only thyroid tissue in the body.

D) Thyroglossal cyst:
 Presents in children and young age
 Females > males
 Sites: Sub-hyoid (most common site)
Supra-hyoid, pre-tracheal
 Clinical picture: Painless lump, mobile with tongue protrusion
spherical, smooth, well defined
cystic  fluctuant swelling
translucent
Not tender and No hotness except if infected
may be complicated by fistula formation
Malignant transformation is rare (papillary type)
 Treatment:
Sis-Trunk operation  a) Removal of the cyst.
b) Removal of the tract.
c) Removal of central part of the hyoid bone.
d) Removal of core of tissues up to foramen
cecum.
 N. B: Thyroglossal fistula is an acquired fistula. It is never congenital.

E) Cold Abscess (TB):

 TB lymphadenitis may involve submental, pre-laryngeal and pre-tracheal
lymph nodes (multiple sites)
 Matted lymph nodes.
 Opaque.
 Aspiration  Caseous material.
 Treatment  anti-tuberculous medications

Midline swellings mobile with deglutition:

 Thyroid nodules (goiter).

 Thyroglossal cyst.
 Median ectopic thyroid tissue.
 Sub-hyoid bursitis.
 Laryngocele.
Solid midline swellings Cystic midline swellings
A) Lymph nodes: A) Mandibular abscess
1-submental B) Sublingual Dermoid cyst
2- pre- laryngeal C) Ranula
3- pre- Tracheal D) Thyroglossal cyst
B) Tumors: E) Ranula
1- Goiter F) Sub hyoid bursitis.
2- Hyoid bone G) Cold abscess (TB)
3- Teratoma H) Laryngocele.
4- Thymoma I) Retro-Pharyngeal abscess
5- Laryngeal tumors
C) Median ectopic thyroid
tissue
D) Nodule in thyroid isthmus
Lateral neck swellings:
Differential diagnosis of lateral neck swellings depends on its anatomical site (anterior
or posterior triangle) and it is sub-divided into solid and cystic swellings.
Solid swellings of the anterior triangle:

A) Lymphadenopathy:
 Most common.
 In children, it is mainly due to inflammatory causes due to recurrent
respiratory tract infections.
 May be local disease in the neck or generalized disease as lymphoma.
 Virchow’s lymph node (Troisier's sign)  enlarged left supra-clavicular
lymph node level lV (metastatic from intra-abdominal malignancies).
 Ultrasonographic features of malignant lymph node:
a) Globular in shape
b) Distorted or lost hilum
c) irregular
d) internal necrosis.
 CT scan  Extracapsular invasion, more accurate than US in assessment of
level VII.
 Biopsy is a very important investigatory tool. US guided FNAC, Core biopsy
or Excisional biopsy may be done.

B) Carotid body tumor (chemoductoma- Potato tumor):

 A carotid body is a nest of chemoreceptors located at carotid
bifurcation. It responds to changes in CO2 and O2.
 Carotid body tumor has a high incidence at high attitudes and about
10% of patients have a positive family history.
 Clinically : 40-60 y
male = Female
Slowly growing
Painless
usually solitary
bosselated surface
Not tender
pulsatile swelling
mobile side to side more than up and down
 Investigations: CT angiography is of choice
 splaying of vessels (ECA, ICA).
MRA if CT is contra-indicated.
 Treatment: Surgical excision
N. B: Carotid body tumors are benign tumors, rare to be malignant
tumors.

C) Schwannoma:
 It is a benign tumor of the neurolemmal sheath.
 It may arise from Vagus nerve, sympathetic chain,
glossopharyngeal nerve, or any nerve in the neck.
 Clinically: Painless lump
may cause compression manifestations as
hoarseness of voice , dysphagia
Smooth, encapsulated, firm and mobile side to side
more than up and down
 Treatment: surgical excision.
D) Sternomastoid tumor:
 It is an arterial insult that occurs during birth.
 It is not a congenital tumor.
 It may lead to congenital torticollis.
 Clinically: noticed at birth or 3-4 weeks of life
history of difficult labor
child’s head turned to one side
swelling in middle third of SCM muscle
fusiform in shape with smooth surface
Squint may be present
  Treatment:
a) Physiotherapy.
b) Tenotomy  sternomastoid is cut at its sternal end followed
by usage of a collar for few weeks.
c) Z- myoplasty may be needed.

Cystic swellings of the anterior triangle

A) Pyogenic abscess:
 Painful and tender swelling
 Skin is red and hot.
 Signs of toxemia may be present.
 Treatment  incision and drainage + Antibiotics.
B) Branchial cyst:
 Presents in adult age group.
 congenital anomaly of the 2nd branchial arch.
 The cyst is lined by stratified squamous epithelium.
 The cyst is filled with fluid rich in cholesterol and mucoid
material.
 Clinically: 15-25 y
male = female
painless swelling deep to the anterior
Border of sternomastoid (upper 1/3).
unilateral, smooth surface, ovoid in shape.
 No tenderness unless cyst is inflamed
Trans-opaque
 Complications:
A) abscess formation  fistula formation.
B) Branchogenic carcinoma (SCC) is rare.
 Treatment  surgical excision.
if inflamed with abscess formation 
incision and drainage + antibiotics.

Solid swellings in the posterior triangle of the neck

Solid swellings of the posterior triangle include lymphadenopathy which is the

most common neck swelling, lipoma and cervical rib.

Cervical Rib syndrome:

 It can cause serious neurological and vascular symptoms.
 Clinical examination of neck usually reveals no abnormalities.
 Usually detected by X-ray.
 Types: a) complete rib.
b) Free end of the rib expands to large bony mass.
c) Fibrous band only.
 Clinically  asymptomatic.
Weakness and wasting of small muscles of the
hand.
Raynaud’s phenomenon.
Trophic changes as gangrene tip of fingers.
  Treatment:
a) asymptomatic no treatment.
b) mild symptoms physiotherapy.
c) severe symptoms scalenotomy + removal of the rib.

cystic swellings in the posterior triangle of the neck

A) Cystic hygroma:
 It arises from lymph system.
 May be present in superior mediastinum.
 Presented at birth or in early years of life.
 Usually, multi-locular
 Slowly growing, painless and not tender.
 Translucent.
 May be small (few cm) and may present with huge swelling.
 Complications: a) may obstruct labor.
b) local compression syndrome.
c) infection.

 Treatment: a) Surgical excision (of choice).

b) Sclerosing therapy as bleomycin injection.

B) Pharyngeal pouch ( Zenkers’s diverticulum):

 It is herniation of pharyngeal mucosa through a weak part of the inferior
constrictor muscle (Killian’s dehiscence) namely the junction between
the oblique fibers of the thyro-pharyngeus and the transverse fibers of
the crico-pharyngeus muscle.
  Clinically: affecting middle and old age.
More common in males.
Halitosis.
regurgitation of food ingested before.
Dysphagia.
mass in junction of upper 1/3 and middle 1/3 of
SCM muscle.
Increase in size during eating and straining.
Disappears on pressure and Compressible.
 Barium swallow is diagnostic.
 Treatment: A) endoscopic staple-assisted esophago-diverticulostomy
B) diverticulectomy and cricopharyngeal myotomy.

c) Ludwig's Angina:
 Rare surgical emergency ( serious connective tissue infection of the floor of the
mouth and/ or submandibular glands.
 Mostly due to dental infections
 Treatment  immediate surgical intervention (drainage of pus + antibiotics).