Approach(To(Neck(Swelling

ANATOMY'

The'limits'of'the'neck'are':'

Medial :'Mildline'of'neck
Lateral :'Anterior'margin'of'trapezius
Superior :'Inferior'border'of'mandible
Inferior1:'Superior'border'of'clavicle'

Lateral'side'of'neck'divided'into':'
(delineates'by'sternocleidomastoid'muscle)'

Anterior1Triangle
Posterior1Triangle1
Anterior(Triangle
Bound&by&:&

Anterior(:(Midline(of(the(neck
Medial(:(Anterior(border(of(sternocleidomastoid
Superior(:(Inferior(border(of(mandible((
Apex(:(Extends(towards(manubrium(sterni

Further&divided&into&4&sub3triangles&:

Submental
Submandibular
Carotid(
Muscular(
Anterior(Triangle(

Contains(4(sub2triangles(:(
Submental
Submandibular-(Digastric)
Carotid
Muscular-
Anterior(Triangle(

Submental*Triangle
Inferior :(Hyoid(bone(
Medial :(Midline(of(neck
Lateral*:(Anterior(belly(of(digastric(muscle
Floor :(Mylohyoid(muscle(
Apex :(Symphysis(menti

Contents :(Anterior(jugular(veins(and(
submental(lymph(nodes
Anterior(Triangle(

Submandibular+Triangle
Superior :(Inferior(border(of(mandible
Anterior :(Anterior(belly(of(digastric(muscle(
Posterior :(Posterior(belly(of(digastric(muscle
and(stylohyoid(muscle
Floor :(Mylohyoid(muscle((

Contents+:(Marginal(mandibular(branch(of(facial(nerve,
lingual(nerve,(hypoglossal(nerve((CN(XII),
facial(and(lingual(arteries(and(veins,
submandibular(glands(and(lymph(nodes
Anterior(Triangle(

Carotid(Triangle
Anterosuperior :(Posterior(belly(of(digastric(muscle(
Anteroinferior(:(Superior(belly(of(omohyoid(muscle
Lateral :(Medial(border(of(sternocleidomastoid(muscle

Contents(:(Common(carotid(artery(and(its(bifurcation
(internal(and(external(carotid(arteries),
internal(jugular(veins,(superior(thyroid(and((
middle(thyroid(veins,(vagus(nerve,(
hypoglossal(nerve,(accessory(nerve
Anterior(Triangle(

Muscular(Triangle
Medial(:(Neck(midline(from(hyoid(bone(to(sternum
Superolateral :(Superior(belly(of(omohyoid
Inferolateral :(Anterior(border(of(sternocleidomastoid
Superior :(Hyoid(bone(

Contents :(Infrahyoid(muscles,(superior(and(inferior(
thyroid(arteries,(anterior(jugular(vein,(larynx,
trachea,(oesophagus,(thyroid(and(
parathyroid(gland((
Posterior(triangle(

Bound&by :
Anterior(:(Posterior&edge&of&sternocleidomastoid&
Posterior :&Anterior&border&of&trapezius&
Inferior :&Middle&⅓&of&clavicle&

Further&divided&into&(divided&by&omohyoid&muscle):&

Occipital(triangle(
Subclavian(triangle(
 Posterior(Triangle(

Occipital(Triangle
Contents':'Accessory'nerve'(CN'XI),'cutaneous'and'
muscular'branch'of'cervical'plexus,'upper'part
of'brachial'plexus,'supraclavicular'nerves,'transverse
cervical'artery

Subclavian(Triangle

Contents':'3rd'part'of'subclavian'artery,'inferior'aspect'of'
external'jugular'vein,'trunks'of'brachial'plexus,'
nerve'to'subclavius'and'lymph'nodes'
Compartments+of+Neck+
Consists+of+4+compartments+each+surrounded+with+fascia+:

i)+Visceral)Compartment)0 Anterior
(Surrounded)by)Pretracheal)layer)
thyroid,+parathyroid,thymus,+larynx,+pharynx+

ii)+Vertebral)Compartment)0 Posterior
(Surrounded)by)prevertebral)layer))
cervical+vertebrae,+spinal+cord,cervical+nerves,+
associated+postural+muscles

iii)+2)Vascular)Compartments > Lateral

(Surrounded)by)carotid)sheaths))
Common+carotid+artery,+internal+carotid+artery,+internal
jugular+vein,+vagus+nerve

Neck+completely+surrounded+by+investing+layer++
 Fascial'Spaces'
● In'between'fascial'layers'in'the'neck'
● May'provide'conduit'for'spread'of'infection'from'neck
to'mediastinum'
● Consists'of'4'spaces':'
i)'Pretracheal)space)
Between'investing'layer'and'pretracheal'fascia
ii)'Retropharyngeal)space)
Between'pretracheal'and'prevertebral'fascia
iii)'Danger)space
Between'alar'and'prevertebral'fascia'
Free'communication'with'posterior'mediastinum,
extending'to'diaphragm'
iv)'Space)within)carotid)sheath
Differential*Diagnosis*of*Neck*Swelling
History(

● Age$:(<16(years(pediatric(neck(mass(either(inflammatory(or(congenital,(16;40(years(most(likely(
inflammatory/congenital(etiology(but(frequency(of(malignancy(start(to(increase,(>40(years(consider(
neoplastic,(suspect(malignancy
● Mass$growth$pattern$:(Characteristics(of(mass,(duration,(growth(pattern,(absence(or(presence(of(
pain.(
● Associated$symptoms:$hoarseness(of(voice,(dysphagia,(otalgia,(difficulty(breathing(especially(
when(lying(down
● Other$symptoms:$fever,(night(sweats,(weight(loss,(reduced(appetite.(High(spiking(fever(suggest(
acute(infection(
● Social$history:(smoking,(alcohol(use,(illicit(drug(use,(HIV(status.(
Physical)Examination

● Location(of(mass
Preauricular)or)angle)of)jaw)→)salivary)or)lymphoid)tissue)in)parotid)
Anterior)aspect)of)SCM)→)enlarged)lymph)nodes,)congenital)mass)such)as)branchial)cleft)cysts
Central)neck)→)thyroid)nodules,)dermoid)cysts)
● Characteristics(of(mass
Discrete,)mobile,)firm,)rubbery,)slightly)tender)→)reactive)lymph)nodes
Hard,)fixed)mass)→)malignancy
Isolated,)tender,)warm,)erythematous,)fluctuant)→)infected)lymph)node
Rapidly)expanding)mass)→)rapidly)growing)lymphoma
Immobile)neck)mass)moves)with)swallowing)→)thyroglossal)duct)cysts/thyroid)tumour
● Other(components(of(examination
Oral)cavity)and)oropharynx)
Nasopharyngeal)and)ear)examination
Assessment)of)cranial)nerve)function
Position)of)trachea)→)presence)of)deviation)from)midline
Abdominal)examination)→)possible)enlargement)of)spleen)or)liver,)or)any)abdominal)masses
Investigation+

● Complete+blood+count+with+differential+
● ESR+or+CRP+→+evaluation+of+systemic+infection/inflammation
● Blood+culture+for+febrile+patients
● Serology+studies+→+Epstein+barr+virus,+cytomegalovirus,+HIV++
● Thyroid+function+test+→+thyroid+nodule/+goitre
Imagings

Ultrasound →)Evaluation)of)thyroid)nodules
→)Used)in)frequent)surveillance)imaging

CT →)Neck)mass)arising)from)or)adjacent)to)bony)structure
→)Involvement)of)deep)neck)spaces

MRI →)Infiltrative)soft)tissue)mass,)suspicious)of)perineural)spread,)potential
central)nervous)tissue)in)origin

PET/CT →)Helpful)in)setting)of)malignancy,)primary)disease)identification,
detection)of)distant)metastatic)spread
Diagnostic*Studies*

● Fine*needle*aspiration*
● Core*biopsy
● Ultrasound*or*CT*guided*biopsy
 Evaluation*of
Thyroid*Nodules**
Thyroid(Nodules(
● Thyroid(malignancy(account(for(5(to(10%(of(thyroid(nodules
Evaluation*of*Thyroid*Nodules**

● History*
● Physical*examination
● Evaluation*of*thyroid*function*: serum*TSH*
● Ultrasound*: nodularity,*assess*sonographic*features,*presence*of*additional
nodules*or*lymphadenopathy
History(
→(Age(
→(Rate(of(neck(mass(growth
→(Compressive(symptoms((dysphagia,(dysphonia,(dyspnoea)
→(Presence(of(pain(over(neck(mass
→(Symptoms(of(hypo/hyperthyroidism
→(Family(history(of(thyroid(disease(or(cancer
→(Previous(head(and(neck(or(whole(body(irradiation
→(Previous(surgery((head(and(neck,(upper(oesophageal/(thoracic)(
History(

→(Features(suggestive(of(malignancy(:

● Young(age(<20)(or(old(age((>60)
● Rapid(growth(of(mass
● Recent(changes(in(speaking,(breathing,(swallowing
● Hx(of(external(neck(radiation(during(childhood/adolescence
● Family(history(of(thyroid(cancer(or(MEN(type(2

→(Sudden(increase(in(nodule(size(with(pain(→(cysts(or(localised(thyroiditis
Physical)Examination)

● Thyroid)dimension)and)consistency
● Nodule)location
● Nodule)size)
● Number)of)nodules
● Presence)of)neck)tenderness
● Moves)with)swallowing
● Presence)of)retrosternal)extension
● Cervical)central)or)lateral)lymph)node)enlargement
Physical)Examination
→)Physical)signs)suggestive)of)malignancy):

● Firm)to)hard)consistency)of)nodule
● Irregular)shape
● Fixation)to)underlying)or)overlying)tissues
● Vocal)cord)paralysis
● Suspicious)regional)lymphadenopathy)
Measurement*of*Serum*TSH

● Thyroid*function*should*be*assessed*in*all*patients*with*thyroid*nodules

● If*serum*TSH*less*than*normal,
→*indicating*overt*or*subclinical*hyperthyroidism**
→*Possibility*of*hyperfunctioning*nodule*
→*Thyroid(scintigraphy(should(be(performed(next

● If*serum*TSH*normal*or*elevated
→*Proceed(with(Ultrasound
→*For*FNA*if*nodule*meet*sonographic*criteria*for*sampling*
Thyroid(Scintigraphy(

→(Radioiodine(imaging(used(to(determine(
functional(status(of(nodule

→(Uses(iodine(radioisotopes((123=I)(or(
technetium=99m(pertechnetate(

→(Most(benign(and(virtually(all(malignant(
thyroid(nodules(concentrate(radioisotope(
less(avidly(than(adjacent(normal(thyroid(tissue(

→(Contraindicated(during(pregnancy(

*(Outcomes(:(Nonfunctioning,+autonomous+or+indeterminate
Thyroid(Scintigraphy(

Nonfunctioning*

→ Nodules(appear(cold(

→(Uptake(less(than(surrounding(tissue

→(Require(further(evaluation(by(FNA
Thyroid(Scintigraphy(

Autonomous(

→(Appear(hot

→(Uptake(greater(than(surrounding(tissue

→(Hyperfunctioning(nodule(

→(Rarely(are(malignant(< does(not(require(FNA
Thyroid(Scintigraphy(

Indeterminate
→+Result(from(superimposition(of(abnormal(nodule
and(normal(thyroid(tissue(

→(Represent(small(non9functioning(nodule(anterior(
or(posterior(to(normal(thyroid(tissue(

→(May(also(represent(functioning(nodule(that(don’t(
produce(enough(thyroid(hormones(to(suppress(TSH

→(Should(be(evaluated(further(by(ultrasound.(For(FNA
if(meet(sonographic(criteria(for(sampling(
Thyroid(Ultrasonography(

● For(assessing(:

→(nodule/gland(size

→(thyroid(parenchyma(

→(Location(of(nodule

→(Characteristics(of(nodule

→(Presence(or(absence(of(cervical(
lymph(node(enlargement
TI#RADS(Level( Follow(Up(Based( Frequency(of( FNA(Biopsy(
on(Size((cm) Follow(Up( Threshold((cm)
(Years)(

TR3( >(1.5(cm( 1,3(and(5 >(2.5(cm(

● If(presence(of(
TR4 >(1.0(cm 1,2,3(and(5 >(1.5(cm( multiple(nodules,(
2"nodules"with"
TR5 >(0.5(cm Annually(up(to(5( >(1.0(cm( the"highest"ACR"
years
TI4RADS"grades
should(be(
biopsied(
 Fine%Needle%Aspiration%
● FNA%cytology%reporting%utilises%Bethesda%system
→%Non%diagnostic%
→%Benign
→%Atypia/Follicular%lesion%of%undetermined%
significance%%(AUS/FLUS)

→%Follicular%neoplasm

→%Suspicious%of%malignancy

→%Malignant
Management(
Pre/Perioperative+Management+of+Hyperthyroidism

● All+elective+surgery+should+be+postponed+until+euthyroid/+near+euthyroid+state
achieved+

● For+urgent+surgery,+rapid+control+with+high+dose+MMI+or+PTU,+beta+blockers,+
Lugol’s+iodine+and+glucocorticoid+are+recommended+