Neck swellings

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Neck Swelling Differential Diagnosis:

Neck Swelling Differential Diagnosis BY Professor Atef Allam Professor of Vascular and Endovascular Surgery Head of Vascular Surgery Unit Faculty of Medicine, Al- Azhar University, Cairo, Egypt

Swellings of the Neck Differential Diagnosis:

Swellings of the Neck Differential Diagnosis Classification A - Those occurring in the midline - Those in the side of the neck Classification B - Acute swelling - Chronic swelling

Middle Swellings:

Middle Swellings Ludwig Angina Enlarged submental lymph node Sublingual dermoid Lipoma in submental region Thyroglossal cyst Subhyoid bursitis Extrinsic carcinoma of the larynx (late) Goitre (thyroid isthmus / pyramidal lobe) Enlarged lymph node Cystic hygroma (suprasternal space ) Retrosternal goitre Thymic swelling Dermiod cyst ( can occure anywhere in the midline )

In the side of the neck:

In the side of the neck IN THE SUBMANDIBULAR TRIANGLE Enlarged lymph nodes Submandibular salivary gland Deep or plunging ranula Extension of growth from the jaw IN THE CAROTID TRIANGLE Aneurysm of the carotid arteries Carotid body tumours Branchial cyst Bronchogenic carcinoma Goitre Sternmastoid tumour IN THE POSTERIOR TRIANGLE Supraclavicular lymph nodes Cervical rib / cystic hygroma / lipoma / pharyngial pouch Subclavian aneurysm / aberrant thyroid /

Ludwig angina:

Ludwig angina Cellulites is serious when arises beneath the deep fascia. The inflammatory exudates are held tightly under tension by the unyielding deep fascia and tend to tract towards the mediastinum. Ludwig angina is a form of cellulites that starts in the submandibular Region and spread to the floor of the mouth. It produces a diffuse swelling beneath the jaw and inside the mouth with fixing the tongue. It might dangerous complication: - oedema glottis - mediastinitis -fatal septicaemia

Branchial CYST:

Branchial CYST Though congenital , it usually appears in adolescent and adults . Oval cystic swelling ( sometimes firm ) deep to the upper third of The sternomastoid muscle ( half in front and half behind the muscle ) The diagnosis is confirmed by finding cholesterol crystals in aspiration Frome the vestigial remnants of the second bronchial cleft The cyst is usually lined by squamous epithelium, its contents( clear fluid or like toothpaste). In young adults, sometimes in later life at anterior border of the upper third of the sternomastoid as a fluctuant swelling which may Transilluminate. Aspirated fluid contains cholesterol crystals.


CERVICAL RIB Extra rib arising from the 7 th cervical vertebra occurs in 0-46 per cent of persons . Anotomical types :- A complete The free end of rib expands into a Large bony mass. A rib ending in a tepering point, which is connected by a fibrous band A fibrous band closely the scalenus medius alone Clinical type :- 1- cervical rib with local symptoms. Lump in the lower part of the neck which may be visible. on palpation the lump is found to be bony hard and totally fixed. Type (B) is most likely to give rise to these signs. 2- cervical rib with vascular symptoms. Vascular symptoms occur only when a cervical rib is complete. 3- cervical rib with nerve-pressure symptoms


LIPOMA Slowly growing tumour encapsulated or diffuse . Occur anywhere in the body where fat is found ‘ universal tumour ‘ The head and neck area, abdominal wall, and the thighs are particularly favoured sites. Encapsulated lipomas shows definite edge and lobulated. Sense of fluctuation may be obtained , it is painless, Multiple lipomas are not uncommon. Excessive amount of fibrous tissue ( fibrolipoma ) Telangiectasis with lipomas (naevolipoma). Sarcomatous changes. Myxomatous degeneration, saponification calcification sometimes occur in lipomas of long duration


LIPOMA Clinical types 1- subcutaneous 2- subfascial 3- subsynovial :- around joints especially the knee 4- intra-articular 5- intermuscular 6- parosteal 7- subserous 8- submucous :- in the larynx causes respiratory obstruction can occur in the tongue in the intestine intussuusception 9- Extradural a lipoma is rare variety of spinal tumour. Owing to the absence of fat within the skull intracranial lipomas do not occur 10-Intraglandular :- in the pancreas renal capsule and in the breast Diffuse lipoma occasionally occurs in the subcutaneous tissue of the neck


DERMOID SYSTS Cysts lined by squamous epithelium 1- Teratomatous dermoids are found in the ovary, testis, retroperitoneum , superior mediastinum, and the presacral area. Malignant change ( carcinomatous or sarcomatous ) can occur Teratomas arise from ‘ totipotent ’ cells, containing representative cells from all three embryonic layers: ectoderm, endoderm, mesoderm . Teratomatous ‘dermoids’, for example, contain hair, teeth, muscle, gland tissue . 2-Sequestration dermoids are not new growths, but are formed by the inclusion of epithelial ‘nests ’ beneath the surface at places where lines of developing skin meet and join ( midline, external angular process root of nose, 3- Implantation dermoids follow puncture wounds, commonly of the fingers, when living epithelial cells are implanted beneath the surface


EPIDERMOID CYST SEBACEOUS CYST This is a cyst containing keratin and its breakdown products, surrounded by an epithelial wall. Affecting young and old, rare in childhood . It is a result of inflammation around the pilosebaceous follicle. Unilocular and spherical there may be a connection with the surface by a keratin-filled duct , it raises the epidermis to produce a firm, elastic, dome shaped protuberance mobile over the deeper structures . Tethered to the epidermis , central keratin-filled punctum . The common sites face, neck, shoulders and chest solitary /multiple If inflamed become tender and Suppuration may occur. Cyst contains yellowish-white material composed of fat an epithelial cells Complications :- 1- infection 2- ulceration 3- sebaceous horn


ECTOPIC THYROID Some residual thyroid tissue along the course of the thyroglossal tract is not uncommon, and may be lingual, cervical or intrathoracic. Median ectopic thyroid :- Swelling in the upper part of the neck and is usually mistaken for a thyroglossal cyst Lateral aberrant thyroid :- ( No evidence ), may be a metastasis in a cervical lymph node from an occult thyroid carcinoma.

Thyroglossal cyst :

Thyroglossal cyst May be present in any part of the thyroglossal tract the common situation, in order of frequency, are beneath the hyoid, in the region of the thyroid cartilage, and above the hyoid bone. The swelling moves upwards on protrusion of the tongue as well as on swallowing. The wall contains nodules of lymphatic tissue. An infected cyst is often mistaken for an abscess and incised, a thyroglossal fistula arises which is never congenital , it follows infection or inadequate removal of a thyroglossal cyst

Cystic Hygroma:

Cystic Hygroma Lymphangioma arising under the deep fascia and extending deeply between the muscles. Usually located at the root of the neck an may spread to the mediasinum and pectoral region. {mediastinm extension is suspected if it gets tense on straining } It is usually multilocular but may be unilocular { hydrocele of the neck } It is translucent


SWELLINGS OF THE LYMPH NODES In tuberculous lymphadenitis, the lymph nods might break down and liquefy, the resulting cold abscess may erode the deep fascia and reach the plane of the superficial fascia, forming what is called a collar-stud abscess. There are approximately 800 lymph nodes in the body, 300 of them lie in the neck. Usually multiple. Infection occurs from the oral and nasal cavities, the ear, the scalp and face .The affected lymph nodes are enlarged and tender, varying degree of pyrexia. Chronically inflamed lymph nodes which do not resolve in the space of 3 or 4 weeks are nearly always tuberculous or lymphoma . Affect children or young adults, it can occur for the first time at any age. Usually one group of cervical nodes is first infected. widespread cervical lymphadenitis can occur, periadenitis or matting of the lymph nods is evident. A primary focus in the lungs must be suspected Renal investigate for T.B. should be done. Abscess / collar stud abscess / sinus may be accompanied. Liver / spleen and other lymph nodes should be investigated for lymphoma


SWELLINGS OF THE SUBMANDIBULAR SALIVARY GLAND Infection may or may not be associated with calculus. Differentiation from enlarged submandibular lymph nodes is made by a history of enlargement of the swelling ( sometimes with a colic ) at the time of meals By digital palpation by which the deep part of the salivary gland can be felt but not the lymph nodes. Further, pressure on the swelling may result in the flow of pus through the orifice of the wharton’s duct.

Carotid body tumour chemodectoma or ‘potato’ tumour:

Carotid body tumour chemodectoma or ‘potato’ tumour This potentially malignant growth is located at the bifurcation of the common carotid artery, i.e. at the level of the upper border of the thyroid cartilage. It gives rise to a hard ovoid lobulated swelling under the upper third of the sternomastoid , movable laterally but not vertically, as it is attached to the carotid. Pulsation of the carotid arteries can be felt in front, but the swelling itself is not pulsatile . pressure over the swelling may cause slowing of the pulse-rate and a feeling of faintness ( carotid body syndrome ) { chemoreceptor }

Sternomastoid tumour:

Sternomastoid tumour Is not a tumour It is the result of birth injury to the sternomastoid muscle, causing thormbosis and subsequent fibrosis. It gives rise to a circumscribed firm mass within muscle, this usually subsides spontaneously but may, later on, lead to wryneck . ألتواء الرقبه

Aneurysm of the carotid and subclavian A:

Aneurysm of the carotid and subclavian A Pulsatile palpable mass in supraclavicular fossa. Loud bruit and thrill. Neurological symptoms –cervical rib. Thromboembolic complications in arm-digital ischemia (90%). Punctate cynotic lesion in hand. Radial/ ulnar pulse may be lost. Brachial plexus compression---- pain Duplex and angiogram are diagnostic

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