Dr. Ali Al-Taey
Arab Board (C.A.B.S)
High diploma in surgery

 Diagnosis of a lump in the neck can often be made with
 acareful history and examination.
History
answer four critical questions:
1. Is there one or more than one lump?
2. Where is the lump?
3. Is it solid or cystic?
4. Does it move with swallowing ,or protrude with tongue?
Ask about onset ,duration, if it is first attack or occur before.
if change in size ,colour of skin or discharge ,tender.
Upper r.tract infection.fever,any G.I.T

Physical Examination
Complete head and neck exam
Visualize all mucosal surfaces (direct, indirect)
Palpate oral and pharyngeal surfaces
Emphasize location, mobility and consistency of neck mass (vascular,
salivary, nodal, inflammatory, congenital, neoplastic)
Local examination:
Size
Site
Shape
Surface
Consistency
Fixation: deep/superficial
Pulsatility
Compressibility
Transillumination
Bruit

Investigations
1. CBC :- ( infection , lymphoma ……..etc. ) .
2. U/E :- ( Parathyroid ) .
3. TFT :- ( Thyroid ) .
4. PTH :- ( Parathyroid )
5)Calcitonin . Thyroglobulin :- ( Thyroid ) .
6. Tuberculine test :- ( T.B. ) .
7. CXR :- ( Lung lesions ) .

Fine Needle Aspiration Biopsy (FNAB)
Indication:
Not obvious abscess
Persists following antibiotics
No contraindications (vascular?)
Fine gauge needle (23 - 27)
Skilled pathologist
reducedSeparates neoplasm
from carcinoma or lymphoma
Ultrasonography –
useful in differentiating
solid from cystic masses and
congenital cysts from solid lymph nodes andglandular tumors.
Useful for solid versus cystic (congenital cyst vs. lymph
node/glandular tumor)
Noninvasive
Critical Bleeding complications reduced.

 Radionucleotide Scanning –
 Also indicate the functionality
 of the mass.


 PETscan
 indicates the functional activity of a mass
 A more radio-intense mass has greater metabolic
activity and is usually neoplastic
pET useful for differentiated between recurrent cancer and scar.

 Computed Tomography (CT) –
 Benefits :
 1. It can distinguish cystic from solid lesions .
 2. Define the origin and full extent of deep, ill-defined masses .
 3. When used with contrast can delineate vascularity or blood flow.
4. In patients with metastatic SCCa to the neck from an unknown primary, CT
should be obtained to detect an unknown primary lesion .
5. To help with staging purposes.
N.B. : Lucent changes within nodes, size larger than 1.5cm, and loss of sharpness
of nodal borders are often signs of metastatic carcinoma

 Magnetic Resonance Imaging
 It is currently better for upper neck and skull base
masses due to motion artifact on CT.

 Open excisional biopsy
 Repeated exam and workup fail to reveal with an
equivocal or negative FNAB
 Prepare for complete neck dissection
 Frozen section results
 Inflammatory or granulomatous: culture tissue
 Adenocarcinoma or lymphoma: close wound

Posterior triangle
1)Supraclavicular lymph.
2)cystic hygroma-cystic Swelling.
3)pharyngeal pouch.
4)lipoma.
5)cervical rib-palpable lump.
6)clavicular tumour.
7)cold abscess.

CERVICAL LYMPHADENOPATHY
Causes of cervical lymph gland enlargement
Infection
Non-specific specific
specific specific
Glandular fever
Tuberculosis
Syphilis
Toxoplasmosis
Cat-scratch fever (Rochalimaea henselae)
Metastatic tumour
From head, neck, chest and abdomen
Primary reticuloses
Lymphoma
Lymphosarcoma
Reticulosarcoma
Sarcoidosis

cervical lymph glands
Enlargement of the cervical lymph glands is the most common cause
of a swelling in the neck.
Age When associated with tonsillitis,(a sore throat). the majority of
patients are below the age of 10 years. or can occur at any age.
painful lump just below the angle of the jaw.,
the lump may be large enough to be visible or felt by the child’s parent
when washing the neck..
Recurrent severe episodes can cause loss of weight and slow down the
rate of growth and body maturation.
Social history Recurrent sore throats and upper
respiratory tract infections are more common
The child may snore at night, have difficulty in breathing, have nasal speech
because of tonsillar and adenoid hyperplasia, and suffer from recurrent chest
infections.
Cause The child and the parents frequently appreciate the relationship between
the appearance of the lump and an episode of tonsillitis.

 the tonsils drains to the upper deep cervical lymph glands.
Called(the tonsillar gland).
 the enlarged glands will be tender.
 Each gland is firm in consistence, solid and discrete,( not
fixed but not very mobile).
 The glands on the other side of the neck are often not have
been noticed by the parents.
 General examination
 Look for the presence of enlarged lymph glands elsewhere.
None should be enlarged.
The gland just below and deep to the angle of the mandible

Tuberculous cervical lymphadenitis and abscess
The human tubercle bacillus can enter the body via
the tonsils, and from there move to the cervical lymph
glands. The upper deep cervical glands are most often
affected.
Tuberculous lymphadenitis is common in children and
young adults, and in the elderly.

a lump in the neck.This appears gradually, sometimes with,
sometimes without, pain.,
but the elderly sometimes have anorexia and slight weight loss.
If the glands break down into an abscess, the swelling increases in
size, becomes more painful and some time discolouration of the
overlying skin.
When the glands are very painful, neck movements
and swallowing may be painful.
Immunization Ask whether the patient has been vaccinated
with BCG.
Family history Check that no one in the family has had tuberculosis.
Social history Tuberculosis is more common in the poor .
The pain can be intense if the glands grow rapidly and necrose.Systemic
symptoms are unusual in the young
Previous history Elderly patients often have a history of swollen neck
glands when young – sometimes treated at that time by surgical excision.

 slightly tender there is no abscess present, the
overlying skin should look normal.,
 In the early stages, the
 glands are firm, discrete As caseation increases and
the glands necrose, the infection spreads beyond the
capsules of the
 glands. This makes the lumps enlarge and coalesce.
A typical patch of tuberculous lymphadenitis is an indistinct,
firm mass of glands which occupies the upper half of the deep
cervical lymph chain, partlybeneath and partly in front of the
sternomastoidmuscle.

Thank you

Branchial cyst
It is a remnant of a branchial cleft,
usually the second cleft.
lined with squamous epithelium,
History
Age Although these cysts are present at birth,
symptoms until adult life.
The majority present between the ages of15 and 25 years,
but a number appear in the 40s and 50s.
Sex Males and females are equally affected.
but there are also patches of lymphoid tissue in the wall which are
connected with the other lymph tissue in the neck and whichcan become
infected.

Symptoms
A painless swelling in the upper lateral part of the neck.
The pain is usually causedby infection in the lymphoid tissue in
the cyst wall.
not associated with any other congenital abnormality
Examination
Position A branchial cyst lies behind the anterior edge of the
upper third of the sternomastoid muscle.
The lump may be painful when it first
appears and later cause attacks of pain
associated with an increase in the size of the
swelling
A severe throbbing pain, exacerbated by
moving the neck and opening the mouth,
develops if the
contents of the cyst become infected and
purulent . General effects These cysts have
no systemic effects and are

Shape The cyst is usually ovoid, Surface Their surface is smooth
and the edge distinct
Composition.
The lump fluctuates. This sign is not always easy
to elicit, especially if the cyst is small and the sternomastoid
muscle thick.
The lump is contains desquamated epithelial cells that
make its contents thick and white. Sometimes the fluid is
golden yellow
and shimmers with fat globules and cholesterol.
crystals secreted by the sebaceous glands in the epithelial
lining. Such cysts may transilluminate.
The cyst cannot be reduced or compressed.

 Relations It is important to ascertain that the bulk
 of the mass is deep to the upper part of the sternomastoid
muscle. It is not very mobile because it is closely tethered to
the surrounding structures.

Branchial fistula (or sinus)
This is a rare congenital abnormality. It is the remnant
of a branchial cleft, usually the second cleft,
The patient complains a small dimple in the skin at the
junction of the middle and the lower third of the anterior
edge of the sternomastoid muscle.
Clinical pictures:
discharges clear mucus, and sometimes becomes swollen and
painful and discharges pus.
Swallowing accentuates the openings on the skin.
When the whole branchial cleft stays patent, the fistula connects
the skin with the oropharynx, just behind the tonsil. In most
cases the upper end is obliterated and the track should really be
called a branchial sinus.

Carotid body tumour
It is tumour of the chemoreceptor tissue in the carotid body .
It is therefore a chemodectoma.(usually benign, but can
become quite large occasionally, malignant.
History:
Age Chemodectomata commonly appear in patients
between the ages of 40 and 60 years.
Symptoms :is a painless, slowly growing lump.
The patient may notice that the lump pulsates, and may also
suffer from symptoms of transient cerebral ischaemia
(blackouts ,transient paralysis or paraesthesia). These
symptoms
are unusual because the increasing compression of the carotid
artery by the tumour is a very slow process.

Carotid body tumour
Development The lump grows so slowly
Carotid body tumours may be bilateral.
Examination
palpating a lump close to the bifurcation of the carotid
artery .Carotid body tumours are therefore found in the
upper part of the anterior triangle of the neck, level
with the hyoid bone and beneath the anterior edge of
the sternomastoid muscle.
Pressure in this area can induce a vasovagal attack. Position The carotid
bifurcation is at, or just below , the level of the hyoid bone.

Composition :The majority of these tumours are solid
and hard. do not fluctuate. They are often called potato
tumours
.Sometimes these tumours pulsate. a transmitted
pulsation from the adjacent carotid artery,
or a palpable external carotid artery running over the
superficial aspect of the lump.
a true expansile pulsation from a soft of these tumours are
hard. Those which are soft and very vascular not only have an
expansile pulsation, but can also be compressed.
Relations The lump is deep to the cervical fascia and
beneath the anterior edge of the sternomastoid muscle.
The common carotid artery can be felt below the mass,

 the external carotid artery may pass over this tumour is
indistinguishable from an enlarged lymph gland.
 The carotid arteries, these tumours can be moved from
 side to side but not up and down.

Cystic hygroma
(Lymph cyst, lymphocele, lymphangioma)
 A cystic hygroma is a congenital collection of
lymphatic sacs which contain clear, colourless
lymph.
 channels that failed, during intra-uterine
development, to connect with and become normal
lymphatic pathways.
 Lymph cysts commonly occur near the root of the arm
and the leg (i.e. in the anatomical junction between
the limbs and head and the trunk).

History
Age The majority of cystic hygromata present at
birth or within the first few years of life,.
Occasionally large lymphoceles can be seen in elderly
patients.
Symptoms The only symptom is the lump, but the parents of
an affected child are usually more concerned about the
disfigurement caused by the cyst.
Examination
Position Cystic hygromata are commonly found
around the base of the neck, usually in the posterior triangle,
but they can be very big and occupy the whole of the
subcutaneous tissue of one side of the neck.
but they occasionally stay empty until infection or trauma in adult life
causes them to fill up and become visible
Family history This condition is not familial.

Pharyngeal pouch
A pharyngeal pouch is a pulsion diverticulum of the
pharynx through the gap between the horizontal fibres
of the cricopharyngeus below and the lowermost
oblique fibres of the inferior constrictor muscle
above.
If swallowing is uncoordinated so that the
sphincter-like fibres of the cricopharyngeus do not
relax, the weak unsupported area just above these
fibres (known as Killian’s dehiscence) bulges out.

History
Age Pharyngeal pouches appear in middle and old age.
Sex They are more common in men than in women.
Symptoms
recurrent sore throats before noticing the common presenting
symptom of regurgitation of froth and food. Regurgitation at
night causes bouts of coughing and choking, and if pieces of food
are inhaled, a lung abscess may develop.
As the pouch grows, it presses on the oesophagus and causes
dysphagia.
The regurgitated food is undigested and comes up into the
mouth at any time. There is no bile or acid taste to it.
Patients can sometimes swallow their first few mouthfuls
of food (until the pouchis full), but thereafter have
difficulty in swallowing

 Position In most patients there is no palpable but if,appears
behind the sternomastoid
 muscle, below the level of the thyroid cartilage.
 Shape. It feels like a bulging deep structure.
 The pouch is not palpable when it is smaller
 Composition The lump is soft and sometimes
 indentable. It can be compressed and sometimes
emptied.
 Compression may cause regurgitation. Although
 the mass may disappear with compression, not to
 return until the patient eats again,
Size Most pouches only cause a swelling of 5–10cmdiameter.
so many patients have symptoms but noabnormal physical signs.
It is dull to percussion and does not fluctuate or transilluminate.

Relations
A pharyngeal pouch lies deep to the deep fascia, behind the
sternomastoid muscle, and is fixed deeply. Its origin from a
structure behind the trachea can be appreciated during
palpation, but the neck of the pouch and its attachment to the
oesophagus cannot be felt.
General examination Pay special attention to the chest,
as there may be an aspiration pneumonia, collapse
of a lobe or a lung abscess
It cannot be moved about in the neck. Lymph glands The cervical lymph glands should
not be enlarged . Local tissues The surrounding tissues feel normal.Indeed, when the
pouch is empty the whole neck feels normal.

Sternomastoid ‘tumour’
(Ischaemic contracture of a segment of the sternomastoid muscle)
This is a swelling of the middle third of the sternomastoid muscle.
an infarcted segment of the muscle, caused by the trauma of birth. lump
disappears and the abnormal segment of muscle becomes fibrotic and
contracted.
History
Symptoms The mother may notice the lump or that the child keeps their
head turned to one side –torticollis. Attempts to turn the head straight
may cause pain or distress.
. If the muscle damage becomes an area of permanent fibrosis, the twist
and tilt of the head to one side becomes more noticeable as the child
grows.
Age The lump is noticed at birth or in the first few weeks of life.If the muscle is not
extensively damaged, theswelling slowly subsides, the muscle spasm
relaxesand the torticollis disappears .
The lump Position The swelling lies in the middle of the sternomastoid muscle (i.e.
in the middle third of theneck on the antero-lateral surface

Tenderness in the first few weeks of life.
The swelling is fusiform, The surface is smooth.
Edge The anterior and posterior edges of the lump are distinct
but the superior and inferior edges, where the lump becomes
continuous with normal muscle, are indistinct.
Surrounding structures and local lymph glands These
should be normal.
Contraction of the left sternomastoid turns
the head towards the right, but tilts the head to the
left.
Composition At first the lump is firm and solid and easy to feel, but as it
gradually becomes harder it begins to shrink and may become impalpable.

Cervical rib
Although the cervical rib can cause serious neurological
and vascular symptoms in the upper arm,
clinical examination of the neck does not usually reveal any
abnormalities.
The abnormal rib is usually detected with an X-ray.
Sometimes there is afullness at the root of the neck
. Occasionally it can be associated with aneurysmal change in
the subclavian artery. The common neurological symptoms
caused by
a cervical rib are pain in the C8 and T1 dermatomes,
and wasting and weakness of the small muscles in
the hand. Vascular symptoms such as Raynaud’s
phenomenon, trophic changes, even rest pain and
gangrene, may occur but are uncommon.

Thyroglossal cyst
 The thyroid gland develops from the lower portion
of
 the thyroglossal duct, which begins at the
foramen
 caecum at the base of the tongue and passes
down
 to the pyramidal lobe of the isthmus of the thyroid
 gland. If a portion of this duct remains patent, it
can
 form a thyroglossal cyst.
 Theoretically, thyroglossal cysts can occur anywhere between the
base of the tongue and the isthmus of the thyroid gland, but they are
commonly found in two sites: between the isthmus of the thyroid
gland and the hyoid bone, and just above the hyoid bone.
Thyroglossal cysts within the tongue and in the floor of the mouth are
rare.

 History
 Age majority are seen in patients between 15 and 30 years old.
Sex They are more common in women than in men.
 Symptoms
 a painless lump (The commonest ).
 Pain, tenderness and an increase in size occur only if infected.
 Examination
 Position Thyroglossal cysts lie close to the mid-line, somewhere between
the chin and second tracheal ring.
 Colour, temperature and tenderness,
 the overlying skin will be red, hot and tender (infected.)
 When there is no infection, the overlying skin is normal.
 Shape and surface spherical and smooth, with a clearly defined edge.
 Size They vary from 0.5 to 5 cm in diameter.
 Duration of symptoms The lump may have been present for many years before an
increase in its size causes the patient to complain.
 Systemic symptoms There are no systemic symptoms associated with this condition
 Because a lump in the front of the neck is so noticeable, patients often complain of
these cysts when they are very small.

 Composition Thyroglossal
 cysts have a firm or hard consistence, orSome
cysts are too tense and others too small to
fluctuate,
 the majority of thyroglossal cysts are between
these extremes and fluctuate.
 the contents have become thickened by
 desquamated epithelial cells or the debris of past
 infection, or because they are too small.

THE THYROID GLAND
.
 SYMPTOMS OF THYROID DISEASE

A lump in the neck
 The majority of thyroid swellings grow slowly and painlessly.
 the patient will come across a swelling coincidentally when washing,
or a member of their family or a close friend will point it out to
 them..
 In a few patients, a lump will appear suddenly and may be
 painful, or a long-standing lump may enlarge quickly.
 A rapid change in the size of part of the gland, or
 of an existing lump,may be caused by haemorrhage
 into a necrotic nodule, a fast-growing carcinoma

 Discomfort during swallowing
 Dyspnoea
Pain
 Pain is not a common feature.
 Acute and subacute thyroiditis can present with
apainful gland, and Hashimoto’s disease often causes
an uncomfortable ache in the neck. Anaplastic
carcinoma can cause local pain and pain referred to
the ear if it infiltrates surrounding Structures
 Hoarseness.

 Plan for the examination of a
patient with a goitre
 Look at the whole patient for
agitation,
 nervousness or lethargy.
 Examine the hands for sweating,
tremor,
 tachycardia.
 Examine the eyes for
exophthalmos, lid lag,
 ophthalmoplegia, chemosis.
 Examine the neck: always check
that the lump
 moves with swallowing.
 Palpate the cervical lymph glands.


