Approach to lateral neck swelling in adults and children

Approach to Lateral Neck Swellings

Approach to Lateral
Neck Swellings
• Moderator-
• Prof Shailendra Kr Yadav
(MCh, MS)
• Dr. Faraz Ahmad
(MS)
• Presented By-
Dr. Debmoy Ghatak
JR III

Approach to Lateral Neck Swellings
-Contents-
• Clinical scenarios
• Relevant Anatomy
• Differential diagnosis- Age specific
• Guidelines for neck swellings
• Elaboration of each diagnosis

Clinical Scenario 1
• A 13-year-old girl came with a swelling on the right side
of the lower jaw since 1month. She had difficulty in
mastication. Mild pain associated with swelling.
• On examination, solitary diffused swelling - on the right
submandibular region lying anterior to the right SCM in
upper 1/3rd.
• Non-pulsatile, with smooth surface texture. Surrounding
skin was normal. Not moving with protrusion of the
tongue or on deglutition.
• On palpation, surface temperature was not raised,
nontender, soft in consistency, fluctuant, compressible,
and not reducible. No secondary changes were noted.
Journal of Orofacial Sciences
Vol. 6• Issue 2• July 2016
Clinical Scenario 1

Clinical Scenario 2
• A 2 year old developmentally normal female child
presented with complaints of swelling in the right side of
the neck for 20 days.
• He was apparently normal except for a history of
respiratory tract infection 2 weeks before the onset of
swelling. The swelling gradually increased to attain the
present size.
• On inspection, it was approximately 3x2.5 cm, present in
the right upper part of the neck. Margins - not well
defined. It was mobile, cystic, fluctuant, non-tender,
nonpulsatile . In Transillumination test the mass was
brilliantly transilluminant
• USG was performed. The report described an irregular,
multiloculated, cystic swelling of 4.3x2 cm size in the
right upper anterior triangle of neck extending to the
posterior triangle of neck Gnanavel et al., Anat Physiol
2015, 5:1

• A 12-year-old male patient, previously healthy,
sought medical attention complaining of a
progressively growing mass on the right side of
the neck, during the last month. The patient
referred fever and oral bleeding since the
beginning of the symptoms. He denied weight
loss and night sweats. His primary care
physician prescribed antibiotics, without any
improvement.
• On physical examination, three painless
enlarged lymph nodes were present on the right
cervical chain. On palpation, all nodules were
hard, fixed to surrounding tissues, without
fluctuation points, and showed well-defined
limits. The rest of the physical examination was
unremarkable.
Autops Case Rep. 2012 Oct-Dec; 2(4): 53–60.
Clinical Scenario 3

Relevant Anatomy
• Triangles of Neck
Anterior Triangle
Posterior Triangle
• Sub Triangles
Anterior triangle comprises
1. Submental Triangle
2. Submandibular /
Digastric triangle
3. Carotid Triangle
4. Muscular Triangle
• Posterior triangle comprises of
Occipital triangle
Omoclavicular triangle

Relevant anatomical
structures that may
give rise to lateral
neck swelling.

From American Journal Of Roentjenology-
2002
Line of separation between levels I and II is
posterior margin of submandibular gland.
Separation between levels II and III and IV is
posterior edge of sternocleidomastoid muscle.
Line of separation between levels IV and V is
oblique line extending from posterior edge of
sternocleidomastoid muscle to posterior edge of
anterior scalene muscle.
Posterior edge of internal jugular vein separates
level IIA and IIB nodes. Carotid arteries separate
levels III and IV from level VI. Top of
manubrium separates levels VI and VII.

Differential diagnosis in Children
Neck masses in children
Developmental
/ Congenital
Inflammatory/
Reactive
Neoplastic

• Sternomastoid tumor – MCC Mass in infants.
• Cystic Hygroma,
• Branchial Cleft Abnormalities.
• Vascular Malformations,
• Hemangiomas.
• Thyroglossal Duct Cysts (Midline swelling).
• Dermoid Cysts (Mostly Midline).
Congenital
Congenital Neck Mass in Children

Reactive
lymphadenopathy
• Reactive viral
LAP is most
common cause of
cervical
lymphadenopathy
in children
worldwide.
• <4yrs age reactive
LAP is relatively
common.
Infectious
lymphadenitis
• Mycobacterial
infections (MCC
in India-
4.36/1000 pop)
• Viral,
• Staphylococcal
• Cat-scratch
disease (In US)
Immunological
• Kawasaki disease
(Immunologically
mediated
vasculitis group
of ds).

Neoplasm
• Lipomas,
• Fibromas,
• Neurofibromas
• Salivary Gland Tumors.
Benign
Lesions
• Metastatic Nasopharyngeal
Carcinoma,
• Lymphoma
• Rhabdomyosarcoma
• Thyroid Carcinoma.
Malignant
Lesion

General Plan for diagnosis
History
Clinical
Examination
Radiological
Examination
Histopathological
examination

Acute Causes (Days to weeks)
Subacute Causes (Weeks to months)
Chronic Causes (Months together)

Differential Diagnosis in Adult
ACUTE
CAUSES
Post Traumatic
Post Infective/ Inflammatory

Post Traumatic
• Hematoma
• Pseudoaneurysm or arteriovenous fistula
Post Infective/ Inflammatory
• Reactive lymphadenopathy.
• Acute sialadenitis
• Acute Staphylococcal or streptococcal infection
• Viral URI
• Mycobacterium tuberculosis(Neck suppuration for any extrapulmonary disease)
• Rare causes-
• Cytomegalovirus
• Epstein-Barr virus infection
• HIV infection Blood/sexual contact

Subacute disease
• Infective
• Neoplastic
• Systemic diseases- rare
disorders
• Idiopathic diseases-very
rare causes

SUBACUTE CAUSES
Infective
Tuberculosis
Neoplastic
Hodgkin lymphoma
Squamous cell carcinoma-HPV
related
Upper aerodigestive tract squamous
cell carcinoma
Metastatic cancer
Parotid tumors
Chronic sialadenitis
Non-Hodgkin lymphoma

Subacute diseases
Systemic diseases-
Rare disorders
Amyloidosis
Sarcoidosis
Sjögren syndrome
Idiopathic diseases –
Very Rare Causes
Castleman disease
(angiofollicular
lymphoproliferative
disease)
Kikuchi disease
(histiocytic necrotizing
lymphadenitis)
Kimura disease Endemic
in Asia;
Rosai-Dorfman disease

Congenital cysts
• Branchial cleft
cyst
• {Thyroglossal
duct cyst – MCC
Cystic swelling in
neck of childhood
• Dermoid cyst}
Midline Swelling
Goiters (enlarged
thyroid)
• Graves disease
• Hashimoto
thyroiditis
• Toxic
multinodular
goitre
Thyroid Nodules-
• Cold thyroid
nodule
• Thyroid
carcinoma-
Lateral Aberrant
thyroid
• Toxic functional
adenoma
Chronic
Causes

Chronic
Causes
Relatively common-
Lipoma
Laryngocele
Liposarcoma
Rare causes-
Glomus jugulare and
Glomus vagale tumor
Cervical Rib
Zenker’s diverticulum

Discussion
HistoryHistory
Specific histories may point out to particular diagnosis many a times.
Infectious mass may have h/o developing within a few days or weeks of an upper respiratory infection,
dental infection, trauma, travel, or exposure to certain animals.
In children h/o difficult child birth
How old is the pt ?
H/o Blunt or sharp trauma may give rise to hematoma
H/o Blunt or sharp trauma with shearing force may give rise to AV Malformation
H/o contact to TB in family/ surroundings
H/o past TB
H/o Past radiation
H/o endocrine malignancy in family
H/o addiction- Alcohol and Tobacco Smoking
H/o- Indigenous food (Nitrate rich food in southern china, Iodine deficient food in foothills )
H/o M.U.S.I.C ? (HPV, HIV related Cx)

• Most neck masses in adults are neoplastic rather than infectious.
• A malignant neck mass should be suspected based on the following "stand-alone"
features detected by the initial history
• Lack of an infectious etiology
• Duration of ≥2 weeks or unknown
• Additional findings that may increase the suspicion for a malignant etiology include
• History:
• Age >40 years
• Tobacco or alcohol abuse
• History of head and neck cancer
• H/0 skin cancer of the scalp, face, or neck.
• Immunocompromised status
Discussion
HistoryHistory

• Additional findings that may increase the suspicion for a malignant etiology
• Symptoms:
• Hoarseness or recent voice change
• Otalgia or recent hearing loss ipsilateral to the neck mass
• Nasal congestion or epistaxis ipsilateral to the neck mass
• Oral cavity or oropharyngeal ulcer
• Odynophagia or dysphagia
• Pharyngitis or "sore throat"
• Hemoptysis or blood in saliva
• Dyspnea
Discussion
HistoryHistory

• Salivary or lymphoid tissue in the parotid system.
Preauricular and angle of the
jaw
• Most commonly -thyroid or malignant in origin. Also represent a
dermoid cyst.Central neck –
• Adults-suggest potential malignant involvement. Congenital
masses, such as the second branchial cleft cyst, are common in the
pediatric population.
Anterior aspect of the SCM,
high jugulodigastric region
• High index of suspicion for malignancy.Posterior triangle
• Malignancy metastasizing from below the clavicle, such as
gastrointestinal sources, lung or gynecological.
Supraclavicular masses,
especially on the left side
Clinical
Examination
Discussion
Mass localization

• Supraclavicular lymph node drains a different set of organs in right and left.
• The thoracic duct drains all the visceral organs and finally ends up in left IJV in
left supraclavicular space hence giving rise to more prevalent left supraclavicular
LN enlargement in visceral malignancies.
• Virchows node in Left supraclavicular basin is one of the “Renowned one” !
• Malignancy metastasizing from below the
clavicle, such as gastrointestinal sources, lung
or gynecological.
Supraclavicular
masses, especially on
the left side
Clinical
Examination

• Characteristics of the mass —
• Palpation of the neck mass is critical.
• Neck masses due to "reactive" lymph nodes are usually discrete, mobile, firm or
rubbery but not rock hard, and slightly tender.
• Rock-hard, fixed masses raise concern for malignancy. Lymph nodes representing
metastatic disease may be matted to the underlying structures and are usually
nontender.
• Infected lymph nodes are usually isolated, asymmetric, tender, warm, and
erythematous; they may be fluctuant.
• Soft, ballotable, mobile masses are often congenital cysts. However, in adults, cystic
neck masses may represent nodal metastases from human papillomavirus (HPV)-
related oropharyngeal squamous cell carcinoma (OPSCC) .
• In a review of 29 isolated cystic neck lesions thought to be branchial cleft cysts, in
patients over 40 years, 31 percent were found to be malignant on final pathological
review.
Clinical
Examination
Differential diagnosis of cystic neck lesions, Sira J, Makura ZG
Ann Otol Rhinol Laryngol. 2011;120(6):409.

• A rapidly expanding mass (over days to weeks) raises concern for
infection or a rapidly growing lymphoma.
• A firm, lateral neck mass that moves from side to side but not up and
down indicates involvement with the carotid sheath, such as a carotid
body tumor or vagal schwannoma.
• A pulsatile quality or bruit suggests a vascular lesion.
• An immobile midline neck mass that elevates with swallowing
indicates a thyroid source, such as a thyroglossal duct cyst or thyroid
tumor.
Clinical
Examination
Clinical
Examination

• The oral cavity and oropharynx should be examined with
thorough inspection of visible mucosa and bimanual palpation
of the floor of the mouth and tongue and neck.
• Limited tongue mobility may indicate muscle or nerve
invasion from tumor.
• Examination of the oropharynx requires a bright light and
tongue depressor. The examiner should ask the patient
to open the mouth but not to protrude the tongue.
• Suspicious signs include tonsil asymmetry or mass or
ulcer in any location.
• Palpation of the oral tongue, base of tongue, and tonsils
can help confirm suspicion of a mass, especially if a
patient relates symptoms in these areas.
Clinical
Examination

• The oropharynx may be difficult to examine completely due to anatomic
constraints, and the base of tongue cannot be examined without flexible
laryngoscopy or indirect (mirror) laryngoscopy.
• Examination of the ears may indicate a unilateral serous effusion related to
nasopharyngeal carcinoma.
• A nasopharyngeal examination should be performed if there is no obvious etiology on
oral and oropharyngeal examination; this usually requires a mirror examination and/or
use of a flexible fiberoptic endoscope.
• A thorough examination of the skin of the head and neck can indicate a potential primary
skin malignancy such as squamous cell carcinoma or melanoma.
• Assessment of cranial nerve function can suggest a neural tumor or ominous neural
involvement by adjacent lymph nodes.
Clinical
Examination

• The thyroid gland should be carefully palpated and movement of the
neck mass with swallowing noted. The position of the trachea should
be evaluated for any deviation from midline.
• The abdominal examination should pay particular attention to possible
enlargement of spleen or liver and presence of any masses.
• Genitals should also be examined (Testicular Ca may present with left
supraclavicular LAP).
• A generalized skin rash may suggest a viral illness, whereas a
localized skin lesion may indicate a more specific etiology (eg, cat
scratch disease or tularemia).
Clinical
Examination

USG-
• HRUSG Neck
• EBUS-
CECT
• CECT Head
and Neck
• PET CT
• CECT W/A
• CECT Thorax
Contrast MRI
Radiological
Examination
Radiological
Examination Discussion

HPE
FNAC-
Blind Imaging guided
Transcutaneous
CT Guided
USG
Guided
EBUS-TBNA
Open biopsy
Incision
biopsy
Excision
Biopsy
Punch
Biopsy
DiscussionHistopathological
examination

Guidelines For Adult Neck Mass (SAGES 2017)
By AAO-HN Surgery

Branchial Cleft cyst
• Account for almost 20 percent of
pediatric neck masses.
• Second branchial cleft cysts- MCC
-type of branchial cleft anomaly.
• Location-
• The sinus tract of a second
branchial cleft cyst will travel
through the deep structures of the
neck and open into the tonsillar
fossa

• Theories of origin-
• 1. Congenital theories: The classic theory that the cyst develops from
remnants of the embryonic gill apparatus.
• 2. Lymph node theories: In 1949, King concluded that the cyst arises from
cystic changes in parotid epithelium.
• 3. Branchial theory: Cyst develops from imperfect obliteration of the
pharyngeal cleft.
• 4. Pre-Cervical Sinus Theory: The cyst develops from investigates of the
cervical sinus rather than of the pharyngeal clefts or pouches.

• King’s criteria any cyst arising outside the midline of the neck and having
lymphoepithelial characteristics should be regarded as a branchial cyst
• FNAC
The criteria for FNA cytology diagnosis of branchial cyst are:
• a) Thick, yellow, pus-like fluid
• b) anuclear, keratinizing cells
• c) squamous epithelial cells of variable maturity and
• d) a back ground of amorphous debris
• Histopathology
More than 90% of branchial cleft cysts are lined by stratified squamous epithelium.
May or may not be keratinized.

• Treatment-
• Inflamed cysts are best treated with intravenous antibiotics, with or
without aspiration or incision and drainage, followed by interval
excision.
• Pre operative cross sectional study i.e MRI neck should be done to
know anatomical extent of the disease.
• Complete excision of the tumor under general anesthesia is the
treatment of choice.

Sternomastoid tumor of infancy (SMTI)
• A unique form of perinatal fibromatosis.
• Presents as a hard mass within the
sternocleidomastoid (SCM) muscle of the neonate
mostly associated with difficult vaginal delivery
with instrumentation
• SMTI is the most common cause of a neck mass in
the perinatal period.
• Diagnosis is mostly clinical.
• Treatment is mostly conservative, parents may be
directed with massage with controlled stretching
of the neck on a twice-daily basis. Effective in
about 95% cases before the age of 1 year.
• INDICATIONS FOR SURGERY
• Restriction of motion (lacking 30° of full
rotation or more) persisting after child achieves
walking age, when a patient has undergone at
least 6 months of controlled manual stretching
and has residual head tilt
Cheng JC, Tang SP. Outcome of surgical treatment of congenital muscular
torticollis. Clin Orthop Relat Res 1999;362:190–200

Cystic Hygroma
• Cystic hygromas are the cystic variety of lymphangioma.
• It can manifest anywhere in the body. Common locations -
cervico-facial regions (especially posterior cervical
triangle), axilla, mediastinum, groin and below tongue.
Lymphangiomas are usually classified as
• Capillary,
• Cavernous
• Cystic Lymphangiomas.
• They may also be classified more conveniently, on the
basis of size of the cysts contained, as
• Microcystic,(<2 cm)
• Macrocystic (>2 cm)
• Mixed Lymphangiomas.

• C/f- Apparent at birth is a painless mass. May present
with complications or effects of cystic hygroma, such as
respiratory distress, feeding difficulty, fever, sudden
increase in the size and infection in the lesion.
• On clinical examinations, they appear soft, compressible,
non-tender, brilliantly transluminant and without any
bruit.
• Ultrasound of the lesion usually features multi-cystic
lesion with internal septations and no blood flow is
detected on color doppler.
• Mx- Symptomatic and complicated lesions need Surgical
excision
• Surgical excision of the complex cystic hygromas,
involving deep and vital structures, is a demanding task.
The possible complications during surgery are damage to
facial nerve, facial artery, carotid vessels, internal jugular
vessels, thoracic duct and pleura, and incomplete
excision in case of infiltration to the surrounding
structures.
• Sclerotherapy with
intralesional Bleomycin
and OK432 is being tried
• 60% sympotamatic relief.
Update
Mahajan JK, Bharathi V, Chowdhary SK, Samujh R, Menon P, Rao KL. Bleomycin as
intralesional sclerosant for cystic hygromas. J Indian Assoc Pediatr Surg. 2004;9:3–7.
Cystic Hygroma

Extrapulmonary TB
• Tuberculous lymphadenitis is among the most
frequent presentations of extrapulmonary
tuberculosis (TB)
• Cervical lymphadenopathy is the most common
manifestation
• C/f-a unilateral mass appears in the anterior or
posterior cervical triangles; submandibular and
supraclavicular lymph node involvement also
occurs.
• The most common group of lymph nodes affected
is upper deep jugular and jugulodigastric node.
• The most common systemic symptoms of malaise
and weight loss. Even fewer patients had cough,
fever, or haemoptysis.
• The commonest age group affected are 11–20
years followed by 21–30 years

Lymphadenitis
Periadenitis/ Matting
Cold abscess
'Collar stud' abscess
Sinus Formation
Extrapulmonary TB
5 Stages Of TB LAP
(Put forth by Dr. Jones and Campbell)

Extrapulmonary TB
• USG
• CECT Neck
• MRI Neck
• CXR- Associated chest lesions on radiography are found in
<20% cases.
Radiological Exam-
• Fine needle aspiration cytology (FNAC)Cytopathology-
• CBNAAT From aspirateConfirmative test-
• HIV I and II Test
• ESR
• Mantoux test – positivity is not diagnostic and negative is not exclusive
for Negative diagnosis.
• Endobronchial ultrasound-guided transbronchial needle aspiration
(EBUS-TBNA) may be useful in the setting of isolated intrathoracic
• Sputum smear and culture – Positive sputum cultures are uncommon (0
to 14 percent) in the setting of tuberculous lymphadenitis
Ancillary Test-

Extrapulmonary TB
• Management-
• Needs conservative medical management mostly with 6months of
category 1(First line ) ATT
• Surgery other than excision biopsy is not generally needed in any
patient.
• Multiple aspirations using a wide bore needle are needed only in
patients with abscesses.
• The abscesses and sinuses generally get healed within few months .
Recurrence of local or systemic disease with minimum follow up of
six months after completion of chemotherapy are very uncommon.

Collar Stud Abscess
Principle of management of Collar stud abscess
was put forward by Dr. Hamilton Bailey himself
(1945).
Acc to Bailey,
• One requires surgical excision in toto
taking care no to leave any remnant of
Lymph node in the basin.
• Cover the wound to its full extent with
sterile nonadherent dressing
• Immobilise neck , fix dressing properly,
and reopen 1st dressing after 7 days.
Thiersch grafting may or may not be done.

Metastatic Lymphadenopathy
• Lip and oral cavity primaries usually metastasize to lymph nodes in levels I to III;
• Oropharyngeal, hypopharyngeal, and laryngeal primaries commonly metastasize to levels
II to IV
• Nasopharyngeal and thyroid primaries as well as lymphoma can spread to level V .
• While the majority of malignant neck masses arise from supraclavicular primary
malignancies, 50% of masses in level IV and the supraclavicular fossa arise from primary
malignancies below the clavicle, including the chest and gastrointestinal tract.
• Skin cancers can metastasize to levels I to V as well as the external jugular, postauricular,
suboccipital, and parotid regions.
• Nasopharyngeal, tongue base, and midline oral cavity (tongue) cancers may result in
bilateral cervical metastases and patients with distant lymphadenopathy may have a
malignancy outside the head and neck, including lymphoma, lung, breast, or
gastrointestinal tract, and should undergo thorough evaluation of those possible sources.

Lateral Aberrant Thyroid
• The term Lateral Aberrant Thyroid was coined by Shrager.*
• It was PEMBERTON who in his article first coordinated and related lateral lymph node
metastasis to be from a primary of Papillary carcinoma of thyroid in his paper Treatment
of Carcinoma of the Thyroid Gland, Ann. Surg. 100:906, 1934; Malignant Lesions of the
Thyroid Gland, Surg., Gynec. & Obst. 69:417, 1939
• Data can be misinterpreted as did Lahey in 1940 in his paper Lahey, F. H.; Hare, H. F.,
and Warren, S.: Carcinoma of the Thyroid, Ann. Surg. 112:977, 1940 where he
misinterpreted the lateral lymph node mass as primary and the thyroid node as Metastasis.
*Shrager, V. L.: Lateral Aberrant Thyroids,
Surg., Gynec. & Obst. 3:465, 1906
1944

• Approach to thyroid and related swellings deserves detailed
elaboration.

Acute Sialadenitis
• History- older, debilitated persons with dehydration
or recent dental procedures
• Physical findings- Rapid or gradual onset of pain and
swelling; local edema, erythema, tenderness, or ﬂuctuance
consistent with an abscess, Bimanual compression toward
the duct opening may expel purulent discharge into the
oral cavity.
• Diagnosis-Clinical, USG and Contrast-enhanced CT
• Management- Sialagogues, gentle massage; abscess,
express by compressing the gland

• History-15 to 34 years of age and > 55 years,
constitutional symptoms/ Type-B Symptoms, later
splenomegaly, painful LAP After alcohol ingestion
• Physical findings-Painless, rapidly growing lymph
node; rubbery, soft,mobile
• Diagnosis-Contrast-enhanced CT of the neck,chest,
abdomen, pelvis; biopsy
• Management-Refer to oncology , depending on staging
ABVD Chemotherapy or Chemoradiation
Hodgkin lymphoma

Carotid Body Tumors
aka Paraganglioma
• History- Flushing, palpitations, hypertension if
hormonally active, dysphagia, dyspnea,
eustachian tube dysfunction
• Physical findings- Painless swelling in
oropharyngeal or upper anterior triangle of the
neck; pulsatile, compressible with a bruit or
thrill, mobile from medial to lateral direction
• Diagnosis- CT, CT angiography (lyre sign);
plasma and urine metanephrines, catecholamines
• Management- Surgery or embolization, refer to
specialist.

Laryngocele
• History- Repetitive nose blowing, coughing,
or blowing into a musical instrument
• Physical findings- Midline, may be lateral
swelling, superior to thyroid cartilage;
resonant, bulges on Valsalva, gurgling on
pressure- Bryce’s Sign, intermittent, globus
sensation
• Diagnosis- Clinical, CECT Neck
• Management- No treatment is required in
most cases, but symptomatic patients
need marsupialization or deroofing of the
laryngocele.

• Mantoux test was negative. FNAC suggestive of
Mucocele, because of thick mucosal fluid.
Ultrasonogram suggested as Cystic Sol.
• MRI gives evidence of fairly large irregular
cystic lesion measuring about 7 × 22 × 35 mm3
in size, noted at right submandibular region,
anterolateral to right sternocledomatoid muscle.
• Submandibular incision was given and complete
enucleation of the cyst had been done.
• The cystic lining was sent for histopathological
examination.
• Histopathology revealed that the cyst wall has
flattened lining epithelium underlying fibro
vascular connective tissue and diffuse infiltrated
with lymphocytes suggestive of branchial cyst.
Clinical Scenario 1

Clinical Scenario 2
• A 2 year old developmentally normal female child
presented with complaints of swelling in the right side of
the neck for 20 days.
• He was apparently normal except for a history of
respiratory tract infection 2 weeks before the onset of
swelling. The swelling gradually increased to attain the
present size.
• On inspection, it was approximately 3x2.5 cm, present in
the right upper part of the neck. Margins - not well
defined. It was mobile, cystic, fluctuant, non-tender,
nonpulsatile . In Transillumination test the mass was
brilliantly transilluminant
right upper anterior triangle of neck
Gnanavel et al., Anat Physiol
2015, 5:1

right upper anterior triangle of neck and extending to the
posterior triangle of neck and was diagnosed as cystic
hygroma.
• Aspirate of the lesion provided translucent mild straw
coloured clear fluid.
• MRI neck was done and proper extent delineated prior to
surgery.
• The cyst was excised in toto under GA.
• HPE of cyst wall provided “the wall of the sac is lined by
a single layer of flattened epithelium”.
Clinical Scenario 2

• Computed tomography (CT) of the neck revealed multiple, bilateral
nodular masses images, some coalescent, on the pharyngeal,
submandibular regions, and along the carotid arteries, measuring up to
4.0 cm.
• Serology for Epstein-Barr virus (EBV) was IgG positive and IgM
negative.
• An incisional biopsy was performed, and multiple, irregular fragments
were removed, measuring 2.0 × 1.0 × 0.4 cm. All samples were
submitted to histopathological evaluation, which revealed marked
fibrosis and reactive lymphoid tissue with expanded paracortical zones.
• The histological fndings combined with the immunohistochemical
results were consistent with metastatic lymphoepithelial carcinoma.
Based on histological diagnosis, endoscopic exam of the
nasopharyngeal cavity was undertaken, resulting in a disclosure of a
suspicious mass localized on the nasopharynx, confrmed by CT images.
• Given the histological, clinical, and tomographic fndings, diagnosis
was concluded as lymph node metastatic undifferentiated
nonkeratinizing nasopharyngeal carcinoma (NPC).
Clinical Scenario 3

Take Home Message
• Any lateral neck mass/ swelling should be evaluated with caution
• Antibiotics should only be given if there is s/s of any recent infection
otherwise it delays the primary diagnosis
• >40 yrs all lateral neck swellings should be suspected to be neoplastic until
otherwise proven
• Proper history taking and meticulous clinical examination is key to attain a
diagnosis.
• “Failure to find a primary above clavicle should prompt to look for it
below”
• Suitable cross sectional studies should be done.
• FNAC,Core Cut/True Cut biopsy is preferred.
• OPEN BIOPSY SHOULD BE THE LAST Resort and deterred until extremely
necessary.

Approach to lateral neck swelling in adults and children

Approach to lateral neck swelling in adults and children

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