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DIFFERENTIAL DIAGNOSIS OF NECK SWELLINGS.
ANATOMY OF THE NECK REGION
Anatomists use the term triangles of the neck to describe the divisions created by the major muscles in the region.
The side of the neck presents a somewhat quadrilateral outline, limited, * above, by the lower border of the body of the mandible, and an imaginary line extending from the angle of the mandible to the mastoid process; * below, by the upper border of the clavicle; * in front, by the middle line of the neck; * behind, by the anterior margin of the Trapezius.
This space is subdivided into two large triangles by Sternocleidomastoid, which passes obliquely across the neck, from the sternum and clavicle below, to the mastoid process and occipital bone above
The triangular space in front of this muscle is called the Anterior triangle of the neck; and that behind it, the Posterior triangle of the neck.
Anterior Triangle of Neck
Bounded by anterior border of sternocleidomastoid, lower edge of jaw and the midline
The upper part of the triangle is also known as digastric triangle or submandibular triangle; as it lies above the digastric muscle.The structures deep to the sternocleidomastoid are considered to be inside the anterior triangle.
Posterior triangle Of Neck
Bounded by the posterior border of the sternocleidomastoid, anterior edge of the Trapezius muscle and clavicle
Midline Lumps
Ludwig,s angina Enlarged submental lymph nodes Dermoid cyst Thyroglossal cyst Subhyoid bursitis Pretracheal and prelaryngeal lymph nodes Thymic swelling Enlarged lymph nodes or lipoma in the
suprasternal space of burns Thyroid swelling
Swellings in Anterior Triangle Branchial Cyst Brachial fistula/sinus Parotid tumour Laryngocoele Enlarged submandibular lymph
nodes Submandibular salivary gland
enlargement Plunging ranula
Swellings in Anterior Triangle
Carotid artery aneurysm Cold abcess (Lymph node swelling) Neurofibroma vagus Carotid body tumour-rare Sternomastoid tumour-rare Tumours of the mandible-rare
Swellings in Posterior Triangle
SOLID:* Lymphoma* Lipoma* Cervical Rib* Metastatic Lymph Nodes* Tuberculous Lymph nodes* Pharyngeal Pouch* Pancoast Tumour
Cystic* Lymphangioma (Cystic Hygroma or Hydrocele of the neck)* Haemangioma
- Arterial-Venous-Capillary ( Salmon Patch,
Port Wine StainStrawberry angioma)
Pulsatile
* Subclavian Artery Aneurysm* Vertebral Artery Aneurysm
Symptoms Associated with Neck Lumps
Lump in the neck persisting for more than two weeks, especially if it is not associated with a cold, flu, or other infection.
Cancers of the mouth, throat, voice box (larynx), thyroid, and some lymphomas can appear first as a painless, growing neck lump.
Symptoms Associated with Neck Lumps
Change in the voice including hoarseness that persists for more than two weeks
Growth in the mouth
Swollen tongue
Blood in the saliva or phlegm
Swallowing problems
MANAGEMENT
Detailed history of the patient.* Systemic illness- general malaise, fever and rigors, contact with people with infectious diseases, loss of appetite, loss of weight, irritation of the skin.
* Head and Neck Symptoms
Diagnosing Neck Masses
Examination of some masses / swelling may allow a physician to determine their cause based on location, size, and consistency.
In other cases, however, additional tests may be required.
EXAMINATION
1) Number of lumps – single/multiple.2) Site of lump – anterior/posterior
triangle.3) Consistency of the lump –
solid/cystic.4) Movement of the lump – with
swallowing/protrusion of tongue.5) Examination of Head, Neck and
Eyes.
MEDICAL HISTORY INCLUDES
Is it a hard lump? Is it a relatively soft, pliable, bag-like
(cystic) mass? Is it a painless bag-like (cystic)
mass? Is the entire neck swollen? Where is the lump located?
Has it been growing bigger? Over how many months?
What other symptoms are present? Is there a rash? Do you have difficulty breathing?
Diagnosing Neck Masses
Changes in the skin – It is important to examine changes in the skin that could indicate basal cell carcinoma, squamous cell cancer, and malignant melanoma.
Persistent Ear Pain or ear pain while swallowing may be a symptom of infection or a growth in the throat.
INVESTIGATIONS
Baseline investigations CBC, LFT, RFT, Serum Electrolytes, Viral Markers.
Blood culture and sensitivity (TB) Chest X-ray (cervical rib, malignancy, bilateral
hilar lymphadenopathy) Mycodot/Mantoux test Virology ( HIV, EBV) Ultrasound (reveals lump consistency) FNAC CT (defines masses)
Radiographic Investigation of the Neck Masses
MRI – Magnetic Resonance Imaging can clearly highlight soft tissue pathologies better than the C.T. Scan.
It uses a magnetic field rather than x-rays (radiation).
Diagnosing Neck Masses
F.N.A.C – Fine Needle Aspiration Biopsy is
Safe
Rapid
Inexpensive
Presurgical planning
Avoids open biopsy
Definitive Treatment
Depends as the case may be……