Differential Diagnosis of Head and Neck Differential Diagnosis of Head and Neck Swellings and it’s managementSwellings and it’s management

M.D.S DepartmentM.D.S Department

College of DentistryCollege of Dentistry

King Saud UniversityKing Saud University

Head and Neck SwellingsHead and Neck Swellings

A number of masses may develop in the head and neck, A number of masses may develop in the head and neck, and these may also be called and these may also be called swellings,swellings, growths, growths, tumors, lumps, and bumpstumors, lumps, and bumps..

While some head and neck masses are cancerous, While some head and neck masses are cancerous, many many are notare not. .

However, it is important to investigate if any abnormal However, it is important to investigate if any abnormal bump or swelling persists for bump or swelling persists for more than two weeksmore than two weeks..

Head and Neck – Complex region

Numerous Lymph nodes are located in the Head & Neck region

Salivary glands

Thyroid gland, Parathyroid glands, Thymus gland etc.,

What Causes Head and Neck Swellings ?What Causes Head and Neck Swellings ?

(i)(i) Cysts, thyroid masses, vascular masses, salivary Cysts, thyroid masses, vascular masses, salivary gland masses e.t.c, can cause swellings in the head gland masses e.t.c, can cause swellings in the head and neck.and neck.

(ii)(ii) Enlargement of lymph nodes in the head and neck Enlargement of lymph nodes in the head and neck can also cause a swelling.can also cause a swelling.

(iii) Inflammatory / Infectious conditions can also cause lumps of the head and neck region.

(iv) Benign & Malignant masses can cause swelling of the head and neck.

Symptoms Associated with Neck LumpsSymptoms Associated with Neck Lumps

Lump in the neck persisting for more than two weeks, Lump in the neck persisting for more than two weeks, especially if it is not associated with a cold, flu, or other especially if it is not associated with a cold, flu, or other infection. infection.

Cancers of the mouth, throat, voice box (larynx), Cancers of the mouth, throat, voice box (larynx), thyroid, and some lymphomas can appear first as a thyroid, and some lymphomas can appear first as a painless, growing neck lump.painless, growing neck lump.

Symptoms Associated with Head & Neck Symptoms Associated with Head & Neck LumpsLumps

Change in the voice including hoarseness that Change in the voice including hoarseness that persists for more than two weekspersists for more than two weeks

Growth in the mouthGrowth in the mouth

Swollen tongueSwollen tongue

              Blood in the saliva or phlegmBlood in the saliva or phlegm

    Swallowing problemsSwallowing problems

Diagnosing Head and Neck MassesDiagnosing Head and Neck Masses

Examination of some masses / swelling may allow a Examination of some masses / swelling may allow a physician to determine their cause based on location, physician to determine their cause based on location, size, and consistency.size, and consistency.

In other cases, however, additional tests may be In other cases, however, additional tests may be required.required.

Diagnosing Head and Neck MassesDiagnosing Head and Neck Masses

Changes in the skin –Changes in the skin – It is important to examine It is important to examine changes in the skin that could indicate basal cell changes in the skin that could indicate basal cell carcinoma, squamous cell cancer, and malignant carcinoma, squamous cell cancer, and malignant melanoma. melanoma.

Persistent Ear Pain or ear pain while swallowing may Persistent Ear Pain or ear pain while swallowing may be a symptom of infection or a growth in the throat.be a symptom of infection or a growth in the throat.

Radiographic Investigation of the Head and Neck Radiographic Investigation of the Head and Neck MassesMasses

MRI – Magnetic Resonance ImagingMRI – Magnetic Resonance Imaging can clearly can clearly highlight highlight soft tissue pathologiessoft tissue pathologies better than the C.T. better than the C.T. Scan.Scan.

It uses a magnetic field rather than x-rays (radiation).It uses a magnetic field rather than x-rays (radiation).

Radiographic Investigation of the Head and Neck Radiographic Investigation of the Head and Neck MassesMasses

CT SCAN –CT SCAN – Computed tomography is less accurate than M.R.I Computed tomography is less accurate than M.R.I for the soft tissue examination, but is very useful to locate bony for the soft tissue examination, but is very useful to locate bony tumors and their dimensions and extensions.tumors and their dimensions and extensions.

C.T with contrast is used to enhance the visibility of abnormal C.T with contrast is used to enhance the visibility of abnormal tissue during examination.tissue during examination.

Radiographic Investigation of the Head and Neck Radiographic Investigation of the Head and Neck MassesMasses

PET (Positron Emission Tomography)PET (Positron Emission Tomography) and and SPECT (Single SPECT (Single Photon Emission Tomography)Photon Emission Tomography) are useful after diagnosis to help are useful after diagnosis to help determine the grade of a tumor or to distinguish between determine the grade of a tumor or to distinguish between cancerous and dead or scar tissue. cancerous and dead or scar tissue.

They involve injection with a radioactive tracer.They involve injection with a radioactive tracer.

Diagnosing Head and Neck MassesDiagnosing Head and Neck Masses

F.N.A.C – Fine Needle Aspiration BiopsyF.N.A.C – Fine Needle Aspiration Biopsy is is

SafeSafe

RapidRapid

InexpensiveInexpensive

Presurgical planningPresurgical planning

Avoids open biopsyAvoids open biopsy

Head and Neck SwellingsHead and Neck Swellings

(i) Enlargement of lymph nodes(i) Enlargement of lymph nodes

This is the most common cause of new neck swellings. This is the most common cause of new neck swellings.

Lymph nodes, which are part of the immune system, Lymph nodes, which are part of the immune system, can enlarge when the body rallies to fight an infection.can enlarge when the body rallies to fight an infection.

When the infection recedes, lymph swelling subsides as When the infection recedes, lymph swelling subsides as well.well.

((ii) Benign Swellingsii) Benign Swellings of the Head and Neckof the Head and Neck

Benign Swellings / masses do not spread (metastasize) Benign Swellings / masses do not spread (metastasize) to surrounding tissue and are not cancerous.to surrounding tissue and are not cancerous.

Nevertheless, benign masses can be serious if they Nevertheless, benign masses can be serious if they impact nerves or exert pressure in the head and neck, impact nerves or exert pressure in the head and neck, and are therefore often removed surgically. and are therefore often removed surgically.

These include cysts, thyroid masses, vascular masses, These include cysts, thyroid masses, vascular masses, salivary gland masses, and others.salivary gland masses, and others.

(ii) Benign Swellings(ii) Benign Swellings of the Head and Neckof the Head and Neck

Congenital/ Developmental CystsCongenital/ Developmental Cysts

(i) Thyroglossal cyst(i) Thyroglossal cyst

(ii) Branchial cyst(ii) Branchial cyst

(iii) Sebaceous cyst(iii) Sebaceous cyst

(iv) (iv) Dermoid cystDermoid cyst

Developmental Cyst - ThyroglossalCyst

Most common congenital neck mass Arrested migration of thyroidArrested migration of thyroid 50% present before age 20 Midline (75%) or near midline (25%) Elevates on swallowing/protrusion of tongue Surgery is the only treatment.

Developmental Cyst - Branchial CystBranchial Cyst

Remnants of incompletely obliterated branchial clefts/pouchesRemnants of incompletely obliterated branchial clefts/pouches Located anterior & deep to sternomastoid muscle.Located anterior & deep to sternomastoid muscle. Painless swellingPainless swelling Young adultsYoung adults M = F ratioM = F ratio Unilateral, 75%of cases on left side.Unilateral, 75%of cases on left side.

Developmental Cyst - Branchial CystBranchial Cyst

Cystic mass anterior to SCM, below mandible

May get infected

Persistence of 2nd branchial cleft

May have small sinus tract into tonsillar fossa

Contains cholesterol crystals

Surgical Management of the Branchial CystSurgical Management of the Branchial Cyst

Developmental Cyst Sebaceous cystSebaceous cyst

A sebaceous cyst is a a benign, harmless growth that A sebaceous cyst is a a benign, harmless growth that occurs under the skin and tends to be smooth to the occurs under the skin and tends to be smooth to the touch. touch.

Ranging in size, sebaceous cysts are usually found on Ranging in size, sebaceous cysts are usually found on the scalp, face, neck and ears. the scalp, face, neck and ears.

They are formed when the release of sebum, a medium-They are formed when the release of sebum, a medium-thick fluid produced by sebaceous glands in the skin, is thick fluid produced by sebaceous glands in the skin, is blocked. blocked.

Developmental Cyst Sebaceous cystSebaceous cyst

Unless they become infected and painful or large, Unless they become infected and painful or large, sebaceous cysts do not require medical attention or sebaceous cysts do not require medical attention or treatment, and they usually go away on their own.treatment, and they usually go away on their own.

If they become infected, the physician may drain the If they become infected, the physician may drain the fluid and cells that make up the cyst wall. Or, if the cyst fluid and cells that make up the cyst wall. Or, if the cyst causes irritation or cosmetic problems, it may be causes irritation or cosmetic problems, it may be removed through a simple excision procedure.removed through a simple excision procedure.

Dermoid cystDermoid cyst

A dermoid cyst is a congenital defect (present from birth) that occurs during embryonic development when the skin layers do not properly grow together.

A dermoid cyst is lined with epithelium, which contains tissues and cells normally present in skin layers, including hair follicles, sebaceous (skin oil), and sweat glands.

These glands and tissues secrete their normal substances which collect inside the cyst, causing it to grow and enlarge.

Ranula Ranula presents as a Cystic swelling in the floor of mouth.

It occurs as a mucous extravasation from sublingual salivary gland.•

May extend through the mylohyoid muscles into the neck- “Plunging Ranula”

Surgical treatment is by removal of the Sublingual gland associated with the swelling.

(iii) Inflammatory Lumps of the Head and Neck

Cervical Adenitis secondary to acute URTI-tonsillitis, EBV etc- are common and is detected from history.

Inflammatory Lumps of the Head and Neck

Chronic inflammatory disease like Tuberculosis, Sarcoidosis, Cat Scratch disease.

These disease processes have to be treated medically. For example, Patients with tuberculous lymphadenitis should undergo anti-tuberculosis drug therapy.

Surgical Management of Infections in the Head and Neck Region

Submandibular Abscesses, Ludwig’s Angina occur secondary to Submandibular Abscesses, Ludwig’s Angina occur secondary to odontogenic infections and Parotid or submandibular gland odontogenic infections and Parotid or submandibular gland abscesses etc, need to undergo incision and drainage under G.A, abscesses etc, need to undergo incision and drainage under G.A, along antibiotic treatment.along antibiotic treatment.

(iv) Neoplastic Masses of the Head and Neck

Neoplastic Masses can be classified into two types (i.e) benign and malignant masses.

Neoplastic Masses of the Head and Neck

Benign Head and Neck Masses

•Any structure of the head and neck may be involved.

Skin, SC Tissue, fat, nerve muscle, blood vessel can be affected.

For example, Lipoma (Fat), Fibroma (Fibrous tissue), Hemangioma( Blood vessel), Neuroma (Nerve).

Benign Head and Neck Masses

Benign tumors of the Benign tumors of the Salivary gland like Pleomorphic adenoma, Warthins tumour etc., can present with a significant head and neck swelling.

Multinodular goitre, cyst, adenoma can affect the Thyroid glands.

Malignant Masses of the Head and Neck

Malignant Masses of the Head and Neck

- Malignant masses can occur anywhere in the upper

aero-digestive tract.

- May also arise from skin and soft and hard tissues of

head and neck-SCC, melanoma

- It can occur from the salivary glands, thyroid gland,

parathyroid gland.

Malignant Swellings of the Head and NeckMalignant Swellings of the Head and Neck

Head and neck masses are malignant, if they spread to Head and neck masses are malignant, if they spread to surrounding tissue. In the head and neck, tumors may surrounding tissue. In the head and neck, tumors may

be either be either primary primary or or secondarysecondary..

What are primary tumors?What are primary tumors?

Primary tumorsPrimary tumors originate in the head or neck itself, originate in the head or neck itself, including the thyroid, throat, larynx, salivary gland, including the thyroid, throat, larynx, salivary gland, brain, or other locations. brain, or other locations.

Primary tumors of the head and neck typically spread to Primary tumors of the head and neck typically spread to the lymph nodes in the neck. the lymph nodes in the neck.

What are secondary tumors ?What are secondary tumors ?

Secondary cancersSecondary cancers are tumors that have spread from are tumors that have spread from primary tumors in other parts of the body to the head or primary tumors in other parts of the body to the head or neck. neck.

Most often, secondary tumors of the neck originate in Most often, secondary tumors of the neck originate in the lung, breast, kidney, or from melanomas in the skin.the lung, breast, kidney, or from melanomas in the skin.

Cancers in the nasal and sinus passages may spread to Cancers in the nasal and sinus passages may spread to

the brain through nerves in the skull.the brain through nerves in the skull.

Head and Neck Cancer- Squamous Cell.Carcinoma

6th most common cancer worldwide

HNSCC ~ 5% all cancers

S.C.C most common upper aero digestive tract malignancy

Smoking

50% HNSCC occur in oral cavity

Management presents considerable functional and aesthetic

problems

Multidisciplinary approach imperative

Treatment of Head and Neck - Treatment of Head and Neck - Squamous Cell Squamous Cell CarcinomaCarcinoma

Removal of Primary tumor + cervical nodes

Surgery / Radiation / Chemotherapy

Sometimes palliation

Cervical neck disease reduces survival by 50%

LymphomasLymphomas

Lymphomas are malignant cell infiltrations of the lymphatic Lymphomas are malignant cell infiltrations of the lymphatic system.system.

Once a malignancy begins in one part of the lymph system, Once a malignancy begins in one part of the lymph system, it often spreads throughout the rest of the system before it it often spreads throughout the rest of the system before it is detected. is detected.

LymphomasLymphomas

Lymphomas share similar symptoms such as painless Lymphomas share similar symptoms such as painless swelling of the lymph nodes, fever and fatigue. swelling of the lymph nodes, fever and fatigue.

Broadly, they are classified as either Broadly, they are classified as either non-Hodgkin'snon-Hodgkin's and and Hodgkin'sHodgkin's. .

Summary

Head and Neck lumps are not that uncommon

Usually benign in kids

Don’t ignore adult neck lump especially when cause not apparent.

History and Examination, radiology, FNA

Surgical, Medical, Chemotherapy and radiation treatment options are available for malignant masses.