NECK SWELLING

Dr.Syed Alam Zeb

DIFFERENTIAL DIAGNOSIS

• ENLARGED LYMPH NODES: Due to, Bacterial, Viral infections. Tuberculosis. Leukemias, Lymphomas or mets. from tumours.

• SWELLING IN THE ANGLE OF THE JAW: May be due to,

Enlarged jugalodiagastric lymph nodes.

Cystic Hygromas in children.

Enlarged submandibular or parotid gland.

Carotid body tumour.

• MIDLINE SWELLINGS:

Ludwigs angina.

Enlarged submental lymph nodes.

Thyroglossal cysts.

Thyroid enlargement.

Thymic enlargement.

• LATERAL SWELLINGS:

Lymph nodes.

Collar stud’s absceses.

Branchial Cysts.

Thyroid swelling.

Pharyngeal pouch.

Laryngocele.

• Lipomas, Neurofibromas, Haemangiomas, Dermoid and Sebacious cysts can occur any where in the neck area.

CYSTIC HYGROMA IN A CHILD

COLLAR STUD’S ABSCESS

PAROTID TUMOUR

THYROGLOSSAL CYST

THYROID ENLARGEMENT

MANAGEMENT

• Take detail history.• Thorough examination of head and neck

area.• Determine the nature of swelling.• Investigate accordingly.• Consider biopsy, FNAC or excision.• Definite treatment depends on the nature of

swelling.

THYROID ENLARGEMENT

CAUSES OF THYROID ENLARGEMENT: 1 .Multinodular goiter due to iodine deficiency. 2.Single nodule which may be a dominant nodule in

MNG.,tumor, or cyst. 3.Generalized enlargement like toxic goiter in grave’s disease,

nontoxic goiter of puberty.

• 4. Thyroid tumors: Papillary ca, Follicular ca, Ana plastic ca, Medullary ca, Lymphomas or secondary tumors.

• 5.Thyroiditis like Hashimoto’s disease and Riedels thyroiditis.

MANAGEMENT OF THYROID NODULE

• History.• Examination.• Ultrasound neck.• FNAC.• TFTs, T3,T4 and TSH.• Thyroid scan.• Bone scan, chest x-ray and liver us in tumors.

TOXIC GOITER

• Caused either by graves’ disease or toxic adenoma.

• Clinical features include palpitations, sweating, loss of weight and increased appetite. Patient looks nervous, has tremors, palm sweating, increased pulse rate and protruding eyes..exophthalmoses.

Toxic goiter cont:

• Investigations show a rise in T3 ,T4 and fall in TSH.

• Thyroid scan will show either a hot nodule or generalized enlargement with increased uptake.

• Initially patient is treated with beta blockers and antithyroid drugs.

• Surgery considered when patient is euthyroid

SURGERY FOR GOITER

• MNG and Graves disease: Subtotal thyroidectomy.

• Toxic nodule/ malignant nodule: Thyroid lobectomy ..

• In malignant cases total thyroidectomy is sometimes performed .

POST-OPERATIVE COMPLICATIONS

• Hemorrhage.

• Haematoma formation.

• Recurrent laryngeal nerve damage.

• Hypothyroidism.

• Hypocalcaemia.

• Keloid scar formation.

• Tracheomalacia.

HYPERPARATHRODISM

CAUSES:

Hyper secretion of parathyroid hormone either due to Adenoma of one of the four parathyroid glands or due to hyperplasia of all the four glands.

• PRIMARY HYPERPARATHYRODISM: When the glands are producing increased amounts of PTH.

• SECONDARY HYPERTHYRODISM: When there is demand for increased amounts of PTH.as in chronic renal failure.

• TERTIARY HYPERTHYRODISM: Initially there is demand for increased amounts, but later on the glands become autonomous without demand.

• PTH regulates the serum Calcium levels.

• In hyperparathyroidism the serum calcium levels are high.

• PTH acts on the bones and mobilizes the calcium from there.

• Bones become very weak, prone to fractures.

CLINICAL FEATURES

• 50% patients are asymptomatic.

• Majority present with dyspeptic symptoms.

• Some present with bone pains and spontaneous fractures.

• Kidney stone formation very common in these patients.

• Few patients have psychiatric problems.

INVESTIGATIONS

• Tests for the confirmation/ diagnosis of the disease.

• Tests for the localization of hyper functioning parathyroid gland.

TESTS FOR THE DIAGNOSIS

• Serum calcium, usually elevated.

• 24 hrs urinary calcium is raised.

• Serum phosphate is low.

• Serum alkaline phosphatse is raised.

• Serum PTH levels are elevated.

• Skeletal survey for bone changes.

TESTS FOR LOCALIZATION

• Ultrasound neck.

• MRI.

• Isotope scans.

• Selective venous sampling.

X-ray in hyperparathyroidism

• Resorption of the terminal phalyngeal bones is typical.

• Osteitis fibrosa cystica. Multiple cysts are formed in the bones.

ISOTOPE SCANS

• CYSTA-MIBI scan showing a parathyroid adenoma.

• Thallium-technetium subtraction scan is also useful.

TREATMENT

• If there is adenoma of the gland, excise that particular gland.

• If there is hyperplasia of all the four glands, excise all the four, but reimplant some parathyroid tissue in to the sternomastoid muscle.