Kamis, 23 Februari 2012

Neck Swellings-Types, definitions, Etiology, Clinical Features, Investigations, Differential Diagnosis and Treatment

This is a heterogeneous group of lesions, presenting clinically as fluctuant, soft or firm, lateral or midline neck swellings. The lesions may be asymptomatic, sensitive or painful, movable or fixed, solitary or multiple.
Cysts, infectious diseases, autoimmune and systemic diseases, and neoplasms are included in this group of lesions, which usually cause diagnostic problems.

  1. Branchial cyst
  2. Thyroglossal duct cyst
  3. Dermoid cyst
  4. Cystic hygroma
  5. Nonspecific lymphadenitis
  6. Submandibular sialadenitis
  7. Tuberculosis
  8. Heerfordt syndrome
  9. Sjögren syndrome
  10. Hodgkin disease
  11. Metastatic carcinoma in the lymph nodes
Branchial Cyst

Definition Branchial cyst or cervical lymphoepithelial cyst is a relatively rare lesion, located in the upper lateral neck along the anterior border of the sternocleidomastoid muscle.

Etiology Developmental, like lympho epithelial cysts.
Clinical features It appears as an asymptomatic, soft, fluctuant swelling 1–10 cm in diameter, usually lateral. It usually becomes apparent between the ages of 20 and 40 years.
Laboratory tests Histopathological examination.

Differential diagnosis Dermoid cyst, lymph-node enlargement, sialadenitis, salivary gland tumors, soft-tissue benign tumors.

Treatment Surgical removal.

Branchial cyst on the lateral side of the neck.

Thyroglossal Duct Cyst

Thyroglossal duct cysts very often appear in the midline of the neck, usually below the hyoid bone and submentally. Clinically, the lesion presents as a painless, fluctuant, movable swelling.

Definition Thyroglossal duct cyst is a rare developmental lesion that may form along the thyroglossal tract.

Etiology Remnants of thyroglossal duct epithelium.

Clinical features The cyst is usually located under the hyoid bone but can be located anywhere fromthe suprasternal notch to the foramen cecumof the dorsal tongue. Intraorally, it appears as a painless, fluctuant swelling usually 1–3 cm in diameter, located in the midline of the dorsumof the tongue close to the foramen cecum. Occasionally, a fistula may form following infection. The cyst is most often diagnosed in patients under 20 years of age.

Laboratory tests Histopathological examination, 99mTc or 125I scan.

Differential diagnosis Median rhomboid glossitis, benign and malignant tumors.

Treatment Surgical removal.

Thyroglossal duct cyst on the dorsum of the tongue.

Thyroglossal duct cyst: swelling of the midline of the neck.

Dermoid Cyst

Dermoid cysts, when they develop below the geniohyoid muscle, protrude submentally as a painless, doughy swelling . In such cases, the differential diagnosis should include thyroglossal duct cyst, periapical and soft-tissue abscesses, and sublingual sialadenitis.

Definition and etiology Dermoid cyst is an uncommon developmental cystic lesion arising from embryonic epithelial remnants.

Clinical features It presents as a slow-growing, painless swelling with a normal or yellowish-red color and a characteristic soft doughlike consistency on palpation. The size varies from a few millimeters to 10 cm in diameter, and the lesion usually occurs in the midline of the floor of the mouth (Fig. 297). If the cyst is located above the geniohyoid muscle, it can displace the tongue upward and create difficulty in mastication, speech, and swallowing. When the cyst occurs below the geniohyoid muscle, it may protrude submentally. Rarely, dermoid or epidermoid cysts may develop in the lips. The cyst frequently appears in early adulthood.

Laboratory tests Histopathological examination.

Differential diagnosis Ranula, abscess, lymphoepithelial cyst, cystic hygroma.

Treatment Surgical removal.

Dermoid cyst: submental swelling, with a double-chin appearance.

Cystic Hygroma

Definition Cystic hygroma is a form of lymphangioma that consists of large cystic spaces.

Etiology Developmental.

Clinical features It appears as a large, soft swelling of the neck, extending to the submandibular or submental area, and occasionally to the buccal and the parotid area. It usually appears at birth or by 3 years of age, and may cause aesthetic or respiratory problems.

Differential diagnosis Branchial cyst, diffuse lymphadenopathy, parotitis, submandibular sialadenitis, hemangioma.

Treatment Surgical removal

Cystic hygroma: diffuse swelling of the neck.

Nonspecific Lymphadenitis

Definition Lymphadenitis is a lymphoid hyperplasia of the lymph nodes.

Etiology Infections (bacterial, viral, fungal).

Clinical features Lymph nodes in the neck area (submandibular, subdigastric, mid-jugular, low jugular, cervical) may produce neck swellings. In acute infections, the lymph nodes appear enlarged, tender, soft, and movable, while in chronic conditions they are enlarged, but not tender, and are firm, and occasionally fixed. Enlarged lymph nodes may be single or multiple.

Differential diagnosis Submandibular sialadenitis, non-Hodgkin lymphoma, Hodgkin disease, HIV infection, bacterial infections.

Treatment Treatment of the specific infection.

Submandibular and cervical lymph-node enlargement due to herpetic oral infection.

Submandibular Sialadenitis

Definition This is an inflammatory disorder of the submandibular salivary glands.

Etiology Infections, and rarely sialoliths, trauma.

Clinical features The condition presents as a tender swelling, usually unilateral, at the angle and the body of the mandible. The overlying skin is usually erythematous, and the duct orifice is red intraorally.

Differential diagnosis Lymph-node enlargement, buccal cellulitis, lymphomas, tuberculosis, sarcoidosis, Sjögren syndrome.

Treatment Antibiotics

Submandibular sialadenitis: swelling at the angle of the mandible and the neck.


Oral manifestations of tuberculosis are uncommon and present as a wide spectrumof lesions, usually secondary to pulmonary infection. Regional lymphadenopathy usually accompanies the oral lesions.
A particular formof cervical lymph-node tuberculosis is known as scrofula. Clinically, it presents as a swelling of numerous cervical lymph nodes that occasionally leads to the formation of numerous fistulas though the overlying skin. The differential diagnosis should include lymphoma, submandibular sialadenitis, and actinomycosis.
Tuberculosis, lymph node involvement and fistula formation.

Heerfordt Syndrome

Definition Heerfordt syndrome, or uveoparotid fever, is a rare form of sarcoidosis.

Etiology Unknown. It is presumably related to an infectious agent.

Clinical features The condition is characterized by a bilateral, firm, painless swelling of the parotid glands, ocular lesions (uveitis, conjunctivitis, keratitis), facial paralysis, skin lesions, and low-grade fever. Submandibular and sublingual salivary gland enlargement may also occur.

Laboratory tests Histopathological examination, Kveim skin test, radiography.

Differential diagnosis Sjögren syndrome, Mikulicz syndrome.

Treatment Steroids. Often the symptoms resolve spontaneously within two or three years.

Sarcoidosis, multiple red nodules on the upper lip.

Sarcoidosis: multiple lesions on the perioral skin

Sjögren Syndrome

Definition Sjögren syndrome is a chronic autoimmune disease of the exocrine glands.

Etiology Unknown.

Clinical features Two forms of the disease are recognized: primary and secondary, when it is associated with collagen diseases. The cardinal clinical manifestations include a recurrent enlargement of the parotid, submandibular and lacrimal glands, lymphadenopathy, purpura, Raynaud phenomenon, myositis, and renal and pulmonary manifestations. Keratoconjunctivitis sicca, xerostomia, cheilitis, dental caries, and candidiasis are common manifestations. The disease most frequently affects women between 40 and 60 years of age.

Laboratory tests Histopathological examination, serological tests—antinuclear antibodies (ANA), anti-SSA (Ro), SS-B (La) antibodies.

Differential diagnosis Heerfordt syndrome, Mikulicz syndrome, collagen diseases, graft-versus–host disease.

Treatment Steroids and immunosuppressive drugs. Artificial saliva and tears.

Sjögren syndrome: bilateral enlargement of the submandibular glands

Sjögren syndrome: dry and lobulated tongue.

Hodgkin Disease

Definition Hodgkin disease is a malignant disease of the mononuclear cell system.

Etiology Unknown.

Clinical features Painless and persistent swelling, usually of the cervical and supraclavicular lymph nodes or other lymph-node groups, is the common presenting sign. In the early stages the lymph nodes are often movable, and later they become fixed to the surrounding tissues. Anorexia, weight loss, fever, night sweats, and pruritus may accompany lymphadenopathy. Oral ulceration may also occur.

Laboratory tests Histopathological examination, immunological markers.

Differential diagnosis Non-Hodgkin lymphoma, tuberculosis, infectious mononucleosis.

Treatment Chemotherapy, radiotherapy

Hodgkin disease: swelling of the cervical lymph nodes.

Metastatic Carcinoma in the Lymph Nodes

Metastases of oral squamous-cell carcinoma are a relatively common phenomenon and mainly occur in the regional cervical lymph nodes, via the lymphatic vessels. It has been estimated that approximately 30–50% of patients with oral carcinoma present at diagnosis with cervical metastases. The submandibular and jugular nodes are more frequently affected. Clinically, the metastases are not tender, and are usually firm, fixed, and swelling. The metastatic deposits are usually lateral, and rarely bilateral.

Differential diagnosis Submandibular sialadenitis, Hodgkin disease, leukemia, tuberculosis, syphilis, infectious mononucleosis.

Metastatic cervical lymph-node swelling from a posterior lateral squamouscell carcinoma of the tongue.