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A STUDY ON HISTOPATHOLOGICAL AND CLINICAL EVALUATION OF NECK SWELLINGS IN SURGICAL OUTPATIENTS--AN OBSERVATIONAL STUDY.

BACKGROUND

Neck swellings are frequently encountered in the clinical practice and the cause is usually benign. In general practice inflammatory lymph nodes are the most common cause, mostly with tuberculous aetiology in Indian environment due to malnourishment and poor socioeconomic status. [1] However, the lump may be the presentation of more serious disease (ex-malignancy or chronic infection) and so a thorough assessment and diagnosis are essential. If there is any doubt as to the cause, then the patient should be reviewed and/ or referred for specialist assessment. Patients over the age of 40 are more likely to have a neoplastic cause. Inflammatory, congenital and traumatic causes are more common in younger patients, but neoplasm should still be borne in mind. [2] Fine Needle Aspiration Cytology (FNAC) is a simple, quick and cost-effective method to sample superficial masses found in the head and neck. [3]

The technique is performed in the outpatient department and causes minimal trauma to the patient. An early differentiation of benign from malignant pathology is beneficial, as it greatly influences the planned treatment. [4] It can be both diagnostic and therapeutic in cystic swellings. [5] It is helpful for the diagnosis of salivary gland tumours where it can differentiate between a malignant and a benign tumour with over 90% accuracy. [6] FNAC is particularly helpful in the work-up of cervical masses and nodules, because biopsy of cervical swelling should be avoided unless all other diagnostic modalities have failed to establish a diagnosis. [7] FNAC does not give the same architectural detail as histology, but it can provide cells from the entire lesion as many passes through the lesion can be made while aspirating. [8]

Two new dimensions of medical practice are non-invasive diagnosis and cost control. UItrasonography qualifies eminently in regards. While there have been many reports on its use in thyroid diseases, there are few reports on its general use in the diagnosis of head and neck diseases. Ultrasonography gives accurate information as to the form and content of cervical masses and enables to distinguish solid from cystic lesions. It may also alert us to the probabilities of malignant versus benign nature of neck swellings.

This study is an effort to assess the incidence of various swellings in neck through clinical examination and usefulness of FNAC as well as ultrasonography.

Aims and Objectives

* The primary objective of this study is to elucidate the incidence and distribution of various aetiologies in the patients presenting with neck swellings and study the cause of neck swellings in our surgical outpatient department.

* The second objective is to assess the usefulness of FNAC and Ultrasonography of neck in the diagnosis of neck masses in the outpatient department.

MATERIALS AND METHODS

After Institutional Ethics Committee approval and written and informed consent, this hospital-based descriptive study in the setting of outpatient department of general surgery in a tertiary care Govt. General Hospital was carried out from December 2014 to 2016 in a sample of 100 patients who presented with neck swellings to the OPD of surgery department.

Inclusion Criteria

Patients of age > 15 yrs. presenting with asymptomatic/ symptomatic neck swellings, patients belonging to both sexes.

Exclusion Criteria

Patients presenting with congenital anomalies, vascular anomalies, patients with bleeding diathesis, pregnant patients.

Method of Collection of Data

Data was collected using a detailed well-designed proforma. Detailed history was taken, and thorough physical examination was carried out and basic relevant investigations like routine blood investigations including Hb%, TC, DC, ESR, Blood Sugar, Serum Creatinine, Serum Bilirubin, Viral markers- HIV 1/2, HBsAg, HCV, etc. were done in the OPD to arrive at a provisional diagnosis. All the cases of neck swellings were sent to Department of Pathology, where fine needle aspiration cytology (FNAC) will be done with 2123-G needle attached to the 10 mL plastic disposable syringe. All the patients were also investigated by ultrasonography of neck to determine the position of the swelling and its relation to vital structures and other important features of the swellings. After completion of FNAC and USG of all the neck swellings, the findings and results will be analysed and the pattern of lesions of the neck swellings will be compared to other studies.

Statistical Analysis

Data was analysed using descriptive statistics. Data is expressed as percentage or absolute numbers.

RESULTS

There were 61 females and 39 males between 15 and 84 yrs. showing a female preponderance (1.56: 1). Sex distribution is mentioned in Figure 1 and age wise distribution of swellings was represented in Figure 2. Of the 100 neck swellings when categorised based on tissue of origin, there is clear preponderance of thyroid swellings accounting to 57% followed by swellings of lymph nodes 27%, then 15% contributed by soft tissue swellings (lipoma, abscess, soft tissue tumours). Lastly with 1% incidence is salivary gland swelling. They were represented in Table 1.

Based on type of lesions the data regarding neck swelling, it was deducted that most of the neck swellings were benign (43%) followed by inflammatory (34%) swellings. Malignant swellings occupied the 3rd place amongst the neck swellings. Benign lesions were most common, of which thyroid goitres were more common in female sex (8.5:1) that is represented in Table 1, Table 2 and Figure 3 and Figure 4. The most common lymph nodal lesion is tuberculosis/ granulomatous lymphadenitis was more common in males (10: 1) represented in Table 6. In toto malignant lesions accounted for 23% of cases and their incidence rose sharply after 4th decade that is represented in Table 2 and Figure 5. The most common benign lesion was nodular goitre, inflammatory lesion was thyroiditis (Table 6 and Figure 8). Most common malignant lesion was metastatic secondaries of neck and papillary carcinoma thyroid which was more common in young females as represented in Table 7. In segment of people with HIV positive status, which occupied 10% of the sample TB lymphadenitis was more common (70%) as represented in Figure 9.

FNAC is an easy and suitable tool for the assessment of patients with neck swellings in the outpatient clinics. On ultrasonography, malignant lesions were hyperechoic or of heterogeneous signal intensity. Benign lesions showed predominantly hypoechoic character. Multinodular goitre of thyroid showed nodular appearance with mixed echogenic character. Ultrasonography is a pretty useful tool to distinguish cystic swelling from solid ones and to determine their location. Figures 10 to 15 represent the clinical photographs of the patients with different neck swellings.

In the study the patient's age ranged from 15-84 years, the mean age being 41.85 years.

Data expressed as percentage and absolute number.

Data expressed as absolute numbers.

Data expressed as percentage and absolute number.

Data expressed as absolute numbers.

Data expressed as absolute numbers.

Data expressed as absolute numbers.

Data expressed as absolute numbers.

Clinical Photographs of the Patients

DISCUSSION

Most of the catchment of the Government General Hospital is from the rural areas. The people from these rural areas have low socioeconomic status and mostly uneducated. Most of the males regularly chew tobacco and smoke. Mostly, females are house-bound and ignorant about their health and nutrition. So infectious and malignant conditions constitute a significant proportion of health problems among them.

Diagnostic cytology when performed by well-trained experienced individual offers a high degree of reliability and feasibility. In our study, the spectrum of lesions observed from the neck confirms its utility as an effective tool in the diagnostic workup of this area.

The present study was demonstrated that there was clear female preponderance in the incidence of neck swellings. Although, there were many clinical studies that reported uneven data regarding gender distribution, this study was comparable to the study of Modi et al, Soni et al and Ahmad et al, whose studies showed female preponderance. [9,10,11] The youngest patient was 15 yrs. old and oldest was 84 yrs. and mean age being 41.5 yrs. Age distribution of the swellings when assessed showed clustering of the lesions from the age group of 20 yrs. to 40 yrs. in the active period of one's lifetime. This could be because of the physiological demand that could not meet the daily demands of the patients who are mostly undernourished manual labourers below poverty line. This study results were comparable to the study done by Hitendar Basista et al and Manjula et al. [12,13] The inflammatory and benign lesions were found to be most common below the age of 40 yrs. The prevalence of malignant lesions rose sharply after 4th decade, which is expected as the same happens in rest of the body. [14]

Total of 100 neck swellings were evaluated, out of which 57 swellings were of thyroid origin, 27 were of lymph nodal origin, 15 were of soft tissue origin and 1 was of salivary gland origin. This study showed clear preponderance of thyroid swellings over lymph nodal swellings. Though many other studies had lymph nodal swellings in greater proportion. This study showed thyroid swellings in dominant proportion that too in female sex. [15,16,17] This study was comparable to study done by Hitendar Basista et al, where thyroid was the most common tissue of origin of lesion. The most common single pathological diagnosis was goitrous lesion of thyroid (38%) followed by Tuberculous affection of lymph node (11%). Our results were comparable to the study by Hitender Basista et al. Many of the other studies in the literature showed predominance of tubercular lymphadenitis as in studies by Ahmad et al, Garima Gupta et al and reactive lymphadenitis in study by Manjula et al. [18] However, the incidence of Tubercular lymphadenitis in our study was 11% and is still comparable to studies of Manjula et al (16.84%) and Jindal et al (19.84%).

Our Government General Hospital caters most of the patients from fluorosis endemic areas. This might be the reason for higher prevalence of Iodine deficiency disorders such as thyroid goitre.19 The fluoride endemicity coupled with higher malnutrition and ignorance about health in females might prove as the reason for female gender preponderance of neck swellings. [20,21]

The inflammatory lesions contributed to 34% of cases in our study. This is in contrast to 74.66% in study by Garima Gupta et al, the reason being the predominance of benign thyroid lesions in our study. Tubercular affection of lymph node and abscess, i.e. the infective ones (53%) occupied the majority of inflammatory lesions, malnutrition and health ignorance the most plausible reasons.

It was found that tubercular affection of lymph node below the age of 40 yrs. and malignancy above the age of 40 yrs. are the most common reasons for lymph node swelling. Thus, a high index of clinical suspicion and FNAC can make the diagnosis closer without advanced tests. [22,23] Advanced tests such as ELISA and PCR are costly and not available in public sector setting.

In our study, the malignant lesions comprised 22% of the neck masses. Frequency of incidence in different studies vary from 7.5% to 38.6%. Lymph node malignant lesions comprised of Metastatic deposits, Hodgkin's and Non-Hodgkin's lymphoma. Metastatic deposits to the lymph nodes were mostly from squamous cell carcinoma elsewhere. [24] Thyroid malignancies were mostly papillary carcinomas (80%), which were found to be more common in females < 40 years. [25] Among the salivary gland lesions, one case of mucoepidermoid carcinoma was reported. Our results of thyroid and salivary gland malignancies were found similar to the study of Jindal et al.

Lipoma was found to be the most common benign soft tissue lesion of neck (6%). It could be considered similar to the studies of Manjula et al and Jindal et al.

Immunocompromised patients were found to be more commonly inflicted with tuberculous affection of lymph node amongst the neck swellings. Lack of immunity predisposes them to secondary activation of tuberculosis.

To Summarise

* The most common tissue of origin of neck swelling was found to be thyroid.

* The thyroid swellings showed a clear female preponderance, and this translated to the whole sample.

* The most common single pathological diagnosis was Goitrous lesion of thyroid followed by tuberculous affection of lymph node.

* Lymph node swelling of neck below the age of 40 years is more likely to be tubercular and above the age of 40 years to be malignant.

* Secondary deposits to lymph node is more likely from squamous cell carcinoma elsewhere.

* Papillary carcinoma is the commonest of thyroid malignancies and is more commonly found in females of age < 40 years.

* Neck masses in immunocompromised patients are more likely to be due to infective aetiology and tuberculosis in particular.

CONCLUSION

The most common single pathological diagnosis in our study was found to be Goitrous lesion of thyroid, most likely attributed to the endemicity of fluorosis in the catchment area of the hospital. High index of suspicion of malignancy needs to be borne in mind in dealing with a lymph node swelling in elderly. Fine needle aspiration cytology clubbed with ultrasonography offers simple methods of diagnosis of neoplastic and non-neoplastic lesions in the neck to confirm clinical diagnosis. It can be performed as an outpatient procedure without complications. The procedure is acceptable to most of the patients. There is no need for anaesthesia and results can be made available within short duration of time.

REFERENCES

[1] Roland N, Bradley PJ. Neck swellings. BMJ 2014;348:g1078. 10.1136/bmj.g1078, 348:g1078.

[2] Rosenberg TL, Brown JJ, Jefferson GD, et al. Evaluating the adult patient with a neck mass. Med Clin North Am 2010;94(5):1017-29.

[3] Orell SR, Sterrett GF, Walters NI, et al. Manual and Atlas of FNAC. 2nd edn. New York: Churchill Livingstone 1995: p. 250.

[4] Watkinson JC, Wilson JA, Gaze M, et al. Stell and Maran's Head and neck surgery. Chap-2 and 20-21. 4th edn. Oxford: Butterworth-Heinemann 2000.

[5] Afridi S, Malik K, Wahed I. Role of fine needle aspiration biopsy and cytology in breast lumps. J College of Physicians and Surgeons Pakistan 1995;5:75-7.

[6] Burnand KG, Young AE, Lucas J, et al. The new Aird's companion in surgical studies. 3rd edn. China: Elsevier 2005.

[7] Layfield LJ. Fine-needle aspiration of the head and neck. Pathology (Phila) 1996;4(2):409-38.

[8] Kirk RM, Ribbans WJ. Clinical surgery in general. 4th edn. Edinburgh: Elsevier 2004.

[9] Modi P, Oza H, Bhalodia J. Utility and adequacy of fine needle aspiration cytology in head and neck lesions: a hospital based study. Int J Sci Stud 2014;2:100-5.

[10] Soni S, Pippal SK, Yashveer B, et al. Efficacy of fine needle aspiration cytology in diagnosis of neck masses. World Articles in Ear, Nose and Throat 2010;3:1. www.waent.org

[11] Ahmad T, Naeem M, Ahmad S, et al. fine needle aspiration cytology (FNAC) and neck swellings in the surgical outpatient. J Ayub Med Coll Abbottabad 2008;20(3):30-2.

[12] Basista H, Modwal A, Prasad B. Clinicopathological evaluation of neck masses. Sch J App Med Sci 2015;3(9B):3235-41.

[13] Manjula K, Prasad CSBR, Gayathri BN, et al. Cytomorphological study of lateral neck swellings. Journal of Clinical and Diagnostic Research 2011;5(5):1016-9.

[14] Jindal U, Singh K, Baghla A, et al. Spectrum of head and neck swellings in the rural population of India based on fine needle aspiration findings. The Internet Journal of Head and Neck Surgery 2012;5:2.

[15] El-Hag IA, Chiedozi LC, al-Reyees FA, et al. Fine needle aspiration cytology of head and neck masses. Seven year's experience in a secondary care hospital. Acta Cytol 2003;47(3):387-92.

[16] Lawrence C, Imad AH, Shara NMNM. Study of Fine Needle Aspiration of head and Neck masses. Acta Cytol 2003;47:387-92.

[17] Muddegowda PH, Srinivasan S, Lingegowda JB, et al. Spectrum of cytology of neck lesions: comparative study from two centers. Journal of Clinical and Diagnostic Research JCDR 2014;8(3):44-5.

[18] Gupta G, Joshi DS, Shah A, et al. FNAC of head and neck swellings. GCSMC J Med Sci 2014;3(1):38-41.

[19] Hetzel BS, Potter BJ, Dulberg EM. The iodine deficiency disorders: nature, pathogenesis and epidemiology. World Rev Nutr Diet 1990;62:59-119.

[20] Kuna SK, Bracic I, Tesic V, et al. Ultrasonographic differentiation of benign from malignant neck lymphadenopathy in thyroid cancer. J Ultrasound Med 2006;25(12):1531-7.

[21] Knox MA. Thyroid nodules. Am Fam Physician 2013;88(3):193-6. http://www.btf-thyroid.org/.lump, Neck and NICE CKS, February 2010.

[22] Sheahan P, Fitzgibbon JG, O'Leary G, et al. Efficacy and pitfalls of fine needle aspiration in the diagnosis of neck masses. Surgeon 2004;2(3):152-6.

[23] Cheng ATL, Dorman B. Fine needle aspiration cytology: the Auckland experience. Australian and New Zealand Journal of Surgery 1992;62(5):368-72.

[24] Goyal A, Tiwari RS, Desai AA. Diagnostic role of ultrasonography in neck swellings. Indian Journal of Otolaryngology and Head & Neck Surgery 1999;51(4):67-71.

[25] Gupta A, Ly S, Castroneves LA, et al. A standardized assessment of thyroid nodules in children confirms higher cancer prevalence than in adults. J Clin Endocrinol Metab 2013;98(8):3238-45.

G. Padmasree (1)

(1) Professor and HOD, Surgery, ACSR Government Medical College, Nellore, Dr. NTR University of Health Sciences (Affiliated], Vijayawada, Andhra Pradesh, India.

'Financial or Other Competing Interest': None.

Submission 21-07-2018, Peer Review 14-08-2018, Acceptance 20-08-2018, Published 27-08-2018.

Corresponding Author: Dr. G. Padmasree, D/No. 4-23-4, Sanjay Gandhi Colony, 1st Line, Opposite Men's Medical Hostel, Guntur-522007, Guntur District, Andhra Pradesh, India.

E-mail: padmasri155155@gmail.com

DOI: 10.14260/jemds/2018/863

Caption: Figure 5. Distribution of Age and type of Lesion

Caption: Figure 8. Distribution of Inflammatory Lesions of the Neck

Caption: Figure 10. Clinical Photograph of patient showing Metastatic deposit (Squamous Cell Carcinoma) in Cervical Nodes

Caption: Figure 11. Clinical Picture of another patient showing Metastatic secondary deposits in Neck

Caption: Figure 12. Clinical Picture of the patient showing TB Lymphadenitis

Caption: Figure 13. Clinical Picture of the patient showing Nodular Goitre

Caption: Figure 14. Clinical Picture of the patient showing Colloid Nodule of Thyroid

Caption: Figure 15. Clinical Picture of patient showing Thyroiditis

Caption: Figure 16. Clinical Picture of the patient showing Papillary Carcinoma Thyroid
Table 1. Incidence of Neck Swellings based on Tissue of
Origin

Tissue of Origin   Incidence N = 100

Thyroid            57% (57)
Lymph nodes        27% (27)
Soft tissue        15% (15)
Salivary           1% (1)
Total              100

Table 2. Distribution of Neck Swellings
based on the type of Lesion

Type of Lesion   N = 100

Inflammatory     34%
Benign           43%
Malignant        23%

Table 3. Incidence based on Pathology

Tissue of       Pathology                  N = 100
Origin

Lymph           TB/ Granulomatous LN       11%
nodes (27%)     Reactive lymphadenitis     4%
                Non-Hodgkin's lymphoma     6%
                Hodgkin's lymphoma         1%
                Metastatic deposit to LN   6%

Thyroid         Cystic                     2%
lesions (57%)   Goitre                     38%
                Thyroiditis                9%
                Malignant                  8%

Soft            Lipoma                     6%
tissue (15%)    Abscess                    7%
                Spindle cell tumour        1%

Salivary        Mucoepidermoid carcinoma   1%
gland (1%)      Submandibular gland

Table 4. Correlation between Sex and Tissue of Origin

Origin        Male   Female   N = 100

Lymph Node    20     7        27%
Thyroid       9      48       57%
Salivary      0      1        1%
Soft Tissue   10     5        15%

Table 5. Correlation between Sex based on Pathological
Diagnosis

                          Male N = 37   Female N = 63   Total N = 100

TB/Granulomatous LN       10            1               11
Reactive lymphadenitis    3             1               4
Non-Hodgkin's lymphoma    3             2               5
Hodgkin's lymphoma        1             0               1
Metastatic deposits       3             3               6
Goitre                    4             34              38
Thyroiditis               1             8               9
Malignant                 1             7               8
Lipoma                    3             3               6
Primary skin malignancy   1             0               1
Abscess                   5             2               7
Spindle cell tumour       1             0               1

Table 6. Distribution of Benign Lesions based on
Pathological Diagnosis

Pathological Diagnosis                         No.

Lipoma                                         6

                         Cystic lesions        2
                         Colloid nodule        4
Thyroid                  Follicular neoplasm   8
                         Nodular goitre        16
                         Thyroglossal cyst     1

Total                                          37

Table 7. Distribution of various Malignant Lesions of Neck

Tissue           Pathological Diagnosis       Total

Lymph node       Metastatic carcinoma         6
                 Non-Hodgkin's lymphoma       5
                 Hodgkin's lymphoma           1

Thyroid gland    Papillary carcinoma          6
                 Anaplastic carcinoma         1

Soft tissue      Rhabdomyosarcoma             1
                 Primary skin lesion          1
                 (squamous cell carcinoma)

Salivary gland   Submandibular                1
                 (mucoepidermoid carcinoma)

Total                                         22

Figure 1. Sex distribution of Neck Masses

Sex distribution

Male     39%
Female   61%

Note: Table made from pie chart.

Figure 2. Age distribution of Cases

Age wise distribution

>20     10%
21-40   47%
41-60   28%
>60     15%

Note: Table made from pie chart.

Figure 3. Incidence of Neck Swellings based on Tissue of
Origin

INCIDENCE--TISSUE OF ORIGIN

Thyroid       57%
Lymph nodes   27%
Soft tissue   15%
Salivary      1%

Note: Table made from pie chart.

Figure 4. Incidence of Neck Swellings based on
type of Lesion

INCIDENCE-TYPE OF LESION

inflammatory   34%
benign         43%
malignant      23%

Note: Table made from

Figure 6. Age distribution of
Thyroid Swelling

Age distribution of thyroid swelling

               < 20 yrs   21-40 yrs   41-60 yrs   > 60 yrs

inflammatory   0          8           1           0
Benign         4          19          12          5
Malignant      0          5           1           2

Figure 7. Age distribution of Lymph Nodal Swellings

Age distribution of lymphnodal swellings (n = 27)

               < 20 yrs   21-40 yrs     41-60 yrs   > 60 yrs

inflammatory   3          7             3           2
Benign         0          0             0           0
Malignant      1          0             7           4

Figure 9. Nature of Lesion in Immunocompromised

DISTRIBUTION IN
IMMUNOCOMPROMISED

Thyroid
Nodular goiter   10%

Tuberculosis     70%

Abscess          10%

Other            20%

Thyroid
Papillary
Carcinoma        10%

Note: Table made from pie chart.
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Title Annotation:Original Research Article
Author:Padmasree, G.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Aug 27, 2018
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