Differential diagnosis of swellings of head & neck

1. DIFFERENTIAL DIAGNOSIS OF SWELLINGS
OF HEAD & NECK
Dr. Saleh Bakry

2. NEED FOR DIFFERENTIAL DIAGNOSIS?
• Lesions of oral and perioral areas must be identified
and characterized so that specific therapy can lead to
elimination of the lesion.

3. ORDERLY STEPS TO IDENTIFY AND
CHARECTERIZE THE LESION
• Health history.
• History of the specific lesion.
• Clinical examination.
• Radiographic examination.
• Laboratory examination.
• Biopsy- If indicated.

4. Reason for Health History?
Two basic reasons :
• A pre-existing medical problem may affect or be
affected by the surgeons treatment of the patient.
• Lesion under investigation may be an oral
manifestation of a systemic disease.

5. I. History of the lesion Duration
1. Duration.
2. Change of Size of the lesion ( size & rate)
3. Has the lesion changed its character (Did the lump
become an ulcer etc.).
4. Symptoms (Pain, dysphagia, anesthesia, Tenderness
of adjacent L.N) associated with the lesion?
5. Any historic reason for the lesion?
(ex: Trauma, recent tooth ache etc )

6. II. CLINICAL EXMINATION
• To determine the clue to its nature.
• Includes Inspection, palpation, percusion and
auscultation.

7. A. Role of anatomic location of the
lesion ?
• Is to know which tissue are contributing to the
lesion.
• Cause has to be elicited based on the anatomic
location.

8. B. Surface of the lesion.
Smooth, lobulated, irregular.
C. Color of the lesion .
• Ex: A bluish swelling which blanch on pressure A
vascular lesion.
• One which do not blanch may be indicative of a
Mucus containing lesion.

9. D. Sharpness of the boundaries of the
lesion.
• To determine whether mass is fixed to bone, arising
from bone and extending to soft tissues/Infiltrating
in nature.

10. E. Consistency of the lesion
• As SOFT in case of Lipoma.
• As FIRM In case of FIBROMA.
• As HARD in case of an osteoma/tori.
F. Presence of fluctuation & pulsation
• Pulsation : Indicates the fluid with in the mass
• Fluctuation : Indicates a large vascular component.

11. F. Lymph Node examination :
Five imp. Characteristics has to be included.
1. LOCATION
2. SIZE (giving the diameter in centimeters)
3. TENDERNESS (painful versus nonpainful)
4. DEGREE OF FIXATION (Movable/fixed)
5. TEXTURE ( soft, hard/firm )

12. III. Radiographic examination
• Gives clue to the true nature of the lesion.
• Ex : A cyst appears as a radiolucency with
sharp radiographic borders.
• A ragged radiolucency may be indicative of the
more aggressive lesion, such as malignancy.
• Use of radiographic dyes/Instruments in
conjunction with routine radiographic
procedures.

13. IV. BIOPSY
 Excisional biopsy.
 Incisional biopsy.
 Drill biopsy.
 Punch biopsy.
 Frozen section biopsy.
 Curettage biopsy.
 Oral cytology.
 Aspiration biopsy.

14. MID LINE SWELLINGS

15. • Enlarged sub mental lymph nodes.
• Lipoma.
• Nasopalatine cyst:
 Incisive canal cyst.
 Nasopalatine canal cyst.
• Fissural cyst:
 Median mandibular cyst.
 Median Palatine cyst.
 Median alveolar cyst.
 Epstein pearls.
• Dermoid cyst.
• Epidermoid cyst.
• Thyroglossal duct cyst.

16. LATERAL NECK
SWELLINGS

17. ACCORDING TO THEIR SITES MAY BE DIVIDED IN TO
1. Sub mandibular Triangle
2. Carotid Triangle
3. Posterior Triangle

18. SUBMANDIBULAR TRAINGLE
• Enlarged lymph nodes.
• Enlargement of submandibular salivary gland.
• Deep / Plunging ranula.
• Extension of growth from the jaw.
• Sjogren’s syndrome.

19. CAROTID TRIANGLE
• Thyroid swelling – will be deep to sternomastoid.
• Aneurysm of the carotid artery.
• Carotid body tumor.
• Branchial cyst.
• A Sternomastoid tumor in a new born.

20. POSTERIOR TRIANGLE
• Enlarged supraclavicular lymph nodes.
• Cystic Hygroma.
• Pharyngeal pouch.
• Sub clavian aneurysm.

21. PERICORONAL
RADIOLUCENCIES

22. 1. Dentigerous cyst.
2. Primordial cyst.
3. Calycifying odontogenic cyst.
4. Ameloblastoma.
5. Unicystic ameloblastoma.
6. Adenomatoid odontogenic tumors.
7. Ameloblastic fibroma.

23. DIFFERENTIAL DIAGNOSIS

24. PERIAPICAL
RADIOLUCENCIES

25. 1. Radicular cyst.
2. Periapical scar.
3. Surgical defect.
4. Periapical cemento-osseous dysplasia.
5. Traumatic bone cyst.
6. Dentoalveolar abscess.
7. Periapical granuloma.
8. Chronic suppurative osteomylities.
9. Cementoblastoma (osteolytic stage).
10. Cemento-ossyfing fibromas (osteolytic stage).

26. DIFFERENTIAL DIAGNOSIS OF PERIAPICAL
RADIOLUCENCY
• Well defined radiolucency + untreated asymptomatic teeth +
non vital pulp → Radicular cyst.
• Teeth with endodontic treatment + asymptomatic, non-
enlarging radiolucency at the apex → Periapical scar.
• Endodontic treated teeth + asymptomatic radiolucency after
root resection → surgical defect.
• Periapical radiolucency in the mandibular premolar – molar
region + vital tooth → Traumatic bone cyst as radicular cyst is
occurred more common in the anterior region.

27. DIFFERENTIAL DIAGNOSIS OF PERIAPICAL
RADIOLUCENCY
• Teeth with vital pulp + mainly in the mandibular incisor
region + older patient → Periapical cemento-osseous
dysplasia.
• Teeth with vital pulp + mainly in mandibular premolar –
molar region + young patient → Traumatic bone cyst.
• The Traumatic bone cyst can be confused with median
mandibular cyst but the median mandibular cyst causes a
separation of the teeth while the Traumatic bone cyst
does not.

28. INTERRADICULAR
RADIOLUCENCIES

29. 1. Lateral radicular cyst.
2. Lateral developmental cyst.
3. Incisive canal cyst.
4. Median mandibular cyst.
5. Glogulomaxillary cyst.
6. Primordial cyst: may occur interradicularly in a
region where a tooth failed to develop.
7. Odontome.

30. DIFFERENTIAL DIAGNOSIS

31. MULTILOCULAR
RADIOLUCENCIES

32. CYST:
• Odontogenic keratocyst.
• Primordial cyst.
• Aneurysmal bone cyst.
TUMORS:
• Ameloblastoma.
• Odontogenic myxoma.
• Central haemangioma of the bone.
• Metastatic tumor to the jaws.
OTHERS:
• Central giant cell granuloma.
• Giant cell lesion of hyperparathyroidism.

33. DIFFERENTIAL DIAGNOSIS
• If the lesion is present in the posterior part of the
mandible + patient is over 30 years old + parasethesia of
the lip → ameloblastoma.
• If the lesion is present in the posterior part of the
mandible + patient is over 30 years old + no parasethesia
of the lip → Multilocular cyst.
• If the lesion present in the posterior part of the mandible
+ patient is between 10 - 30 years old + pain and
parasethesia of the lip are rare → Odontogenic myxoma.

34. MULTIPLES SEPARATE
WELL DEFINED
RADIOLUCIENCIES

35. 1. Basal cell nevus syndrome.
2. Multiple myeloma.
D.D
• The multiple R.L lesion of MM are usually smaller and
more numerous.
• Laboratory findings show elevated serum globulin
leading to reversed albumin/globulin ratio (A: G ratio)
and the presence of Bence-Jones protein in urine →
MM.

36. SOLITARY
RADIOLUCEMCIES WITH
RAGGED AND POORLY
DEFINED BORDERS

37. 1. Squamous cell carcinoma.
2. Malignant minor salivary gland.
3. Osteogenic sarcoma – osteolytic types.
4. Chondrosarcoma.
5. Fibrosarcoma.
6. Fibrous dyplasia.
7. Metastatic tumor to the jaw.
8. Ewing's sarcoma.
9. Burkitt's lymphomas.
10.Chronic alveolar abscess.
11.Chronic osteomylities.
12.Osteoradionecrosis.

38. DIFFERENTIAL DIAGNOSIS
• The D.D of this lesion is very difficult as the clinical
features of the entire lesion are the same.
• For that the D.D depend mainly on the patient age
and the location of the lesion and some additional
features.
• Patients age:
– SCC occur in older patients.
– Chondrsarcoma and OS occur in young patients.

39. • Location of the lesion:
– SCC and OS occur in the mandible more than the
maxilla.
– Chondrsarcoma occurs in the maxilla more than
the mandible.
• Additional features:
– If the patient had a history of tobacco smoking
and alcohol consumption + rapid growth swelling
→ SCC.
– Sun-ray appearance in the radiograph → OS.

40. SOLITARY CYST LIKE
RADIOLUCENCIES NOT
NECESSARILY
CONTACTING TEETH

41. 1. Residual cyst.
2. Traumatic bone cyst.
3. Primordial cyst.
4. Odontogenic keratocyst.
5. Unicystic ameloblastoma.
6. Giant cell lesion.
7. Focal cementoosseous dysplasia.
8. Incisive canal cyst.
9. Midpalatine cyst.
10. Ossifying fibroma.
11. Benign non odontogenic tumors.

42. ODONTOGENIC KERATOCYST
• Should be differentiated from: Residual cyst,
Traumatic bone cyst and Primordial cyst.
• By aspiration:
 Amber colored fluid → Residual cyst or Primordial
cyst.
 Cheesy, thick and yellow material → Odontogenic
keratocyst.
 Air or non productive aspiration → Traumatic bone
cyst.
• By presence or absence of the tooth:
 If the tooth fail to develop → Primordial cyst.
 If the tooth was extracted and the cyst was
associated with it → Residual cyst.

43. INCISIVE CANAL CYST AND MIDPALATINE CYST
• Should be differentiated from:
mucoepidermoid tumor (low grade) and
lipoma.
• For mucoepidermoid tumor (low grade):
 Occur mainly in the lateral aspect of the palate
near the anterior palatine foramen.
 On aspiration give → viscous, clear, sticky fluid
not an amber colored fluid.

44.  For lipoma: differentiated from cyst by
aspiration.
 Incisive canal cyst can be easily differentiated
from midpalatine cyst → Incisive present in the
canal above the palatine papillae while midpalatine
cyst present in the midline of the palate
posterior to the papillae.

45. MESENCHYMAL NON
ODONTOGENIC TUMOR
(SARCOMA)

46. 1. Fibrosarcoma
2. Neurofibrosarcoma
3. Chondrosarcoma
4. Osteogenic Sarcoma
5. Giant Cell Tumor
6. Rhabdomyosarcoma
7. Ewing's Sarcoma
8. Plasma Cell Myeloma
9. Burkitt's Lymphoma
10. Hodgkin's Lymphoma
11. Kaposi's Sarcoma

47. FIBRO-OSSEOUS
DISEASES

48. • Ossifying fibroma.
• Osteoblastoma.
• Osteoma.
• Tori-extosis.
• Cemento-osseous dysplasia.
– Periapical cemental dysplasia.
– Focal cemento-osseoua dysplasia.
– Florid cemento-osseoua dysplasia.

49. SOFT TISSUES TUMORS

50. 1. Papilloma
2. Pyogenic granuloma
3. Pregnancy tumors
4. Peripheral giant cell granuloma
5. lipoma
6. Hemangioma

51. LESION OF THE LIP

52. 1. Mucocele.
2. Minor salivary gland tumors.
3. Minor salivary gland calculus.
4. Nasolagial cyst.
5. Lipoma.
6. Fibroma.
7. Squamous cell papillom.
8. Hemangioma.
9. Lymphangioma.

53. TUMORS AFFECTING THE
TONGUE

54. I. Benign tumors
• Vascular in origin:
– Hemangioma.
– Lymphangioma.
• Neural in origin:
– Neurolemmoma.
– Neurofibroma.
• Muscular in origin:
– Lieomyoma.
– Rhabomyoma.
• Fibrous in origin:
– Fibroma.

55. • Salivary gland:
– Canalicular adenoma.
– Basal cell adenoma.
II. Malignant tumors
• Epithelial in origin:
– Squamous cell carcinoma.
• Mesenchymal in origin:
– Rhabomyosarcoma.
– Neurofibrosarcoma.
III. Cyst
• Thyroglossal duct cyst.
• Demoid & epidermoid cyst.
• Mucous extravasation or retention cyst.

56. PALATAL SWELLING

57. I. Benign Tumors
• Nerve in origin:
– Neurolemmoma.
– Neurofibroma.
• Vascular in origin:
– Hemangioma.
– Lymphangioma.
• Muscle in origin:
– Rhabomyoma.
• Osseous in origin:
– Osteoma.
– Torus palatinous.

58. II. Malignant tumors
• Epithelial in origin:
– Squamous cell carcinoma.
• Mesenchymal in origin:
– Rhabdosarcoma.
– Kaposis sarcoma.
III. Salivary gland
• Benign tumors:
– Plemorphic adenoma.
– Basal cell adenoma.
• Malignant tumors:
 Adenocystic carcinoma.
 Mucoepidermoid carcinoma.

59. IV. Cyst
• Non odontogenic fissural cyst:
– Nosopalatine cyst.
– Median palatine cyst.
– Globlomaxillary cyst.

60. THANK YOU