neck swellings - The Medical Post

neck swellings - The Medical Post

Neck Swellings Dr. Vishal Sharma Neck Triangles Anterior Triangle

Boundaries: Anterior = midline of neck Posterior = S.C.M. anterior border Superior = lower border of mandible Floor = deep layer of deep cervical fascia Roof = Superficial layer of deep cervical fascia Subdivision: by digastric & omohyoid muscles into

submental, submandibular, carotid, muscular Contents: carotid arteries, internal jugular vein, vagus, recurrent laryngeal nerves, submandibular gland, Levels I, II, III, IV & VI lymph nodes Posterior Triangle

Boundaries: Posterior: Trapezius anterior border Anterior: S.C.M. posterior border Inferior: Middle 1/3rd of clavicle Floor: deep layer of deep cervical fascia

Roof: Superficial layer of deep cervical fascia Subdivision: occipital & supra-clavicular by omohyoid Contents: subclavian artery, brachial plexus, spinal accessory nerve, level V lymph nodes Neck Lymph Nodes

Sloan Kettering Classification Level I: Submental + submandibular nodes Level II: Upper jugular nodes (upper 1/3 of IJV) Level III: Middle jugular nodes (middle 1/3 of IJV) Level IV: Lower jugular nodes (lower 1/3 of IJV)

Level V: Posterior triangle nodes Level VI: Anterior compartment nodes Level VII: Superior mediastinal nodes Submental Lymph nodes (Level Ia): Lateral: Anterior digastric belly (both sides)

Inferior: Body of hyoid Submandibular Lymph nodes (Level Ib) Posterior: Posterior digastric belly Anterior: Anterior digastric belly Superior: Body of mandible

II Anterior Posterior Superior

Inferior Lateral Posterior

Skull base Carotid border of border of

III sterno- sterno-

hyoid cleidomastoid bifurcation

or hyoid Carotid Cricoid bifurcation

or hyoid IV Cricoid

Clavicle Level V: Posterior triangle nodes Posterior: Trapezius anterior border Anterior: S.C.M. posterior border Inferior: Middle 1/3rd of clavicle

Level VI: Anterior compartment nodes Superior: Body of hyoid bone Inferior: Supra-sternal notch Lateral: Lateral border of sterno-hyoid Level VII: Superior mediastinal nodes Classification of neck swelling

according to position Ubiquitous neck swellings Midline neck swellings Anterior triangle neck swellings Posterior triangle neck swellings

Ubiquitous neck swellings Sebaceous cyst Lipoma Neurofibroma, schwannoma Hemangioma Dermoid cyst

Teratoma Hydatid cyst Midline swellings Lymph node (submental, Delphian, suprasternal) Ludwigs angina

Thyroglossal cyst Sublingual dermoid Subhyoid bursitis Thyroid swelling (isthmus & pyramidal lobe)

Laryngeal tumors Sternal tumor Cold abscess Thymus tumors

Submandibular triangle swellings Lymph node (level 1b) Cold abscess Submandibular salivary gland enlargement (deep lobe is bimanually ballotable) Plunging ranula

Mandibular tumor Carotid + muscular triangle swellings Branchial cyst

Branchiogenic cancer Laryngocoele (external) Thyroid lobe swelling Lymph node (II, III, IV) Cold abscess

Carotid body tumour Carotid aneurysm Sternomastoid tumor of newborn Posterior triangle swellings Cystic hygroma Pharyngeal pouch (Zenkers diverticulum)

Lymph node (level V) Cold abscess Cervical rib Clavicular tumour Subclavian artery aneurysm

Classification by etiology Congenital / Developmental Infectious / Inflammatory Neoplastic: Benign / Malignant Congenital neck swellings

a. Cystic Sebaceous cyst Dermoid cyst Branchial cyst

Thyroglossal cyst Thymic cyst b. Solid: Ectopic thyroid c. Vascular

Hemangioma Lymphangioma Inflammatory neck swellings Lymphadenitis

Viral Bacterial Granulomatous Sialadenitis Parotid Sub-mandibular

Deep neck space abscess Neoplastic neck swellings Skin: Squamous cell Ca, Malignant melanoma Soft tissue: Benign: Lipoma, Fibroma, Schwannoma Malignant: Rhabdomyosarcoma

Lymph node: Lymphoma, Metastasis Thyroid: Benign / Malignancy Vascular: Carotid body tumor, Angioma Hemangioma & lipoma

Cervical Lymphadenopathy A. Inflammatory hyperplasia 1. Acute lymphadenitis

2. Chronic lymphadenitis 3. Granulomatous lymphadenitis Bacterial: tuberculosis, secondary syphilis Viral: infectious mononucleosis, AIDS Parasitological: toxoplasmosis

Non-specific: sarcoidosis B. Neoplastic: lymphoma, lymphosarcoma, metastatic C. Lymphatic leukemia D. Autoimmune: systemic lupus erythematosus Lymph node consistency

Firm, rubbery: lymphoma Soft : infection or cold abscess Multiple, firm, shotty: syphilis, viral Matted (connected): tuberculosis , sarcoidosis, malignant Rock hard, immobile, fixed to skin: metastatic

Tuberculous lymphadenitis Involves upper deep cervical chain & posterior triangle lymph nodes Development of peri-adenitis matted nodes

Development of caseation cold abscess Abscess tracking down to skin forms subcutaneous collection collar stud abscess Tuberculous lymphadenopathy

Lymphoma More common in children & young adults 60 - 80% children with Hodgkins have neck mass Signs & symptoms: Fever + malaise Night sweats

Weight loss Pruritus Rubbery lymph nodes Metastatic lymph node Seen in older patients

Level 1: oral cavity Level 2, 3, 4: larynx, oropharynx, hypopharynx, thyroid Level 5: nasopharynx Left supraclavicular fossa: lung, stomach, testis

Unknown Primary Lesion (UPL) Synonym: 1. metastasis of unknown origin 2. occult primary Definition: metastatic lymph node with primary site hidden or undetected Primary malignancy sites (as per frequency):

1. Nasopharynx 2. Oropharynx (base of tongue) 3. Hypopharynx (pyriform fossa) 4. Larynx

5. Thyroid Investigations for UPL 1. Fibreoptic nasopharyngoscopy + laryngoscopy 2. Rigid panendoscopy

3. Excision biopsy of I/L tonsil + blind biopsy of tongue base, pyriform fossa, fossa of Rosenmuller, tonsilo-lingual sulcus, retro molar trigone 4. CT scan from skull base to superior mediastinum 5. Excision biopsy of metastatic lymph node

Ranula Introduction Rana means frog (blue translucent swelling in floor of mouth looks like underbelly of frog) Simple ranula: Bluish cyst located in floor of

mouth. Painless mass, does not change in size in response to chewing, eating or swallowing Plunging ranula: Sub-mandibular neck swelling with or without cyst in floor of mouth Simple Ranula

Plunging ranula Plunging ranula Etiology Simple ranula: partial obstruction or severance of

sublingual duct leads to epithelial-lined retention cyst. Commonly traumatic. Plunging ranula: 1. sublingual gland projects through or behind mylohyoid muscle 2. ectopic sublingual gland on cervical side of mylohyoid muscle

Treatment Marsupialization: un-roofing of cyst & suturing of cyst margin to adjacent tissue. Failure = 60-90% Sclerosing agents: intra-lesional injection of Bleomycin or OK-432

Intra-oral excision: of ranula alone (failure = 60%) or ranula + sublingual gland (failure = 2 %) Trans-cervical approach for plunging ranula: complete removal of cyst + sublingual gland Marsupialization

Intra-oral excision Ranula specimen Thyroglossal cyst

Embryology Thyroid appears as epithelial proliferation in floor of mouth. Thyroid descends in front of pharynx as bi-lobed diverticulum, connected to tongue by thyroglossal duct.

The duct normally disappears later. Thyroglossal cysts are cystic remnant of thyroglossal duct. Commonest congenital anomaly of thyroid Location Cyst may lie at any point along migratory pathway

of thyroid gland Commonest site: sub-hyoid (50%) Second common site: supra-hyoid . Other common sites: base of tongue, at level of thyroid cartilage, sublingual

Least common site: at level of cricoid cartilage Location 1 = base of tongue 2 = sublingual 3 = supra-hyoid

4 = sub-hyoid 5 = in front of thyroid cartilage 6 = in front of cricoid cartilage

Clinical features Commonly seen in early childhood Midline, round swelling, 2-4 cm in diameter Swelling moves up with swallowing Swelling moves up with protrusion of tongue Swelling mobile horizontally but not vertically

Cyst increases in size with URTI Neck swelling moving with swallowing Thyroid swelling Thyroglossal cyst (mobile horizontally)

Subhyoid bursitis (oval, long axis horizontal) Pre-laryngeal & pre-tracheal lymph nodes Laryngocele Midline neck swelling

Ultra-sonography CT scan axial cut MRI sagittal cut

Sistrunks operation Consists of complete surgical excision of cyst & its tract along with body of hyoid bone & core of tongue tissue around suprahyoid tongue base up to foramen caecum Thyroid scan mandatory before cyst excision as

cyst may contain only functioning thyroid tissue Patient position & incision Exposure of cyst + tract Exposure & cutting of hyoid bone

Removal of tongue tissue Removal of cyst + tract Complications

1. Infection of cyst & abscess formation 2. Throglossal fistula 3. Malignancy (1%) Infected cyst

Thyroglossal fistula Branchial cleft cysts Embryology

Branchial anomalies Cyst: remnant of branchial clefts or pouch without internal or external opening Sinus: persistence of cleft with skin opening Fistula: persistence of both cleft + pouch with openings in skin & pharynx

Fistula tract lies caudal to structures derived from its arch & dorsal to structures of following arch Branchial anomalies In children, fistulas are more common than sinuses, which are more common than cysts

In adults, cysts predominate Branchial cleft anomalies + biliary atresia + congenital cardiac anomalies = Goldenhar's complex First branchial cleft cyst

Type I: Contains only ectodermal elements without cartilage or adnexal structures. Present as duplication of external auditory canal. Type II: Contains both ectoderm & mesoderm. Present as abscess below angle of mandible. Fistula ends internally around Eustachian tube

Second branchial cleft cyst Commonest branchial anomaly Painless, fluctuant mass along anterior border of middle 1/3rd of sternocleidomastoid muscle Fistula tract opens externally along lower 1/3 rd of SCM, passes deep to 2nd arch structures (external

carotid, stylohyoid muscle, posterior belly of digastric); superficial to internal carotid (3 rd arch); ends internally in tonsillar fossa Second branchial cleft cyst

Second branchial cleft cyst Third branchial cleft cyst Painless, fluctuant mass along anterior border of lower 1/3rd of sternocleidomastoid muscle Fistula tract opens externally along lower 1/3 rd of

SCM, passes deep to 3rd arch structures (internal carotid, glossopharyngeal nerve); superficial to superior laryngeal nerve (4th arch): opening internally in base of pyriform fossa Fourth branchial cleft cyst

Presents as mass along anterior border of lower 1/3rd of stenomastoid or as recurrent thyroiditis Fistula tract opens externally along lower 1/3 rd of SCM, passes deep to 4th arch structures (superior laryngeal nerve ); superficial to recurrent laryngeal nerve (6th arch); opening internally in apex of

pyriform fossa CT scan 1 branchial cyst st CT scan 2 branchial cyst

nd CT scan 3 branchial cyst rd Coronal MRI

Sagittal MRI Axial MRI Treatment

Abscesses treated first with incision & drainage + broad-spectrum antibiotics Elective surgical excision of cyst with its tract traced up to its origin in pharyngeal wall done after infection resolves Branchial fistula excised with 2 horizontally placed incisions (stepladder incision)

Excision of branchial cyst Branchial fistula excision Laryngocoele

Arises from expansion of saccule of laryngeal ventricle due to ed intra-luminal pressure in larynx or congenital large saccule Causes of ed intra-luminal pressure in larynx: Occupational (?): trumpet players, glass blowers

Coexistence of larynx cancer Male : female 5:1, Peak age = 6th decade, Unilateral in 85 % cases, 1% contain carcinoma Swelling enlarges on Valsalva

Types of laryngocoele Internal (20%): contained entirely within endolarynx with bulge in false vocal fold & aryepiglottic fold External (30%): only neck swelling without visible endolaryngeal swelling Combined (50%): Also extends into anterior triangle of

neck through foramen for superior laryngeal nerve & vessels in thyrohyoid membrane. Dumbbell shaped. Types of laryngocoele Internal

External Combined 89

Clinical Features Hoarseness Stridor in large endolaryngeal laryngocoele Neck swelling Manual compression of neck swelling results in

escape of fluid / gas into airway (Boyces sign) 10% cases are pyocele: sore throat, cough Flexible laryngoscopy Swelling of false vocal folds & ary-epiglottic fold Swelling easily emptied

Escape of purulent fluid into airway = pyocoele 91 X-ray neck AP view X-ray soft tissue neck AP

view during Valsalva maneuver shows airfilled radiolucent swelling 92 CT scan: mixed laryngocoele

Treatment No symptom: no treatment Infected laryngocoele: aspiration & antibiotics Internal laryngocoele: endoscopic marsupialization External laryngocoele: Excision by external

approach. Cyst exposed by removing upper half of thyroid cartilage. Cyst incised at its neck & stitched. Endoscopic marsupialization External approach

Carotid body tumor Pulsating, compressible mass in carotid triangle Mobile only horizontally not vertically Angiography: vascular mass b/w external & internal carotid arteries (Lyres sign)

Rx: Radiation or close observation in elderly. Surgical resection for small tumors in young patients with hypotensive anesthesia & preoperative measurement of catecholamines. Lyre sign

Sternomastoid tumor of infancy Firm mass of SCM, becomes prominent when chin turned away & head tilted towards the mass Due to birth trauma causing infarction / hematoma with subsequent fibrotic replacement Rx: Physical therapy. Myoplasty of SCM for

refractory cases. Hypopharyngeal pouch Introduction Hypopharyngeal pouch is an acquired pulsion

diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagus In contrast, congenital diverticulum like Meckel's diverticulum is covered by all muscle layers of visceral wall

Weak spots b/w muscles Origin of Zenkers diverticulum Etiology

1. Tonic spasm of cricopharyngeal sphincter: C.N.S. injury Gastro-esophageal reflux 2. Lack of inhibition of cricopharyngeal sphincter

3. Neuromuscular in-coordination between thyropharyngeus & cricopharyngeus 4. Second swallow against closed cricopharynx These lead to increased intra-luminal pressure in hypopharynx & mucosa bulges out via weak areas Clinical features

1. Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia 2. Regurgitation of entrapped food: leads to foul taste bad odor nocturnal coughing choking 3. Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve

4. Weight loss: due to malnutrition 5. Compressible neck swelling on left side: reduces with a gurgling sound (Boyce sign) Complications 1. Lung aspiration of sac contents

2. Bleeding from sac mucosa 3. Absolute oesophageal obstruction 4. Fistula formation into: trachea major blood vessel

5. Squamous cell carcinoma within Zenker diverticulum (0.3% cases) Investigations Chest X-ray: may show sac + air - fluid level Barium swallow

Barium swallow with video-fluoroscopy Rigid Oesophagoscopy Flexible Endoscopic Evaluation of Swallowing Barium swallow

Barium swallow with Video-fluoroscopy Rigid Esophagoscopy Staging

Lahey system: Stage I: Small mucosal protrusion Stage II: Definite sac present, but hypo-pharynx & esophagus are in line Stage III: Hypopharynx is in line with pouch & esophagus pushed anteriorly

Stage 1 Stage 2 Stage 3

Surgical Treatment 1. Cricopharyngeal myotomy: combined with others 2. Diverticulum invagination: Keyart 3. Diverticulopexy: Sippy-Bevan 4. External or open Diverticulectomy: Wheeler

5. Rigid Endoscopic Diverticulotomy Cautery (Dohlman) Laser Stapler

6. Flexible Endoscopic Diverticulotomy with Laser Treatment Protocol 1. Small sac (< 2cm): Cricopharyngeal (CP) myotomy + invagination

2. Large sac (2-6 cm): Open Diverticulectomy with CP myotomy or Endoscopic Diverticulotomy with CP myotomy 3. Very large sac (> 6 cm): Open Diverticulectomy with CP myotomy or Diverticulopexy with CP myotomy

Cricopharyngeal myotomy Diverticulum invagination Diverticulum pushed into hypopharynx lumen & muscle + adjacent tissue are oversewn. CP myotomy is usually combined with this.

External diverticulectomy Endoscopic diverticulotomy Diverticuloscope advanced so its upper lip is within

esophagus & lower lip is within diverticulum View through diverticuloscope Cautery, laser, or stapling device used to divide common party wall between pouch & esophagus

View through diverticuloscope Endoscopic diverticulotomy Dohlmans instruments

Diverticulopexy Sac mobilized & its fundus fixed to sternocleidomastoid muscle in a superior, non-dependent position. CP myotomy is also done. Cystic hygroma

Synonym: cystic lymphangioma Definition: congenital, benign, multi-loculated, lymphatic lesion classically found in posterior triangle of neck Other sites: axilla, mediastinum, groin & retroperitoneum

Etiology: failure of lymphatics to connect to venous system; abnormal budding of lymphatic tissue; sequestered lymphatic cell rests Clinical Features 50-65% cases present at birth, 80-90% by 2 years

Soft, painless, compressible trans-illuminant mass present in posterior triangle of neck. Overlying skin can be bluish or normal . Sudden se in size due to infection or intra-cystic bleeding. Look for tracheal deviation, airway obstruction, cyanosis, feeding difficulty, failure to thrive

Stage Clinical Features Complication rate

Stage I U/L infrahyoid 20%

Stage II U/L suprahyoid 40%

Stage III U/L infrahyoid + suprahyoid 70%

Stage IV B/L suprahyoid 80%

Stage V B/L infrahyoid + suprahyoid 100%

Cystic hygroma Investigations USG: used to detect CH in utero CT scan: Contrast helps to enhance cyst wall visualization & relationship to surrounding blood

vessels. CH appears isodense to CSF. Macrocystic: cystic spaces > 2 cm Microcystic: cystic spaces < 2 cm MRI: Best investigation. CH appears hyperintense on T2 & hypointense on T1-weighted images. MRI: CH causing airway compression Treatment Asymptomatic: 1. watchful waiting 2. sclerosing agents: OK-432 (Picibanil), bleomycin,

ethanol, doxycycline, Interferon, fibrin sealant Infected cases: intravenous antibiotics & drainage; definitive surgery after 3 months

Surgical excision: mainstay of treatment. Done with Cautery, Laser, Radiofrequency Kawasaki syndrome Etiology: idiopathic multisystem vasculitis

Diagnosis (presence of any 5): 1. Fever > 5 days. 2. Conjunctival injection. 3. Red / desquamated palm / sole. 4. Injected oral cavity 5. Polymorphous rash. 6. Cervical lymph node

enlargement Permanent cardiac damage in 20% untreated cases Thank You


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