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Transcript neck swellings - The Medical Post | Trusting Medicine
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
Anterior Posterior
II
Lateral
Posterior
Superior
Inferior
Skull base
Carotid
border of border of
III
bifurcation
sterno-
sterno-
or hyoid
hyoid
cleido-
Carotid
mastoid
bifurcation
Cricoid
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)
Ludwig’s angina
Sublingual dermoid
Thyroglossal cyst
Subhyoid bursitis
Thyroid swelling (isthmus & pyramidal lobe)
Laryngeal tumors
Cold abscess
Sternal tumor
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 (Zenker’s 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
• Abscess bursts spontaneously → tuberculous sinus
Tuberculous lymphadenopathy
Lymphoma
More common in children & young adults
60 - 80% children with Hodgkin’s 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
Sistrunk’s 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 1/3rd of
SCM, passes deep to 2nd arch structures (external
carotid, stylohyoid muscle, posterior belly of
digastric); superficial to internal carotid (3rd 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 1/3rd 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 1/3rd 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
st
1
branchial cyst
CT scan
nd
2
branchial cyst
CT scan
rd
3
branchial cyst
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 (Boyce’s 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 (Lyre’s 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 Zenker’s 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
Dohlman’s 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
• Acute stridor: aspiration, emergency tracheostomy
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
• Rx: high dose aspirin & immunoglobulin
Thank You
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