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Neck Swellings Dr. Vishal Sharma.

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1 Neck Swellings Dr. Vishal Sharma

2 Neck Triangles


4 Anterior Triangle

5 Boundaries: Anterior = midline of neck. Posterior = S. C. M
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

6 Posterior Triangle

7 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

8 Neck Lymph Nodes


10 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


12 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

13 Lateral border of sterno-hyoid
Anterior Posterior Superior Inferior II Lateral border of sterno-hyoid Posterior border of sterno-cleido-mastoid Skull base Carotid bifurcation or hyoid III Cricoid IV Clavicle

14 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

15 Classification of neck swelling according to position
Ubiquitous neck swellings Midline neck swellings Anterior triangle neck swellings Posterior triangle neck swellings

16 Ubiquitous neck swellings
Sebaceous cyst Lipoma Neurofibroma, schwannoma Hemangioma Dermoid cyst Teratoma Hydatid cyst

17 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

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

19 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

20 Posterior triangle swellings
 Cystic hygroma  Pharyngeal pouch (Zenker’s diverticulum)  Lymph node (level V)  Cold abscess  Cervical rib  Clavicular tumour  Subclavian artery aneurysm

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

22 Congenital neck swellings
a. Cystic  Sebaceous cyst  Dermoid cyst  Branchial cyst  Thyroglossal cyst  Thymic cyst b. Solid: Ectopic thyroid c. Vascular  Hemangioma  Lymphangioma

23 Inflammatory neck swellings
Lymphadenitis Viral Bacterial Granulomatous Sialadenitis Parotid Sub-mandibular Deep neck space abscess

24 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

25 Hemangioma & lipoma

26 Cervical Lymphadenopathy

27 A. Inflammatory hyperplasia 1. Acute lymphadenitis 2
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

28 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

29 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

30 Tuberculous lymphadenopathy

31 Lymphoma More common in children & young adults
% children with Hodgkin’s have neck mass Signs & symptoms: Fever + malaise Night sweats Weight loss Pruritus Rubbery lymph nodes

32 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

33 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

34 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

35 Ranula

36 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

37 Simple Ranula

38 Plunging ranula

39 Plunging ranula

40 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

41 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

42 Marsupialization

43 Intra-oral excision

44 Ranula specimen

45 Thyroglossal cyst

46 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



49 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 .

50 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

51 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

52 Neck swelling moving with swallowing
Thyroid swelling Thyroglossal cyst (mobile horizontally) Subhyoid bursitis (oval, long axis horizontal) Pre-laryngeal & pre-tracheal lymph nodes Laryngocele

53 Midline neck swelling

54 Ultra-sonography

55 CT scan axial cut

56 MRI sagittal cut

57 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

58 Patient position & incision

59 Exposure of cyst + tract

60 Exposure & cutting of hyoid bone

61 Removal of tongue tissue

62 Removal of cyst + tract

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

64 Thyroglossal fistula

65 Branchial cleft cysts

66 Embryology




70 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

71 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

72 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

73 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

74 Second branchial cleft cyst

75 Second branchial cleft cyst

76 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

77 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

78 CT scan 1st branchial cyst

79 CT scan 2nd branchial cyst

80 CT scan 3rd branchial cyst

81 Coronal MRI Sagittal MRI Axial MRI

82 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)

83 Excision of branchial cyst

84 Branchial fistula excision

85 Laryngocoele

86 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

87 Swelling enlarges on Valsalva

88 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.

89 Types of laryngocoele Internal External Combined

90 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

91 Flexible laryngoscopy
Swelling of false vocal folds & ary-epiglottic fold Swelling easily emptied Escape of purulent fluid into airway = pyocoele

92 X-ray neck AP view X-ray soft tissue neck AP view during Valsalva maneuver shows air-filled radiolucent swelling

93 CT scan: mixed laryngocoele

94 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.

95 Endoscopic marsupialization

96 External approach

97 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 & pre- operative measurement of catecholamines.

98 Lyre sign

99 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.

100 Hypopharyngeal pouch

101 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

102 Weak spots b/w muscles

103 Origin of Zenker’s diverticulum

104 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 thyro-pharyngeus & cricopharyngeus 4. Second swallow against closed cricopharynx These lead to increased intra-luminal pressure in hypopharynx & mucosa bulges out via weak areas

105 Clinical features Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia Regurgitation of entrapped food: leads to  foul taste  bad odor  nocturnal coughing  choking Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve Weight loss: due to malnutrition Compressible neck swelling on left side: reduces with a gurgling sound (Boyce sign)

106 Complications Lung aspiration of sac contents Bleeding from sac mucosa
Absolute oesophageal obstruction Fistula formation into:  trachea  major blood vessel Squamous cell carcinoma within Zenker diverticulum (0.3% cases)

107 Investigations Chest X-ray: may show sac + air - fluid level
Barium swallow Barium swallow with video-fluoroscopy Rigid Oesophagoscopy Flexible Endoscopic Evaluation of Swallowing

108 Barium swallow

109 Barium swallow with Video-fluoroscopy

110 Rigid Esophagoscopy

111 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

112 Stage 1

113 Stage 2

114 Stage 3

115 Surgical Treatment Cricopharyngeal myotomy: combined with others
Diverticulum invagination: Keyart Diverticulopexy: Sippy-Bevan External or open Diverticulectomy: Wheeler Rigid Endoscopic Diverticulotomy  Cautery (Dohlman)  Laser  Stapler Flexible Endoscopic Diverticulotomy with Laser

116 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): or Diverticulopexy with CP myotomy

117 Cricopharyngeal myotomy

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

119 External diverticulectomy

120 Endoscopic diverticulotomy
Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum

121 View through diverticuloscope
Cautery, laser, or stapling device used to divide common party wall between pouch & esophagus

122 View through diverticuloscope

123 Endoscopic diverticulotomy

124 Dohlman’s instruments

125 Diverticulopexy Sac mobilized & its fundus fixed to sternocleido-mastoid muscle in a superior, non-dependent position. CP myotomy is also done.

126 Cystic hygroma

127 Synonym: cystic lymphangioma
Definition: congenital, benign, multi-loculated, lymphatic lesion classically found in posterior triangle of neck Other sites: axilla, mediastinum, groin & retro peritoneum Etiology: failure of lymphatics to connect to venous system; abnormal budding of lymphatic tissue; sequestered lymphatic cell rests

128 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

129 U/L infrahyoid + suprahyoid 70%
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%

130 Cystic hygroma

131 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.

132 MRI: CH causing airway compression

133 Treatment Asymptomatic: 1. watchful waiting 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

134 Kawasaki syndrome Etiology: idiopathic multisystem vasculitis
Diagnosis (presence of any 5): 1. Fever > 5 days Conjunctival injection. 3. Red / desquamated palm / sole. 4. Injected oral cavity 5. Polymorphous rash Cervical lymph node enlargement Permanent cardiac damage in 20% untreated cases Rx: high dose aspirin & immunoglobulin

135 Thank You

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