5Boundaries: Anterior = midline of neck. Posterior = S. C. M Boundaries: Anterior = midline of neck Posterior = S.C.M. anterior border Superior = lower border of mandibleFloor = deep layer of deep cervical fasciaRoof = Superficial layer of deep cervical fasciaSubdivision: by digastric & omohyoid muscles into submental, submandibular, carotid, muscularContents: carotid arteries, internal jugular vein, vagus, recurrent laryngeal nerves, submandibular gland, Levels I, II, III, IV & VI lymph nodes
7Boundaries:Posterior: Trapezius anterior borderAnterior: S.C.M. posterior borderInferior: Middle 1/3rd of clavicleFloor: deep layer of deep cervical fasciaRoof: Superficial layer of deep cervical fasciaSubdivision: occipital & supra-clavicular by omohyoidContents: subclavian artery, brachial plexus, spinal accessory nerve, level V lymph nodes
36IntroductionRana 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 swallowingPlunging ranula: Sub-mandibular neck swelling with or without cyst in floor of mouth
46EmbryologyThyroid 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
49LocationCyst may lie at any point along migratory pathway of thyroid glandCommonest site: sub-hyoid (50%)Second common site: supra-hyoidOther common sites: base of tongue, at level of thyroid cartilage, sublingualLeast common site: at level of cricoid cartilage.
50Location 1 = base of tongue 2 = sublingual 3 = supra-hyoid 4 = sub-hyoid5 = in front of thyroid cartilage6 = in front of cricoid cartilage
51Clinical features Commonly seen in early childhood Midline, round swelling, 2-4 cm in diameterSwelling moves up with swallowingSwelling moves up with protrusion of tongueSwelling mobile horizontally but not verticallyCyst increases in size with URTI
52Neck swelling moving with swallowing Thyroid swellingThyroglossal cyst (mobile horizontally)Subhyoid bursitis (oval, long axis horizontal)Pre-laryngeal & pre-tracheal lymph nodesLaryngocele
57Sistrunk’s operationConsists 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
70Branchial anomaliesCyst: remnant of branchial clefts or pouch without internal or external openingSinus: persistence of cleft with skin openingFistula: persistence of both cleft + pouch with openings in skin & pharynxFistula tract lies caudal to structures derived from its arch & dorsal to structures of following arch
71Branchial anomaliesIn children, fistulas are more common than sinuses, which are more common than cystsIn adults, cysts predominateBranchial cleft anomalies + biliary atresia + congenital cardiac anomalies = Goldenhar's complex
72First 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
73Second branchial cleft cyst Commonest branchial anomalyPainless, fluctuant mass along anterior border of middle 1/3rd of sternocleidomastoid muscleFistula 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
76Third branchial cleft cyst Painless, fluctuant mass along anterior border of lower 1/3rd of sternocleidomastoid muscleFistula 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
77Fourth branchial cleft cyst Presents as mass along anterior border of lower 1/3rd of stenomastoid or as recurrent thyroiditisFistula 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
82TreatmentAbscesses treated first with incision & drainage + broad-spectrum antibioticsElective surgical excision of cyst with its tract traced up to its origin in pharyngeal wall done after infection resolvesBranchial fistula excised with 2 horizontally placed incisions (stepladder incision)
86Arises from expansion of saccule of laryngeal ventricle due to ed intra-luminal pressure in larynx or congenital large sacculeCauses of ed intra-luminal pressure in larynx:Occupational (?): trumpet players, glass blowersCoexistence of larynx cancerMale : female 5:1, Peak age = 6th decade, Unilateral in 85 % cases, 1% contain carcinoma
88Types of laryngocoeleInternal (20%): contained entirely within endolarynx with bulge in false vocal fold & aryepiglottic foldExternal (30%): only neck swelling without visible endolaryngeal swellingCombined (50%): Also extends into anterior triangle of neck through foramen for superior laryngeal nerve & vessels in thyrohyoid membrane. Dumbbell shaped.
90Clinical Features Hoarseness Stridor in large endolaryngeal laryngocoeleNeck swellingManual compression of neck swelling results in escape of fluid / gas into airway (Boyce’s sign)10% cases are pyocele: sore throat, cough
91Flexible laryngoscopy Swelling of false vocal folds & ary-epiglottic foldSwelling easily emptiedEscape of purulent fluid into airway = pyocoele
92X-ray neck AP viewX-ray soft tissue neck AP view during Valsalva maneuver shows air-filled radiolucent swelling
94Treatment No symptom: no treatment Infected laryngocoele: aspiration & antibioticsInternal laryngocoele: endoscopic marsupializationExternal laryngocoele: Excision by external approach. Cyst exposed by removing upper half of thyroid cartilage. Cyst incised at its neck & stitched.
97Carotid body tumor Pulsating, compressible mass in carotid triangle Mobile only horizontally not verticallyAngiography: 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.
99Sternomastoid tumor of infancy Firm mass of SCM, becomes prominent when chin turned away & head tilted towards the massDue to birth trauma causing infarction / hematoma with subsequent fibrotic replacementRx: Physical therapy. Myoplasty of SCM for refractory cases.
101IntroductionHypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagusIn contrast, congenital diverticulum like Meckel's diverticulum is covered by all muscle layers of visceral wall
104Etiology1. 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
105Clinical featuresEntrapment of food in pouch: sensation of food sticking in throat & later dysphagiaRegurgitation of entrapped food: leads to foul taste bad odor nocturnal coughing chokingHoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerveWeight loss: due to malnutritionCompressible neck swelling on left side: reduces with a gurgling sound (Boyce sign)
106Complications Lung aspiration of sac contents Bleeding from sac mucosa Absolute oesophageal obstructionFistula formation into: trachea major blood vesselSquamous cell carcinoma within Zenker diverticulum (0.3% cases)
107Investigations Chest X-ray: may show sac + air - fluid level Barium swallowBarium swallow with video-fluoroscopyRigid OesophagoscopyFlexible Endoscopic Evaluation of Swallowing
111Staging Lahey system: Stage I: Small mucosal protrusion Stage II: Definite sac present, but hypo-pharynx& esophagus are in lineStage III: Hypopharynx is in line with pouch& esophagus pushed anteriorly
115Surgical Treatment Cricopharyngeal myotomy: combined with others Diverticulum invagination: KeyartDiverticulopexy: Sippy-BevanExternal or open Diverticulectomy: WheelerRigid Endoscopic Diverticulotomy Cautery (Dohlman) Laser StaplerFlexible Endoscopic Diverticulotomy with Laser
116Treatment Protocol 1. Small sac (< 2cm): Cricopharyngeal (CP) myotomy + invagination2. Large sac (2-6 cm):Open Diverticulectomy with CP myotomyor Endoscopic Diverticulotomy with CP myotomy3. Very large sac (> 6 cm):or Diverticulopexy with CP myotomy
127Synonym: cystic lymphangioma Definition: congenital, benign, multi-loculated, lymphatic lesion classically found in posterior triangle of neckOther sites: axilla, mediastinum, groin & retro peritoneumEtiology: failure of lymphatics to connect to venous system; abnormal budding of lymphatic tissue; sequestered lymphatic cell rests
128Clinical 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