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Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS.

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Presentation on theme: "Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS."— Presentation transcript:

1 Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS

2 Head & Neck It is an intricate anatomical region Many of its structures have highly complex anatomy Have important physiological functions Different functional problems Different specialties are involved Interdisciplinary cooperation

3 Head & Neck Different disorders are included: Disorders of respiration Disorders of speech Disorders of swallowing & deglutition Disorders of sensation Disorders of external appearance Disorders of endocrine glands (Thyroid & Parathyroid glands)

4 Head & Neck These disorders could be: Congenital (e.g. cleft palate) Trauma (RTA, FFH……) Tumors Primary Secondary

5 Head & Neck Most of operation are multidisciplinary Reconstructive surgery plays an important role in the surgery of head & neck Aim of any surgery should be restoration of normally functioning oral cavity, with respect to speech & deglutition Restoration of normal endocrine status

6 Head & Neck Normal functioning oral cavity means: Competent oral seal Stable upper & lower Jaws Normal dentition Tongue of a normal bulk & mobility Often requires the restoration of both bony contours & soft tissue outlines

7 Neck Lumps A/ Congenital NL B/ Infective NL C/ Tumors of Head & Neck D/ Thyroid gland disease E/ Parathyroid gland disease

8 A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumors 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele

9 1- Lymphangiomas

10 Lymphangiomas Are malformations of the lymphatic system (which is responsible for returning excess fluid from tissues into the venous system) It can occur at any age It can affect any part of the body > 90% affect children less than 2 Y., usually in the head & neck Could be congenital or acquired

11 Lymphangiomas Congenital LA are often associated with chromosomal abnormalities (Turner Syndrome) Acquired LA may resultfrom trauma, inflammation or lymphatic obstruction Commonly diagnosed before birth using foetal ultrasonography

12 Lymphangiomas 35 % of lymphangiom. of all types occur in the cheek, tongue & floor of mouth 25 % in the Neck 15 % in the Axilla

13 1- Lymphangiomas Embryology: The lymph system arises from 5 primitive sacs developed from the venous system 2 jugular sacs 2 posterior sciatic sacs 1 retroperitonial sac Endothelial buds extend from these centrifugally to form the peripheral lymphatic system

14 1- Lymphangiomas Pathology: Lymphangiomas are classified into 3 groups a - Lymphangioma simplex: composed of thin-walled capillary-sized lymphatic channels b - Cystic hygroma: composed of cysts varying in size from a few millimetres to several centimetres in diameter c - Cavernous lymphangioma: composed of dilated lymphatic spaces often with fibrous adventitia

15 Lymphangioma Simplex - Form 30% of all lymphang. - Small in size (few mm) - Can occur anywhere in the mouth; lips, tongue & cheek where tissue planes are tighter - Pale, soft & fluctuant lesions

16 Cystic Hygroma Forms 30 % of the whole It consists of large, multinodular cystic masses which may be communicated or isolated Have more space to expand into the tissue planes of the neck

17 Cystic Hygroma Have thin walls Contained fluid can be clearly seen Usually occurs in the cervico-facial region spreading into the cheek, mouth, tongue, parotid gland & even into the ear canal & eye

18 Cystic Hygroma Histologically, the cyst is lined by a single layer of flattened endothelium, fetal fat & cholesterol crystals Rare tumors 0,5 % of large series of neck lumps No sex or side predominance 2/3 are noted at birth 9/10 are noted before the end of the 2 nd year

19 Cavernous Lymphangiomas Forms 40 % of these lesions Mainly occurring in the tongue At the base of the tongue, they must be differentiated from a lingual thyroid, a lingual carcinoma, or an internal laryngocele

20 Cavernous Lymphangiomas May occur at the lateral border of the tongue Some cheek lesions reach enormous size & are very difficult to eradicate, since total excision produces an unacceptable cosmetic defect

21 Lymphangiomas Clinical Features: Most of these Tumors manifest themselves at birth or shortly afterwards Lymphangiomas in the mouth can first appear in adult life Recurrences can occur after surgery in infancy, & usually occur on the periphery of the facial area, such as the ear, parotid or posterior triangle

22 Lymphangiomas Clinical Features: Size is the most prominent first symptom & chief complain for presentation Stridor; may occur if the cyst is big enough Laryngeal displacement, may occur Mediastinal widening Sudden increase in size due to spontaneous haemorrhage may be fatal

23 Lymphangiomas Treatment: It has been suggested that complete regression occurs in about 15 %, but many claim never to have seen this Recurrences usually appear within the first 9 months after surgery in about % Recurrence rate is higher with cavernous lymphangioma than with cystic hygroma, because of residual cyst growing with the patient

24 Lymphangiomas Treatment: 1- Aspiration 2- Injection of sclerosants 3- Radiotherapy 4- Coagulation diathermy 5- Cryosurgery 6- Surgery

25 Lymphangiomas Treatment: 1- Aspiration - Rarely done because of high recurrence rate 2- Injection of Sclerosants - Also rarely done nowadays - Should be avoided because of the proximity to major vessels & nerves - It also thickens the walls & tissue planes which makes surgery much more difficult & increase morbidity

26 Lymphangiomas Treatment: 3- Radiotherapy - Should be avoided in young patients - Danger of retarded bone - Danger of retarded tissue growth - Danger of induced malignancy 4- Coagulation diathermy - Usually used in lymphangio. of the base of the tongue - Can be repeated safely if necessary

27 Lymphangiomas Treatment: 5- Cryotherapy - May also be used in non-operable cases 6- Surgery # Incision & drainage: - this should only be done in cases of infected lymphangiomas # Total excision:

28 Lymphangiomas # Total excision : - Should only be delayed in the premature infant - Delay in otherwise healthy infants only leads to continuing morbidity and increased mortality - No operation should be done without a preop. Chest radiograph to rule out mediastinal involvement - Damage to facial, hypoglossal & accessory nerves may be difficult to avoid - It is difficult to get a good cosmetic result in huge cysts because of the tissue displacement & the large amount of skin that must be removed

29 Lymphangiomas # Total excision : - Intraoral lymphangiom. should be removed from an external approach since they are almost certainly much more extensive than expected

30 A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele

31 2/ Midline Dermoid Tumours - 20 % of all dermoid cyst are found in the neck - 30 % in the head & face - Dermoids form 30 % of all midline cysts - There is no sex predominance

32 2/ Midline Dermoid Tumours There are 3 varities of dermoid cyst in the head and neck: 1- Epidermoid cyst 2- True dermoid cyst 3- Teratoid cust

33 2/ Midline Dermoid Tumours 1- Epidermoid cyst: - Is a benign cyst usually found on the skin - Develops out of ectodermal tissue - Results from implantation of epidermis into the dermis - May become very large, causing pressure on adjacent structures like nerves (trigeminal neuralgia)

34 2/ Midline Dermoid Tumours 1- Epidermoid cyst: - Has no adnexal structures - Lined by squamous epithel. - Contain cheesy keratinous material

35 2/ Midline Dermoid Tumours 2 - True Dermoid Cyst (DC): - Dermoid is a loose term given to cysts lined by squamous epith. Occuring in various parts of the body - DC is a cystic teratoma that contains developmentally mature skin completely with hair follicles and sweat glands, or clumps of hair, sebum, blood, fat, bone, nails, teeth, eyes, cartilage & etc… - They are almost always benign - Malignant ones develop usually Sq.c.c. in adults - Malignant DC in infants and children developendodermal sinus tumour

36 2/ Midline Dermoid Tumours 2 - True Dermoid Cyst (DC): - Lined by squamous epithel. - Contains skin appendages such as hair, hair follicles, sebaceous glands & sweat glands - DC are tow types: a/ Congenitalb/ Acquired

37 2/ Midline Dermoid Tumours 2 - True Dermoid Cyst (DC): a/ Congenital: - Is derived from ectodermal differntiations of multipotential cells pinched off at the time of closure of anterior neuropore - It therefore occurs along lines of fusion

38 2/ Midline Dermoid Tumours 2 - True Dermoid Cyst (DC): b/ Acquired: - Is due to implantation of epidermis at the time of a puncture type of injury - It often solid with cystic spaces containing sebaceous material

39 2/ Midline Dermoid Tumours 3 – The Teratoid Cyst: - The rarest variety in the neck & is nearly always diagnosed in the first year of life - Can be lined by squamous or respiratory epithelium - Contains elements formed from ectoderm, endoderm & mesoderm - May contain nails, teeth, brain, muscle & glands, etc….

40 2/ Midline Dermoid Tumours 3 – The Teratoid Cyst: - An unusual type is sacrococcygeal teratoma which can be considered as foetus in foeto (an included foetus)

41 2/ Midline Dermoid Tumours Clinical features : - These cysts present either as solid or cystic mass - Usually in the midline of the neck between the suprasternal notch and the submental region - Can also occur lateral to the submandibular gland - Painless swelling is the only symptom - If the cyst is large can cause obstructive symptoms - 20% occur in the mouth, either deep to the mylohyoid (sublingual) or superficial to it (submental), which may interfer with chewing & swallowing. They present in the 2 nd and 3 rd decades, but are probably present since birth

42 2/ Midline Dermoid Tumours Treatment: - Complete excision should be done in all cases

43 2/ Midline Dermoid Tumours


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