1. Done by: Aisha MOHIUDDIN & SHAHD ALYOUSOF.
Neck Masses
Done by: Aisha MOHIUDDIN & SHAHD ALYOUSOF.

2. Neck Masses are divided into:
Midline neck masses
Lateral neck masses: can be grouped according to the neck triangles.

3. 1- Thyroglossal Duct Cyst:
Cystic midline swelling
Mostly affects young children but may occur at any age.
Rounded
2-4 cm
Increases in size in upper respiratory tract infection.
Moves with tongue protrusion {thyroglossal duct attachment to the foramen
caecum at the base of the tongue}
Sites:
Development starts at foramen caecum, passes through the base of the tongue and
then descends in front, behind or through the hyoid bone to form the thyroid gland.
Treatment:
Complete surgical excision.

5. 2- Sublingual Dermoid Cyst:
Midline submental swelling.
Does not move or protrude (Not attached to foramen caecum)
It arises from the floor of the mouth and needs differentiation from ranula
Treatment:
Surgical Excision

6. 3- Submental Nodes: 2-8 nodes situated in the submental triangle
between the platysma and mylohyoid muscles.
They drain:
Chin
Middle part of the lower lip
Incisor region of gingiva
Anterior floor of mouth
Tip of the tongue
Enlarged  draining areas should be looked for
infections or malignancies.

7. 4- Pre-laryngeal and pre-tracheal nodes:
They belong to the juxta-visceral chain of nodes
Lie in front of the larynx and trachea
Drain:
Larynx
Trachea
Thyroid isthmus
Anteriomedial aspect of the thyroid lobes
Pre-laryngeal  Cricothyroid membrane
Pre-tracheal  Thyroid isthmus

8. 5- Thymic cyst:
Thymus develops from the 3rd pharyngeal pouch and then descends through the neck to the mediastinum.
Remnants may persist anywhere in its path. (mandible angle to neck midline)
Swelling  cystic or solid
Children or adults
Neck mass anterior and deep to the middle third of sternocleidomastoid muscle.
Rare condition
Treatment  Surgical excision, sternotomy if it extends to the mediastinum.

9. 6- branchial cyst:
Common in the second decade of life but can occur at any age.
Cyst presents as a swelling in the upper part of the neck, anterior to sternocleidomastoid muscles.
Mass is smooth, round, fluctuant, nontender and non-trasillumunant.
In case of upper respiratory infection  Painful increase in size.
May be associated with a sinus or a fistula.

10. A second arch branchial sinus has an external opening at the junction of lower and middle of the anterior border of sternocleidomastoid and may exude mucoid discharge.
It may have an internal opening in the tonsillar fossa.
When both internal and external openings are present, it is called a branchial fistula.
Treatment:
surgical excision along with its tract, if present.

11. BRANCHIAL SINUS OR FISTULA:
1. An external opening along the anterior border of sternocleidomastoid muscle.
2. A tract which ascends just deep to deep cervical fascia along the carotid artery.
3. The tract passes deep to second arch structures, i.e. external carotid artery, stylohyoid and posterior belly of digastric but superficial to third arch structure, i.e. internal carotid artery (the tract passes between internal and external carotid arteries). It also runs superficial to hypoglossal nerve.
4. Pierces the pharyngeal wall and ends in the tonsillar fossa.
Complete excision of the tract can be accomplished by step-ladder incisions.
Third branchial cleft sinus is uncommon.
Its external opening is at the same place as second cleft sinus but internal opening is situated in pyriform sinus. Tract passes behind both internal and external carotid vessels but is superficial to vagus and hypoglossal nerves.

12. 8- PLUNGING RANULA
It is a pseudocyst caused by extravasation of mucus from obstruction to sublingual salivary gland.
It presents as an isolated swelling in the submandibular area
Transilluminant.
Treatment is total excision along with removal of sublingual gland.

13. Summary: Thyroglossal Duct Cyst: Thymic Cyst: Cystic midline swelling
Moves with tongue protrusion
Sublingual Dermoid Cyst:
Midline submental swelling.
Does not move or protrude
Submental Nodes  Submental triangle
Pre-laryngeal and pre-tracheal nodes  juxta-visceral chain
Thymic Cyst:
mass anterior and deep to the middle third of sternocleidomastoid muscle.
Brachial Cyst:
upper part of the neck, anterior to sternocleidomastoid muscles.
May be associated with a sinus or a fistula.
Plunging Ranula:
Pseudocyst
Isolated swelling in the submandibular area
Transilluminant.

15. CAROTID BODY TUMOR Mostly presents after 40 years.
It is a very slow-growing tumor and the history of mass in the neck may extend into several years.
It presents as a painless swelling.
Pulsatile.
Bruit can be heard with a stethoscope.
It moves from side to side but not vertically.
It may extend into the parapharyngeal space and present in the oropharynx.

16. DON’T do (FNAC) or biopsy because of the vascularity of tumor!
INVESTIGATION
Contrast-enhanced CT.
MRI with gadolinium.
MRI angiography = (Lyre’s sign).
For functional tumors:
Serum catecholamines.
Urinary metanephrines.
Vanillylmandelic acid (VMA).
DON’T do (FNAC) or biopsy because of the vascularity of tumor!

17. TREATMENT Surgical when the patient is: - Younger than 50 years.
- Surgically fit.
- If the tumor extends into the oropharynx causing difficulty in speech, swallowing or breathing.
Radiotherapy
- Older patients.
Unfit for surgery.
Who refuse surgery or have a metastatic disease. 

18. PARAPHARYNGEAL TUMOURS
Present in the:
Upper neck near the angle of mandible.
Retromandibular area.
Intraorally displacing the tonsil.
Lateral pharyngeal wall.
Soft palate medially.
N.B: Majority of these tumors are of salivary gland origin. PLEOMORPHIC ADENOMA is the most common type and the most common tumor of the parotid gland.

19. INVESTIGATION
CT, MRI, FNAC.

20. TREATMENT
Surgical resection.

21. CYSTIC HYGROMA
Occurs most commonly in the posterior triangle of the neck.
Arises from obstruction or sequestration of jugular lymph sac.
90% are seen before 2 years of age. (When present at birth, they cause difficulty in labor).
Other common sites are axilla and groin.
Due to infection, it becomes painful and increases in size. Spontaneous regression is unpredictable.
MORPHOLOGY:
soft, cystic, multilocular, partially compressible and brilliantly trans-illuminant.
N.B: It may extend to involve laryngeal or pharyngeal structures to cause stridor, respiratory and swallowing difficulty.

23. TREATMENT
Surgical excision with preservation of neural and vascular structures.
Complete excision may not be possible in a single operation.
If causing respiratory distress may be aspirated or may require tracheostomy to relieve respiratory obstruction.
Recurrence rate after surgical excision is only 5% if whole tumour is removed mac- roscopically but it is 50% if some part is left.

24. TUBERCULAR LYMPH NODES
Any lymph node group can be involved.
It can occur in any age or sex.
Involved lymph node may be single, multiple or matted due to periadenitis.
Tubercular abscess may form when node(s) caseate.
It may become adherent to the skin and underlying structures.

26. INVESTIGATION FNAC Lymph node biopsy.
X-ray chest, skin test and work-up for other nodal group involvement should be done.

27. TREATMENT
Initial 2 months course of four drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) followed by 4 months course of rifampicin and isoniazid.
If drug treatment fails, surgical excision of lymph node mass or abscess is occasionally required.

28. METASTATIC LYMPH NODES
Any lymph node group can be involved depending on the site of primary malignancy.
Upper cervical lymph nodes are commonly involved in malignancies of upper aerodigestive tract.
Nasopharyngeal malignancies spread to accessory chain of nodes in the posterior triangle.
The most common sites are tonsil, base of tongue, nasopharynx and pyriform sinus.
Node(s) in supraclavicular area should alert the surgeon to the possibility of an infraclavicular primary malignancy in:
Lung, breast, stomach, colon, kidney, ovary and testis.

29. LYMPHOMAS
Both Hodgkin and non-Hodgkin lymphomas may present with cervical lymphadenopathy.
Other lymphatic structures of the Waldeyer ring may also be involved and cause symptoms of:
dysphagia, serous otitis media or respiratory obstruction.
N.B: In such cases, other lymph nodes in the axilla, groin and abdomen should be examined in addition to spleen and liver enlargement.

32. N.B: Cervical rib, if asymptomatic, does not require treatment.
Occasionally an extra rib may arise from the seventh cervical vertebra and end anteriorly by attaching to the first rib.
This rib may produce a bony hard lump in the supraclavicular region. Most often it is seen on the right but may be present on the left or is bilateral.
Subclavian artery and brachial plexus which normally pass between anterior and middle scalene muscles over the first rib have now to pass over the cervical rib (a vertebral space higher) and are thus compressed. It produces neurological or vascular symptoms:
Patient may complain of tingling sensation or numbness along the upper side of forearm and hand due to compression of the lower part of brachial plexus.
When subclavian artery is compressed, hand becomes cold and numb with intermittent claudication of upper limb. Due to arterial compression an aneurysm may develop with mural thrombus which may shoot emboli to the distal arterial system of the upper limb.
N.B: Cervical rib, if asymptomatic, does not require treatment.

34. STERNOMASTOID TUMOUR Mostly seen in the newborns due to birth trauma.
Fibrosis and later shortening of the sternocleidomastoid muscle causes torticollis.
Face is turned to opposite side but the head is tilted on the ipsilateral shoulder.
A mass can be palpated in the sternocleidomastoid muscle on physical examination.
In long-standing cases, asymmetry of face and head can develop as a sequel.

37. Treatment Passive exercises of the neck in early stages.
Surgery is done when the condition is persistent and likely to cause facial hemihypoplasia (It consists of division of sternomastoid muscle).

38. Thank You For Your Attention