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