Non thyroid neck swellings

Non thyroid neck swellings

1. Dr SUNDARPRAKASH SIVALINGAM Associate Professor in Surgery NON-THYROID NECK SWELLINGS DR.SUNDARPRAKASH SIVALINGAM ASSOCIATE PROFESSOR SURGERY

2. BENIGN – CHILD 80 ADULT 20 MALIGNANT – CHILD 20 ADULT 80 MIDLINE Thyroglossal cyst, dermoid cyst LATERAL Ranula (submental/submandibular) Branchial cyst (carotid) Cystic hygroma , TB lymphadenitis, Cervical rib (posterior)

3. Etiology – abnormal development of branchial apparatus Age – late childhood/ early adulthood, 20-25 yrs, appears late though congenital as fluid within it takes time to accumulate C/F Painless, oval/rounded swelling, soft , sometimes transilluminated, non compressible Becomes painful and tender if infected after URTI Site – anterior triangle ( carotid) Pathology – cholesterol crystals

4. Types 2 nd branchial cleft cyst (mc) Deep to and along ant border of SCM If infected – sinus Tract b/w 2 nd arch structures (ECA, post digastric, SCM) and 3 rd arch structures (ICA) If fistula – 2 openings, external along ant border of SCM at lower 1/3 rd , internal – perforates pharyngeal wall and opens in tonsillar fossa (ant border of post pillar behind the tonsil)

5. 3 rd branchial cleft cyst Uncommon, deep to both ECA and ICA, sup to hypoglossal nerve and vagus nerve Opens into pyriform fossa 1 st branchial cleft cyst Less common Along ant border of mandible, angle of mandible, below ear lobe Opens into EAC

6. Diagnosis USG FNAC – cholesterol crystals, lymphoid tissue Contrast X Ray (Fistulogram) Treatment Surgical excision along with its tract

7. CYSTIC HYGROMA Etiology Congenital cystic lesion due to incomplete development, obstruction or sequestration of normal lymphatic system ( jugular lymphatic sac) Associated with chromosomal anomaly Age - < 2 yrs (90%), can be present at birth Site – lower part of posterior triangle (mc), base of tongue, cheeks, supraglottis

8. C/F Painless, slow growing, fluctuant, soft swelling, with indiscrete margins, partially reducible, varies in size, transilluminated, increase in size on coughing or crying If infected – painful and increase in size Pathology – contains multiple loculi of clear lymph

9. Complications Stridor – if involve larynx, pharynx Respiratory difficulty Feeding problem Difficult labour Diagnosis Antenatal USG CT, MRI

10. Treatment Tracheostomy if stridor Complete excision Sclerotherapy - Injection sclerosing agents like absolute alcohol, bleomycin, TCA

11. Head and neck – 7% of dermoid cyst MC site – floor of mouth post or lateral to frenulum, midline (submental) C/F Slow growing, painless cystic swelling, non transilluminated, can lead to difficulty in swallowing, speech and respiration Children and young adults, 10-15 yrs Pathology – contains epidermoid appendages like hair, hair follicles, sweat glands, sebaceous glands

12. Types Sublingual – MC Floor of mouth, above myelohyoid Cervical At submental triangle, below myelohyoid, double chin appearance Diagnosis – USG Neck D/D – sebaceous cyst – skin mobile in dermoid cyst over swelling Treatment – complete surgical excision

13. Etiology Mucous retention cyst of sublingual salivary glands due to obstruction of their secretory ducts Types Intra oral Cystic translucent bluish mass in lateral part of floor of mouth, pushes tongue up Plunging ranula – neck swelling in submental/ submandibular region, painless, transilluminated

14. Complications Difficulty in swallowing Difficulty in chewing Difficulty in speaking Treatment Excision along with sublingual gland Marsupialization if large (as thin walled so grows into various structures If ruptures – recurrence Plunging ranula – trans cervical approach

15. PHARYNGEAL POUCH It is a protrusion of mucosa through Killian’s dehiscence, a weak area of the posterior pharyngeal wall between thyropharyngeus (oblique fibres ) and cricopharyngeus ( transverse fibres ) of the inferior constrictor muscle of the pharynx. Thyropharyngeus is supplied by pharyngeal plexus from cranial accessory nerve. Cricopharyngeus is supplied by external laryngeal nerve. Pharyngeal pouch is a pulsion diverticulum . It starts in the midline of posterior pharyngeal wall. Once it expands and reaches the vertebra, it deviates towards left side of the neck because of resistance of vertebra. The protrusion is usually towards left .

16. Stages Small diverticulum pointing towards vertebra. It is asymptomatic and incidentally diagnosed by barium meal X-ray. Foreign body sensation in pharynx may be present . 2. Large, globular diverticulum with vertical mouth/opening causing regurgitation, violent cough, dysphagia , respiratory infection . Regurgitation is more after meals and while turning the neck. Problems in pharyngeal pouch Progressive dysphagia Respiratory problems like pneumonia, lung abscess Abscess in the neck due to infection in the pouch Weight loss and cachexia

17. Differential Diagnosis Branchial cyst. Cold abscess in the neck. Lymph cyst. Haemangioma neck . Clinical Features Pain, dysphagia , recurrent respiratory infection, swelling in the neck on the left side which is smooth, soft and tender. Regurgitation during night while turning neck, smooth, soft, tender swelling in the posterior triangle of the left side of the neck ; typical gurgling noise while swallowing—are typical features . It is common in males. Swelling is deep to sternocleidomastoid muscle below the level of thyroid cartilage; initially soft and emptying; impulse on coughing may be evident unless opening of the pouch is blocked due to recurrent inflammation .

18. Investigations Barium swallow—lateral view shows pharyngeal pouch. Chest X-ray shows pneumonia. CT neck is very useful.

19. Treatment Antibiotic is started to control infection. Pharyngeal pouch is excised by an oblique neck incision (approach from neck). As there is cricopharyngeal spasm, cricopharyngeal myotomy (i.e. cutting of cricopharyngeal circular muscle fibres without opening mucosa) is done to prevent the recurrence. Indications for surgery Progressive symptoms. Recurrent respiratory complications. Dysphagia . Complications of surgery Infection, either mediastinitis or lung infection ( Pneumonia or lung abscess) Pharyngeal fistula Abscess in the neck Oesophageal stenosis and recurrence

20. LARYNGOCELE It is a unilateral narrow necked, air containing diverticulum resulting from herniation of laryngeal mucosa. It occurs in professional trumpet players, glass blowers and in people with chronic cough. Types a. External: It is situated in the anterior third of the laryngeal ventricle , between the false cords and thyroid cartilage, herniates through the thyrohyoid membrane where it is pierced by superior laryngeal nerve. b. Internal: Confi ned within the larynx, presents as a distention of false cords. c. Combined.

21. Clinical Features Swelling in the neck in relation to larynx, adjacent to thyrohyoid membrane which is smooth, soft, resonant and is more prominent while blowing, coughing and Valsalva manoeuvre . It moves upwards during swallowing with expansile impulse on coughing. Infection is quite common in the sac of laryngocele , leading to the blockade of opening of the sac causing an abscess. Pus often may be discharged into the pharynx repeatedly. Hoarseness and cough. If large, causes obstruction to larynx.

22. Diagnosis Clinical features, X-ray neck, laryngoscopy , CT scan. Treatment External laryngocele : Excision through neck incision. Neck of the sac should be ligated . Thyrohyoid membrane is repaired using 3 zero nonabsorbable polypropylenes sutures. Internal laryngocele : Marsupialisation , with the help of laryngoscope. Typical laryngocele in the neck which becomes prominent after blowing. X-ray lateral show radiolucent air in the neck.

23. U/L MC – young children (1-8 yrs) Etiology – due to focus of infection in tonsils, adenoids, dental, oral cavity JD lymph nodes C/F – fever, malaise, ln enlarged and tender Diagnosis – WBC count, USG Treatment – antibiotic therapy, surgical drainage of abscess

24. Chronic infection of lymph nodes due t o Mycobacterium tuberculosis Route of infection – I/L tonsil, secondary t o pulmonary TB, hematogenous C/F Painless, unilateral, gradual increase in size m o s t common seen in posterior triangle Evening rise of temp, night sweats, weight loss Stages Adenitis – enlarged ln Periadenitis – matted ln (2-3 ln)

25. Cold abscess – central caseation within ln Collar stud abscess (dumb bell shaped) – rupture of cold abscess, pus enters sup fascia below the skin Discharging sinus – pus ruptures through skin Diagnosis Mantoux test/ tuberculin skin test – positive (> 10 mm) USG – matted ln with central necrosis Chest X Ray PA view – pulmonary TB

26. FNAC – granulomas, acid fast bacilli Excision biopsy C/S CBC Treatment ATT Complete excision along with surrounding fibrous capsule – if residual ln after ATT If active pulmonary TB – excision not done

27. M avium complex (avium and intercellulare) M fortuitum M kansassi M scrofulaceum Age – children < 6 yrs Site – pre auricular, submental, upper jugular Diagnosis – tuberculin test positive (10-15 mm) Treatment – coplete surgical excision

28. Extra rib arising from C7 vertebra attached to 1 st rib Right side is m ost common, but can be left side or bilateral Types 1. Complete bony: Cervical rib is radio-opaque, anteriorly ends over the first rib or manubrium . 2. Complete fibrous : Cannot be demonstrated radio logically. 3. Combined: Partly bony partly fibrous . 4. Partial bony: With free end expanding as bony mass, which is felt in the neck.

29. C/F Bony hard lump in supra clavicular region Compression of branchial plexus and subclavian artery Branchial plexus compression – tingling, numbness, pain along upper forearm and fingers Loss of power of hand

30. Subclavian artery compression –excessive sweating of hands, cold and numb hands, pale and blue hands due to cyanosis, pain in forearm worsens on exercise Diagnosis Adson’s test – positive – weak pulse on turning neck on same side X Ray Treatment Asymptomatic – no treatment Symptomatic – excision by supraclavicular, transaxillary approach

31. Carotid bodies – chemoreceptor organs containing cells situated at bifurcation of CCA contain acetylcholine and catecholamine stimulated by increase pco2, decrease po2, increase H+ (higher altitudes) Site – carotid triangle at CCA bifurcation Age – mc 5 th decade Region – high altitude areas like Tibet, Peru Etiology – chronic hyperplasia in high altitude areas -> carotid body hyperplasia Familial – 10% autosomal dominant

32. C/F Painless slow growing swelling of many years duration in carotid triangle Pulastile Compressible – size decreases with carotid compression and increases on release of pressure Mobility from side to side and not up and down Bruit, thrill + Can extend to parapharyngeal space and oropharynx pushing the tonsil medially

33. If large can cause pressure symptoms like dysphagia, change in voice Pressure on swelling can lead to faintness (carotid body syncope) Rare regional and distant metastasis Diagnosis Serum catecholamines 24 hrs urine vanellyl mandelic acid CECT MRI with gadolinum MRI angiography/ DSA

34. Lyre’s sign – widening of angle/ splaying between ICA and ECA on angiography Avoid FNAC, open biopsy as highly vascular Treatment Younger age/ no metastasis/ fit – surgical resection by trans cervical approach Large tumours – do arterial embolization first to decrease bleeding Elderly > 50 yrs/ metastasis/ unfit - RT

35. Children and young adults 55% of paediatric ca Hodgkin’s/ non hodgkin’s C/F Painless, mobile, non tender, discrete, rubbery, progressively enlarging lymph nodes in the neck Other sites of ln enlargement – axilla, groin and abdomen Hypertrophy of spleen and liver Hypertrophy of waldeyer’s ring including tonsils Fever

36. Pressure symptoms like dysphagia, respiratory obstruction Serous otitis media Diagnosis FNAC Needle biopsy Open biopsy Treatment Early stage – RT Advanced stage – CT, CT+RT.....

37. Types Pre styloid Mainly salivary gland tumours Pleomorphic adenoma Warthin’s tumour Mucoepidermoid ca Site – deep lobe of parotid C/F – mass or bulge on tonsillar fossa, soft palate, lateral pharyngeal wall Displace the above structures mediallty Painless swelling

38. Post styloid Neurogenic tumours Schwannomas/ neurilemmomas Neurofibroma Paraganglioma Malignant schwannoma C/F Firm neck mass showing bulge in lateral pharyngeal wall Can displace the lateral pharyngeal wall medially

39. Pressure symptoms of hoarseness of voice, dysphagia, trismus Painless Nasal obstruction and aural fullness Diagnosis CT/MRI DSA Rigid endoscopy 24 hrs VMA FNAC

40. Treatment Surgical resection Lower neck – trans cervical approach Upper neck – trans cervical trans mandibular approach Parotid – cervico parotid approach

41. Congenital torticolis Age – at birth Etiology Birth trauma – venous obstruction or haematoma formation during..... Labour ..... Leads to infarction of central portion of SCM which leads to fibrosis Fibrosis causes contraction or shortening of SCM Swelling in the SCM

42. C/F Circumscribed firm mass palpable in middle 1/3 rd of SCM Torticolis – face turned to opposite side, head fixed on shoulder on same side Asymmetry of head and face Treatment Conservative – regular active and passive neck movements to avoid contraction Surgery – division of SCM at its lower end

43. Age - > 50 yrs M>F Can be occult primary – unknown primary Painless hard swelling non tender fixed t o skin or deeper structures . Common sites of primary Oral cavity, tongue, tonsils Salivary glands Pharynx— nasopharynx Larynx Oesophagus Lungs GIT Thyroid

44. Diagnosis Complete examination of digestive tract, tracheo bronchial tree, breasts, thyroid, genito urinary tract Pan endoscopy Imaging – X Rays, USG neck and abdomen, CT, MRI....., PET scan FNAC If FNAC shows malignancy biopsy Biopsy Punch biopsy of hidden areas Excision biopsy of tonsils

45. Treatment Depends on primary site Occult primary – RND Post op RT to nasopharynx, I/L tonsil, C/L neck....., base of tongue Need to do regular follow up

46. Spreading cellulitis (mainly B/L) involving submandibular, submental and sublingual spaces Myelohyoid divides the submandibular space into lower submaxillary and upper sublingual space Etiology Age 20-50 yrs Organisms – streptococci, staphylococci , H.influenza , E coli , pseudomonas MC – dental infections, lower premolar and molar

47. Dental extraction Tonsillar infection Fracture mandible Injury to oral mucosa – tongue, floor of mouth Submandibular sialadenitis Post radiotherapy osteoradionecrosis of mandible ONLY LOCAL SPREAD NO LYMPHATIC SPREAD

48. C/F Marked progressively painful odynophagia Trismus Tongue pushed upwards and backwards Swollen tender woody hard swelling in submandibular and submental region Marked rapidly increasing cellulitis Drooling of saliva Diagnosis Clinical features, increased leucocyte count X Ray/ CT/ MRI

49. Complications Spread to retropharyngeal space, parapharyngeal space and mediastinum Airway obstruction due to laryngeal oedema, tongue push up, swelling Septicaemia Tongue necrosis Aspiration leading to pneumonia and lung abscess Treatment Medical – antibiotics, fluids, analgesics

50. Surgical Tracheostomy if airway compromised I&D of abscess Intra oral – if localised to sublingual space External/cervical – if involves submandibular region Steps Transverse incision between angles of mandible two finger breaths below margin of mandible Vertical incision in midline

51. Serous fluid drained Incision not closed. Antibiotic soaked ribbon gauze placed and dressing done daily Wound allowed to heal by secondary intention Extraction of infected teeth

52. ACUTE R P ABSCESS Etiology Age Mc children < 3-4 yrs Boys Adults Suppuration of RP ln due to infections of adenoids, nasopharynx, PNS, nasal cavity and tonsils Petrositis due to acute mastoiditis Penetrating injury to post pharyngeal wall due to trauma or iatrogenic

53. FB impaction at cricopharynx and upper oesophagus Organisms – streptococci, staphylococci C/F Dysphagia and odynophagia Airway obstruction leading to stridor/stertor Croupy cough Torticolis – stiff rigid neck Hot potato voice Rapidly increasing sore throat Drooling of saliva

54. Fever, malaise Lymphadenopathy U/L bulge in post pharyngeal wall, cant cross midline due to median raphe Diagnosis X Ray soft tissue neck lateral view Air shadow in prevertebral space/ widening of prevertebral space (normal width 3.5 mm, > 50% width)/ presence of gas CT Scan/ MRI

55. Complications Spread to mediastinum and danger space (most dangerous) Septicaemia Meningitis Airway obstruction Treatment Hospitalization IV antibiotics IV fluids steroids

56. Tracheostomy – if stridor I&D of abscess Intra oral No GA – chance of rupture Position – supine with head low/ rose position Vertical incision at most fluctuant area on lat part of post pharyngeal wall Do suction to prevent aspiration

57. PRE VERTEBRAL SPACE ABSCESS Etiology Adults TB cervical spine and prevertebral space Types TB retropharyngeal ln Seen in children aged 8-10 yrs Lateral type/ U/L Cant cross midline TB cervical spine/ caries of cervical spine Any age, infection in prevertebral space Can cross midline B/L/ midline swelling

58. C/F Slow in onset/ insidious Less severe symptoms Dysphagia Throat discomfort Fluctuant swelling in midline or lateral Non tender enlarged JD ln Painless lump in throat Dyspnoea Chronic cough, evening rise of temp, night sweats, loss of appetite, loss of weight

59. Diagnosis X Ray cervical spine Caries Loss of normal curvature/ straightening of cervical spine Bony destruction of vertebra X Ray Neck – prevertebral widening X Ray Chest – TB, mediastinitis CT/MRI FNAC Mantoux test

60. Complications Can extend to danger space, mediatinum and parapharyngeal space Airway obstruction and laryngeal oedema Pus can extend to coccyx Spontaneous rupture leading to pneumonia, lung abscess Septicaemia Treatment ATT IV fluids Tracheostomy

61. I&D of abscess Transcervical approach Vertical incision at anterior or posterior border of SCM Orthopaedics treatment for caries spine

62. PHARYNGO MAXILLARY ABSCESS/ LATERAL PHARYNGEAL ABSCESS Etiology Any age but common in young adults Organisms – staphylococci, streptococci, bacteroides, E coli Infection from peritonsillar space (mc), retropharyngeal space, parotid space Tonsillitis, adenoiditis, pharyngitis,sialadenitis Dental infections – last molar, infected cysts, fistulas CSOM/ASOM – bezold’s abscess Penetrating injuries to neck Iatrogenic – during procedures, inj

63. C/F High fever, odynophagia, sore throat, torticolis Anterior compartment Prolapse of tonsils and tonsillar fossa Trismus due to spasm of pterygoid muscles Swelling at angle of mandible Odynophagia and dysphagia Bulging of tonsil, soft palate Posterior compartment Pharyngeal bulging behind posterior pillar Swelling in parotid region

64. CN palsy – IX, X, XI, XII CN I/L palsy of palate, larynx, tongue Horner’s syndrome – involvement of sympathetic chain – I/L anhidrosis, ptosis, enophthalmos, constricted pupil Diagnosis CT/ FNAC/ USG/ X Ray Complications Airway obstruction/ laryngeal oedema Thrombophlebitis of jugular vein Carotid artery rupture Mediastinitis/ RP abscess

65. Pneumonia/ emphysema Meningitis Septicaemia Treatment IV antibiotics – cephalosporins, aminoglycosides Fluids Analgesics Tracheostomy – if airway obstruction Surgical drainage

66. I&D of abscess Transcervical approach GA Horizontal incision 2-3 cm below angle of mandible (level of hyoid) Abscess is aspirated Drain placed for 2-3 days AVOID TRANS ORAL APPROACH – chance of damage to greater vessels