SURGERY PPT-neck-swellings with few topicsppsx

neck swelling with explanation of few topics

1. Neck Triangles

3. Anterior Triangle

4. 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

5. Posterior Triangle

6. Boundaries:
Posterior: Trapezius anterior border
Anterior: S.C.M. posterior border
Inferior: Middle 1/3
rd
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

7. Neck Lymph Nodes

9. 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

11. 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

12. Anterior PosteriorSuperior Inferior
IILateral
border of
sterno-
hyoid
Posterior
border of
sterno-
cleido-
mastoid
Skull base Carotid
bifurcation
or hyoid
III Carotid
bifurcation
or hyoid
Cricoid
IV Cricoid Clavicle

13. Level V: Posterior triangle nodes
Posterior: Trapezius anterior border
Anterior: S.C.M. posterior border
Inferior: Middle 1/3
rd
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

14. Classification of neck swelling
according to position
•Ubiquitous neck swellings
•Midline neck swellings
•Anterior triangle neck swellings
•Posterior triangle neck swellings

15. Ubiquitous neck swellings
•Sebaceous cyst
•Lipoma
•Neurofibroma, schwannoma
•Hemangioma
•Dermoid cyst
•Teratoma
•Hydatid cyst

16. 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

17. Submandibular triangle swellings
•Lymph node (level 1b)
•Cold abscess
•Submandibular salivary gland enlargement (deep
lobe is bimanually
ballotable)
•Plunging ranula
•Mandibular tumor

18. 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

19. Posterior triangle swellings
 Cystic hygroma
 Pharyngeal pouch (Zenker’s diverticulum)
 Lymph node (level V)
 Cold abscess
 Cervical rib
 Clavicular tumour
 Subclavian artery aneurysm

20. Classification by etiology
•Congenital / Developmental
•Infectious / Inflammatory
•Neoplastic: Benign / Malignant

21. Congenital neck swellings
a. Cystic
 Sebaceous cyst  Dermoid cyst
 Branchial cyst  Thyroglossal cyst
 Thymic cyst
b. Solid: Ectopic thyroid
c. Vascular
 Hemangioma  Lymphangioma

22. Inflammatory neck swellings
•Lymphadenitis
–Viral
–Bacterial
–Granulomatous
•Sialadenitis
–Parotid
–Sub-mandibular
•Deep neck space abscess

23. 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

24. Hemangioma & lipoma

25. Cervical
Lymphadenopathy

26. 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

27. 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

28. 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

29. Tuberculous lymphadenopathy

30. Lymphoma
More common in children & young adults
60 - 80% children with Hodgkin’s have neck mass
Signs & symptoms:
•Fever + malaise
•Night sweats
•Weight loss
•Pruritus
•Rubbery lymph nodes

31. 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

32. 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

33. 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

34. Ranula

35. 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

36. Simple Ranula

37. Plunging ranula

38. Plunging ranula

39. 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

40. 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

41. Marsupialization

42. Intra-oral excision

43. Ranula specimen

44. Thyroglossal cyst

45. 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

48. 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
.

49. 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

50. 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

51. Neck swelling moving with
swallowing
•Thyroid swelling
•Thyroglossal cyst (mobile horizontally)
•Subhyoid bursitis (oval, long axis horizontal)
•Pre-laryngeal & pre-tracheal lymph nodes
•Laryngocele

52. Midline neck swelling

53. Ultra-sonography

54. CT scan axial cut

55. MRI sagittal cut

56. 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

57. Patient position & incision

58. Exposure of cyst + tract

59. Exposure & cutting of hyoid bone

60. Removal of tongue tissue

61. Removal of cyst + tract

62. Complications
1. Infection of cyst & abscess formation
2. Throglossal fistula 3. Malignancy (1%)
Infected cyst

63. Thyroglossal fistula

64. Branchial cleft cysts

65. Embryology

69. 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

70. 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

71. 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

72. Second branchial cleft cyst
•Commonest branchial anomaly
•Painless, fluctuant mass along anterior border of
middle 1/3
rd
of sternocleidomastoid muscle
•Fistula tract opens externally along lower 1/3
rd
of
SCM, passes deep to 2
nd
arch structures (external
carotid, stylohyoid muscle, posterior belly of
digastric); superficial to internal carotid (3
rd
arch);
ends internally in tonsillar fossa

73. Second branchial cleft cyst

74. Second branchial cleft cyst

75. •Painless, fluctuant mass along anterior border of
lower 1/3
rd
of sternocleidomastoid muscle
•Fistula tract opens externally along lower 1/3
rd
of
SCM, passes deep to 3
rd
arch structures (internal
carotid, glossopharyngeal nerve); superficial to
superior laryngeal nerve (4
th
arch): opening internally
in base of pyriform fossa
Third branchial cleft cyst

76. Fourth branchial cleft cyst
•Presents as mass along anterior border of lower
1/3
rd
of stenomastoid or as recurrent thyroiditis
•Fistula tract opens externally along lower 1/3
rd
of
SCM, passes deep to 4
th
arch structures (superior
laryngeal nerve ); superficial to recurrent laryngeal
nerve (6
th
arch); opening internally in apex of
pyriform fossa

77. CT scan 1
st
branchial cyst

78. CT scan 2
nd
branchial cyst

79. CT scan 3
rd
branchial cyst

80. Coronal MRISagittal MRIAxial MRI

81. 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)

82. Excision of branchial cyst

83. Branchial fistula excision

84. Laryngocoele

85. •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 = 6
th
decade,
Unilateral in 85 % cases, 1% contain carcinoma

86. Swelling enlarges on Valsalva

87. 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.

88. 88
Types of laryngocoele
Internal External Combined

89. 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

90. 90
Flexible laryngoscopy
▪Swelling of false vocal
folds & ary-epiglottic fold
▪Swelling easily emptied
▪Escape of purulent fluid
into airway = pyocoele

91. 91
X-ray neck AP view
X-ray soft tissue neck AP
view during Valsalva
maneuver shows air-
filled radiolucent
swelling

92. CT scan: mixed laryngocoele

93. 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.

94. Endoscopic marsupialization

95. External approach

96. 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.

97. Lyre sign

98. 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.

99. Hypopharyngeal
pouch

100. 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

101. Weak spots b/w muscles

102. Origin of Zenker’s diverticulum

103. 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

104. Clinical features
1.Entrapment of food in pouch: sensation of food
sticking in throat & later dysphagia
2.Regurgitation of entrapped food: leads to  foul taste
 bad odor  nocturnal coughing  choking
3.Hoarseness: due to spillage laryngitis or sac
pressure on recurrent laryngeal nerve
4.Weight loss: due to malnutrition
5.Compressible neck swelling on left side: reduces with
a gurgling sound (Boyce sign)

105. Complications
1.Lung aspiration of sac contents
2.Bleeding from sac mucosa
3.Absolute oesophageal obstruction
4.Fistula formation into:
 trachea  major blood vessel
5.Squamous cell carcinoma within Zenker
diverticulum (0.3% cases)

106. Investigations
•Chest X-ray: may show sac + air - fluid level
•Barium swallow
•Barium swallow with video-fluoroscopy
•Rigid Oesophagoscopy
•Flexible Endoscopic Evaluation of Swallowing

107. Barium swallow

108. Barium swallow with
Video-fluoroscopy

109. Rigid Esophagoscopy

110. 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

111. Stage 1

112. Stage 2

113. Stage 3

114. Surgical Treatment
1.Cricopharyngeal myotomy: combined with others
2.Diverticulum invagination: Keyart
3.Diverticulopexy: Sippy-Bevan
4.External or open Diverticulectomy: Wheeler
5.Rigid Endoscopic Diverticulotomy
 Cautery (Dohlman)  Laser  Stapler
6.Flexible Endoscopic Diverticulotomy with Laser

115. 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):
Open Diverticulectomy with CP myotomy
or Diverticulopexy with CP myotomy

116. Cricopharyngeal myotomy

117. Diverticulum invagination
Diverticulum pushed into hypopharynx lumen &
muscle + adjacent tissue are oversewn.
CP myotomy is usually combined with this.

118. External diverticulectomy

119. Endoscopic diverticulotomy
Diverticuloscope advanced so its upper lip is within
esophagus & lower lip is within diverticulum

120. View through diverticuloscope
Cautery, laser, or stapling device used to divide
common party wall between pouch & esophagus

121. View through diverticuloscope

122. Endoscopic diverticulotomy

123. Dohlman’s instruments

124. Diverticulopexy
Sac mobilized & its fundus fixed to sternocleido-
mastoid muscle in a superior, non-dependent
position. CP myotomy is also done.

125. Cystic hygroma

126. •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

127. 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

128. Stage Clinical Features Complication rate
Stage I U/L infrahyoid 20%
Stage II U/L suprahyoid 40%
Stage IIIU/L infrahyoid + suprahyoid 70%
Stage IV B/L suprahyoid 80%
Stage VB/L infrahyoid + suprahyoid 100%

129. Cystic hygroma

130. 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.

131. MRI: CH causing airway
compression

132. Treatment
•Asymptomatic: 1. watchful waiting
2. 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

133. Kawasaki syndrome
•Etiology: idiopathic multisystem vasculitis
•Diagnosis (presence of any 5): 1. Fever > 5 days.
2. Conjunctival injection. 3. Red / desquamated
palm / sole. 4. Injected oral cavity 5.
Polymorphous rash. 6. Cervical lymph node
enlargement
•Permanent cardiac damage in 20% untreated cases
•Rx: high dose aspirin & immunoglobulin

134. 134
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