Cystic Swelling Neck Lymph Diagnosis Investigation Epidermal Cyst Notes

Cystic Swellings Neck Swellings And Metastasis Lymph Node Neck

Cystic Swellings

A cyst is a swelling containing fluid. True cysts are lined by endothelium or epithelium. They contain clear serous fluid, mucoid material, pus, blood, lymph or toothpaste-like material.

• The false cysts do not have lining epithelium. They can be degenerative cysts as in the case of tumours which undergo tumour necrosis or tumour degeneration.
• or merely a collection of fluid which is walled off by coils of bowel as in tuberculous encysted ascites or an exudation cyst as in pseudopancreatic cyst.

Read And Learn More: General Surgery Notes

Classification of Cyst

1. Congenital Cyst

• Sequestration dermoid cyst
• Branchial cyst
• Thyroglossal cyst
• Lymphangioma
• Cysts of embryonic remnants: Cyst of the urachus, vitellointestinal duct cyst.

2. Acquired Cyst

• Retention cyst: Sebaceous cyst, galactocele, spermatocele, Bartholin’s gland cyst
• Distension cyst: Thyroid cyst, ovarian cyst
• Exudation cyst: Hydrocele
• Degenerative cyst: Tumour necrosis
• Traumatic cyst: Haematoma, implantation dermoid cyst
• Cystic tumours: Cystadenoma of the pancreas, cystadenoma of the ovary

3. Parasitic Cyst

• Cysticercosis
• Hydatid cyst

Clinical Examination of Cysts in General

Students are requested to follow the standard practice of examination of the swelling in the form of inspection, palpation, percussion and auscultation in the clinical examination. Some important tests for cystic swellings are given on the next page.

1. Location: Most of the congenital cystic swellings have a typical location wherein diagnosis can be made with fair accuracy. A few examples are as follows:

• The branchial cyst occurs at the junction of the upper one-third and lower two-thirds of the sternocleidomastoid muscle, whereas the opening of the branchial fistula occurs at the junction of the upper two-thirds and lower one-third of the sternocleidomastoid muscle.
• Dermoid cyst: Midline, outer or inner canthus of the eye.
• Meningocele: Swelling in the newborn at the lumbosacral region.
• Ganglion: On the dorsum of the hand and foot

2. Shape: The majority of the cystic swellings are round or oval.

• Subhyoid bursitis: Transverse oval cystic swelling in the midline of the neck.
• Thyroglossal cyst: Vertically placed oval swelling in the midline of the neck.
• Sebaceous cyst: Hemispherical swelling.

3. Surface: Almost all the cystic swellings in the skin and subcutaneous tissue have smooth surfaces.

4. Consistency: Fluctuation is positive in all cystic swellings. However, depending on the contents, the fluctuation may be different, which an experienced surgeon can diagnose.

• Soft cystic: Thyroglossal cyst, meningocele, lymph cyst.
• Tensely cystic: Ganglion, tensely cystic swellings in the neck may feel firm or solid, for example, tense thyroid cyst. Cysts in the breast may feel firm or hard.
• Yielding in cases of lipoma, as fat at body temperature behaves like fluid (pseudo fluctuation).
• Soft with firm thickened periphery: Cold abscess
• Half-filled like a rubber hot water bottle: Branchial cyst.
• Putty or toothpaste: Sebaceous cyst (true fluctuation is not found).
• Cross-fluctuation for swellings having two components connected to each other, for example, plunging ranula.

Rules of Elicitation of Fluctuation

• • Mobile swelling has to be fixed.
  • Both hands should be used.
  • With the index finger and thumb of one hand, the swelling is pressed—these are ‘active’ fingers and the impulse is received by the thumb and index finger of the other hand (passive fingers).
  • Fluctuation should be elicited in both directions, as fleshy muscle in the thigh can be fluctuant across but not in the longitudinal direction.
  • When swelling is smaller than 2 cm in size, Paget’s test is done. Cystic swellings feel soft in the centre and firm at the periphery. Solid swellings feel firmer at the centre than periphery.

5. Transillumination test: Cystic swellings which contain clear fluid show positive transillumination.

6. Mobility: Almost all the cystic swellings in the skin, subcutaneous tissue or in the deeper plane are benign and as a rule, they should have free mobility. However, this is not true due to various anatomical factors.

• Branchial cyst: Restricted mobility is due to its adherence to the sternomastoid muscle.
• Thyroglossal cyst: Transverse mobility is absent because the cyst is tethered by the remnant of the thyroglossal duct.
• Sebaceous cyst: Limited mobility due to the adherence to the skin.

7. Sign of compressibility: The swellings which have communication with a cavity or with tissue spaces give the positive sign of compressibility.

• Thus, a steady pressure is applied over the swellings. The swelling may disappear completely or may partially disappear.
• However, when pressure is released the swelling fills up slowly. Hence, it is also called the ‘sign of refilling’.

Compressible Swellings

• Haemangioma
• Lymphangioma
• Meningocele

8. Plane of the swelling

• Almost all significant cystic swellings in the neck are deep to deep fascia. Thus, contracting the sternomastoid for laterally placed swellings and bending the chin against resistance for centrally placed swellings must be done to define the plane of swelling.
• Subcutaneous swellings become more prominent when the underlying muscles are contracted as in limbs.
• Swelling due to semimembranous bursitis almost disappears on the flexion of the knee and becomes more prominent on the extension of the knee.
• Sebaceous cysts are attached to the skin at the site of the punctum.

9. Pulsations

• Expansile: Aneurysms are characterised by expansile pulsations. When two fingers are placed over the swelling on the sides, the fingers are not only elevated but are also separated. Popliteal aneurysms typically give this sign.
• Transmitted: When the swelling is situated over a vessel, the fingers are raised but not separated, for example, pseudopancreatic cysts. When the swelling pushes the vessel anteriorly, transmitted pulsation can be obtained, for example, the cervical rib pushing the subclavian artery.
• Pulsation can also be present in vascular tumours, such as osteogenic sarcoma or secondaries from carcinoma thyroid, etc.

Aneurysm Tests

• Expansile pulsations: Finger separation sign
• Proximal compression test: Decreased size
• Distal compression test: Size may increase
• Thrill and bruit are present and distal pulses may be weak

Effects of Aneurysm

Effects of Aneurysm: TIPS

• Thrombosis, Ischaemia
• Pressure, Skin changes

Some Useful TIPS

1. Thrombosis: It is one of the common effects of aneurysm particularly aortic and popliteal, resulting in ischaemia in the distal territory.

2. Ischaemia: Distal parts may become gangrenous and/or can have ischaemic ulcers or claudication.

3. Pressure effects

• Effect on bone: Erosion of the vertebral body as in aortic aneurysm. This does not happen in the TB spine.
• Effect on nerves: Popliteal aneurysm can give rise to foot drop due to pressure on the lateral popliteal nerve.
• Effect on the veins: Results in congestion and oedema of the leg.
• On the oesophagus: Dysphagia as in aortic aneurysm.

4. Skin changes may be in the form of oedema and redness.

Complications of Cysts in General

1. Infection, Example sebaceous cyst
2. Calcification, for Example, haematoma, multinodular goitre with cyst, hydatid cyst
3. Pressure effects: Ovarian cyst pressing on the iliac veins.
4. Haemorrhage within thyroid cyst.
5. Torsion: Ovarian dermoid.
6. Transformation into malignancy.
7. Ovarian cachexia: Large ovarian tumour with pedal oedema, anorexia, loss of weight, lordosis.

Dermoid Cyst

This is a cyst lined by squamous epithelium containing desquamated cells. The contents are thick and sometimes toothpaste-like which is a mixture of sweat, sebum desquamated epithelial cells and sometimes even hair.

Clinical Types of Dermoid Cyst

1. Congenital or Sequestration Dermoid

• They occur along the line of embryonic fusion, due to dermal cells being buried in deeper planes.
• The cells which are sequestrated in the subcutaneous plane proliferate and liquefy to form a cyst.
• As it grows, it indents the mesoderm (future bone) which explains the bony defects caused by dermoid cysts in the skull or facial bones.
• Even though they are congenital, they manifest as a swelling during childhood or later in life. Often they can be mistaken for lipoma and sebaceous cysts.
• They can occur anywhere in the midline of the body or the face.

Origin of Dermoid Cyst

• The face is developed from 5 processes—2 maxillary, 2 mandibular and 1 frontonasal.
• Dermoid cyst occurs in the line of embryonic fusion of these processes.

1. External and internal angular dermoid cyst: At the fusion lines of frontonasal and maxillary processes.
2. Median nasal dermoid cyst: At the root of the nose at the fusion lines of the frontal process.
3. In the suprasternal space of Burns.
4. Sublingual dermoid cyst.
5. Pre-auricular dermoid cyst—in front of the auricle.
6. Post-auricular dermoid cyst behind the auricle.

Complications of Dermoid Cyst

1. Infection
2. Suppuration: Abscess
3. Ovarian dermoid: Torsion

Clinical Features of Dermoid Cyst  

• Though congenital, the cyst manifests in childhood or during adolescence. A few cases also manifest in the 30–40 years age group.
• Typically, the patient presents with a painless, slow-growing swelling.
• Soft, cystic and fluctuant; transillumination is negative.
• Rarely, it may be putty-like in consistency.
• The underlying bony defect gives the clue to the diagnosis.
• The classical location of the cyst (along the line of fusion) is a feature of the sequestration dermoid cyst.

2. Implantation Dermoid Cyst

• This is common in women, tailors, and agriculturists who sustain repeated minor sharp injuries.
• Following a sharp injury, a few epidermal cells get implanted into the subcutaneous plane. There, they develop into an implantation dermoid cyst.
  • Hence, it is typically found in the fingers, palm and sole of the foot.
  • As the cyst develops in the areas where the skin is thick and keratinised, it feels firm to hard in consistency.

3. Teratomatous Dermoid Cyst

• Teratoma is a tumour arising from totipotential cells. Thus, it contains ectodermal, endodermal and mesodermal elements—hair, teeth, cartilage, bone, etc.
• Common sites are the ovary, testis, retroperitoneum and mediastinum.

4. Tubuloembryonic Dermoid Cyst

• They arise from ectodermal tubes. A few examples are thyroglossal cysts and post-anal dermoid cysts.
• Ependymal cyst of the brain.

Treatment of Dermoid Cyst

Excision of the cyst.

Epidermal Cyst (WEN)

This is popularly called a sebaceous cyst. It is a misnomer. This occurs due to obstruction to one of the sebaceous ducts.

• Resulting in the accumulation of sebaceous material. Hence, this is an example of a retention cyst.
• Sites: Scalp, face, back, scrotum, etc. It does not occur in the palm and sole, where sebaceous glands are absent. In the back, scalp and scrotum, multiple cysts are often found.

Epidermal Cyst Clinical Features

• They are slow-growing and appear in early adulthood or middle age.
• Hemispherical or spherical swelling located in the dermis. A dark spot in the centre (punctum) filled with keratin is a diagnostic feature of this cyst. The punctum indicates blockage of the duct.
• In 20–30% of cases, instead of opening into the skin, the sebaceous duct opens into the hair follicle. Hence, punctum is not seen.
• It has a smooth surface, round borders, soft and putty consistency and is nontender.
• The cyst can be moulded into different shapes which is described as the sign of moulding.
• A sign of indentation refers to pitting on pressure over the swelling.
• The swelling is mobile over the deep structures, and the skin is free all around except for an area of adherence at the site of the punctum.
• In the scalp, loss of hair is a feature of the swelling because of the constant slow expansion of the cyst.

 

Comparison of congenital dermoid cyst and sebaceous cyst

Epidermal Cyst Treatment

• Incision and avulsion of the cyst with the wall. Very often, during dissection, the cyst wall ruptures. Care should be taken to excise the entire cyst wall. If not, recurrence can occur.
• When it is small it can be excised along with the skin.

Epidermal Cyst Complications

1. Infection can occur due to injury or scratch resulting in an abscess. The cyst will be tender, red and warm to the touch. It should be treated like an abscess by incision and drainage. After one to two months, the cyst can be excised.

2. Sebaceous horn results due to slow drying of the contents which are squeezed out, especially if a patient does not wash the part. Thus, it is not common to find a large sebaceous horn nowadays because of better ways of living and sanitation.

3. Calcification

4. Cock’s peculiar tumour refers to an infected, ulcerated cyst of the scalp with pouting granulation tissue and everted edge resembling epithelioma.

5. Rarely, basal cell carcinoma can arise in a longstanding sebaceous cyst.

Interesting—Sebaceous Cyst

• Syndrome: Gardner’s syndrome
• Tumour: Cock’s peculiar tumour
• Parasitic worm: Demodex folliculorum
• Strawberry scrotum: Multiple sebaceous cysts of scrotum

Ganglion

It is a tense, cystic swelling which occurs due to myxomatous degeneration of the synovial sheath lining the joint or tendon sheath. It is common around joints because of abundant fibrous tissue. It contains gelatinous fluid.

Ganglion Common Sites

• The dorsum of the hand is the common site, at the scapholunate articulation.
• In the foot, dorsal or lateral aspect.
• Small ganglion in relation to the flexor aspect of fingers.

Ganglion Clinical Features

• The majority of patients are between 20 and 50 years.
• A round to oval swelling in the dorsum of the hand, with a smooth surface and round borders. The skin over the swelling is normal.
• The swelling is tensely cystic and fluctuant. Transillumination is negative. It is mobile in the transverse direction.
• When the tendons are put into contraction, the mobility of the swelling gets restricted.
• A ganglion is not connected with the joint space. Sometimes, it gives an impression of becoming small due to slipping away between bones.

Ganglion Treatment

1. Asymptomatic ganglion is better left alone.
2. Aspiration of the ganglion and injection of sclerosants may reduce the size of the ganglion.
3. Sometimes, rupture of the cyst due to trauma may result in a permanent cure.
4. Surgical excision can be done. However, the recurrence rate is high.

Ganglion Differential Diagnosis (DD)

• Implantation dermoid cyst, when occurs in the feet or hand.
• Exostosis of the bone has to be considered if swelling is very hard.
• Bursa (vide infra)

Compound Palmar Ganglion

Compound Palmar Ganglion Aetiology

• Tuberculous tenosynovitis of the tendon sheaths affects the flexor tendons. This is a common cause in India.
• Rheumatoid arthritis with involvement of multiple joints causing thickening of synovial membrane—common cause in Western countries.

Compound Palmar Ganglion Pathology

• As a result of tuberculous tenosynovitis, typical caseous material collects within the flexor tendon sheaths.
• The tendons get matted, a swelling develops in the palm and another swelling develops in the lower aspect of the forearm.
• The thickening of the synovial membrane, fibrin particles in the fluid and melon seeds are characteristic of this condition.

Compound Palmar Ganglion Clinical Features

• The majority of patients are below 40 years of age.
• The concavity of the palm is obliterated.
• Soft, cystic, fluctuant, transillumination—negative swelling situated above and below the flexor retinaculum.
• Cross-fluctuation test between these two swellings is positive, which is diagnostic of compound palmar ganglion.
• Restricted mobility of the fingers due to matting of the tendons.
• Wasting of the small muscles of the hand.
• Paraesthesia due to compression on the median nerve.

Compound Palmar Ganglion Investigations

1. The ESR may be increased if it is due to tuberculosis.
2. Aspiration of the swelling and fluid can be sent for acid-fast bacilli.
3. Synovial biopsy.

Compound Palmar Ganglion Treatment

1. Antituberculous treatment (ATT) in case of tubercular pathology. If the response rate is not satisfactory—exploration, decompression, synovectomy and release of matted tendons is the treatment.
2. Control of rheumatoid arthritis, with complete excision of the synovial sheath, in cases due to rheumatoid arthritis.

Summary of Compound Palmar Ganglion

• Tuberculosis and rheumatoid arthritis—common causes.
• Synovial thickening will clinch the diagnosis.
• Cross-fluctuation test is an important clinical finding.
• Antituberculous treatment, if it is due to tuberculosis.
• Decompression or synovectomy may be required in both conditions mentioned above.

Glomus Tumour

This is also called glomangioma or angioneuromyoma. Glomus is a specialised organ.

Glomus Tumour

• A rare and benign tumour
• The most painful tumour
• The smallest benign tumour does not turn malignant.
• The nail bed is the most common site.
• Histologically, it is an angioneuromyoma.
• It is radioresistant.
• Excision gives a permanent cure.
• The function of glomus is concerned with heat regulation.

Structure of Glomus (Glomus Body)

Abundant arteriovenous anastomosis surrounded by large clear cells (glomus cells) and medullated and non-medullated nerve fibres in between the cells is characteristic of glomus.

Clinical Features of Glomus Tumour

1. Typical site: Under the nail beds of hands and feet.
2. It is purple-red in colour, usually single, and the size does not exceed 1 cm in diameter.
3. Glomus tumour is usually seen in the 5th decade.
4. Excruciating pain either at rest or on the movement of the finger or on pressure is a pathognomonic feature of this tumour. Pain is due to compression of the nerve fibres by dilated glomus vessels.
5. The tumour is compressible.

Glomus Tumour Treatment

Surgical excision results in a permanent cure.

Glomus Tumour Differential Diagnosis

1. Subungual melanoma: Painless and pigmented
2. Granuloma pyogenicum: Mild pain, bleeds on touch and evidence of infection is present.
3. Chronic infection with granuloma.

Bursa

Bursa means a sac or a sac-like cavity containing fluid lined by endothelium. It is meant to reduce the friction between the tendons of the muscle and the bone.

• Bursitis refers to inflammation of a bursa resulting in the accumulation of excessive fluid inside the bursa. This results in swelling in the anatomical sites of the normal bursa.
• The causes of chronic bursitis include constant pressure, constant irritation or minor injuries.
• Some examples of bursitis are given.

Bursae and bursitis

Bursa Clinical Features

• A cystic swelling in a known anatomical site of a bursa is chronic bursitis unless proven otherwise.
• Bursitis produces a soft, cystic, circumscribed or oval swelling with fluctuation.
• As the majority of bursitis contain inflammatory fluid, they do not show transillumination.
• In a few cases, signs of inflammation may be present.

Bursa Complications

1. Secondary infection may result in an abscess.
2. Frequent friction may result in ulceration.
3. Cosmetic deformity.

Bursa Treatment

1. Excision is indicated only in the presence of symptoms such as pain or complications mentioned above.
2. The chances of recurrence are high.

Semimembranosus Bursa

This is the most common swelling in the popliteal space. It presents as a tense cystic swelling when the knee is extended and it becomes flaccid on flexion of the knee.

• It is not compressible as it does not communicate with the joint.
• The differential diagnosis for semimembranosus bursitis is Morrant-Baker’s cyst, which is a herniation of the synovial membrane. The differences between these two swellings are given.

Comparison of semimembranosus bursa and Baker’s cyst

Adventitious Bursae

This refers to a cyst which develops in an anatomical area where no bursa is present. These also occur due to constant pressure or friction. They are summarised below.

1. Tailor’s ankle: Above the lateral malleolus
2. Porter’s shoulder: Between clavicle and skin
3. Weaver’s bottom: Between gluteus maximus and ischial tuberosity
4. Bunion: Between the prominent head of the first metatarsal and skin due to hallux valgus.

The complications and treatment of adventitious bursae are similar to chronic bursitis.

Transilluminator Swellings In The Body

These are the cystic swellings containing clear fluid characterised by fluctuation and transillumination.

1. Lymphangioma
2. Ranula
3. Meningocele
4. Epididymal cyst
5. Vaginal hydrocele

Lymphangioma

Failure of one of the lymphatics to join the major lymph sacs of the body results in a lymphangioma. Hence, it occurs in places where lymphatics are abundant.

• They are dilated lymphatics that project onto the skin surface.
• Common sites: Posterior triangle of the neck, axilla, mediastinum, groin, etc.
• In the neck, it is called cystic hygroma of the neck. As the sac has no communication with lymphatics by the time swelling appears, the lymph is absorbed and is replaced by thin watery fluid (mucus) secreted by endothelium. Hence, it is also called hydrocele of the neck.
• When it is largely confined to the subcutaneous plane, it is called cystic hygroma.

Lymphangioma

• Jugular lymph sac
• Posterior lymph sac
• Cisterna chyli

Sites

• Neck
• Groin
• Retroperitoneum

Types Of Lymphangioma

1. Lymphangioma circumscriptum: If it is less than 5 cm across.
2. Lymphangioma diffusum: If they are more widespread.
3. Lymphoedema ab igne: If they form a reticulate pattern of ridges.

Lymphangioma Clinical Features

• Usually, cystic hygroma presents during infancy or early childhood. Occasionally, present since birth and rarely before birth. They can also present as small vesicles.
• When the child cries or strains the swelling increases in size and becomes prominent due to increased intrathoracic pressure which is transmitted through the root of the neck.
• Typical locations—lateral aspect of neck (posterior triangle), groin, buttocks.
• Soft, cystic, fluctuant, partially compressible swelling. Lymphangioma is a multilocular swelling consisting of aggregation of multiple cysts. These cysts may intercommunicate and may occasionally insinuate between muscle planes. Hence, it gives the sign of compressibility! However, complete reducibility is not a feature.
• The swelling is brilliantly transilluminated because it contains clear fluid (watery lymph).

Transillumination Test

• Should be done in a dark room
• Avoid surface transillumination
• Transillumination may be negative because of infection, sclerotherapy and haemorrhage

Lymphangioma Treatment

Surgical excision is the treatment of choice. All the loculi or cysts should be removed. A careful search has to be made for the extension of lymphangioma through the muscle planes so as to avoid recurrence.

• Sclerotherapy was being used earlier for lymphangioma. Since tissue planes are distorted by sclerosants, dissection becomes difficult.
• Thus, the injection type of treatment is not favoured at present.

Lymphangioma Differential Diagnosis

1. Haemangioma: The posterior triangle of the neck is one of the common sites for haemangioma. Haemangioma is soft, cystic and fluctuant but transillumination is negative and the sign of compressibility is positive.

2. Lipoma: This is a soft lobular swelling with fluctuation because fat behaves like a fluid at body temperature. However, the edge slips under the palpating fingers. Both transillumination and compressibility tests are negative for lipoma.

3. Cold abscess.

Lymphangioma Complications

1. In neonates and infants, lymphangioma can cause difficulty in breathing due to its large size.
2. Occasionally, secondary infection can occur.
3. Lymphangioma in the mediastinum can give rise to dyspnoea, and dysphagia due to compression on the trachea or oesophagus.

Ranula

Ranula is a cystic swelling arising from the sublingual salivary gland and from accessory salivary glands which are present in the floor of the mouth called glands of Blandin and Nuhn.

The word ranula is derived from the resemblance of the swelling to the belly of a frog—Rana hexadactyla.

Ranula Aetiology

• Ranula occurs due to obstruction to the ducts secreting mucus. Hence, it is an example of a retention cyst.
• Some surgeons consider it an extravasation cyst.

Ranula Clinical Features

• Seen in young children and adults.
• The swelling is typically located on the floor of the mouth or under the surface of the tongue, to one side of the midline.
• Soft, cystic, fluctuant swelling, which gives brilliant transillumination.
• It is covered by thin mucosa containing clear, serous fluid. Hence, it is bluish in colour.
• The surface is smooth, borders are diffuse, non-tender swelling.
• Plunging ranula: It is an intraoral ranula with cervical extension, where it passes on the side of mylohyoid muscle and produces a swelling in the submandibular region. Thus, one swelling in the floor of the mouth and the other in the neck gives rise to a plunging ranula. The diagnosis is confirmed by cross cross-functioning test.

Cross-fluctuation Test

• Indicated when a cyst has two interconnected components
• When gentle pressure is applied on one component, the impulse is felt on the other component
• Demonstrated by digital palpation
• Plunging ranula, compound palmar ganglion, iliopsoas abscess, hydrocoele en bisac—cross-fluctuation can be felt.

Ranula Treatment

1. Complete excision of the ranula is the treatment of choice in plunging ranula. Since the cyst wall is very thin, it should be carefully dissected and removed.
2. Marsupialisation is indicated in simple ranula. The ranula is incised and the wall of the cyst is sutured to the mucosa of the floor of the mouth, so as to leave an opening to the exterior (marsupials, for Example, kangaroos).

• • After 5–10 days, the cyst collapses, fibrosis occurs and the entire cavity gets obliterated.
  • Marsupialisation avoids surgical dissection and chances of injury to the submandibular duct.
  • Plunging ranula can be excised by the intraoral approach. Once the intraoral dissection is completed, the cervical extension can be mobilised by the same incision dissecting close to the cyst wall. However, rupture and chances of leaving behind a portion of the cyst wall are high.

Ranula Differential Diagnosis

• A sublingual dermoid cyst is a thick-walled cyst, whitish in colour and not transilluminate.
• Mucus cyst.

Ranula Complications

1. Rupture of the cyst decreases the size but it can reappear at a later date.
2. When the swelling is big, the tongue is pushed upwards and may cause difficulty in speech or swallowing.

Meningocele

Meningocele is a herniation of the meninges through a weak point in the spine (neural arch) where the bony fusion has not taken place effectively. The swelling is covered by pia mater and arachnoid mater without a dural covering. The swelling contains cerebrospinal fluid (CSF). Meningocele is an example of a spina bifida cystica.

Meningocele: Sites

• Lumbosacral: The commonest
• Occipitocervical: Second common
• Root of the nose: Rare

Meningocele Clinical Features

• The swelling has been present since birth.
• Soft, cystic, and fluctuant with brilliant transillumination are the typical features of the swelling.
• A sign of compressibility is present due to the displacement of CSF.
• When the child cries or coughs, an expansile impulse is present.
• On palpating the edge of the swelling, a bony defect is usually found.

Meningocele Treatment

• CT scan is done to look for hydrocephalus. If it is present, a ventriculoperitoneal shunt is done which will reduce the meningocele.
• Excision of the meningocele should be done as early as possible to prevent the rupture and secondary infection.

Excision of Meningocele

• Surgery: As early as possible after birth
• Early closure prevents infection
• Transverse elliptical incision
• Excision of the sac
• Closure of the defect by plication
• Approximation of the muscles

Meningocele Complications

• The skin covering the swelling is very thin and so is prone to ulceration. Due to ulceration, secondary infection and meningoencephalitis can occur.
• Haemorrhage.

Spina Bifida Occulta

In this condition, the neural arch is defective posteriorly. There is no visible swelling.

• It can be suspected when there is a tuft of hair, lipoma, naevus, or pigmented patch of skin overlying the lumbosacral region.
• The child is normal at birth. Neurological symptoms such as weakness, and sciatica-like pain may start appearing at puberty (neurogenic talipes equinus—club foot).
• During this time, because of growth, there may be traction on the spinal cord by a ligament called membrane reunions.
• An X-ray can demonstrate the bifid spine.
• Surgical excision of the membrane gives a permanent cure to the patient, if there are symptoms.

Types of Spina Bifida Cystica

1. Meningocele
2. Meningomyelocele
   • Protrusion of meninges, with nerve root of the spinal cord or disordered spinal cord results in meningomyelocele.
   • Neurological deficits such as foot drop, talipes, and trophic ulcer of the foot (S1 root) may be present.
   • Surgical excision may be followed by residual neurological deficit.
3. Syringomeningomyelocele

• • In this condition, in addition to the meninges, the central canal of the spinal cord is also herniated out.
  • Most of the children are stillborn.
  • Very difficult to treat, if the child survives.

Encephalocele: It is also known as cranium bifidum. It is a neural tube defect characterised by saclike protrusion of the brain and meninges through an opening in the skull.

Comparison of meningocele and meningomyelocele

Differential Diagnosis Of Midline Swellings In The Neck

Midline Swellings (From Above Downwards)

1. Ludwig’s angina
2. Enlarged submental lymph nodes
3. Sublingual dermoid cyst
4. Subhyoid bursitis
5. Thyroglossal cyst
6. Enlarged isthmus of thyroid gland
7. Pretracheal and laryngeal lymph nodes
8. Retrosternal goitre
9. Thymic swelling
10. Swelling in the suprasternal space of Burns: Lipoma or cold abscess or aneurysm.

Ludwigs Angina

1. This is an inflammatory oedema of the floor of the mouth. It spreads to the submandibular region and submental region.
2. Tense, tender, brawny, oedematous swelling in the submental region with putrid halitosis is characteristic of this condition.

Enlarged Submental Lymph Nodes

The three important causes of enlargement:

1. Tuberculosis: Matted submental nodes, firm in consistency, with enlarged upper deep cervical lymph nodes, with or without evening rise of temperature, are suggestive of tuberculosis.

2. Non-Hodgkin’s lymphoma can present with submental nodes along with other lymph nodes in the horizontal group of nodes such as submandibular, upper deep cervical, pre-auricular, post-auricular and occipital lymph nodes (external Waldeyer’s ring). Nodes are firm or rubbery, discrete without matting.

3. Secondaries in the submental lymph nodes can arise from carcinoma of the tip of the tongue, floor of the mouth, and central portion of the lower lip. The nodes are hard in consistency and sometimes, fixed.

Sublingual Dermoid Cyst

It is a type of sequestration dermoid cyst which occurs due to sequestration of the surface ectoderm at the site of fusion of the two mandibular arches. Hence, such a cyst occurs in the midline, on the floor of the mouth.

• When they arise from 2nd branchial cleft, they are found lateral to the midline. Hence, lateral variety.
• The cyst is lined by squamous epithelium and contains hair follicles, sebaceous glands and sweat glands. It does not contain hair.

Sublingual Dermoid Cyst

• Origin: At the site of fusion of 2nd branchial arches
• Site: Midline—common; Lateral—uncommon
• Supraomohyoid variety is common
• Bidigital palpation for demonstration of fluctuation
• Soft, cystic, fluctuant, transillumination negative swelling
• Differential diagnosis
• Ranula: Transillumination is positive
• Thyroglossal cyst: Moves with deglutition

Sublingual Dermoid Cyst Clinical Features

• Young children or patients between the ages of 10 and 20 years present with painless swelling in the floor of the mouth.
• The swelling is soft and cystic. The fluctuation test is positive. Bidigital palpation gives a better idea about fluctuation with one finger over the swelling in the oral cavity and the other finger in the submental region.
• The transillumination test is negative as it contains thick, cheesy, sebaceous material.

Sublingual Dermoid Cyst Differential Diagnosis

1. Ranula: When a sublingual dermoid cyst is in the midline on the floor of the mouth and above the mylohyoid muscle, ranula is considered a differential diagnosis. However, ranula is bluish in colour, and brilliantly transilluminate.

2. Thyroglossal cyst should be considered a differential diagnosis when the sublingual dermoid cyst is below the mylohyoid muscle. A thyroglossal cyst moves up with deglutition, whereas a sublingual dermoid cyst does not.

Sublingual Dermoid Cyst Treatment

Through the intraoral approach, excision can be done for both types of sublingual dermoid cysts.

Subhyoid Bursitis

Accumulation of inflammatory fluid in the subhyoid bursa results in swelling and is described as subhyoid bursitis.

The bursa is located below the hyoid bone and in front of the thyrohyoid membrane.

Subhyoid Bursitis Clinical Features

• The swelling is in front of the neck, in the midline below the hyoid bone.
• The swelling is oval in the transverse direction.
• It moves up with deglutition.
• Soft, cystic, fluctuant and transillumination negative swelling (turbid fluid).
• The swelling may be tender as it contains inflammatory fluid.

Subhyoid Bursitis Treatment

Complete excision

Subhyoid Bursitis Complication

It can develop into an abscess.

Subhyoid Bursitis Differential Diagnosis

1. Thyroglossal cyst is a vertically placed oval swelling, whereas subhyoid bursitis is a transversely placed oval swelling.
   • Thyroglossal cyst moves on protrusion of the tongue outside (subhyoid bursitis does not).
2. Pretracheal lymph node swelling.
3. Ectopic thyroid enlargement.

Midline Swellings In The Neck

 

Thyroglossal Cyst

This is an example of a tubuloembryonic dermoid cyst.

• It arises from the thyroglossal tract/duct which extends from the foramen caecum at the base of the tongue to the isthmus of the thyroid gland.
• Hence, the thyroglossal cyst can develop anywhere along this duct. Four anomalies are shown.
• It is lined by pseudostratified, ciliated, columnar or squamous epithelium which produces desquamated epithelial cells or mucus at times.

Sites of Thyroglossal Cyst

1. Subhyoid: The most common type
2. At the level of thyroid cartilage: 2nd common site
3. Suprahyoid: Double chin appearance
4. At the foramen caecum: Rare
5. At the level of cricoid cartilage: Rare
6. On the floor of the mouth

Thyroglossal Cyst Clinical Features

• Even though congenital, thyroglossal cyst appears around the age of 15–30 years.
• They are more common in females who present with painless, midline swelling. However, in the region of thyroid cartilage, the swelling is slightly deviated to the left side.
• The cyst is soft, cystic, fluctuant, transillumination-negative swelling (very rarely, it can give rise to transillumination). It can be firm if the tension within the cyst is high.
• Mobility: Thyroglossal cysts exhibit 3 types of mobility which are characteristic of this condition:
  • The cyst moves with deglutition.
  • Moves with protrusion of the tongue: Hold the thyroglossal cyst with the finger and thumb and ask the patient to protrude the tongue outside. The movement of the cyst upwards is described as a tug because of its attachment to the hyoid bone.
  • The swelling moves sideways but not vertically as it is tethered by the thyroglossal duct.

Movement on Protrusion of the Tongue

• • The cyst is attached to the hyoid bone. Hence, it gives a classical tug
  • Not always present, cyst below the thyroid cartilage—tug is absent
  • Better appreciated for holding the swelling
• Examination of thyroglossal cyst
  • Cyst proper, mobility
  • Base of the tongue to rule out lingual thyroid and lymph nodes

Thyroglossal Cyst Treatment

• Before the excision of the cyst, a thyroid scan is mandatory since it may be the only functioning thyroid tissue.
• Sistrunk operation: Excision of the cyst along with the entire thyroglossal tract which may include part of the hyoid bone, is the recommended treatment.
• The intimate relationship of the hyoid bone can be explained by its development from 2nd and 3rd branchial arches.

Thyroglossal Cyst Complications

1. Recurrent infection: The wall of the thyroglossal cyst sometimes contains lymphoid tissue which can get infected, resulting in an abscess. If it ruptures or is incised, it results in thyroglossal fistula.
2. Rarely, a papillary carcinoma can occur in the thyroglossal cyst.
3. Fistula.

Recurrent Abscess: Rupture Fistula or Sinus

• Thyroglossal fistula
• Osteomyelitis
• Stitch abscess
• Pilonidal sinus
• Median mental sinus
• Cold abscess
• Umbilical sinus

Thyroglossal Fistula

Thyroglossal fistula is never congenital. It is always acquired due to the following reasons:

Thyroglossal Fistula

• • Always acquired
  • The first opening is in the midline
  • Semilunar sign or hood sign
  • It gets pulled up with protrusion of the tongue

1. Infected thyroglossal cyst rupturing into the skin.
2. Inadequately drained infected thyroglossal cyst.
3. Incompletely excised thyroglossal cyst.
4. The track is lined by columnar epithelium.

Thyroglossal Fistula Clinical Features

• Previous history of swelling in front of the neck, which is now painful, red and ruptured resulting in discharging pus. Once the pus is drained, the opening closes. However, after an interval of time, the ‘pain and discharge’ reappear.
• When there is no infection, the fistula discharges only mucus and the surrounding skin is normal. Infected fistulae are tender, discharging pus and the skin is red hot.
• The majority of the patients presenting are young in the age group of 10–20 years.
• A fistulous opening in the centre of the neck which is covered by a hood of skin can occur due to increased growth of the neck when compared to that of a fistula. This is described as a semilunar sign or hood sign.

Thyroglossal Fistula Treatment

• Infection is controlled with antibiotics.
• Surgical excision should include the fistula with removal of the entire tract up to the foramen caecum. Otherwise, recurrence will occur.
• The central portion of the hyoid bone is removed due to close proximity of the fistula.
• An elliptical incision is preferred as it gives a neat scar.
• This operation is called Sistrunk’s operation.

Sistrunk’s Operation

• The fistula with the entire thyroglossal tract is excised.
• The central portion of the hyoid bone and lingual muscle are removed.
• Removal is facilitated by pressing the posterior 1/3rd of the tongue.
• Do not perforate the thyrohyoid membrane.
• Incomplete removal results in recurrence.

Anomalies Of Thyroglossal Duct

The thyroglossal duct extends from the foramen caecum to the thyroid cartilage.

• Various anomalies have been given.
• However, thyroglossal cyst is common. Lingual thyroid and ectopic thyroid tissue are uncommon swellings.
• They have to be kept in mind as a differential diagnosis of the swellings in the midline of the neck.

Thyroglossal Duct Anomalies

• Lingual thyroid
• Levator glandular thyroid
• Ectopic thyroid tissue
• Thyroglossal cyst

Swelling Arising From Isthmus Of The Thyroid Gland

Almost all the diseases of the thyroid gland result in enlargement of the isthmus. However, solitary nodules and cysts can occur in relation to the isthmus. The swelling moves with deglutition. However, it does not move on protrusion of the tongue.

Pretracheal And Prelaryngeal Lymph Nodes

These lymph nodes produce nodular swelling in the midline. One or two discrete nodes are palpable. They can enlarge due to the following conditions:

1. Acute laryngitis: The nodes are tender and soft.
2. Papillary carcinoma of the thyroid: The nodes are firm without matting, with or without evidence of thyroid nodule.
3. Carcinoma of the larynx: The nodes are hard in consistency.
4. In India, tuberculosis should be considered as a possible diagnosis when other diseases are ruled out.

Swellings In The Suprasternal Space Of Burns

1. Lipoma: Soft and lobular, edge slips under the palpating finger.
2. Sequestration dermoid cyst is a midline, soft, cystic, fluctuant swelling.
3. Gumma produces a firm swelling with evidence of syphilis elsewhere in the body.
4. Thymic swellings, and an aneurysm of the innominate or subclavian artery, are the other causes.

Differential Diagnosis Of Lateral Swellings In The Neck

Before we discuss the swellings on the lateral side of the neck, it is essential to Know the various triangles in the neck. these are discussed below.

Triangles of the Neck

Each side of the neck is a quadrilateral space subdivided by sternocleidomastoid into anterior triangle and posterior triangle. They are further subdivided as given below.

Anterior Triangle

1. Submental triangle
2. Digastric (submandibular) triangle
3. Carotid triangle
4. Muscular triangle

Posterior Triangle

1. Occipital triangle
2. Supraclavicular triangle

Swellings In Submandibular Triangle

The submandibular triangle is a part of the anterior triangle.

• This is bounded inferiorly by the anterior and posterior belly of digastric muscles with their tendon, and superiorly by the attachment of deep fascia to the whole length of the mandible.
• This triangle is covered by deep fascia.
• The floor is formed by mylohyoid muscle which arises from the mylohyoid line of the mandible, thus closing the space.

Swellings in the submandibular triangle are :

1. Enlarged submandibular lymph nodes—common
2. Submandibular salivary gland enlargement—common
3. Plunging ranula—not uncommon
4. Ludwig’s angina—not uncommon
5. Lateral sublingual dermoid cyst—rare
6. Tumours of the mandible—rare

Enlarged Submandibular Lymph Nodes

They form a nodular swelling which is deep to deep fascia. They are palpable only in the neck (not intraorally). The nodes can get enlarged due to the
following conditions:

1. Acute lymphadenitis: Very often, poor oral hygiene or a caries tooth produces painful, tender, soft enlargement of these lymph nodes. Extraction of the tooth or with improvement of oral hygiene, lymph nodes regress.

2. Chronic tuberculous lymphadenitis can affect these nodes along with upper deep cervical nodes. The nodes are firm and matted.

3. Secondaries in the submandibular lymph nodes arise from carcinoma of the cheek, tongue, and palate. The nodes are hard with or without fixity.

4. Non-Hodgkin’s lymphoma can involve submandibular lymph nodes along with a horizontal group of nodes in the neck. The nodes are firm or rubbery in consistency.

Submandibular Salivary Gland Enlargement

The various causes of submandibular salivary gland enlargement have been discussed in the salivary gland chapter.

• The common causes are chronic sialadenitis with or without a stone, tumours of the salivary gland or enlargement due to autoimmune diseases.
• They form irregular or nodular swelling. The diagnosis is confirmed by digital palpation of the gland.
• The enlarged submandibular gland is digitally palpable because the deep lobe is deep to the mylohyoid muscle.

Submandibular Salivary Gland Enlargement

• Calculus
• Chronic sialoadenitis
• Cancer
• Chronic diseases: Autoimmune

Differential Diagnosis Of Swellings In The Carotid Triangle

The carotid triangle has the following boundaries: lateral by sternomastoid muscle, superomedially by digastric muscle and stylohyoid muscle and anteromedially by omohyoid muscle.

Some important swellings in this triangle are as follows:

1. Branchial cyst
2. Lymph node swelling (cold abscess)
3. Aneurysm of carotid artery
4. Enlargement of the thyroid gland
5. Carotid body tumour—rare
6. Laryngocele—rare
7. Sternomastoid tumour—rare
8. Neurofibroma of the vagus

Branchial Cyst

Branchial Cyst Aetiology

• The branchial cyst arises from vestigial remnants of the 2nd branchial arch.
• The cyst is lined by squamous epithelium and contains desquamated epithelial cells which slowly form a toothpaste-like material.

Branchial Cyst Clinical Features

• Even though congenital, the majority of patients are young between the age group 15 and 25 years.
• The swelling is typically located in the anterior triangle of the neck partly under cover of the upper 1/3rd of the anterior border of the sternomastoid.
• This can be explained because of the development of sternomastoid muscle from the myotome in the ridge of the second branchial arch.
• The swelling has a smooth surface and round borders. It is soft, cystic, fluctuant and transillumination negative. The consistency is that of a rubber bag half filled with water. The swelling is very often firm due to thick inspissated content.
• In such situations, it is very difficult to elicit fluctuation. The mobility of the swelling is also restricted because of its adherence to the sternomastoid muscle.
• Sternomastoid contraction test: The swelling becomes less prominent.
• If contents are aspirated, it contains cholesterol crystals.
• No other lesion is found in the neck (lymph nodes).

Swellings Containing Cholesterol Crystals

• Branchial cyst
• Dental cyst
• Dentigerous cyst
• Hydrocele

Branchial Cyst Treatment

• Excision of the cyst along with its entire epithelial lining with a curved incision centred over the swelling. One must ensure that the epithelial lining is removed completely or else recurrence will occur.
• Sometimes cysts may grow backwards in between the ‘fork’ of the common carotid artery as far as pharyngeal constrictors.

Branchial Cyst Complication

Since the wall is rich in lymphatic tissue, it can undergo secondary infection with pain and swelling. Hence, the swelling has to be excised.

Branchial Cyst Differential Diagnosis

There is no differential diagnosis in a classical case of the branchial cyst. However, a few swellings have to be considered as differential diagnosis.

1. Cold abscess occurs in young patients due to tuberculosis of jugulodigastric nodes. The presence of multiple lymph nodes in the neck with or without fever gives a clue to the diagnosis.

2. Lymphangioma is a brilliantly transilluminate, partially compressible swelling. However, the anterior triangle is not a common site for lymphangioma.

3. Lipoma can also occur in the neck, though it is an uncommon site

Branchial Fistula

This is always congenital and occurs due to persistent 2nd branchial cleft.1

• The external opening is situated at the junction of the middle 1/3rd and lower of the sternomastoid.
• The tract from the skin passes through the fork of the common carotid artery deep to the accessory and hypoglossal nerve and opens in the anterior or posterior pillars of the tonsils. The tract is lined by ciliated squamous epithelium and discharges a mucopurulent discharge. Sometimes, the upper end is blind resulting in a sinus.
• The patient may complain of a dimple, discharging mucus and the dimple becomes more obvious when the patient is asked to swallow.
• Usually seen in growing adults (30% of cases).
• Can be unilateral or bilateral, equally common in males and females.
• It is also called the lateral fistula of the neck. (The thyroglossal fistula is called the median fistula of the neck.)

The Branchial Fistula Passes Superficial to the following Structures

Branchial Fistula Treatment

• A fistulogram can be done by injecting methylene blue into the external opening and defining the tract. This is followed by an exploration of the tract. At surgery, it should be carefully dissected up to the internal opening and then excised.
• May have to be done by two different incisions: An upper incision at the upper border of the thyroid cartilage and a lower incision encircling the fistula and dissecting upwards.

Branchial Fistula Complication

Recurrent infection of the fistula.

Cold Abscess Due To Tuberculosis

In India, this is the most common cystic swelling in the carotid triangle. The cold abscess occurs as a result of caseation necrosis of the lymph nodes.

• This forms a soft, cystic, fluctuant swelling with negative transillumination.
• The presence of other lymph nodes in the neck or sinuses in the neck gives a clue to the diagnosis.
• Loss of appetite, weakness and fever with chills may be other features.

Aneurysm Of The Common Carotid Artery

Atherosclerosis is the most common cause of aneurysm. This weakens the vessel walls uniformly and produces fusiform dilatation of the blood vessel.

• Hypertension is another factor which adds to the aneurysm.
• The abdominal aorta is the most common site for aneurysms followed by the popliteal artery.

Aneurysm Types

• Fusiform: Atherosclerosis, hypertension.
• Saccular: Due to injury.
• False: In this condition, there is a sac lined by cellular tissue which communicates with the artery through an opening in its wall.

Aneurysm Causes

Aneurysm: Causes

• Congenital: Berry aneurysm in the circle of Willis
• Traumatic
• Degenerative: Atherosclerosis
• Rare causes:
  • Syphilis: Endarteritis obliterans
  • Mycotic: Infective emboli
  • Subacute bacterial endocarditis, Marfan’s syndrome, Polyarteritis

Clinical Features of Aneurysm

• Elderly patients are commonly affected.
• Evidence of atherosclerosis in the form of thick-walled vessels is present.
• Tensely cystic (feels firm), fluctuant, transillumination negative swelling with expansile pulsation (when the fingers are kept over the aneurysm, they are not only elevated but they are also separated).
• Compressibility is positive.
• On exerting pressure proximally the swelling diminishes in size—classically it happens in a case of popliteal aneurysms on compression of the femoral artery.
• Bruit or thrill is characteristic of this condition.

Treatment Of Aneurysm

Angiography to confirm the diagnosis followed by repair of aneurysm with graft—PTFE graft (polytetrafluoroethylene graft).

1. Excision and end-to-end graft.
2. Excision and end-to-side graft.
3. Excision and side-to-side graft.
4. Excision and bypass grafting, matas aneurysmorrhaphy

Carotid Body Tumour (Chemodectoma)

Carotid Body Tumour Introduction

This is a benign tumour arising from chemoreceptors in the carotid body. They are situated in the tunica adventitia at the bifurcation of the common carotid artery.

• Hence, such a tumour is called chemodectoma.
• The function of the carotid body is the regulation of pH
• It may be associated with phaeochromocytoma.
• Chronic hypoxia can lead to carotid body hyperplasia. Hence, there is a higher incidence of chemodectoma in people living at higher altitudes.

Chemoreceptors: Sites

Carotid Body Tumour Clinical Features

• Middle-aged or elderly patients are affected (5th decade).
• The patient gives a long history of painless, slow-growing swelling for many years.
• Typical location: In the upper part of the anterior triangle of the neck, at the level of the hyoid bone, beneath the anterior edge of the sternomastoid muscle.
• The surface is smooth or lobulated, the borders are round and there is an oval, vertically placed swelling. Consistency is firm to hard. Hence, called a classical potato tumour.
• Horner’s syndrome and unilateral vocal cord paralysis can occur due to the involvement of the nerves.
• Pressure on the tumour gives rise to syncopal attack due to a decrease in the pulse rate (carotid body syndrome).
• Moves in the transverse direction.
• The carotid artery is stretched over the swelling and so, transmitted pulsations are felt.
• Intraoral examination shows prolapse of the ipsilateral tonsil unless it grows in parapharyngeal space.
• Shamblin classification
  • Class 1: Localized—minimal vascular attachment.
  • Class 2: Partially surrounds carotids.
  • Class 3: Encase carotids—resection difficult and may need temporary interruption of cerebral circulation.

Carotid Body Tumour

• Rare tumour
• Rarely malignant
• Rarely bilateral
• Rarely grows fast
• Rarely do patients present early
• Rarely metastasises
• Experience of a general surgeon with this tumour is very, very rare

Carotid Body Tumour Diagnosis

• Carotid angiography should be done, if there are neurological symptoms, such as a syncopal attack. It may demonstrate the separation of the carotid bifurcation.
• Lyre sign: Splaying of the carotid artery can be seen.
• Incision biopsy is dangerous.
• Colour Doppler should be the first investigation.

1. Separation of internal and external carotid arteries by the tumour and
2. vascular blush

Carotid Body Tumour Treatment

• Excision of the tumour with reconstruction
• No role for radiotherapy.

Carotid Body Tumour Complications

Very rarely, it can turn into a malignant carotid body tumour with lymph nodal metastasis.

Carotid Body Tumour Precautions

• Do not biopsy from within the mouth—carotid body tumour can displace the tonsil medially.
• Should not do FNAC.
• Should not do an open biopsy.
• When you feel some pulsations over a lymph node in the carotid triangle—remember the carotid body tumour.

Sternomastoid Tumour

• This is not a tumour, it is a misnomer.
• Injury to the sternomastoid during birth causes rupture of a few fibres and haematoma. Later, healing occurs with fibrosis, resulting in a swelling in the middle of the sternomastoid muscle.
• The other possible theory is that this is a congenital anomaly—short sternomastoid muscle.

Sternomastoid Clinical Features

• This is seen in infants or children. Firm to hard, 1–2 cm swelling in the middle of the sternomastoid muscle.
• Tender and mobile sideways. Medial and lateral borders are distinct but superior and inferior borders are continuous with the muscle.
• Many cases are associated with torticollis.

Sternomastoid Treatment

• Gentle manipulation of the child’s head
• Physiotherapy to stretch the shortened sternomastoid muscle.
• Division of lower attachment of sternomastoid from clavicle and sternum with or without removal of lump is the surgical treatment.

Laryngocele

It occurs due to herniation of the laryngeal mucosa (external laryngocele). When it enlarges within the larynx, it may displace the vocal cord, produce hoarseness and is called internal laryngocele.

Laryngocele

• Very rare
• Increased laryngeal pressure
• Expansile impulse on cough
• Treatment: Ligation of its neck and division of the whole sac.

Laryngocele Causes

• Glass blowers, musicians, wind instruments and trumpet players are commonly affected.
• Chronic cough may be one of the predisposing factors.

Laryngocele Clinical Features

• Smooth, oval, boggy swelling which moves upwards on swallowing, in relation to thyrohyoid membrane (subhyoid position).
• Swelling becomes prominent when the patient is asked to cough or blow (Valsalva manoeuvre).
• Expansile cough impulse is present.
• Tympanitic note on percussion (resonant)

Laryngocele Treatment

• Excision of the sac—in external laryngocele
• Marsupialisation—in internal laryngocele.

Laryngocele Differential Diagnosis

Other cystic swellings, such as branchial cysts and lymphangioma, should be ruled out.

Laryngocele Complications

Secondary infection results in laryngopyocele. The opening in the thyrohyoid membrane may be blocked by mucopus in such cases.

Pharyngeal Pouch

Herniation or protrusion of mucosa of the pharyngeal wall through Killian’s dehiscence.

Killian’s dehiscence is a potential area of weakness between the two parts of the inferior constrictor muscle:

1. Upper oblique fibres (thyropharyngeus) and
2. Lower horizontal fibres (cricopharyngeus).

Aetiopathogenesis

Due to an increase in the retropharyngeal pressure, mucous membrane bulges in between parts of inferior constrictor muscles due to neuromuscular imbalance. Hence, it is a pulsion diverticulum.

The course of the Diverticulum

Pulsion diverticulum deviates to one side mostly to the left because of the rigid vertebral column in the midline, posteriorly.

Pharyngeal Pouch Diagnosis

• Initially, a foreign body sensation is present in the throat. Later, gurgling sound, regurgitation of food on turning to one side, sense of suffocation, cough or dysphagia are present.
• Aspiration may cause dyspnoea later.

Pharyngeal Pouch Treatment

• Barium swallow followed by excision of the pouch
• Cricopharyngeal myotomy may also be done.

Schwannoma Of The Vagus Nerve

This condition produces swelling in the carotid triangle in the region of thyroid swelling.

• It is a vertically placed oval swelling
• It is firm to hard in consistency
• On pressure over the swelling, dry cough and in some cases, bradycardia may occur.

Differential Diagnosis Of Swellings In The Posterior Triangle

The posterior triangle is an interesting area as far as swellings are concerned. It is the most common area of metastasis in lymph nodes from occult primary.

• Lymphangiomas, haemangiomas, cold abscesses, and lymphomas commonly occur here.
• Interesting cases of cervical rib, Pancoast’s tumour, and aneurysms also occur here.

Boundaries of Posterior Triangle

• Anteriorly: Sternomastoid (posterior border)
• Laterally: Trapezius (anterior border)
• Above: Mastoid process
• Below: Clavicle

Most of the swellings have been discussed under appropriate chapters. Haemangioma, metastasis in the cervical lymph nodes and Pancoast’s tumour have been discussed below.

Posterior Triangle Classification

Common swellings in the posterior triangle are given below.

Swellings in the posterior triangle

Haemangioma

Haemangioma Definition

This is a swelling due to congenital malformation of blood vessels. It is an example of hamartoma.

Haemangioma Classification

1. Depending on the Origin

• Capillary
• Cavernous
• Arterial

2. Depending on the Behaviour of the Lesion

• Involuting haemangioma
  • Superficial – Strawberry naevus, Capillary haemangioma
  • Deep – Cavernous
  • Combined (superficial + deep) – Strawberry naevus, Capillary haemangioma, Cavernous haemangioma
• Noninvoluting
  • Port-wine stain – Port-wine stain, Capillary haemangioma, Naevus flammeus
  • Cavernous haemangioma
  • Arteriovenous fistula

Capillary Haemangioma

It consists of dilated capillaries and proliferation of endothelial cells. Hence, it commonly occurs in the skin. It can be of the following types:

Capillary Haemangioma

• Skin and soft tissue involvement
• Salmon patch: Midline forehead
• Port-wine stain: Head and neck
• Strawberry angioma: Compressible
• And watch policy is the best

1. Salmon patch is a bluish patch over the forehead, in the midline, present at birth and disappears by 1 year of age. Hence, no treatment is required.

2. Port-wine stain is an extensive intradermal haemangioma. This is bluish-purple in colour, commonly affects the face or other parts of the skin, is present at birth, usually progresses and does not regress.

Port-wine Stain

• • Port-wine colour even though to start with it is red in colour.
  • Occurs usually in the face, but can also occur on the shoulder and trunk.
  • Regression does not occur.
  • Treatment: Pulsed dye laser, photocoagulation, dermabrasion.
  • Worrying because it becomes more keratotic and nodular as age advances.
  • Injection of sclerosants may be needed.
  • Noninvoluting haemangioma is its other name.
  • Extensive intradermal capillary dilatation
  • Remember as PORT-WINE
• It is a non-involuting capillary haemangioma (dilatation due to defective maturation of cutaneous innervations during embryogenesis).
• The area supplied by sensory branches of the fifth cranial nerve is involved.
• Starts with a light red colour and progresses to deep colour.
• Pulsed dye laser using light with a specific wavelength of 585 or 595 nanometres is one of the best treatments available. This process is called ‘photothermolysis’.
• It may be associated with Sturge-Weber syndrome.

3. Strawberry angiomas produce swelling which protrudes from the skin surface. The child is normal at birth. After a month, a bright red swelling appears over the head and neck region, which exhibits signs of compressibility.

The lesion consists of immature vascular tissue. Even though the lesion grows initially, by 5–7 years of age, swelling regresses and colour fades. Hence, no specific treatment is necessary. The treatment is indicated only when the swelling persists. 70% resolve by 7 years of age.

Venous (Cavernous) Haemangioma

This occurs in places where venous space is abundant, for Example lip, cheek, tongue, and posterior triangle of the neck.

Cavernous Haemangioma

• Compressible swelling
• Bluish warm, non-tender swelling
• Associated with arteriovenous communication
• Associated with lipoma: Naevolipoma

Venous Haemangioma Clinical Features

• History of swelling in the neck of long duration. A history of bleeding is present when it occurs in the oral cavity.
• The swelling is warm and bluish in colour but not pulsatile.
• Soft, fluctuant, transillumination is negative.
• Compressibility is present. This sign is also called ‘sign of emptying’ or ‘sign of refilling’.
• When the swelling is compressed between the fingers, blood diffuses under the vascular spaces and when pressure is released, it slowly fills up. Compressibility is a diagnostic sign of haemangioma.

Venous Haemangioma Differential Diagnosis

1. Lymphangioma is brilliantly transilluminated. If a lymphangioma is infected or has been treated with preliminary injections, it may not show transillumination.
2. Lipoma is not compressible.
3. Cold abscess
4. Branchial cyst when it is in an anterior triangle.

Treatment of Cavernous Haemangioma

Principles

1. Injection is the first line of treatment of cavernous haemangioma. It makes the swelling fibrotic, less vascular and smaller. Thus, excision can be done at a later date.

2. Excision of haemangioma in the oral cavity is more difficult than in the neck.

3. It is better to have control of the external carotid artery in the neck while excising haemangioma in the oral cavity. If necessary, the external carotid artery should be ligated in order to control the bleeding.

4. Adequate blood to be arranged.

5. Previous embolisation into the feeding artery decreases the size of the haemangioma (therapeutic embolisation).

6. Large haemangiomas in the oral cavity should be excised only after preliminary sclerotherapy and taking all the precautions mentioned above.

Injection Line of Treatment

• Boiling water, hypertonic saline or sodium tetradecyl sulphate (STD solution) can be used
• In multiple spaces, in multiple sittings
• Obliteration occurs due to aseptic thrombosis and fibrosis
• Lesion becomes flat

Swellings: Treated with Sclerosants

• Haemangioma
• Haemorrhoids
• Prolapse rectum
• Oesophageal varices
• Varicose veins

Syndromes Associated with Haemangioma

Syndromes associated with haemangioma and their findings

Complications of Haemangioma

• Ulceration and bleeding: Commonly occurs with capillary haemangioma
• Infection: Septicaemia usually precipitated by a small ulcer
• High-output cardiac failure

Congenital Arteriovenous (Av) Fistula (Arterial Haemangioma)

An abnormal communication between artery and vein results in AV fistula.

• AV fistula can be congenital or acquired.
• Such AV fistula has structural and functional effects.

Arteriovenous Fistula: Types

• Congenital
• Traumatic
• Iatrogenic: Created in cases of renal failure

Congenital Arteriovenous Structural Effect

Since high-pressure blood from an artery flows into the vein, the veins get dilated, tortuous and elongated. This arterialisation of the vein results in secondary varicose veins.

Congenital Arteriovenous Physiological Effect

Increased pulse rate, increased cardiac output, and increased pulse pressure result due to increased venous pressure and arteriovenous shunt.

Congenital Arteriovenous Functional Effect

• Soft, cystic, fluctuant, transillumination negative, pulsatile swelling.
• A continuous bruit or murmur is characteristic.
• Nicoladoni’s sign or Branham’s sign
  • On compressing the feeding artery, the venous return to the heart diminishes, resulting in a fall in pulse rate and pulse pressure.
  • On compressing the feeding artery, pulsation or continuous murmur may also disappear and swelling will diminish in size.
• If the AV fistula is big, a high-output cardiac failure can occur.
• The affected part is swollen (because of high pressure) then—local gigantism. Thus, overgrowth of the limb or toe can occur.
• Distal to the AV fistula, there are ischaemic ulcers, due to comparative reduction in the blood supply.

Congenital Arteriovenous Investigations

Angiography with DSA (digital subtraction angiography) pictures are essential before treating these patients.

Congenital Arteriovenous Treatment

• Therapeutic embolisation is the treatment of choice for arteriovenous fistula, in congenital cases.
• Acquired lesion needs to be observed or treated by quadruple ligation if needed.

Cirsoid Aneurysm

• Not an aneurysm
• It is an AV fistula occurring in older people affecting the temporal region.
• The arteries and the veins are dilated and tortuous and are compared to a pulsating bag of worms.

Cold Abscess In The Posterior Triangle

Cold Abscess Causes

• Posterior cervical lymph nodes primarily involved—route of infection from adenoids or other lymph nodes in the anterior triangle.
• Lower posterior lymph nodes or Scalene node—route of infection from lungs.
• From tuberculous cervical spine: Caries spine
• • Clinically, it presents as pain in the back, cold abscess and neurological presentation.
  • Rust’s sign: A child with a caries spine will support the head by holding the chin.
  • Cold abscess from the caries spine can rupture anteriorly or posteriorly.

1. Anterior rupture: It ruptures deep into a prevertebral layer of deep cervical fascia. From here, it can take the following routes:

• Upper cervical region: Presents as deep-seated abscess in the posterior wall of the pharynx in the midline.
• Lower cervical region: Pus will press on the oesophagus and trachea forwards.
• Laterally pus passes deep to prevertebral fascia behind the carotid sheath in the posterior triangle.

2. Posterior rupture: Pus may enter the spinal canal and then can travel along the anterior primary division of the cervical spinal nerves.

Cold Abscess Diagnosis

• Cervical spine X-ray to rule out spinal tuberculosis.
• Chest X-ray to rule out pulmonary tuberculosis.
• Nondependent aspiration of the cold abscess followed by AFB staining.

Cold Abscess Treatment

• Antituberculous treatment
• Nondependent aspiration, if cold abscess is present.
• Please refer to orthopaedic books for specific treatment of TB spine.

Cold Abscess Differential Diagnosis

• Haemangioma—compressible
• Lymphangioma—transilluminate
• Schwannoma

Lymph Nodes Secondaries (Metastasis) In The Head And Neck

Head And Neck Introduction

Very often, the patients present to the surgeon with lymph node swelling in the neck with or without any complaints. If there is an obvious lesion in the oral cavity, the diagnosis is easy.

• On the other hand, difficulty arises in locating the primary malignancy, which is hidden or occult.
• It is important to know the anatomical location of the lymph nodes in the neck and drainage area so that drainage areas can be investigated.
• Before understanding the various lymph nodes, drainage areas and block dissection, it is advisable to know the surgical anatomy of the neck and lymphatic drainage.

Surgical Anatomy Of Neck

The neck is that region of the body that lies between the lower border of the mandible the suprasternal notch and the upper border of the clavicle.

• Its boundaries include the mandible and the zygomatic process of the temporal bone.
• The external auditory canal, the mastoid process, the superior nuchal line, the external occipital protuberance, the manubrium sterni, the clavicle, the acromioclavicular joint and the spinous process of the 7th cervical vertebra.

Fascial Layers of Neck

• Two fascial layers in the neck: Superficial cervical fascia and deep cervical fascia.
• Superficial cervical fascia corresponds to subcutaneous tissue.
• The deep cervical fascia (fascia colli) is the important layer for functional and selective neck dissection. It is this layer that divides the neck into various compartments.

Deep Cervical Fascia

It has superficial and deep components.

1. Superficial layer (investing or anterior fascia): It is attached to the following structures—occipital protuberance, mastoid process, capsule of the parotid gland, angle of the jaw, and body of the mandible to the symphysis.

• Here, it proceeds around the contralateral side in a similar manner. It then goes posteriorly across the spinal process of the cervical vertebrae. Anteriorly, it passes from the mandible to the hyoid bone.
• Inferiorly, it attaches to the sternum, the upper edge of the clavicle, the acromion, and the spine of the scapula. At the inferior border, in the midline, the superficial layer splits into two different layers just superior to the manubrium of the sternum.
• The space between these two layers is known as the suprasternal space of Burns. From posterior to anterior, the superficial layer splits to enclose the trapezius.
• The portion of the omohyoid muscle that crosses the posterior triangle of the neck, and the sternocleidomastoid muscle. In a similar way, it envelops the strap muscles, before ending in the midline.
• The superficial veins of the neck lie on or within this superficial layer of the deep cervical fascia.

2. Deep layer (prevertebral fascia): The deep or prevertebral layer, like the superficial layer, attaches posteriorly to the spinous process of the cervical vertebrae.

• Above, it reaches the skull base at the jugular foramen and carotid canal, then passes across the basilar process to the opposite side. It covers the muscles of the back that enter the neck immediately deep into the trapezius muscle.
• At the upper limit of the posterior triangle, the spinal accessory nerve crosses the posterior triangle at this level, along with some lymph nodes.
• At the lower end, both fascial layers further separate, the deep layer covers the scalene muscles, whereas the superficial layer remains attached to the trapezius muscle and the clavicle.

Lymphatic Drainage of Neck

• The cervical lymphatics are divided into superficial and deep. The superficial lymphatics perforate the cervical fascia and drain into the deep lymphatics.
• The deep vessels and nodes are most commonly found along blood vessels, nerves and muscles. For example: The internal jugular vein is classically described as a jugular chain of lymph nodes. Look for this finding in the ultrasound examination of the neck.
• Lymph nodes have been given numbers according to their levels and drainage sites which are given below.

Memorial Sloan-Kettering Cancer Centre: Lateral Lymph Node Classification

Level 1: Lymph nodes in the submental triangle and submandibular triangle.

Level 2: Upper jugular nodes. Deep to the sternocleidomastoid muscle, anterior to the posterior border of the sternocleidomastoid.

• Posterior to the posterior aspect of the posterior belly of the digastric, superior to the level of the hyoid.
• Level 2 is further divided into (2a) which is inferior and in front of the line of the spinal accessory nerve, and (2b) is above and posterior to the line of the spinal accessory nerve.

Level 3: Middle jugular nodes from hyoid superiorly to cricothyroid membrane inferiorly.

Level 4: Lower jugular nodes from the cricothyroid membrane superiorly to the clavicle inferiorly.

Level 5: Posterior cervical region from anterior border of trapezius posteriorly to posterior border of sternocleidomastoid anteriorly and clavicle inferiorly.

• Above the line of spinal accessory nerve.
• Below the level of the spinal accessory nerve.

Level 6: Anterior compartment nodes from hyoid bone superiorly to suprasternal notch inferiorly and laterally by the medial border of the carotid sheath.

Level 7: Upper mediastinal nodes inferior to suprasternal notch (no longer used).

Drainage Area

• Level 1a lymph nodes: Floor of mouth, anterior oral tongue, anterior mandibular alveolar ridge, lower lip.
• Level 1b lymph nodes: Oral cavity, anterior nasal cavity, soft tissue of midface, submandibular gland.
• Level 2a and 2b nodes: Oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, parotid gland.
• Level 3 lymph nodes: Oral cavity, nasopharynx, oropharynx, hypopharynx, larynx.
• Level 4 lymph nodes: Hypopharynx, thyroid, cervical oesophagus, larynx.
• Level 5 lymph nodes: Scalp, parotid gland, nasopharynx, thyroid gland, etc.
• Level 6 lymph nodes: Thyroid gland, glottic and subglottic larynx, apex of pyriform sinus, cervical oesophagus.

Rational for Subzones

• Level 2 subzones
  • Oropharynx and nasopharynx—2b
  • 9 should be mobilised
  • Oral cavity, larynx and hypopharynx—may not be necessary to dissect 2b, if level 2a is not involved.
• Level 4 subzones
  • Level 4a nodes—increased risk in level 6
  • Level 4b nodes—increased risk in level 5
• Level 5 subzones
  • Oropharynx, nasopharynx, and cutaneous—5a
  • Thyroid—5b.

 Level – Lymph Node Group

• 1a – Submental nodes
• 1b – Submandibular nodes
• 2a – Upper jugular, anterior to 9
• 2b – Upper jugular, posterior to 9 (submuscular recess)
• 3 – Middle jugular nodes
• 4a – Lower jugular nodes (behind the clavicular head of the sternocleidomastoid muscle)
• 4b – Lower jugular nodes (behind the sternal head of the sternocleidomastoid muscle)
• 5a – Posterior triangle nodes (spinal accessory group)
• 5b – Posterior triangle nodes (transverse cervical artery group, supraclavicular
• group)
• 6 – Anterior ( central) compartment lymph nodes (paratracheal, peri thyroidal,
  Delphian)

The reason why lymphatic spread occurs widely is given.

Factors which Accelerate Local and Regional Spread of Malignant Tumour

• Angiogenesis
• Lymphangiogenesis
• Lack of basement membrane on lymphatic vessels
• Extracapsular breakout

Clinical Presentation of Metastatic Deposits in the Lymph Nodes

1. Majority of patients are elderly males (>50 years), present with painless swelling in the neck of a few months duration.

2. The symptoms with which a patient presents to the hospital give the clue to the site of origin of the primary. A few examples are given below:

• Difficulty in swallowing: Carcinoma posterior 1/3rd of the tongue, oropharyngeal carcinoma or carcinoma oesophagus.
• Difficulty in breathing: Laryngeal cancer
• Hoarseness of voice: Larynx or thyroid
• Obvious growth in the oral cavity: Carcinoma cheek, alveolus, tongue, etc.
• Haemoptysis, difficulty in breathing: Bronchogenic carcinoma
• Epistaxis, ear pain or deafness: Nasopharyngeal carcinoma

Nasopharyngeal Carcinoma: Trotter’s Triad

• Conductive deafness
• Homolateral immobility of soft palate
• Pain in the side of the head due to the involvement of the 5th cranial nerve.

Neck Clinical Signs

• Lymph nodal metastasis appears as a hard, nodular or irregular mass in the anatomical location of the lymph nodes.
• Early cases may have some mobility. However, in the majority of cases, nodes get fixed and they attain a huge size. Very often, what appears as one lymph node, is a complex mass of multiple lymph nodes.
• On the sternomastoid contraction test or chin test, these nodal swellings become less prominent.
• Skin ulceration is a late feature. A prominent skin fold is due to infiltration into the platysma—platysma sign.
• The primary malignancy may be evident in the anterior third of the tongue, cheek, alveolus, etc.
• The posterior one-third of the tongue should be palpated with a gloved finger.

Occult Primary Sites

• Posterior 1/3rd of tongue, oropharynx
• Nasopharynx, sinuses
• Upper oesophagus, bronchus, thyroid

Secondaries in the lymph nodes can cause pressure effects or may cause paralysis of nerves.

• Upper anterior deep cervical lymph nodes can cause hypoglossal nerve paralysis where the tongue points towards the side of the lesion.
• When there is no evidence of the primary lesion clinically, the situation is described as occult primary with secondaries in the neck.
• Pain in the distribution of the trigeminal nerve (face) suggests nasopharyngeal malignancy infiltrating the skull base (foramen lacerum).

Clinical Examination in a Case of Lymph Nodes in the Neck

• • Lymph nodes: All groups
  • Drainage areas

Pressure effect on

• • Hypoglossal nerve
  • Accessory nerve
  • Cervical sympathetic chain

Types Of Secondaries In The Neck

1. Secondaries in the neck with known primary

• In this case, secondaries in the neck are present and the site of the primary tumour is clinically identified either in the oral cavity, pharynx, thyroid, etc.
• Primary may be treated by surgery or radiotherapy as the case may be.
• Secondaries may need radical neck dissection.

2. Secondaries in the neck with clinically unidentified primary

• Here the hard neck nodes are present but the primary is not identified clinically. However, it is detected after investigations. Example: Oropharyngeal carcinoma.
• FNAC is done to confirm the diagnosis.
• Various investigations like pan endoscopy, blind biopsies, and CT may be done to establish the primary.

3. Secondaries in the neck with an occult primary: It is a biopsy-proven cancer of neck nodes which even after complete clinical and radiological workup reveals or yields no demonstrable primary lesion.

How do you Suspect Metastasis in the Neck?

Any elderly patient presenting to the hospital with a firm to hard lymph node in the neck of short duration with or without fixity. He has no signs and symptoms of inflammation such as fever or pain to begin with.

Having suspected a metastatic deposit, remember the following facts:

• 80% of them are metastatic deposits.
• The majority of malignant neoplasms are epithelial in origin.
• Nodes in the upper half (levels 1 and 2) can be due to primary in the oral cavity, tongue, oropharynx, and larynx.
• Nodes in the lower half (levels 3 and 4) can be due to primary in the thyroid, and tongue.
• Nodes in the supraclavicular region (level 5): Carcinoma in the GIT, genitourinary tract, lungs and nasopharynx.
• Nodes in the paratracheal, suprasternal region (level 6): Papillary carcinoma thyroid

Rule of 80 in Neck Masses

• 80% of neck masses are neoplastic
• 80% of neoplastic masses occur in males
• 80% of neck masses are malignant
• 80% of malignant neck masses are metastatic
• 80% of metastatic neck masses are from primary sites above the clavicle

Neck Dissections

Neck Dissections Introduction

• Crile in 1906, first described a standardised dissection of cervical nodes by applying anatomical and oncological principles including removal of surrounding fibrofatty tissue from various compartments of the neck.
• Radical neck dissection (RND) causes significant functional and cosmetic morbidity.
• Today adjuvant chemoradiotherapy is an important modality of treatment.
• Thus with a better understanding of tumour biology, the natural history of disease and the availability of adjuvant radiotherapy, radical neck dissection is not frequently done but its modifications are done.

Classification of Concepts

1. RND is the standard basic procedure for cervical lymphadenectomy against which all other modifications are compared.
2. Modifications of the RND which include preservation of any non-lymphatic structures are referred to as modified radical neck dissection (MRND).
3. Any neck dissection that preserves one or more groups or levels of lymph nodes is referred to as a selective neck dissection (SND).
4. An extended neck dissection refers to the removal of additional lymph node groups or non-lymphatic structures relative to the RND.

Metastasis In Cervical Lymph Nodes Various Levels

Cervical Lymph Nodes Classification

1. Radical neck dissection (RND)

2. Modified radical neck dissection (MRND)

• Type 1 (11 preserved)
• Type 2 (11, 1JV preserved)
• Type 3 (11, 1JV, and SCM preserved) “Functional neck dissection”

3. Selective neck dissection (SND)

• Supraomohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type

4. Extended radical neck dissection

• Rule of 80 in neck masses

Cervical Lymph node indications

• Carcinoma tongue, carcinoma floor of the mouth
• Malignant melanoma
• Metastatic lymph nodes from the pharynx and upper oesophagus.

Cervical Lymph Nodes Contraindications

• Fixed nodes, evidence of distant metastasis
• Untreatable primary cancer

Cervical Lymph Nodes Types (Details of the Neck Dissections)

1. Classical Radical Neck Dissection (Crile’s Operation)

Removal of levels I to V nodes + IJV, sternocleidomastoid + spinal accessory and submandibular salivary gland + Tail of parotid.

Incision

1. MacFee: Two incisions are given

• The upper incision extends from the mastoid process to the hyoid bone up to the point of the chin across the intermediate tendon of the digastric muscle.
• The lower incision is given 2 cm above the clavicle—from the anterior border of the trapezius to the midline.
• Gives a very good exposure and the vascularity of the flaps is good. No corners and hence, no necrosis.

• Double transverse incision
• A 3-point intersection is avoided
• Subsequent blowouts of the carotid artery can be avoided

2. Crile’s incision

• The upper incision is similar to MacFee. The other incision is oblique along the length of the sternocleidomastoid inclining more in the posterior triangle.
• When the sternocleidomastoid has to be removed as a part of neck dissection or to clear the lymph nodes which are badly stuck to a jugular vein or to accommodate the PMMC flap, Crile’s incision is better.
• Here all the cervical lymph nodes from level 1 to level 6 are removed along with non-lymphatic structures such as the sternocleidomastoid muscle, internal jugular vein, accessory nerve (11), submandibular salivary gland and cervical sympathetic plexus. A few examples wherein radical neck dissection is done are carcinoma tongue, oropharyngeal carcinoma, etc.

• Furcate incision—otherwise called Y incision
• A 3-point intersection occurs which may give rise to necrosis

2. Modified Radical Neck Dissection (MRND)

Type 1

• Preserve one structure: Spinal accessory nerve
• Classically done for squamous cell carcinoma of the upper aerodigestive tract with clinically positive neck dissection.

Type 2 MRND

Preserve two structures: Spinal accessory and 1JV.

Type 3 MRND or Bocca’s functional neck dissection.

• Preserve three structures: Spinal accessory, sternocleidomastoid and internal jugular vein.
• Done for metastatic well-differentiated carcinoma thyroid. In this, all the lymph nodes from level 1 to level 5 are removed but nonlymphatic structures are preserved.
• Dissection is from the lower border of the mandible to the clavicle and from the anterior border of the trapezius to the midline.

3. Selective Neck Dissection

Here any of the lymphatic compartments is preserved (which should have been removed as part of classic RND). A few examples are given below.

• Supraomohyoid dissection: Removal of nodes in levels 1, 2 and 3 is done for carcinoma oropharynx and carcinoma cheek. Usually done for carcinoma floor, lateral tongue, etc.
• Lateral neck dissection: Levels 2, 3, 4 are removed as in carcinoma larynx and cervical oesophagus.
• Posterolateral neck dissection: Levels 2 to 5 are removed as in cutaneous malignancy of the posterior scalp and neck. Can also be done for thyroid malignancies.
• Anterior neck dissection
  • En bloc removal of lymph structures in level 6
  • Perithyroidal nodes
  • Pretracheal nodes
  • Precricoid nodes (Delphian)
  • Paratracheal nodes along recurrent nerves
  • Limits of the dissection are the hyoid bone, suprasternal notch and carotid sheaths.
  • Indications
    • Selected cases of thyroid carcinoma
    • Parathyroid carcinoma
    • Subglottic carcinoma
    • Laryngeal carcinoma with subglottic extension
    • Ca of the cervical oesophagus

4. Commando’s Operation

RND, hemimandibulectomy with radical glossectomy. It is a very radical and aggressive surgery done for carcinoma tongue.

Cervical Lymph Nodes Investigations

1. Complete blood picture

2. Chest X-ray can provide the following information:

• Secondaries in the lungs with cannonball appearance as in cases of malignant melanoma of the head and neck.
• Bronchogenic carcinoma can be suspected by an irregular dense shadow in the peripheral lung fields.
• Large mediastinal node mass may be seen, with or without tracheal shift.

3. Biopsy from clinically obvious lesions (tongue, cheek, lips, etc.).

4. Triple endoscopy includes

• Direct and indirect laryngoscopy
• Oesophagoscopy
• Bronchoscopy and biopsy of the suspicious area.

5. X-ray base of the skull may show destruction of the bone by the tumour.

6. CT scan of the sinuses, nasopharyngeal area, or skull base to detect a primary growth, its extension, etc.

7. FNAC of the lymph nodes can give a diagnosis in more than 90% of the cases, avoid incision biopsy as it will result in tumour recurrence and wound necrosis.

8. If the primary tumour cannot be detected on endoscopy, a blind biopsy is taken from the posterior wall of the fossa of Rosenmüller and of the pyriform fossa on the same side.

9. When aspiration cytology is negative, an excision biopsy is advised as a last resort.

Investigation And Management Of The Unknown Primary With Metastasis In The Neck

This is a challenging problem for clinicians to detect primary and to treat the disease. When all investigations fail to come to detect primary, and is called metastasis of unknown origin.

Metastasis In The Neck Certain Facts

1. Even though primary is not found initially, the rate of emergence of primary tumours is about 3% per year.
2. About 10% of patients are cured of the disease but primary is unknown.
3. About 20–30% of patients who have received complete treatment die sometime later but the primary is still unknown.
4. The majority of occult primary nodes are located in level 2 and level 3.
5. Cystic malignant nodes in level 2 can be due to the oropharynx as occult primary and it will be squamous cell carcinoma due to human papillomavirus.
6. Supraclavicular lymph node enlargement is due to a few occult sites, such as bronchogenic carcinoma.
7. Clinical presentation of lymph nodes in the neck can be solid or cystic lesions or solitary or multiple swellings. The swellings are usually located on level 2, followed by level 3.
8. The clinical N stage at presentation is usually N2a, N2b and N2c. The presence of cystic malignant metastases in level 2 is usually due to human papillomavirus (HPV)-related squamous carcinoma, usually with subclinical primaries in the oropharynx.

Metastasis In The Neck Management Principles

1. All patients presenting with confirmed cervical lymph node, metastatic squamous cell carcinoma and no apparent primary site should undergo: Positron emission tomography–computed tomography whole-body scan.

2. Bilateral tonsillectomy: Few consider this not necessary because if the lesion is very small than 0.5 cm, it will anyhow respond to radiation. So why do tonsillectomy?

3. CECT is done from the skull base to the diaphragm.

4. MRI: If we suspect a primary source in the tongue, tonsil, etc. because of level 2/3 lymph node, an MRI is done. Extension of tumours in infratemporal fossa can be better appreciated by MRI scans.

5. Panendoscopy: This is done to visualise the following sites which cannot be examined clinically

• Tongue base Hard palate
• Tonsils Soft palate
• Posterior pharyngeal wall Vallecula
• Paranasal sinuses Post-cricoid fossa
• Nasopharynx Pyriform fossa
• Oral cavity Glottis, subglottis

6. Performance status should be assessed for major surgery, chemotherapy or radiotherapy.

7. Concomitant chemotherapy with radiation should be considered in patients with an unknown primary. Concomitant chemotherapy with radiation should be offered to suitable patients in the postoperative setting, where indicated.

8. Neoadjuvant chemotherapy can be used in gross ‘unresectable’ diseases.

9. Patients should be followed up for at least two months in the first two years and three to six months in the subsequent years.

10. Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients.

11. A positron emission tomography-computed tomography scan at three to four months after treatment is a useful follow-up strategy for patients treated by chemoradiation therapy.

12. Ultrasound-guided fine needle aspiration (FNA) cytology and/or core biopsy under ultrasound guidance. Most often, the report is squamous cell carcinoma.

Metastasis In The Neck Treatment

• Surgery is the main principle of treatment for N1 neck nodes.
• If extracapsular spread is present, surgery should be combined with radiotherapy.
• In advanced diseases, surgery should be done after chemoradiotherapy.
• Cisplatin is the drug of choice.
• The neck dissection is modified radical neck dissection (MRND) including levels 1–5.
• Summary of the treatment.

Metastasis In The Neck Follow-up

• About 30–40% of treated patients with occult primary with metastatic nodes die with no evidence of the primary later.
• In about 30% of patients, the primary will manifest within 1–2 years time.
• About 10% of patients are cured but primary is not detected.

Pancoasts Tumour

Pancoast’s tumour or superior sulcus tumour is a bronchogenic carcinoma arising from the apex of the lung.

• Typically, the patient is an elderly male around 70 years old, a chronic smoker who presents with cough, weight loss, dyspnoea and chest pain.
• As the tumour grows, it compresses the lower roots of brachial plexus C8 and T1 and results in tingling, pain and paraesthesia in the distribution of the ulnar nerve.
• The tumour is felt in the lower part of the posterior triangle. It is hard in consistency, fixed, irregular and sometimes tender. The lower border of the mass cannot be appreciated.

The Pancoast’s syndrome refers to the following components

1. Pancoast’s tumour
2. Erosion of the first rib
3. Paralysis of C8 and T1 nerve roots
4. Horner’s syndrome is due to paralysis of the cervical sympathetic chain. The preganglionic sympathetic fibres of the head and neck are given from the 1st and sometimes the 2nd thoracic segments of the spinal cord.
5. These nerve fibres synapse with the cells in the three cervical sympathetic ganglia. They give rise to postganglionic fibres in the head and neck region.

Thus, anywhere along this pathway, disruption, damage or infiltration of the nerve roots results in Horner’s syndrome. The causes of Horner’s syndrome are depicted.

Horner’s Syndrome

• Common causes
  • Posterior inferior cerebellar artery (PICA) thrombosis
  • Cervical sympathectomy
  • Pancoast’s tumour
• Uncommon causes
  • Syringomyelia
  • Injury to lower roots of brachial plexus
  • Tumour in the neck
  • Aneurysm of carotid artery

Components of Horner’s Syndrome

• Miosis: Small pupil
• Anhidrosis: Absence of sweating.
• Pseudoptosis: Drooping of upper eyelid.
• Enophthalmos: Regression of the eyeball
• Nasal vasodilatation: Nasal congestion

Metastasis In The Neck Investigations

• Chest X-ray: This may demonstrate a dense mass or collapse of the lobe, etc.
• A CT scan may demonstrate infiltration of the tumour into ribs or vertebra.
• Sputum for malignant cells
• Flexible bronchoscopy: Tissue biopsy or sputum sample can be collected.
• FNAC of the tumour gives the diagnosis in the majority of cases.

Metastasis In The Neck Treatment

Palliative radiotherapy. The response rate is poor.

Cystic Swellings Neck Swellings And Metastasis Lymph Node Neck Multiple Choice Questions And Answers

Question 1. The following is true for ranula except:

1. It is a swelling in the floor of the mouth
2. It is a retention cyst
3. It is transilluminate
4. Plunging the ranula produces one more swelling in the submental region

Answer: 4. Plunging ranula produces one more swelling in the submental region.

Question 2. Which one of the following does not give rise to cross-fluctuation?

1. Iliopsoas abscess
2. Compound palmar ganglion
3. Sebaceous cyst
4. Hydrocele in basic

Answer: 3. Sebaceous cyst

Question 3. The following is true for thyroglossal fistula except :

1. Always congenital
2. It is lined by columnar epithelium
3. The semilunar sign is seen in adults
4. Surgery done for this is called Sistrunk’s operation

Answer: 1. Always congenital

Question 4. The following are derived or arise from 2nd branchial arch except :

1. Sternocleidomastoid muscle
2. Branchial cyst
3. Facial muscles
4. Anterior belly of the digastric

Answer: 4. Anterior belly of the digastric

Question 5. Which one of the following swellings does not contain cholesterol crystals?

1. Branchial cyst
2. Sebaceous cyst
3. Dental cyst
4. Hydrocele

Answer: 2. Sebaceous cyst

Question 6. The most important stimulus for carotid body tumours is:

1. Hypoxia
2. Hyperbaric oxygen
3. Hypothermia
4. Hypercarbia

Answer: 1. Hypoxia

Question 7. The tuberculous cervical spine can give rise to a cold abscess in the following locations:

1. The posterior wall of the pharynx in the midline
2. Behind the carotid sheath
3. Front of the carotid sheath
4. Along the anterior primary division of the cervical spinal nerves

Answer: 3. Front of the carotid sheath

Question 8. Pancoast’s tumour has the following features:

1. It is a superior sulcus tumour
2. It can give rise to Horner’s syndrome
3. It can erode the first rib
4. It is usually resectable

Answer: 4. It is usually resectable

Question 9. The components of Horner’s syndrome are the following:

1. Miosis
2. Anhydrosis
3. Pseudoptosis
4. Exophthalmos

Answer: 4. Exophthalmos

Question 10. The following organs drain to posterior triangle lymph nodes:

1. Adenoids
2. Thyroid
3. Retropharynx
4. Tonsil

Answer: 4. Tonsil

Question 11. Content of sebaceous cyst includes:

1. Desquamated epithelial debris
2. Keratin
3. Sebum
4. Pus

Answer: 2. Keratin