Transcript neck swellings - The Medical Post | Trusting Medicine
Neck Swellings
Dr. Vishal Sharma
Neck Triangles
Anterior Triangle
Boundaries: Anterior =
midline of neck
Posterior =
S.C.M. anterior border
Superior =
lower border of mandible
Floor =
deep layer of deep cervical fascia
Roof =
Superficial layer of deep cervical fascia
Subdivision:
by digastric & omohyoid muscles into submental, submandibular, carotid, muscular
Contents:
carotid arteries, internal jugular vein, vagus, recurrent laryngeal nerves, submandibular gland, Levels I, II, III, IV & VI lymph nodes
Posterior Triangle
Boundaries: Posterior:
Trapezius anterior border
Anterior:
S.C.M. posterior border
Inferior:
Middle 1/3 rd of clavicle
Floor:
deep layer of deep cervical fascia
Roof:
Superficial layer of deep cervical fascia
Subdivision:
occipital & supra-clavicular by omohyoid
Contents:
subclavian artery, brachial plexus, spinal accessory nerve, level V lymph nodes
Neck Lymph Nodes
Sloan Kettering Classification Level I: Submental + submandibular nodes Level II: Upper jugular nodes
(upper 1/3 of IJV)
Level III: Middle jugular nodes
(middle 1/3 of IJV)
Level IV: Lower jugular nodes
(lower 1/3 of IJV)
Level V: Posterior triangle nodes Level VI: Anterior compartment nodes Level VII: Superior mediastinal nodes
Submental Lymph nodes (Level Ia): Lateral:
Anterior digastric belly (both sides)
Inferior:
Body of hyoid
Submandibular Lymph nodes (Level Ib) Posterior:
Posterior digastric belly
Anterior:
Anterior digastric belly
Superior:
Body of mandible
Anterior Posterior Superior Inferior II III Lateral Posterior Skull base border of border of sterno sterno hyoid cleido mastoid Carotid bifurcation or hyoid Carotid bifurcation or hyoid Cricoid IV Cricoid Clavicle
Level V: Posterior triangle nodes Posterior:
Trapezius anterior border
Anterior:
S.C.M. posterior border
Inferior:
Middle 1/3 rd of clavicle
Level VI: Anterior compartment nodes Superior:
Body of hyoid bone
Inferior:
Supra-sternal notch
Lateral:
Lateral border of sterno-hyoid
Level VII: Superior mediastinal nodes
Classification of neck swelling according to position
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Ubiquitous neck swellings
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Midline neck swellings
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Anterior triangle neck swellings
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Posterior triangle neck swellings
Ubiquitous neck swellings
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Sebaceous cyst
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Lipoma
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Neurofibroma, schwannoma
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Hemangioma
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Dermoid cyst
•
Teratoma
•
Hydatid cyst
Midline swellings
Lymph node (submental, Delphian, suprasternal)
Ludwig’s angina
Sublingual dermoid
Thyroglossal cyst
Subhyoid bursitis
Thyroid swelling (isthmus & pyramidal lobe)
Laryngeal tumors
Sternal tumor
Cold abscess
Thymus tumors
Submandibular triangle swellings
•
Lymph node (level 1b)
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Cold abscess
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Submandibular salivary gland enlargement (deep lobe is bimanually ballotable)
•
Plunging ranula
•
Mandibular tumor
Carotid + muscular triangle swellings
Branchial cyst
Branchiogenic cancer
Laryngocoele (external)
Thyroid lobe swelling
Lymph node (II, III, IV)
Carotid body tumour
Cold abscess Carotid aneurysm
Sternomastoid tumor of newborn
Posterior triangle swellings
Cystic hygroma
Pharyngeal pouch (Zenker’s diverticulum)
Lymph node (level V)
Cold abscess
Cervical rib
Clavicular tumour
Subclavian artery aneurysm
Classification by etiology
•
Congenital / Developmental
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Infectious / Inflammatory
•
Neoplastic: Benign / Malignant
Congenital neck swellings a. Cystic
Sebaceous cyst
Branchial cyst
Thymic cyst b. Solid: Ectopic thyroid c. Vascular
Hemangioma
Dermoid cyst
Thyroglossal cyst
Lymphangioma
Inflammatory neck swellings
•
Lymphadenitis
–
Viral
–
Bacterial
–
Granulomatous
•
Sialadenitis
–
Parotid
–
Sub-mandibular
•
Deep neck space abscess
Neoplastic neck swellings
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Skin: Squamous cell Ca, Malignant melanoma
•
Soft tissue:
–
Benign: Lipoma, Fibroma, Schwannoma
–
Malignant: Rhabdomyosarcoma
•
Lymph node: Lymphoma, Metastasis
•
Thyroid: Benign / Malignancy
•
Vascular: Carotid body tumor, Angioma
Hemangioma & lipoma
Cervical Lymphadenopathy
A. Inflammatory hyperplasia
1. Acute lymphadenitis 2. Chronic lymphadenitis 3. Granulomatous lymphadenitis Bacterial: tuberculosis, secondary syphilis Viral: infectious mononucleosis, AIDS Parasitological: toxoplasmosis Non-specific: sarcoidosis
B. Neoplastic:
lymphoma, lymphosarcoma, metastatic
C. Lymphatic leukemia D. Autoimmune:
systemic lupus erythematosus
Lymph node consistency
•
Firm, rubbery: lymphoma
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Soft : infection or cold abscess
•
Multiple, firm, shotty: syphilis, viral
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Matted (connected): tuberculosis , sarcoidosis, malignant
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Rock hard, immobile, fixed to skin: metastatic
Tuberculous lymphadenitis
• Involves upper deep cervical chain & posterior
triangle lymph nodes
• Development of peri-adenitis →
matted nodes
• Development of caseation →
cold abscess
• Abscess tracking down to skin forms subcutaneous
collection → collar stud abscess
• Abscess bursts spontaneously →
tuberculous sinus
Tuberculous lymphadenopathy
Lymphoma More common in children & young adults 60 80% children with Hodgkin’s have neck mass Signs & symptoms:
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Fever + malaise
•
Night sweats
•
Weight loss
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Pruritus
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Rubbery lymph nodes
Metastatic lymph node
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Seen in older patients
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Level 1: oral cavity
•
Level 2, 3, 4: larynx, oropharynx, hypopharynx, thyroid
•
Level 5: nasopharynx
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Left supraclavicular fossa: lung, stomach, testis
Unknown Primary Lesion (UPL) Synonym:
1. metastasis of unknown origin 2. occult primary
Definition:
metastatic lymph node with primary site hidden or undetected
Primary malignancy sites (as per frequency):
1. Nasopharynx 2. Oropharynx (base of tongue) 3. Hypopharynx (pyriform fossa) 4. Larynx 5. Thyroid
Investigations for UPL 1. Fibreoptic nasopharyngoscopy + laryngoscopy 2. Rigid panendoscopy 3. Excision biopsy of I/L tonsil + blind biopsy of tongue base, pyriform fossa, fossa of Rosenmuller, tonsilo-lingual sulcus, retro molar trigone 4. CT scan from skull base to superior mediastinum 5. Excision biopsy of metastatic lymph node
Ranula
Introduction
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Rana means frog (blue translucent swelling in floor of mouth looks like underbelly of frog)
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Simple ranula: Bluish cyst located in floor of mouth. Painless mass, does not change in size in response to chewing, eating or swallowing
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Plunging ranula: Sub-mandibular neck swelling with or without cyst in floor of mouth
Simple Ranula
Plunging ranula
Plunging ranula
Etiology
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Simple ranula: partial obstruction or severance of sublingual duct leads to epithelial-lined retention cyst. Commonly traumatic.
•
Plunging ranula: 1. sublingual gland projects through or behind mylohyoid muscle 2. ectopic sublingual gland on cervical side of mylohyoid muscle
Treatment Marsupialization: un-roofing of cyst & suturing of cyst margin to adjacent tissue. Failure = 60-90% Sclerosing agents: intra-lesional injection of Bleomycin or OK-432 Intra-oral excision: of ranula alone (failure = 60%) or ranula + sublingual gland (failure = 2 %) Trans-cervical approach for plunging ranula: complete removal of cyst + sublingual gland
Marsupialization
Intra-oral excision
Ranula specimen
Thyroglossal cyst
Embryology
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Thyroid appears as epithelial proliferation in floor of mouth. Thyroid descends in front of pharynx as bi-lobed diverticulum, connected to tongue by thyroglossal duct.
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The duct normally disappears later. Thyroglossal cysts are cystic remnant of thyroglossal duct.
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Commonest congenital anomaly of thyroid
Location
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Cyst may lie at any point along migratory pathway of thyroid gland
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Commonest site: sub-hyoid (50%)
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Second common site: supra-hyoid
.
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Other common sites: base of tongue, at level of thyroid cartilage, sublingual
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Least common site: at level of cricoid cartilage
Location 1 = base of tongue 2 = sublingual 3 = supra-hyoid 4 = sub-hyoid 5 = in front of thyroid cartilage 6 = in front of cricoid cartilage
Clinical features
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Commonly seen in early childhood
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Midline, round swelling, 2-4 cm in diameter
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Swelling moves up with swallowing
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Swelling moves up with protrusion of tongue
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Swelling mobile horizontally but not vertically
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Cyst increases in size with URTI
Neck swelling moving with swallowing
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Thyroid swelling
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Thyroglossal cyst (mobile horizontally)
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Subhyoid bursitis (oval, long axis horizontal)
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Pre-laryngeal & pre-tracheal lymph nodes
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Laryngocele
Midline neck swelling
Ultra-sonography
CT scan axial cut
MRI sagittal cut
Sistrunk’s operation Consists of complete surgical excision of cyst & its tract along with body of hyoid bone & core of tongue tissue around suprahyoid tongue base up to foramen caecum Thyroid scan mandatory before cyst excision as cyst may contain only functioning thyroid tissue
Patient position & incision
Exposure of cyst + tract
Exposure & cutting of hyoid bone
Removal of tongue tissue
Removal of cyst + tract
Complications 1. Infection of cyst & abscess formation 2. Throglossal fistula 3. Malignancy (1%) Infected cyst
Thyroglossal fistula
Branchial cleft cysts
Embryology
Branchial anomalies
•
Cyst:
remnant of branchial clefts or pouch without internal or external opening •
Sinus:
persistence of cleft with skin opening •
Fistula:
persistence of both cleft + pouch with openings in skin & pharynx • Fistula tract lies caudal to structures derived from its arch & dorsal to structures of following arch
Branchial anomalies
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In children, fistulas are more common than sinuses, which are more common than cysts
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In adults, cysts predominate
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Branchial cleft anomalies + biliary atresia + congenital cardiac anomalies = Goldenhar's complex
First branchial cleft cyst
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Type I:
Contains only ectodermal elements without cartilage or adnexal structures. Present as duplication of external auditory canal.
•
Type II:
Contains both ectoderm & mesoderm. Present as abscess below angle of mandible. •
Fistula ends internally around Eustachian tube
Second branchial cleft cyst
• Commonest branchial anomaly • Painless, fluctuant mass along anterior border of middle 1/3 rd of sternocleidomastoid muscle • Fistula tract opens externally along lower 1/3 rd of SCM, passes deep to 2 nd arch structures (external carotid, stylohyoid muscle, posterior belly of digastric); superficial to internal carotid (3 rd arch); ends internally in tonsillar fossa
Second branchial cleft cyst
Second branchial cleft cyst
Third branchial cleft cyst
• Painless, fluctuant mass along anterior border of lower 1/3 rd of sternocleidomastoid muscle • Fistula tract opens externally along lower 1/3 rd of SCM, passes deep to 3 rd arch structures (internal carotid, glossopharyngeal nerve); superficial to superior laryngeal nerve (4 th arch): opening internally in base of pyriform fossa
Fourth branchial cleft cyst
• Presents as mass along anterior border of lower 1/3 rd of stenomastoid or as recurrent thyroiditis • Fistula tract opens externally along lower 1/3 rd of SCM, passes deep to 4 th arch structures (superior laryngeal nerve ); superficial to recurrent laryngeal nerve (6 th arch); opening internally in apex of pyriform fossa
CT scan 1 st branchial cyst
CT scan 2 nd branchial cyst
CT scan 3 rd branchial cyst
Coronal MRI Sagittal MRI Axial MRI
Treatment
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Abscesses treated first with incision & drainage + broad-spectrum antibiotics
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Elective surgical excision of cyst with its tract traced up to its origin in pharyngeal wall done after infection resolves
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Branchial fistula excised with 2 horizontally placed incisions (stepladder incision)
Excision of branchial cyst
Branchial fistula excision
Laryngocoele
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Arises from expansion of saccule of laryngeal ventricle due to
ed intra-luminal pressure in larynx or congenital large saccule Causes of
ed intra-luminal pressure in larynx:
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Occupational (?): trumpet players, glass blowers
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Coexistence of larynx cancer
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Male : female 5:1, Peak age = 6 th decade, Unilateral in 85 % cases, 1% contain carcinoma
Swelling enlarges on Valsalva
Types of laryngocoele
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Internal (20%):
contained entirely within endolarynx with bulge in false vocal fold & aryepiglottic fold •
External (30%):
only neck swelling without visible endolaryngeal swelling •
Combined (50%):
Also extends into anterior triangle of neck through foramen for superior laryngeal nerve & vessels in thyrohyoid membrane. Dumbbell shaped.
Types of laryngocoele Internal External Combined 89
Clinical Features
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Hoarseness
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Stridor in large endolaryngeal laryngocoele
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Neck swelling
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Manual compression of neck swelling results in escape of fluid / gas into airway ( Boyce’s sign )
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10% cases are pyocele: sore throat, cough
Flexible laryngoscopy
▪
Swelling of false vocal folds & ary-epiglottic fold
▪
Swelling easily emptied
▪
Escape of purulent fluid into airway = pyocoele 91
X-ray neck AP view X-ray soft tissue neck AP view during Valsalva maneuver shows air filled radiolucent swelling 92
CT scan: mixed laryngocoele
Treatment
•
No symptom:
no treatment •
Infected laryngocoele:
aspiration & antibiotics •
Internal laryngocoele:
endoscopic marsupialization •
External laryngocoele:
Excision by external approach. Cyst exposed by removing upper half of thyroid cartilage. Cyst incised at its neck & stitched.
Endoscopic marsupialization
External approach
Carotid body tumor
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Pulsating, compressible mass in carotid triangle
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Mobile only horizontally not vertically
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Angiography: vascular mass b/w external & internal carotid arteries ( Lyre’s sign )
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Rx: Radiation or close observation in elderly.
Surgical resection for small tumors in young patients with hypotensive anesthesia & pre operative measurement of catecholamines.
Lyre sign
Sternomastoid tumor of infancy
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Firm mass of SCM, becomes prominent when chin turned away & head tilted towards the mass
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Due to birth trauma causing infarction / hematoma with subsequent fibrotic replacement
•
Rx: Physical therapy. Myoplasty of SCM for refractory cases.
Hypopharyngeal pouch
Introduction
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Hypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagus
•
In contrast, congenital diverticulum like Meckel's diverticulum is covered by all muscle layers of visceral wall
Weak spots b/w muscles
Origin of Zenker’s diverticulum
Etiology
1. Tonic spasm of cricopharyngeal sphincter: C.N.S. injury Gastro-esophageal reflux 2. Lack of inhibition of cricopharyngeal sphincter 3. Neuromuscular in-coordination between thyro pharyngeus & cricopharyngeus 4. Second swallow against closed cricopharynx These lead to increased intra-luminal pressure in hypopharynx & mucosa bulges out via weak areas
Clinical features
1. Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia 2. Regurgitation of entrapped food: leads to foul taste bad odor nocturnal coughing choking 3. Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve 4. Weight loss: due to malnutrition 5. Compressible neck swelling on left side: reduces with a gurgling sound ( Boyce sign )
Complications 1. Lung aspiration of sac contents 2. Bleeding from sac mucosa 3. Absolute oesophageal obstruction 4. Fistula formation into:
trachea
major blood vessel 5. Squamous cell carcinoma within Zenker diverticulum (0.3% cases)
Investigations
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Chest X-ray: may show sac + air - fluid level
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Barium swallow
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Barium swallow with video-fluoroscopy
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Rigid Oesophagoscopy
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Flexible Endoscopic Evaluation of Swallowing
Barium swallow
Barium swallow with Video-fluoroscopy
Rigid Esophagoscopy
Staging Lahey system:
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Stage I: Small mucosal protrusion
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Stage II: Definite sac present, but hypo-pharynx & esophagus are in line
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Stage III: Hypopharynx is in line with pouch & esophagus pushed anteriorly
Stage 1
Stage 2
Stage 3
Surgical Treatment 1. Cricopharyngeal myotomy: combined with others 2. Diverticulum invagination: Keyart 3. Diverticulopexy: Sippy-Bevan 4. External or open Diverticulectomy: Wheeler 5. Rigid Endoscopic Diverticulotomy
Cautery (Dohlman)
Laser
Stapler 6. Flexible Endoscopic Diverticulotomy with Laser
Treatment Protocol 1. Small sac (< 2cm): Cricopharyngeal (CP) myotomy + invagination 2. Large sac (2-6 cm): Open Diverticulectomy with CP myotomy or Endoscopic Diverticulotomy with CP myotomy 3. Very large sac (> 6 cm): Open Diverticulectomy with CP myotomy or Diverticulopexy with CP myotomy
Cricopharyngeal myotomy
Diverticulum invagination Diverticulum pushed into hypopharynx lumen & muscle + adjacent tissue are oversewn. CP myotomy is usually combined with this .
External diverticulectomy
Endoscopic diverticulotomy
Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum
View through diverticuloscope Cautery, laser, or stapling device used to divide common party wall between pouch & esophagus
View through diverticuloscope
Endoscopic diverticulotomy
Dohlman’s instruments
Diverticulopexy Sac mobilized & its fundus fixed to sternocleido mastoid muscle in a superior, non-dependent position. CP myotomy is also done.
Cystic hygroma
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Synonym : cystic lymphangioma
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Definition: congenital, benign, multi-loculated, lymphatic lesion classically found in posterior triangle of neck
•
Other sites: axilla, mediastinum, groin & retro peritoneum
•
Etiology: failure of lymphatics to connect to venous system; abnormal budding of lymphatic tissue; sequestered lymphatic cell rests
Clinical Features
• 50-65% cases present at birth, 80-90% by 2 years • Soft, painless, compressible trans-illuminant mass present in posterior triangle of neck. Overlying skin can be bluish or normal . Sudden se in size due to infection or intra-cystic bleeding.
• Look for tracheal deviation, airway obstruction, cyanosis, feeding difficulty, failure to thrive
Stage Stage I Stage II Stage IV
U/L suprahyoid
Stage III
U/L infrahyoid + suprahyoid B/L suprahyoid
Stage V Clinical Features
U/L infrahyoid B/L infrahyoid + suprahyoid
Complication rate 20% 40% 70% 80% 100%
Cystic hygroma
Investigations
•
USG: used to detect CH in utero
•
CT scan: Contrast helps to enhance cyst wall visualization & relationship to surrounding blood vessels. CH appears isodense to CSF.
–
Macrocystic: cystic spaces > 2 cm
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Microcystic: cystic spaces < 2 cm
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MRI: Best investigation. CH appears hyperintense on T2 & hypointense on T1-weighted images.
MRI: CH causing airway compression
Treatment
•
Asymptomatic:
1. watchful waiting 2. sclerosing agents: OK-432 (Picibanil), bleomycin, ethanol, doxycycline, Interferon, fibrin sealant •
Infected cases:
intravenous antibiotics & drainage; definitive surgery after 3 months •
Surgical excision:
mainstay of treatment. Done with Cautery, Laser, Radiofrequency •
Acute stridor:
aspiration, emergency tracheostomy
Kawasaki syndrome
•
Etiology:
idiopathic multisystem vasculitis •
Diagnosis (presence of any 5):
1. Fever > 5 days. 2. Conjunctival injection. 3. Red / desquamated palm / sole. 4. Injected oral cavity 5. Polymorphous rash. 6. Cervical lymph node enlargement • Permanent cardiac damage in 20% untreated cases •
Rx:
high dose aspirin & immunoglobulin
Thank You 135