Neck masses- Dr Bayani Tecson- 2/5/20

General consideration

Etiologic origin

 Congenital= thyroglossal duct cyst/ fistula: Branchial anomalies

 Acquired=infection (LN)

Clinical diagnostic consideration

 Location= neck triangles

o Anterior triangle
 Thyroglossal duct remnants; thyroid masses; thymic cyst, dermoid cysts; salivary
gland tumors, branchial cleft remnants
o Posterior triangle
 Cystic hygroma; lymphatic-venous malformations
 Torticollis; lipoblastoma
o Both triangles
 Lymphadenopathy

General Consideration

 Duration
 Since birth
 Acute/ insidious

Associated symptooms

 Signs of inflammation
 Fever
 Weight loos
 Other masses in the body

Lymphadenopathy

Etiologic consideration

 Mostly inflammatory
 Rarely neoplastic

Clinical diagnostic consideration

 Duration
o Acute: oropharyngeal, ear, dental infection
o Chronic: painless, insidious
 TB, atypical mycobacteria
 Neoplasms= lymphomas
  Associated sym: syns of inflammation

LAD

 Do imaging studies: CXR

o Lung patho anf mediastinal lesions
 Treatment
o Inflammatory lesions= treat source
 Antibiotics- staph and step
 Incision and drainage
o Neoplastic/ chronic lesion( TB/ atypical mycobacteria
 Do biopsy( CGD with caseation necrosis)

Thyroglossal Duct Cyst

 Embryology
o 3 weeks AOG
 Thyroid gland- originates as a forgut diverticulum at the base of the toung,
foramen cecum
o Thryroid descernt- intimate realtion with the body of the hyoid bone
 Presentation
o Anterior neck mass
 2-4 years old- baby fat disappears
 Located below the hyoid bone( goes down to the sternal knotch just on the area
og the hyoid)
 Moves with swallowing of the tounge
 Mostly asymptomatic except when infected= connected with the oropharynx,
columnar epi lining secreting mucus.
 Lead to abscess formation
 Rupture of I & D procedure: “ acquired fistula formation” ( if ruptured
and not treated)
o Differential Diagnosis
 LAD
 Hemangioma/ vascular
 Ectopoc thyroid
 Dermoid cyst
o Imaging
 UTZ
 Solid (LAD), cystic
 Presence or absence of thyroid tissue
 Characteristics
o Vascularity, size, calcification, borders
 Nuclear scan
 Docu thyroid tissue( take up idodine)
o Treatment
 Cyst/ fistula
 Systrunk’s operation
o Removal of the body of the hyoid bone9 if not removes the
hyoid, high recurrence and a core of muscles at the foramen
cecum
o A finger inside the patients mouth pushing the base of the
tougue aids in the dissectuin
 Infected cyst/ abscess
o Antibiotics/ I&D
o Prognosis
 Excelent

Brancial anomalyes

o Cyst of sinuses= congenital related to the embryonic process of fusion, closure and
development of neck structures
o Brancial arches and clests= formed in the 7th week AOG
o 6 branchial arches
 Covered by ectorderm external
 Lined with endoderm internallu
 Filled with esoderm(VAN and muscles
o Clefts

Brancial anomalies

o Branchial cyst
o Vestigial remnat of 2nd branchial lcleft
 Most common
 Lined with Squamous epo
 Contains fluis and keratin material
 Anterior to the upper third of the SCM
o Branchial fistula
o Congenital
o Secondary
 Infection and rupture
 I and D of infected cyst
o Anterior to the lower 3rd of the SCM
o Pathologic features
o External opening= anterior border of the lower thir of the SCM
o Internal opening= posterior pharynx just belowe the tonsillar fossa
 Blind internal opening- “branchial sinus”( when the internal opening close
rd th
o 3 and 4 branchial anomalies are rare
o When present= internal opening is at the level of pyriform fossa
o Lining epithelium is ciliated columnar epithelium
o Clinical presentation
 o Mostuy asymptomatic
o Cyst infection
o Golfenhar’s complex
o Branchial anomaly
o Biliary atresia
o Congenital heart disease
o Treatment
o Excision
 Step ladder incision
 Probe through the fistula
 Infusion with methylene blue/ gentian violet
 Passes though the carotid artery bifurcation
 Superficial tp the hypoglossal and glossopharyngeal nerves
 Deep to the posterior belly of digastric muscles

LYMPHANGIOMAS/ LYMPHATIC MALFORMATIONS

o Embryology
o 6W AOG
 SEQUEATRATION OF THE PRIMITIVE LYMH SACS
o Pathology
o Multiple macro-/micro cyst
o Clear lymphatic fluid
o Infiltrating and distorts tissue plans and muscles
o Lined with endothelium
o Associated with aneuploidy and othe malformation
o May contatin nest of vascular tissue Lymphatico venous malform
o Deep cavernous lymphangioma- cystic hygroma
o Clinical presentation
o Prenatal ultrasound
 Cystic mass in the neck
 Cause of hidden mortality
 Highly associated with congenital anomalues
 aBN karyotypes
 hydrops fetalis
 polyhydramnios
o at birth= large swelling may obstruct labor
o Post natal= cystic hydroma
 Mostly asymptomatic
 Neck most common site, at the lower 3 rd of posterior triangle
 Other= axillary groin
 Clinical presentation
 May have intra thoracic extention=10%
o Airway compromise
 o Swallowing difficulty
o Vascular compromise
 Compression symptoms= respiratory distress, dysphaguo
o Infection
o Hemorrhage
 Diagnostics:
 UTZ with doppler
o Cystic nature9macro/micro
o Low flow or high flow( arterial
 Ct/ MRI
o Better anatomical detail- relationship with asjacent vital
structures
o Guide to operative structure
 Treatment
 Observation- small asymptomatic lesiona
 Sclerotherapy
o Large symptomatic, microcyst lesions
o Agents used:
 Hypertonic saline
 Bleomycine( cause pulmon fibrosis)
 Na trtradecyl sulfate
 OK-432
 Doxytetracycline
 Benzyl peniciline
o Aspiration- infected lesion
o Surgical excision
 Residua lesion after sclerotherapy
 Small accessable lesion
 Surgical principles
 Complete excision- as much as possible
o Residual cysts
 Radical excision is never indicated- preserve vital structures
 Unroofing of cyst is acceptable to preserve vital structures
o Requires prolonged drainaged

Torticolis

o Pathology
o SCM fibrosis and contracture
 Unkown cause
 Birth traumas
o Clinical presentation
o Characteristics head posturing
 Tilting of the head to the affected side
  Head rotated to the opposite
 Pa;a[ble mass with the SCM of the affected sides
o If unconrrected
o Facial hypoplasia
o Scoliosis
o Ipsilateral trap atrophy
o Craniofacial deformities
o Other concerns
o Squinting
o Imaging
o Cervical spine xray- mandatory
 Rule out bony vertebral anomaly
o Diagnosis
o Purelu clinical
o Treatment
o Initially concervative neck physiotherapy
 PROM exercises up to 6 months
o Indications for surgery
 Failed concervative treatment
 Vomplications= facial asymentry/ hemifacial hhypo plasia
 Older or above 1 year olf
o Surgical techniques
 3-4 cm skin crease= 1 cm above the clavicle
 Divie the clavicald anf external heads of SCM
 Thickened investif cervical fascia

RESPIRATORY DISTRESS IN CHILDREN

Congenital diaphragmatic hernia

Pulmonary conditions

1. Bronchopulmonary forgut malformations

a. Bronchogenic cyst
b. CPAM
i. CCAM
ii. Broncopulmonary sequestration
iii. CLE
c. Bronchiectasis
d. Foreign body

CDH: Embryology

o Pleuroperitoneal canla
o One continuos pleural and peritoneal cavity
o Septum transversum
 o Last to close in the diaphragm

Pathology

o Failed closure of the pleuroperitoneal canal

o Herniation of the abdominal viscera into the pleural cavity
o Hypoplastic lung
 Essentiallu non functiona
o Contralateral mediastinal shift
 Varying degree of pulmonary hypoplasia
 Compromised gas exchange
o Persistent pulmonary hypertension(PPH)
 Due to the hypoplastic lung leading to decreased bronchial and
pulmonary artery branching
 Results in persistent fetal circulation
 Right to left shunting via PFO or PDA
 Mostly with relative surfactant deficiency
o Clinical presentation
o RDS at birth
o Abdominal cavity is small and scaphoid
o Can be seen in older children
 Recurrent cough
 Recurrent vomiting
 Sudden onset of respiratory distress
o Diagnostic exam
o Amniocentesis with karyotyping
 May show chromosomal defects
o 40% with associated anomalies
 Heart
 Brain
 GUT
 Craniofacial
 Limbs
o Prenatal imaging(US, MRIA)
 As early as 15 weeks
 Presence of herniaited abdominal ciscera
 Abnormal anatomy of upper abdomen
 Contralateral mediastinal shift
 Lung-head ratio= index of severity of left CDH
 LxW of right lung (level of atrium/ HC
 Lung head ration, 11.0= pooor prognosis
 LHR.1.4= good prognosis
 Postnatal CSR
 Multiple lucent structures in involved side
  Contralateral mediastinal shift
 In older children= CXR
o Multiple luscent structures
o Air fluid levels
o Contralateral mediastinal shit
o NGT into the chest
o Contrast study is rarely necessary
 Echocardiography
 Asses the degree of pulmonary hypertension
 Identify the presence of co existing cardiac anomaly
 ABG
 pH of blood=; PaO2; PaCO2:HCO3
 hypoxemia, hypercarbia; metabolic acidosis
 measure degree of shunting
o preductal an post ductal values compared\
o Classificaation
1. Bochdalek hernia
a. Posterior diaphragmatic defect
b. Left sided defect- most common
c. Right side- mostly liver herniation
i. Delayed hernation
2. Morgagni hernia
a. Anterio-medial diaphragmantic defect
b. Mostly transverse comlon herniation
c. Isolated effect are mostly asymptomatice
d. Associated with other anomalies
i. Pentalogy of cantrel
1. Omphalocele
2.
3.
4.
5.

Initial medical treatment

o Prompr CP stabilization
o A physiologic emergency
o Honeymoon period
o 24 to 48 hrs- characterized by a period of relative stability
o Hig PA O2
o Relatively goof perfusion
o Oftern followed by progressive CP deterioration
o Goal of treatment
o Preven pulmon hyper
 o Bara
o Strategies of medical treatment
o Mechanical ventilation woth low gentle setting
o Permissive hypercapnia
o PaCO2 level in 50- 60 mmhg or higher as long as pH remains 7.25 or higher
o HPOV- high frequency oscillatory ventilation
o Avoid injurious effects of conventional ventilation
o Inhaled nitric oxide/ sildenafil
o Bicarb infusion
o Minimizes degree of pulmonary hypertension
o Fluid restriction
o Fluid overload- compound the degree of cardiac failure
o Inotropes support using epinephrine
o Extracorporial membraine oxygenation
o Veno-venous bypass
 Single canuala via IJV
o Veno-arterial bypass is preferred by some centers
 Venous side- right atrium
 Arterial conduit- right common carotid arteri

Surgery

o Tiing is controvertial
o Hemodynamic status is optimized
o Most important factor
o Patientsts on ECMO
o Approach
o Open surgical repair
 Abdominal
 Thoracic
o MIS(thoracoscopy)
 Stable patient
o Definitive surgical treatment
o Left CDH
 Abdominal approach is best
o Right CDH
 Thoracic approach is best
o Technique
o