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Dr. Vishal Sharma
Anterior Triangle .
III. recurrent laryngeal nerves. IV & VI lymph nodes . vagus. carotid. 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 gland.Boundaries: Anterior = midline of neck Posterior = S. muscular Contents: carotid arteries. Levels I. internal jugular vein. submandibular.M. II.C.
Posterior Triangle .
C. spinal accessory nerve.M. brachial plexus.Boundaries: Posterior: Trapezius anterior border Anterior: S. level V lymph nodes . posterior border Inferior: Middle 1/3rd 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.
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 II Lateral Posterior Superior Skull base Inferior Carotid bifurcation or hyoid border of border of sternosternocleidomastoid III hyoid Carotid bifurcation Cricoid or hyoid IV Cricoid Clavicle .
C.M.Level V: Posterior triangle nodes Posterior: Trapezius anterior border Anterior: S. posterior border Inferior: Middle 1/3rd 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 • Ubiquitous neck swellings • Midline neck swellings • Anterior triangle neck swellings • Posterior triangle neck swellings .
Ubiquitous neck swellings • Sebaceous cyst • Lipoma • Neurofibroma. schwannoma • Hemangioma • Dermoid cyst • Teratoma • Hydatid cyst .
Delphian.Midline swellings Lymph node (submental. suprasternal) Ludwig’s angina Thyroglossal cyst Sublingual dermoid Subhyoid bursitis Thyroid swelling (isthmus & pyramidal lobe) Laryngeal tumors Sternal tumor Cold abscess Thymus tumors .
Submandibular triangle swellings • Lymph node (level 1b) • Cold abscess • Submandibular salivary gland enlargement (deep lobe is bimanually ballotable) • Plunging ranula • Mandibular tumor .
IV) Carotid body tumour Cold abscess Carotid aneurysm Sternomastoid tumor of newborn . III.Carotid + muscular triangle swellings Branchial cyst Branchiogenic cancer Laryngocoele (external) Thyroid lobe swelling Lymph node (II.
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 • Infectious / Inflammatory • Neoplastic: Benign / Malignant .
Vascular Hemangioma Lymphangioma Dermoid cyst Thyroglossal cyst .Congenital neck swellings a. Solid: Ectopic thyroid c. Cystic Sebaceous cyst Branchial cyst Thymic cyst b.
Inflammatory neck swellings • Lymphadenitis – Viral – Bacterial – Granulomatous • Sialadenitis – Parotid – Sub-mandibular • Deep neck space abscess .
Fibroma. Metastasis • Thyroid: Benign / Malignancy • Vascular: Carotid body tumor. Malignant melanoma • Soft tissue: – Benign: Lipoma. Angioma .Neoplastic neck swellings • Skin: Squamous cell Ca. Schwannoma – Malignant: Rhabdomyosarcoma • Lymph node: Lymphoma.
Hemangioma & lipoma .
A. Inflammatory hyperplasia 1. Acute lymphadenitis 2. Chronic lymphadenitis
3. Granulomatous lymphadenitis
Bacterial: tuberculosis, secondary syphilis
Viral: infectious mononucleosis, AIDS
Non-specific: sarcoidosis B. Neoplastic: lymphoma, lymphosarcoma, metastatic C. Lymphatic leukemia D. Autoimmune: systemic lupus erythematosus
Lymph node consistency
• Firm, rubbery: lymphoma
• Soft : infection or cold abscess
• Multiple, firm, shotty: syphilis, viral • Matted (connected): tuberculosis , sarcoidosis, malignant • Rock hard, immobile, fixed to skin: metastatic
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: • Fever + malaise • Night sweats • Weight loss • Pruritus • Rubbery lymph nodes .
stomach. oropharynx. 4: larynx.Metastatic lymph node • Seen in older patients • Level 1: oral cavity • Level 2. thyroid • Level 5: nasopharynx • Left supraclavicular fossa: lung. 3. testis . hypopharynx.
Thyroid 3. Oropharynx (base of tongue) 5. metastasis of unknown origin 2. occult primary Definition: metastatic lymph node with primary site hidden or undetected Primary malignancy sites (as per frequency): 1. Larynx . Nasopharynx 2.Unknown Primary Lesion (UPL) Synonym: 1. Hypopharynx (pyriform fossa) 4.
retro molar trigone 4. Fibreoptic nasopharyngoscopy + laryngoscopy 2.Investigations for UPL 1. Rigid panendoscopy 3. Excision biopsy of I/L tonsil + blind biopsy of tongue base. CT scan from skull base to superior mediastinum 5. tonsilo-lingual sulcus. fossa of Rosenmuller. pyriform fossa. Excision biopsy of metastatic lymph node .
Introduction • Rana means frog (blue translucent swelling in floor of mouth looks like underbelly of frog) • Simple ranula: Bluish cyst located in floor of mouth. Painless mass. does not change in size in response to chewing. eating or swallowing • Plunging ranula: Sub-mandibular neck swelling with or without cyst in floor of mouth .
Simple Ranula .
Plunging ranula .
Plunging ranula .
Commonly traumatic. sublingual gland projects through or behind mylohyoid muscle 2. ectopic sublingual gland on cervical side of mylohyoid muscle .Etiology • Simple ranula: partial obstruction or severance of sublingual duct leads to epithelial-lined retention cyst. • Plunging ranula: 1.
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 .
Intra-oral excision .
Ranula specimen .
Thyroglossal cyst .
Thyroglossal cysts are cystic remnant of thyroglossal duct.Embryology • Thyroid appears as epithelial proliferation in floor of mouth. • Commonest congenital anomaly of thyroid . connected to tongue by thyroglossal duct. Thyroid descends in front of pharynx as bi-lobed diverticulum. • The duct normally disappears later.
sublingual • Least common site: at level of cricoid cartilage . at level of thyroid cartilage.Location • Cyst may lie at any point along migratory pathway of thyroid gland • Commonest site: sub-hyoid (50%) • Second common site: supra-hyoid . • Other common sites: base of tongue.
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 .
round swelling.Clinical features • Commonly seen in early childhood • Midline. 2-4 cm in diameter • Swelling moves up with swallowing • Swelling moves up with protrusion of tongue • Swelling mobile horizontally but not vertically • Cyst increases in size with URTI .
Neck swelling moving with swallowing • Thyroid swelling • Thyroglossal cyst (mobile horizontally) • Subhyoid bursitis (oval. long axis horizontal) • Pre-laryngeal & pre-tracheal lymph nodes • Laryngocele .
Midline neck swelling .
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 .
Infection of cyst & abscess formation 2. Malignancy (1%) Infected cyst . Throglossal fistula 3.Complications 1.
Thyroglossal fistula .
Branchial cleft cysts .
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 .
fistulas are more common than sinuses. cysts predominate • Branchial cleft anomalies + biliary atresia + congenital cardiac anomalies = Goldenhar's complex . which are more common than cysts • In adults.Branchial anomalies • In children.
• Fistula ends internally around Eustachian tube . Present as abscess below angle of mandible. Present as duplication of external auditory canal. • Type II: Contains both ectoderm & mesoderm.First branchial cleft cyst • Type I: Contains only ectodermal elements without cartilage or adnexal structures.
fluctuant mass along anterior border of middle 1/3rd of sternocleidomastoid muscle • Fistula tract opens externally along lower 1/3rd of SCM. ends internally in tonsillar fossa . posterior belly of digastric). passes deep to 2nd arch structures (external carotid.Second branchial cleft cyst • Commonest branchial anomaly • Painless. stylohyoid muscle. superficial to internal carotid (3rd arch).
Second branchial cleft cyst .
Second branchial cleft cyst .
glossopharyngeal nerve).Third branchial cleft cyst • Painless. passes deep to 3rd arch structures (internal carotid. superficial to superior laryngeal nerve (4th arch): opening internally in base of pyriform fossa . fluctuant mass along anterior border of lower 1/3rd of sternocleidomastoid muscle • Fistula tract opens externally along lower 1/3rd of SCM.
superficial to recurrent laryngeal nerve (6th arch).Fourth branchial cleft cyst • Presents as mass along anterior border of lower 1/3rd of stenomastoid or as recurrent thyroiditis • Fistula tract opens externally along lower 1/3rd of SCM. passes deep to 4th arch structures (superior laryngeal nerve ). opening internally in apex of pyriform fossa .
CT scan st 1 branchial cyst .
CT scan nd 2 branchial cyst .
CT scan rd 3 branchial cyst .
Coronal MRI Sagittal MRI Axial MRI .
Treatment • Abscesses treated first with incision & drainage + broad-spectrum antibiotics • Elective surgical excision of cyst with its tract traced up to its origin in pharyngeal wall done after infection resolves • Branchial fistula excised with 2 horizontally placed incisions (stepladder incision) .
Excision of branchial cyst .
Branchial fistula excision .
glass blowers • Coexistence of larynx cancer • Male : female 5:1. 1% contain carcinoma . Unilateral in 85 % cases. Peak age = 6th decade.• Arises from expansion of saccule of laryngeal ventricle due to ed intra-luminal pressure in larynx or congenital large saccule Causes of ed intra-luminal pressure in larynx: • Occupational (?): trumpet players.
Swelling enlarges on Valsalva .
Types of laryngocoele • Internal (20%): contained entirely within endolarynx with bulge in false vocal fold & aryepiglottic fold • External (30%): only neck swelling without visible endolaryngeal swelling • Combined (50%): Also extends into anterior triangle of neck through foramen for superior laryngeal nerve & vessels in thyrohyoid membrane. . Dumbbell shaped.
Types of laryngocoele Internal External Combined 89 .
cough .Clinical Features • Hoarseness • Stridor in large endolaryngeal laryngocoele • Neck swelling • Manual compression of neck swelling results in escape of fluid / gas into airway (Boyce’s sign) • 10% cases are pyocele: sore throat.
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 airfilled 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 • Pulsating. . Surgical resection for small tumors in young patients with hypotensive anesthesia & preoperative measurement of catecholamines. compressible mass in carotid triangle • Mobile only horizontally not vertically • Angiography: vascular mass b/w external & internal carotid arteries (Lyre’s sign) • Rx: Radiation or close observation in elderly.
Lyre sign .
Myoplasty of SCM for refractory cases. becomes prominent when chin turned away & head tilted towards the mass • Due to birth trauma causing infarction / hematoma with subsequent fibrotic replacement • Rx: Physical therapy.Sternomastoid tumor of infancy • Firm mass of SCM. .
Hypopharyngeal pouch .
Introduction • Hypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagus • In contrast. congenital diverticulum like Meckel's diverticulum is covered by all muscle layers of visceral wall .
Weak spots b/w muscles .
Origin of Zenker’s diverticulum .
Neuromuscular in-coordination between thyropharyngeus & cricopharyngeus 4. injury Gastro-esophageal reflux 2. Lack of inhibition of cricopharyngeal sphincter 3.N.S. Second swallow against closed cricopharynx These lead to increased intra-luminal pressure in hypopharynx & mucosa bulges out via weak areas .Etiology 1. Tonic spasm of cricopharyngeal sphincter: C.
Weight loss: due to malnutrition 5. Compressible neck swelling on left side: reduces with a gurgling sound (Boyce sign) . 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.Clinical features 1. Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve 4.
3% cases) . Bleeding from sac mucosa 3.Complications 1. Absolute oesophageal obstruction 4. Fistula formation into: trachea major blood vessel 5. Squamous cell carcinoma within Zenker diverticulum (0. Lung aspiration of sac contents 2.
Investigations • Chest X-ray: may show sac + air .fluid level • Barium swallow • Barium swallow with video-fluoroscopy • Rigid Oesophagoscopy • Flexible Endoscopic Evaluation of Swallowing .
Barium swallow .
Barium swallow with Video-fluoroscopy .
Rigid Esophagoscopy .
but hypo-pharynx & esophagus are in line • Stage III: Hypopharynx is in line with pouch & esophagus pushed anteriorly .Staging Lahey system: • Stage I: Small mucosal protrusion • Stage II: Definite sac present.
Stage 1 .
Stage 2 .
Stage 3 .
Surgical Treatment 1. Diverticulum invagination: Keyart 3. Diverticulopexy: Sippy-Bevan 4. Cricopharyngeal myotomy: combined with others 2. Flexible Endoscopic Diverticulotomy with Laser . External or open Diverticulectomy: Wheeler 5. Rigid Endoscopic Diverticulotomy Cautery (Dohlman) Laser Stapler 6.
Very large sac (> 6 cm): Open Diverticulectomy with CP myotomy or Diverticulopexy with CP myotomy .Treatment Protocol 1. Large sac (2-6 cm): Open Diverticulectomy with CP myotomy or Endoscopic Diverticulotomy with CP myotomy 3. Small sac (< 2cm): Cricopharyngeal (CP) myotomy + invagination 2.
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 .
laser.View through diverticuloscope Cautery. or stapling device used to divide common party wall between pouch & esophagus .
View through diverticuloscope .
Endoscopic diverticulotomy .
Dohlman’s instruments .
non-dependent position. . CP myotomy is also done.Diverticulopexy Sac mobilized & its fundus fixed to sternocleidomastoid muscle in a superior.
Cystic hygroma .
sequestered lymphatic cell rests . mediastinum. groin & retroperitoneum • Etiology: failure of lymphatics to connect to venous system. lymphatic lesion classically found in posterior triangle of neck • Other sites: axilla. benign. abnormal budding of lymphatic tissue.• Synonym: cystic lymphangioma • Definition: congenital. multi-loculated.
• 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
U/L infrahyoid + suprahyoid
B/L infrahyoid + suprahyoid
CH appears isodense to CSF. .Investigations • USG: used to detect CH in utero • CT scan: Contrast helps to enhance cyst wall visualization & relationship to surrounding blood vessels. – Macrocystic: cystic spaces > 2 cm – Microcystic: cystic spaces < 2 cm • MRI: Best investigation. CH appears hyperintense on T2 & hypointense on T1-weighted images.
MRI: CH causing airway compression .
doxycycline. fibrin sealant • Infected cases: intravenous antibiotics & drainage. Done with Cautery. emergency tracheostomy .Treatment • Asymptomatic: 1. Radiofrequency • Acute stridor: aspiration. watchful waiting 2. Laser. bleomycin. sclerosing agents: OK-432 (Picibanil). ethanol. definitive surgery after 3 months • Surgical excision: mainstay of treatment. Interferon.
Red / desquamated palm / sole.Kawasaki syndrome • Etiology: idiopathic multisystem vasculitis • Diagnosis (presence of any 5): 1. Fever > 5 days. 2. 4. 6. Injected oral cavity 5. 3. Conjunctival injection. Polymorphous rash. Cervical lymph node enlargement • Permanent cardiac damage in 20% untreated cases • Rx: high dose aspirin & immunoglobulin .
Thank You 135 .