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Neck Triangles
Anterior Triangle
Boundaries: Anterior = midline of neck Posterior = S.C.M. anterior border Superior = lower border of mandible
Posterior Triangle
Boundaries: Posterior: Trapezius anterior border Anterior: S.C.M. 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, brachial plexus, spinal accessory nerve, level V lymph nodes
Submental Lymph nodes (Level Ia): Lateral: Anterior digastric belly (both sides)
III
hyoid
Carotid
bifurcation
Cricoid
or hyoid
IV Cricoid Clavicle
Level V: Posterior triangle nodes Posterior: Trapezius anterior border Anterior: S.C.M. 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
Lipoma
Neurofibroma, schwannoma
Hemangioma
Dermoid cyst
Teratoma
Hydatid cyst
Midline swellings
Lymph node (submental, Delphian, suprasternal)
Ludwigs angina
Thyroglossal cyst
Sublingual dermoid
Subhyoid bursitis
Laryngeal tumors
Sternal tumor
Cold abscess
Thymus tumors
Cold abscess
Submandibular salivary gland enlargement (deep lobe is bimanually ballotable)
Plunging ranula
Mandibular tumor
Cold abscess
Carotid aneurysm
Cold abscess
Cervical rib
Clavicular tumour
Subclavian artery aneurysm
Classification by etiology
Congenital / Developmental Infectious / Inflammatory Neoplastic: Benign / Malignant
Cervical Lymphadenopathy
3. Granulomatous lymphadenitis
Parasitological: toxoplasmosis
Non-specific: sarcoidosis B. Neoplastic: lymphoma, lymphosarcoma, metastatic C. Lymphatic leukemia D. Autoimmune: systemic lupus erythematosus
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
Tuberculous lymphadenopathy
Lymphoma
More common in children & young adults 60 - 80% children with Hodgkins have neck mass Signs & symptoms: Fever + malaise Night sweats Weight loss Pruritus Rubbery lymph nodes
2. occult primary
Definition: metastatic lymph node with primary site
hidden or undetected
Primary malignancy sites (as per frequency):
1. Nasopharynx
2. Rigid panendoscopy
3. Excision biopsy of I/L tonsil + blind biopsy of
Ranula
Introduction
Rana means frog (blue translucent swelling in
Simple Ranula
Plunging ranula
Plunging ranula
Etiology
Simple ranula: partial obstruction or severance of sublingual duct leads to epithelial-lined retention cyst. Commonly traumatic. Plunging ranula: 1. sublingual gland projects through or behind mylohyoid muscle
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
Thyroid appears as epithelial proliferation in floor
thyroglossal duct.
The duct normally disappears later. Thyroglossal
Location
Cyst may lie at any point along migratory pathway of thyroid gland Commonest site: sub-hyoid (50%) Second common site: supra-hyoid . Other common sites: base of tongue, at level of thyroid cartilage, sublingual Least common site: at level of cricoid cartilage
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
Commonly seen in early childhood
Ultra-sonography
Sistrunks operation
Consists of complete surgical excision of cyst &
Complications
1. Infection of cyst & abscess formation 2. Throglossal fistula 3. Malignancy (1%)
Infected cyst
Thyroglossal fistula
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
In children, fistulas are more common than
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
Laryngocoele
Arises from expansion of saccule of laryngeal ventricle due to ed intra-luminal pressure in larynx or congenital large saccule Causes of ed intra-luminal pressure in larynx: Occupational (?): trumpet players, glass blowers Coexistence of larynx cancer
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
Types of laryngocoele
Internal
External
Combined
89
Clinical Features
Hoarseness Stridor in large endolaryngeal laryngocoele Neck swelling Manual compression of neck swelling results in escape of fluid / gas into airway (Boyces sign) 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
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
Lyre sign
Hypopharyngeal pouch
Introduction
Hypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in
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 thyropharyngeus & 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
Complications
1. Lung aspiration of sac contents
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
Rigid Esophagoscopy
Staging
Lahey system:
Stage 1
Stage 2
Stage 3
Surgical Treatment
1. Cricopharyngeal myotomy: combined with others
Cautery (Dohlman)
Laser
Stapler
Treatment Protocol
1. Small sac (< 2cm):
Cricopharyngeal myotomy
Diverticulum invagination
Diverticulum pushed into hypopharynx lumen & muscle + adjacent tissue are oversewn.
External diverticulectomy
Endoscopic diverticulotomy
Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum
Cautery, laser, or stapling device used to divide common party wall between pouch & esophagus
Endoscopic diverticulotomy
Dohlmans instruments
Diverticulopexy
Sac mobilized & its fundus fixed to sternocleidomastoid muscle in a superior, non-dependent position. CP myotomy is also done.
Cystic hygroma
Synonym: cystic lymphangioma Definition: congenital, benign, multi-loculated, lymphatic lesion classically found in posterior triangle of neck Other sites: axilla, mediastinum, groin & retroperitoneum 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
Stage
Clinical Features
Complication rate
Stage I
U/L infrahyoid
20%
Stage II
U/L suprahyoid
40%
Stage III
70%
Stage IV
B/L suprahyoid
80%
Stage V
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 Microcystic: cystic spaces < 2 cm MRI: Best investigation. CH appears hyperintense on T2 & hypointense on T1-weighted images.
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
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
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