Download 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 1/3rd 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
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
Inferior
Skull base
Carotid
border of border of
III
bifurcation
sterno-
sterno-
or hyoid
hyoid
cleido-
Carotid
mastoid
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
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
Midline swellings
 Lymph node (submental, Delphian, suprasternal)
 Ludwig’s angina
 Sublingual dermoid
 Thyroglossal cyst
 Subhyoid bursitis
 Thyroid swelling (isthmus & pyramidal lobe)
 Laryngeal tumors
 Cold abscess
 Sternal tumor
 Thymus tumors
Submandibular triangle swellings
• Lymph node (level 1b)
• Cold abscess
• 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)
 Cold abscess
 Carotid body tumour
 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
• Infectious / Inflammatory
• Neoplastic: Benign / Malignant
Congenital neck swellings
a. Cystic
 Sebaceous cyst
 Dermoid cyst
 Branchial cyst
 Thyroglossal cyst
 Thymic cyst
b. Solid: Ectopic thyroid
c. Vascular
 Hemangioma
 Lymphangioma
Inflammatory neck swellings
• Lymphadenitis
– Viral
– Bacterial
– Granulomatous
• Sialadenitis
– Parotid
– Sub-mandibular
• Deep neck space abscess
Neoplastic neck swellings
• 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
• 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
Metastatic lymph node
• Seen in older patients
• Level 1: oral cavity
• Level 2, 3, 4: larynx, oropharynx, hypopharynx,
thyroid
• Level 5: nasopharynx
• 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
• 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
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
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
• 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.
• The duct normally disappears later. Thyroglossal
cysts are cystic remnant of thyroglossal duct.
• Commonest congenital anomaly of thyroid
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
• Midline, round swelling, 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
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
• In children, fistulas are more common than
sinuses, which are more common than cysts
• In adults, cysts predominate
• Branchial cleft anomalies + biliary atresia +
congenital cardiac anomalies = Goldenhar's
complex
First branchial cleft cyst
• 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 1/3rd of sternocleidomastoid muscle
• Fistula tract opens externally along lower 1/3rd of
SCM, passes deep to 2nd arch structures (external
carotid, stylohyoid muscle, posterior belly of
digastric); superficial to internal carotid (3rd 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 1/3rd of sternocleidomastoid muscle
• Fistula tract opens externally along lower 1/3rd of
SCM, passes deep to 3rd arch structures (internal
carotid, glossopharyngeal nerve); superficial to
superior laryngeal nerve (4th arch): opening internally
in base of pyriform fossa
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 ); superficial to recurrent laryngeal
nerve (6th arch); 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
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
• Male : female 5:1, Peak age = 6th decade,
Unilateral in 85 % cases, 1% contain carcinoma
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
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, 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 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, 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.
Surgical resection for small tumors in young
patients with hypotensive anesthesia & preoperative measurement of catecholamines.
Lyre sign
Sternomastoid tumor of infancy
• Firm mass of SCM, 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. Myoplasty of SCM for
refractory cases.
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
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
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
• 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
Staging
Lahey system:
• Stage I: Small mucosal protrusion
• Stage II: Definite sac present, but hypo-pharynx
& esophagus are in line
• 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 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
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
Clinical Features
Complication rate
Stage I
U/L infrahyoid
20%
Stage II
U/L suprahyoid
40%
Stage III
U/L infrahyoid + suprahyoid
70%
Stage IV
B/L suprahyoid
80%
Stage V
B/L infrahyoid + suprahyoid
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.
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