Laryngocele and Pneumatocele

Laryngocele

• Air-containing diverticulum resulting from laryngeal mucosa herniation.
• Affects trumpet players and those with chronic straining from cough.
• Presents as lateral neck swelling in the carotid triangle.
• Smooth surface.
• Moves upwards during swallowing, exhibiting an expansile impulse on cough.
• More prominent when blowing, coughing, or performing the Valsalva maneuver.
• Soft and cystic in consistency.
• Resonant upon percussion.
• Translucent.
• Compressible.
• Complications: infection leading to abscess, pus repeatedly discharged into the pharynx causing hoarseness, cough, or obstruction to the larynx if large.
• Diagnosed using X-ray of the neck, laryngoscopy, and CT scan.
• Treatment includes excision through a neck incision, ligation of the sac neck, and repair of the thyrohyoid membrane.

Pneumatocele

• Herniation of the lung apex through the supra-pleural membrane (Sibson's fascia).
• Presents as supraclavicular swelling.
• Soft in consistency.
• Increases in size with straining.
• Breathing sounds are resonant.
• Compressible.
• Treatment involves repair of the supra-pleural membrane after reduction.

Sternomastoid Tumour

• Results from birth injury to the sternomastoid muscle.
• Misnomer because it is not a true tumor.
• Caused by rupture of the sternomastoid branch of the external carotid artery (ECA) during forced head rotation at birth, leading to hematoma, fibrosis, and muscle shortening.
• Seen in infants aged 3–4 weeks.
• Presents as swelling of about 2 cm size in the middle part of sternocleidomastoid(SCM) muscle.
• Smooth surface and hard consistency.
• Non-tender and adherent to the muscle.
• Torticollis occurs, causing the head to tilt towards the affected side, and the face rotates towards the opposite side
• Can cause hemifacial atrophy in older age groups due to decreased blood supply from compression of the ECA.
• Compensatory cervical scoliosis and squint may develop.
• Treatment options include division or excision of the lower end of the sternomastoid muscle through a horizontal incision, avoiding injury to adjacent structures.
• Physiotherapy exercises and a torticollis harness for 6–12 months.
• Exercise and active stimulation of muscles in early cases are also treatment options.

Neck Infection

• Can be superficial or deep

Ludwig's Angina

• Diffuse brawny inflammatory edema of the submandibular region and floor of the mouth.
• Caused by streptococcal infection.
• Spreads rapidly, causing dangerous complications.
• Common in severely ill patients with advanced malignancy.
• Precipitating factors: caries teeth, oral malignancy, chemotherapy, cachexia, submandibular salivary infection/calculi, and chronic diseases like diabetes mellitus.
• Symptoms: fever, brawny edema/diffuse swelling of submandibular and submental region, intraoral edema in the floor of the mouth, trismus, halitosis, severe toxicity, dyspnea, and dysphagia.
• Complications: Laryngeal edema and respiratory distress requiring tracheostomy, septicemia, and extension of infection into the parapharyngeal space with internal jugular vein thrombosis.
• Treatment: Antibiotics (IV fluids) and decompression of the submandibular region, by deep incision into the deep fascia and cutting both mylohyoid muscles.
• Left open for delayed suturing or loosely sutured.

Dermoid Cyst

• Cysts lined by stratified squamous epithelium.
• Four types exist.
  • Sequestration.
  • Implantation.
  • Teratomatous.
  • Tubulo alveolar.
• Originates from remnants of fetal ducts, with thyroglossal and branchial cysts as types.

Sequestration Dermoid Cyst

• Inclusion of surface epithelium in subcutaneous tissues along the fusion line of the body during embryonic life.
• Face is the commonest site, with external angular dermoid
• Skull at suture line
• Neck
• Trunk
• Never In limbs
• Structure
  • Fibrous Wall
  • Lining composed of stratified squamous epithelium.
  • Cheesy keratinous material
• Hemispherical.
• Cystic consistency.
• Smooth surface, well-defined edge.
• Painless, non-tender and not fixed unless infected.
• Does not transilluminate.
• Dating since birth or may appear after several years if the cyst distends.

Special Characteristics

• Located in face is often on a bony depression
• Caused by constant pressure
• Gives impulse on cough if there is intracranial connection.
• Located in neck does not move during deglutition, but becomes more prominent with swallowing.
• Complications: Infection, abscess formation, recurrence, and intracranial connection through a bone defect
• Diagnosis: X-ray skull to exclude bone defect or intracranial connection.
• Treatment: Excision.

Implantation dermoid cyst

• Forcible introduction of part of skin into SC tissues
• Commonly in fingers, palms and soles.
  • Fibrous Wall.
  • Lining of Stratified Squamous Epithelium.
  • Cheesy Keratinous Material.
• Presents in manual workers.
• Small in size and has a slowly growing course.
• Tense with cystic swelling.
• Initially painless, later painful and tender due to compression of nerve endings in pulp of finger.
• Treatment is through excision.

Teratomatous Dermoid Cyst

• Benign tumor (benign teratoma).
• Sites:
  • Ovaries
  • Testes
  • Retroperitoneum
  • Sacrococcygeal region
  • Superior mediastinum
• Structure:
  • Fibrous wall.
  • Stratified squamous epithelium lining.
  • Variety of contents like hair, enamel of teeth, cartilage, bone, muscle, and glands.
• Treatment: Excision.

Neck Lymph Node Enlargement

• Differential diagnosis includes tuberculous lymphadenitis, secondaries in lymph nodes, HIV infection, lymphomas, chronic lymphatic leukemia, nonspecific lymphadenitis, infectious mononucleosis, and sarcoidosis.

Tuberculous Lymphadenitis

• Caused by Mycobacterium tuberculosis infection.
• Often originates from tonsils or occasionally from lungs.
• Commonly affects neck nodes, in most cases Jugulodigastric and posterior triangle nodes.
• Can occur in Axilla, Mediastinum, Groin etc
• Maybe associated with lymphoma or HIV.
• Two types:
  • Caseating:
    • More common.
    • Shows periadenitis with matting, forms cold abscess, collar stud abscess and sinus.
    • Often resistant to drug therapy due to poor body resistance.
  • Hyperplastic:
    • Less common
    • Discrete, firm nodes.
    • Responds well to drugs.
    • Fewer complications.

Characteristics and Treatment of Tuberculous Lymphadenitis

• Firm consistency, matted & nontender
• Mobile/fixed
• Can be in neck
• Treatment
  • Anti-tuberculous drugs.
  • Zigzag aspiration is performed using a wide bore needle on the nondependent area to prevent sinus formation.
  • Drainage is achieved via a nondependent incision.

Cold Abscess

• Deep to deep fascia.
• No inflammation.
• With a Smooth surface and soft consistency.
• Fluctuant test, it does not transilluminate.
• Not adherent to skin
• Contains cheesy caseating material.
• Seen in caseating tuberculous lymphadenitis.
• Acid Fast Bacilli (AFB) confirmed via FNAC

Secondaries in Neck Lymph Nodes

• Caused by thyroid
• Can become soft and cystic
• Can infiltrate structures.
  • Carotid arteries
  • Branches of the external carotid artery (severe hemorrhage)
  • Sternomastoid
  • Posterior vertebral muscles.
  • Spinal accessory nerve.
  • Hypoglossal nerve (tongue deviates towards the same side).
  • Cervical sympathetic chain
• C/P
  • Secondary location
  • Dysphagia
  • Dyspnea
  • Hoarseness of voice
  • Ear pain
  • Deafness
  • Spread to skin

Subhyoid Bursitis

• Inflammatory distension of a synovial bursa
• Caused by constant friction
• Swelling on hyoid bone
• Sausage
• Midline, smooth
• Consists of cystic-fluctuant movement, turbid fluid, and possible infection.
• Treatment by excision

Pulsatile Neck Swellings

• Artery lumen
  • Carotid aneurysm
  • Subclavian
  • A-V fistula
• Artery Transmition
  • Carotid body tumor
  • Cervical lymph node
• Highly Vasular
  • Goitre
  • Sarcoma
  • Cercoid aneurysm

Painful Neck Swellings

Thyroid Causes

• Acute thyroiditis
• Subacute thyroiditis
• Painful hashimotos Thyroiditis
• Thyroid nodule
• Thyroid carcinoma
• Thyroiditis

Non Thyroid Causes

• Infected Thyroglossal Cyst
• Infected branchial cyst
• Infected cystic hygroma
• Cervical adenitis
• Globus hustericus

Chronic Neck Swellings

Cystic

• Cold Abscess
• Cystic Lesions Of Thyroid
• Branchial Cyst
• Cystic Hygroma
• Dermoid Cyst

Solid

• Secondaries In Neck Ln
• Thyroid Swelling
• Branchoiogenic Carcinoma
• Sternomastoid Tumor
• Cervical Rib
• Soft tissue tumor

Congenital Abnormalities

• Branchial cyst
• Congenital branchial fistula
• Cervical rib
• Thyroglossal cyst
• Cystic hygroma
• Sequestrated dermoid cyst