Neck Swellings - MU

Okay, here are the updated study notes with the new information incorporated:

• Study notes on neck swellings

Anatomical Background

• The neck is a complex anatomical area with many compartments, triangles, tubes (trachea, esophagus), vessels, and lymph nodes
• Thorough anatomical knowledge of the area is essential for safe clinical and surgical practice

Triangles of the Neck

• The sternomastoid muscle divides each side of the neck into anterior and posterior triangles
• The digastric muscle and superior belly of the omohyoid muscle divide the anterior triangle into 3½ triangles, including the sub-mental, digastric, carotid, and muscular triangles

DD of Neck Swellings

• General swellings can originate from the skin (sebaceous cyst), subcutaneous tissue (lipoma), vessels (hemangioma), nerves (neurofibroma), lymphatics (lymphangioma), or muscles (tumors). These swellings are found everywhere
• Midline neck swellings include submental abscess, Ludwig's angina, plunging ranula, thyroglossal cyst, subhyoid bursitis, nodule or cysts in the isthmus of the thyroid, sequestration dermoid cyst, enlarged lymph nodes (submental, prelaryngeal or pretracheal), and swelling in the suprasternal space
  • Cystic swellings in the suprasternal (Burns’) space include dermoid cysts (Aspiration DD it from a cold abscess), and aortic arch aneurysms (expansile pulsation)
  • Solid swellings in the suprasternal (Burns’) space include Lipoma or LNs
• Lateral neck swellings within the submandibular triangle include submandibular salivary gland enlargement, submandibular lymph node enlargement, plunging ranula, and jaw tumors extending down
• Lateral neck swellings within the posterior triangle include lymph nodes enlargement (most common), cystic hygroma, prominent cervical ribs, subclavian aneurysm, pharyngeal diverticulum, and pneumatocele, these are referred to as General Swellings
• Lateral neck swellings within the carotid and muscular triangle include lymph nodes enlargement (most common), thyroid lobe enlargement (next common), branchial cyst, branchiogenic carcinoma, aneurysm of the carotid vessels, carotid aneurysm, carotid body tumor, swellings of the SCM muscle, and laryngocele

Rule of 7 in the Neck

• Based on the average duration of patients’ symptoms:
  • Symptoms lasting 7 days suggests Inflammation
  • Symptoms lasting 7 months suggests Neoplasm
  • Symptoms lasting 7 years suggests Congenital defect

Rule of 80 in the Neck

• 80% of nonthyroid neck masses are neoplastic
• 80% of neoplastic neck masses are seen in males
• 80% of neoplastic neck masses are malignant
• 80% of malignant neck masses are metastatic
• 80% of metastatic neck masses have a primary site above the clavicle

Fistulae & Sinus of Neck

• Thyroglossal Fistula: Site is midline, opening is crescent-shaped, and the track can be traced
• Tuberculous Sinus: Multiple over T.B. adenitis, undermined edge, cyanotic margin, with thin serous discharge
• Sinus of Hyoid Bursitis: At the hyoid level, oval shape, with pus discharge
• Cervicofacial Actinomycosis: Multiple, with yellowish Sulphur granules (colonies) discharge
• Other types include branchial fistula, osteomyelitis of mandible, and Salivary fistula

Diagnostic Steps for Neck Swellings

• History and clinical examination, investigation, endoscopy & biopsy

Thyroglossal Cyst

• Midline tubulodermoid cyst, due to patency of thyroglossal duct
• A cyst can occur at any point in the course of the thyroglossal track, from foramen cecum to the isthmus of the thyroid gland, with the commonest site just below the hyoid bone in the midline
• Exception: At the level of the thyroid cartilage, the cyst is usually pushed to the left
• Lining: Stratified columnar, cubical or squamous epithelium
• Content: clear viscid or mucoid fluid
• Wall: Thin & may contain thyroid tissue and a narrow fibrous band
  • Extends from cyst wall to hyoid bone either in front, behind or traversing the bone
  • May then extend from hyoid bone upwards to the tongue

Thyroglossal Cyst Clinical Picture

• Single, midline of the neck, rounded or oval shape, smooth surface, well-defined edge, cystic consistency
• Moves up & down with deglutition and protrusion of tongue while the mouth is open
• Moves from side to side & not vertical
• Not tender unless complicated
• Track above it may be palpable

Thyroglossal Cyst - Special Tests, Investigations & Treatment

• Special Test: Thyroglossal tug, when the track is held between 2 fingers, and ask the patient protrudes his tongue while opening his mouth, will feel special tugging sensation
• Investigations: Use thyroid ultrasound or scan to ensure that thyroid gland is in its place
• Treatment: Sistrunk Operation
  • Incision: Horizontal elliptical incision, placed over the cyst, or enclosing fistulous opening
  • Cyst or fistula + the whole track + central part of the hyoid bone + part of the base of the tongue may be excised

Thyroglossal Fistula

• Always acquired
• Lined by columnar epithelium and discharges mucous
• A seat of recurrent inflammation
• Internal opening is connected to the wall of cyst OR remnant near the midline
• Crescentric & convexity directed upwards due to pull of fibrous track, which extends upward to the hyoid bone
• Discharges viscid fluid or pus
• History includes a history of abscess, which was drained spontaneously or surgically
• Followed by small opening, which discharge viscid fluid or pus
• Movements: Characteristically, the external opening moves up with deglutition, and with protrusion of the tongue
• The hood sign is characteristic, having an opening of fistula that is indrawn and has been overlaid by a fold of skin as a hood
• Fibrous track connecting external opening to hyoid bone may be palpable
• Treatment: Sistrunk Operation

Cystic Hygroma

• A cystic swelling due to sequestration of a portion of a jugular lymph sac during the developmental period in utero
  • Occurs in the posterior triangle of the neck (75% - most common), axilla (20%), cheek, tongue, groin, or mediastinum
• Often extension may occur across two or more lymphatic regions, such as involvement of both the neck & axilla
• Multilocular, containing an aggregation of cysts resembling soap bubbles
• Larger cysts are near the surface, while smaller cysts are in deeper planes
• Cysts, even though subcutaneous, commonly extend into deeper planes across many anatomical planes
• Does not communicate with normal lymphatics as lymph gets absorbed and filled with a clear watery mucous derived from endothelial lining, and its fluid does not coagulate

Cystic Hygroma Clinical Features

• Present at birth (so may lead to obstructed labor)
• Occasionally present in early infancy
• Smooth
• Soft & cystic (fluctuant)
• Increases in size during crying
• Brilliantly transilluminant
• Partially compressible
• Not reducible
• Complications include disfigurement of the face, swelling may rapidly increase in size, respiratory obstruction, infection, septicemia, rupture with lymph ooze, and recurrence of cyst (15%)
• Later perform excision of entire aggregation of cysts, while a chest X-ray is used to exclude any mediastinal cystic hygroma

Branchial Cyst

• Branchial Cyst Introduction: 6 branchial arches with 5 pharyngeal pouches (endoderm lining) inside and 5 pharyngeal clefts (ectoderm lining) outside are present
• Normally 2nd, 3rd, 4th clefts disappear to form a smooth neck
• Arises from the remnants of the 2nd branchial cleft
• Persistent 2nd branchial cleft eventually gets sequestered to form a branchial cyst
• Less commonly, cysts can develop from the 1st, 3rd, or 4th clefts, and their location and location of associated fistulas differs accordingly
• Epithelial infusion within a lymph node may be another cause, as branchial cysts contain lymphoid tissues in their wall

Branchial Cyst Clinical Features

• Swelling in the neck beneath the anterior border of the upper ⅓ of the sternocleidomastoid muscle
• Congenital but can be seen in late adolescents & the early 3rd decade
• Equal in frequency in both sexes, and in 3% of the cases, it is bilateral, and it can be familial
• Usually painless unless infected and may form abscesses
• Smooth, soft/tensely cystic and fluctuant
• Often transilluminant, but not compressible or reducible
• Contains cholesterol crystals from the lining of mucous membrane which contains sebaceous gland
• Contains cheesy toothpaste-like material, and is histologically lined by squamous epithelium; may occasionally be a ciliated columnar epithelium, while the cyst wall shows plenty of lymphoid tissue

Branchial Cyst Complications and Investigations

• Recurrent infection
• Rupture may cause acquired branchial fistula at the upper ½ of the SCM muscle
• Brachiogenic carcinoma (Very rare)
• CT scan used to differentiate Chemodectoma, if the cyst feels solid
• Aspiration also used to differentiate if there is a cold abscess with high cholesterol content
• Treatment: Excision under general anesthesia (G/A); and to prevent injuries to major structures during dissection, all structures should be cared for

Branchial Fistula

• Results from a failure of fusion between the 2nd & 5th branchial arches—the cervical sinus remains communicating with the exterior
• Lies on the lower 1/3 of the SCM near its anterior border or on upper part of anterior border of sternomastoid
• Opens high in lateral wall of pharynx behind tonsil (Supratonsillar fossa of Rosenmuller)
• Usually blindly (sinus) or rarely opening into it (fistula) and passes a bifurcation of the carotid
• Characterized by a ciliated columnar epithelium lining surrounded by lymphoid tissue, which explains its frequent inflammation
• Discharge: Is either Mucus or pus (if infected)
• Treatment involves a complete surgical excision of fistula using a 2-3 transverse incision (Step-Ladder incision)

Pharyngeal (Zenker's) Diverticulum

• Results from failure of relaxation of the cricopharyngeal muscle (spasm or achalasia) that increases intraluminal pressure, causing a herniation of pharyngeal mucosa—forming an acquired pulsion diverticulum
• Develops as midline mucosal herniation on the posterior aspect of the pharyngo-esophageal junction through Killian dehiscence
• As posterior extension is limited by the spine, the diverticulum enlarges either to the side (usually left) or behind the esophagus
• Consists mainly of Mucosa & Submucosa
• Complications include bleeding, aspiration, perforation, and predisposal to carcinoma
• Signs include regurgitated non-acidic material a globular, and gurgling sound elicited on palpation is performed the level of the cricoid with air swallow
• Investigations incluce a barium swallow or pharyngeal manometry
• Treatment includes the incision along the anterior margin from hyoid bone anterior

Carotid Body Tumor

• A nodule in the adventitia of the common carotid artery; it is 3-5 mm, flat & brownish
• Consists of Type I or II cells and Supportive cells from the glossopharyngeal nerve, sensitive to Changes in pH & hypoxia, that Helps in autoregulation of respiration
• Well-capsulated, Yellowish, Firm to hard with dense fibrous tissue, and Lobulated
• Vertically placed on the carotid triangle and Located at the level of the hyoid bone deep to the anterior edge of the SCM
• Mostly, Located unilateral
• Painless
• Its' Behavior includes not Screating hormones
• Its' Blood supply is coming from external carotid artery
• Can involve external carotid artery at bifurcation
• Treatment involves resecting a tumor and with a temporary graph if needed

Laryngocele

• A narrow-necked, air-containing diverticulum from herniation of laryngeal mucosa
• Extends beyond the thyroid cartilage & protrudes through the thyrohyoid membrane, producing a lateral neck mass, particularly in trumpet players & chronic strainers
• It's a lateral neck swelling, that comes from inner side

Pneumatocele

• Herniation of the apex of the lung through the supraclavicular Clinical: increaseIn size on streaning, decreasing and dissapearing on releasing the straining
• Auscultation: absent of sounds
• Treatment: sibons repair

Sternomastoid Tumour:

• It is due to birth injury to the sternomastoid muscle
• It is not a true congenital abnormality, it is believed to be due to the rupture of sternomastoid branch of ECA during forced rotation of the head at birth
• In infants of 3–4 weeks of age, the swelling is about 2 cm size at the middle part of the SCM muscle
• Causes Head to be tilted towards the affected side, and the Face to be rotated towards the opposite side

Dermoid Cyst

• Cysts lined by stratified squamous epithelium and can be separated into:
  • Sequestration
  • Implantation
  • Teratoma Etiology and Site: Including External Dermo and Can't move with swolling Treatment: I&D is useful but in all the cases excision is required

Subhyoid Bursitis

• Inflammatory distension of a synovial bursa that's normally present between the hyoid bone & thyro-hyoid membrane
• Leads to Constant irritation when bursa gets bigger
• IN Midline of neck
• Sausage and moved by SCM 1- I&D 2- Excision from surgery

Differential Diagnosis for Neck Swelling

• DDx of pulsatile, painful, and/or chronic of neck swellings can be separated The term in what cyste are formed in the 1st and other

Tuberculous

• Tuberculous lymphadenitis (the most common is discussed, including with
  • Site
  • Associations
  • Types Tuberculoma -
• FNAC is useful