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 Skull base

Inferior Carotid bifurcation or hyoid

border of border of sternosternocleidomastoid

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

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)

Ludwigs 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

Carotid + muscular triangle swellings

Branchial cyst Branchiogenic cancer Laryngocoele (external) Thyroid lobe swelling

Lymph node (II, III, IV)

Carotid body tumour

Cold abscess
Carotid aneurysm

Sternomastoid tumor of newborn

Posterior triangle swellings

Cystic hygroma

Pharyngeal pouch (Zenkers 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 Branchial cyst Thymic cyst b. Solid: Ectopic thyroid c. Vascular Hemangioma Lymphangioma Dermoid cyst Thyroglossal cyst

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 Hodgkins 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)

5. Thyroid

3. Hypopharynx (pyriform fossa) 4. Larynx

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

Sistrunks 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

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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
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X-ray neck AP view

X-ray soft tissue neck AP view during Valsalva maneuver shows airfilled radiolucent swelling
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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 (Lyres 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 Zenkers 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

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

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

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