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Neck Swellings

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

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Neck Swellings

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  1. Neck Swellings Dr. Vishal Sharma

  2. Neck Triangles

  3. Anterior Triangle

  4. 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

  5. Posterior Triangle

  6. 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

  7. Neck Lymph Nodes

  8. Sloan Kettering Classification Level I: Submental + submandibular nodes Level II:Upper jugular nodes (upper 1/3 ofIJV) Level III: Middle jugular nodes (middle 1/3 ofIJV) Level IV:Lower jugular nodes (lower 1/3 ofIJV) Level V: Posterior triangle nodes Level VI:Anterior compartment nodes Level VII: Superior mediastinal nodes

  9. 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

  10. 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

  11. Classification of neck swelling according to position Ubiquitous neck swellings Midline neck swellings Anterior triangle neck swellings Posterior triangle neck swellings

  12. Ubiquitous neck swellings • Sebaceous cyst • Lipoma • Neurofibroma, schwannoma • Hemangioma • Dermoid cyst • Teratoma • Hydatid cyst

  13. 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

  14. Submandibular triangle swellings • Lymph node (level 1b) • Cold abscess • Submandibular salivary gland enlargement (deep lobe is bimanually ballotable) • Plunging ranula • Mandibular tumor

  15. 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

  16. Posterior triangle swellings  Cystic hygroma  Pharyngeal pouch (Zenker’s diverticulum)  Lymph node (level V)  Cold abscess  Cervical rib  Clavicular tumour  Subclavian artery aneurysm

  17. Classification by etiology • Congenital / Developmental • Infectious / Inflammatory • Neoplastic: Benign / Malignant

  18. Congenital neck swellings a. Cystic  Sebaceous cyst  Dermoid cyst  Branchial cyst  Thyroglossal cyst  Thymic cyst b. Solid: Ectopic thyroid c. Vascular  Hemangioma  Lymphangioma

  19. Inflammatory neck swellings • Lymphadenitis • Viral • Bacterial • Granulomatous • Sialadenitis • Parotid • Sub-mandibular • Deep neck space abscess

  20. 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

  21. Hemangioma & lipoma

  22. Cervical Lymphadenopathy

  23. 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

  24. 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

  25. 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

  26. Tuberculous lymphadenopathy

  27. 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

  28. 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

  29. 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

  30. 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

  31. Ranula

  32. 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

  33. Simple Ranula

  34. Plunging ranula

  35. Plunging ranula

  36. 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

  37. 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

  38. Marsupialization

  39. Intra-oral excision

  40. Ranula specimen

  41. Thyroglossal cyst

  42. 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

  43. 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 .

  44. 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

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