بِسْمِ اللهِ الرَّحْمنِ الرَّحِيم
Surgery of the neck(2).
SURGERY OF THE NECK ANATOMY
Extends from the base of skull to the clavicles STRUCTURES: SKIN, SUPERFICIAL FASCIA, VEINS, NODES DEEP CERVICAL FASCIA MAIN ARTERIES, VEINS, NERVES VISCERA OF THE NECK THE ROOT OF THE NECK Triangle Anatomy Anterior Subdivisions: carotid, Muscular Digastric (submandibular/ submental) Posterior Subdivisions: subclavian, OccipitalThyroid 30%
Non thyroid 70%Cervical Lymph nodes
Miscellaneous lumps e.g. Congenital, tumors,
Inflammatory e.g. reactive
Neoplastic
Infective e.g. viral, bacterial protozoal
primary
secondary
Neck lumps.. DDx
Age Duration Associated symptoms (pain, dysphagia, otalgia, hoarseness ,discharge sore tongue, blood in saliva, cachexia, fever, fetor dental caries ) Risk factors (6 S ,Viral) Prior trauma, irradiation or surgery
Exam pharyngeal surfaces, salivary gl.scars& Changes in skin – Lump site/contentExamine neck LN for any mass > 2 weeks
US.doppler= solid cystic vascularity &LN Computed tomography (CT)= Solid ? cystic /bone. MRI for soft tissue mass Radionucleotide scanning in nodular goiter Barium swallow PET scan /SPECT
TB test
Neck Lumps Work up
DDx OF Neck Lumps siteLateral Neck/Ant Δ Solid LAD Cervical rib Schwanomas Cystic Cystic hygroma Pharyngeal pouch Cold abscess Parotid mass SM tumors Subclavian aneurysm
Midline Solid Submental LAD thyroid nodule Cystic Thyroglossal. Dermoid Cysts in thyroid Plunging ranula Subhyoid bursa
Carotid triangle Solid Upper deep cervical LAD Thyroid nodule Carotid body tumour Cystic Branchial cyst Carotid aney. Laryngocele Thymic cyst
Submand .triangle Submandibular LN Submandibular salivary gland
Subcut. abscess Lipoma Epidermoid cyst Hemangioma Hydatid cyst
Lumps arising anywhere
Posterior Neck Δ
DDx OF Neck Lumps moving swallow & tongue protrusion, consistency & no.
BRANCHIAL cleft CYST
Congenital remnant of 2nd branchial cleft passing between int. & ext. carotids connected to pharynxLined by sq. epith. with lymphoid tissue & contains mucoid rich in cholesterol crystalsSmooth painless slowly growing (unless infected ) unilateral cystic mass in carotid Δ at age of 20Y.Partly beneath & protruding along ant. border of sternomastoid at junction of its upper & middle 1/3 & may transilluminate or fluctuate in size ComplicationsInfection (abscess)Acquired branchial fistulaBranchiogenic ca (very rare)Rx Surgical excisionDrainage if infected.Branchial sinus/fistula
Due to rupture, infection or incomplete excision of BC Fistulous courses over CN XII between int. and ext. carotids & felt as a thread passing up & deeply through sternomastoid while the crescentic shape external orifice is at lower 1/3rd of ant. border of sternomastoid with recurrent glairy mucinous or mucopurulent discharge The internal opening occasionally found in tonsillar fossa or near to lat. pharyngeal wall.Rx: Complete surgical excision through stepladder incision with removal of tract (Nerves at risk – CN IX, X, XI XII).CYSTIC HYGROMA (Cavernous lymphangioma)
Hamartomatous lymphatic malformations resulting in multi-cystic mass lined by a single layer of epith. 60% found in neck &rarely in cheek, lip, tongue, axilla, groin or mediastinumOften present at birth or early childhood as expanding mass. Large masses can be diagnosed prenatallyPainless large multilocular cystic masses , partially compressible, vary in size when the child coughs or cries, superficial to SM &extend to post. Δ Contains clear fluid and transilluminate brilliantly Complications1-Respiratory distress due to tracheal compression2- Recurrent Infection3-Obstructed labourRxSurgical excision- difficult with poor cosmetic resultInjection of sclerosing picibanil (OK-432) to sizedrainage when infectedTHYROGLOSSAL DUCT CYST
An unobliterated part of thyroglossal duct (TGD) arising form foramen caecum of tongue & descending down to neck S/S: Children 6-8 years Male = femaleThe commonest midline neck cyst anywhere in course of TGD at midline( 75%) most commonly at sub-hyoid area over thyroid cartilage on 1 side to leftPainless cystic rounded mass ( tender if infected) elevates on tongue protrusion or deglutition due to attachment to hyoid .Investigation= US (cyst)Complications:1-Infection/ abscess due lymphoid tissue in cyst wall 2- Acquired (never congenital) thyroglossal fistula (sinus) when the cyst ruptures onto skin or improperly drained TG abscess as crescentic fold below hyoid discharging mucus or pus 3-Malignant changes very rare. Rx= If infected, aspirate cyst rather than incise it.Surgical excision of cyst /fistula with center of hyoid bone and any suprahyoid tract into the tongue. (Sistrunk’s operation).
* Neurogenic tumours Carotid Body Tumor Chemodectoma=Paraganglioma =Potato tumor
Rare tumor at age of fifties Arise from carotid body located at bifurcation between ICA & ECA Familial in 10- 30% association with phaeochromocytomaBilateral or multiple slowly growing painless , rubbery (potato), pulsatile compressible mass emptied by pressure, then slowly refills,+ bruit. Mobile side to side but not up and downDiagnosis confirmed by angiography or MRA.The tumour must not be biopsied or FNACTreatmentElderly =Observation& surgery best avoided Young = Excision if small + proximal / distal control of CAif large, it may be adherent to vessels so control of CA to be prepared for a bypass vein graftComplications of surgeryVascular injury StrokeCN injury – CN IX,X,XIIOnly in elderly Is posteromedial pulsion diverticulum in Killian's dehiscence between thyropharyngeus &cricopharyngeus mm Dysphagia, halitosis, regurgitation , cough aspiration A neck lump may gurgles on palpation & is left sided Investigation=Ba. swallow & IL Rx =Depends on size and age
• Mass in middle 1/3 of SM• from muscle damage during labour• neck lump and torticollois (Wry neck)• Treatment = physiotherapy to correct torticollois• Surgery to the lump rarely required. Miscellaneous neck lumps