Download MBBS Surgery Presentations 40 Neck Swellings Midline And Lateral Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 40 Neck Swellings Midline And Lateral PPT-Powerpoint Presentations and lecture notes

While shaving, a 45-year-old teacher notices

a marble-sized mass beneath his left ear. The

mass is eventually excised, revealing which

of the following benign parotid gland lesions?

(A) Glandular hypertrophy, secondary to

vitamin A deficiency

(B) Cystic dilation

(C) Mikulicz's disease

(D) Pleomorphic adenoma




A 43-year old man notes shortness of breath. He

is a non smoker. His wife points out that his face

has become slightly swollen. On examination, his

blood pressure is normal. His pupils are equal

and respond to light. Dilated veins are noted

around the shoulders, upper chest, and face. An

x-ray of the chest reveals an opacity in the

superior mediastinum. What is the most likely

diagnosis?

(A) Thymoma
(B) Neurogenic tumor
(C) Lymphoma
(D) Teratodermoid tumor

This 19 year old girl had

a two-week history of a

painless swelling in the

left jugulo digastric

region. FNAC

demonstrated benign

squamous cells, cellular

debris and cholesterol

crystals. CT scan

demonstrated a well

circumscribed cystic

mass, anterior to the

sternomastoid muscle.

This is a typical ?






This young woman

had a one-week

history of a rapidly

enlarging mass in

the upper right neck

with localised

tenderness. The CT

scan again

demonstrates a well

circumscribed

unilocular cyst, with

a smooth wall

This young man has a

prominent painless lymph

node in the jugulodigastric

region. Fine needle

aspiration biopsy indicated

a diagnosis of Hodgkin's

Disease. The 40 year old

man (inset) has a lump in

an identical position, also

painless and present for

months. Fine needle

aspiration biopsy

confirmed the diagnosis of

metastatic squamous cell

carcinoma from a tonsil

cancer. He was a non

smoker.




The man is 60, a heavy

smoker and presents with

a hoarse voice and large

mass in the right upper

neck. Fine needle

aspiration biopsy showed

necrotic debris and the CT

scan demonstrates a

unilocular cystic mass.

The cyst wall is irregular

and this is metastatic

squamous carcinoma,

which has undergone

cystic degeneration. The

primary cancer was in the

hypopharynx

This man has

nasopharyngeal

carcinoma with

multiple metastatic

lymph nodes in the

posterior triangle,

bounded by the

clavicle below,

sternomastoid

muscle anteriorly

and the trapezius

posteriorly..






The young man had

a firm, but not hard

submandibular

swelling which had

been present for 5

years. The CT scan

on the right

demonstrates a

midline dermoid

cyst. This is a well

localised benign

congenital lesion.

This young woman, aged

25, has a well localised

swelling just below the

hyoid bone, which

elevates on protrusion

of the tongue. The CT

scan on the right is from

another patient but

demonstrates identical

pathology of a well

circumscribed cystic

structure lying anterior

to the thyroid cartilage

- thyroglossal cyst.






This young woman

has a prominent

right thyroid

nodule. The

appropriate

investigations are

FNAB and serum

TSH.

This boy, aged 14,

presented with a cystic

mass in the left

submandibular region.

Needle biopsy

demonstrated the

presence of mucoid

material and the CT scan

shows a cystic mass lying

anterior to the left

submandibular salivary

gland. This is a typical

plunging ranula and is due

to extravasation of mucoid

saliva from the sublingual

gland






This elderly man has

a large left

submandibular mass.

An SCC of the cheek

was removed a year

earlier. FNAB

showed metastatic

SCC and the CT scan

demonstrates a

large cystic mass

with a septum,

consistent with

metastatic cancer.

This 45 year old

Asian woman,

recently migrated to

Australia, presented

with a supurating

mass in the right

submandibular

region. A diagnosis

of tuberculosis was

made following

culture of tissue

from the mass






The man is aged

58 has a two-year

history of a

painless slowly

growing mass at

the angle of the

jaw. Needle biopsy

suggested a

diagnosis of

Warthins tumour.










The boundaries of the anterior triangle are:

--------------------------the midline of the neck.

------------------------the body of the mandible.

------------------------the anterior border of the

sternocleidomastoid muscle.

Submental Submandib

Carotid

Muscular

triangle

ular

triangle

triangle

triangle

Boundaries

Superiorly: the

The bellies of the

Superiorly: the

The superior belly

chin

diagastric muscles posterior belly of

of the omohyoid

Laterally: the two

and the mandible

the diagastric

muscle and the

anterior bellies of

muscle

sternohyoid

the diagastric

Laterally: the

muscle

muscle

anterior border of

Medially: the mid-

the

line

sternocleidomastoi

d muscle

Medially: the

superior belly of

the omohyoid

muscle

Contents

The submental

The submandibular

The carotid artery,

The deep structures

lymph nodes

salivary glands and

the internal jugular

including the larnyx,

submandibular

vein, the vagus

trachea, thyroid and

lymph nodes

nerve and the

the oesophagus

internal and

external laryngeal

nerves




The boundaries of the posterior triangle are:

-----------------------the posterior border of the

sternocleidomastoid muscle.

--------------------the mid third of the clavicle.

-----------------------the anterior border of the

trapezius muscle.

Occipital triangle

Supraclavicular

triangle

Boundaries

Anteriorly:

Anteriorly: the posterior border

the Sternocleidomastoid muscle

of the Sternocleidomastoid

Posteriorly: the Trapezius muscle Superiorly: the inferior belly of

Inferiorly: the Omohyoid muscle

the Omohyoid muscle

Inferiorly: the clavicle

Contents

Most lumps arising from the posterior triangle are due to

enlarged occipital or supraclavicular lymph nodes.

Other important structures include the subclavian artery,

the external jugular vein, the accessory nerve, the phrenic

nerve and parts of the brachial plexus.




1A-submental
1B-submandibular
II-Skull base to

carotid bifurcation

III- carotid

bifurcation to

cricothyroid notch

IV- cricothyroid

notch to clavicle

V- post triangle
VI-hyoid to

suprasternal notch







ETIOLOGY (Congenital or Acquired)

LOCATION (Midline or Lateral)

CONSISTENCY (Solid or Cystic)

Ubiqutous

Midline

Lateral Swellings

swellings

Swellings

Anterior

Posterior

Triangle

Triangle

Sebaceous cyst Submental

Submandibular Lymphadenopat

Lymph nodes

gland swelling

hy

Lipoma

Thyroglossal

Thyroid lobe

Cold abscess

cyst

enlargement

Dermoid cyst

Thyroid

Branchial cyst

Cystic Hygroma

Swelling

Schwannoma

Hyoid Bursa

Pharyngeal

Cervical Rib

pouch

Haemangioma

Pretracheal LNs Parotid gland

Subclavian

swelling

artery

aneurysm

Teratoma

Dermoid cyst

Laryngocele

Laryngeal

Lymphadenopat

swelling

hy

Chondroma of

Cold abscess

thyroid

cartilage
Ludwig's angina Carotid body

tumor

Cold abscess

Brown tumor

Thymus tumors




I. SOLID SWELLINGS:
GLANDS: -

Lymph nodes (commonest).



Thyroid gland nodule (2nd common).



Submandibular gland.



Tail of parotid gland.

VESSELS: -

Carotid body tumor.

Glomus jugulare.

NERVES:
Schwannoma or Neurofibroma.
SUBCUTANEOUS: Lipoma.
SCM MUSCLE: - Organized hematoma (infants).

Fibrosarcoma

o BONE- Cervical Rib

II. CYSTIC SWELLINGS:
AIR: -

Laryngocele.
Pneumatocele.
Pharyngeal diverticulum.

FLUID: -

Thyroid gland cyst.
Branchial cyst.
Cystic hygroma (Lymphangioma).



Sebaceous cyst.

ABSCESS: -

Cold abscess (TB cervical lymphadenitis).
Parapharyngeal abscess.

Parotid abscess.

BLOOD : -

Hemangioma.

Aneurysm (Carotid or Subclavian).




I. SOLID SWELLINGS:

GLANDS: -

Lymph nodes
Thyroid gland isthmus nodule.
Median ectopic thyroid tissue.

SUBCUTANEOUS:

Lipoma of Burn's space (Suprasternal

notch).

II. CYSTIC SWELLINGS:
FLUID: -

Thyroid gland cyst in isthmus.

Thyroglossal cyst.

Dermoid cyst (Sublingual or Suprasternal).

Subhyoid bursa.

Sebaceous cyst.

ABSCESS: - Cold abscess.

Pyogenic abscess.

BLOOD : -

Hemangioma.

Aneurysm (Innominate artery).




Patient age

Pediatric (0 ? 15 years): 90% benign
Young adult (16 ? 40 years): similar to pediatric
Late adult (>40 years): "rule of 80s"

Location

Congenital masses: consistent in location
Metastatic masses: key to primary lesion

Congenital

epithelial cysts,

which arise from a

failure of

obliteration of the

second branchial

cleft.




At the fourth week of embryonic

life, the development of 4

branchial clefts results in 5 ridges

known as the branchial arches,

which contribute to the formation

of various structures of the head,

the neck, and the thorax. The

second arch grows caudally and,

ultimately, covers the third and

fourth arches. The buried clefts

become ectoderm-lined cavities,

which normally involute around

week 7 of development. If a

portion of the cleft fails to involute

completely, the entrapped remnant

forms an epithelium-lined cyst with

or without a sinus tract to the

overlying skin.




A solitary, painless mass in the neck of a

child or a young adult.

A history of intermittent swelling and

tenderness of the lesion during upper

respiratory tract infection.

Spontaneous rupture of an infected branchial

cyst may result in a purulent draining sinus to

the skin or the pharynx.

May present with locally compressive

symptoms.

Smooth, nontender, fluctuant mass, along

the lower one third of the anteromedial

border of the sternocleidomastoid muscle

between the muscle and the overlying skin.

May be tender if secondarily inflamed or

infected.

When associated with a sinus tract, mucoid

or purulent discharge onto the skin or into

the pharynx may be present.

Rarely, branchial cleft cysts have been

reported as fluctuant nodules in the thorax

or the posterior mediastinum.




Lymphadenopathy

Vascular neoplasms and malformations

Capillary hemangioma

Carotid body tumor

Lymphatic malformation (cystic hygroma)

Ectopic thyroid tissue

Ectopic salivary tissue




Ultrasonography.

Upper airway

endoscopy.

FNAC

A contrast-

enhanced CT scan

shows a cystic and

enhancing mass in

the neck.

Surgical excision

Stairstep or stepladder incision

Surgery done when the patient is at least age

3 months old.

Surgery should not be attempted during an

episode of acute infection or if an abscess is

present.

Sclerotherapy with OK-432 (picibanil) has

been reported to be an effective alternative.




Present mostly in

infancy as chronic

discharge along

anterior border of

SCM in lower 1/3.




CAROTID BODY

Small, reddish-brown, oval structure, located in

the posteromedial aspect of the carotid artery

bifurcation.

The gland is highly vascular and receives its

blood supply from feeder vessels from the

external carotid artery, typically the ascending

pharyngeal artery.

It is innervated by the Hering nerve, originating

from the glossopharyngeal nerve.

Helps in the body's acute adaptation to

fluctuating concentrations of oxygen, carbon

dioxide, and pH.

How? By increasing the ventilatory rate.




Rare neoplasms,

Represent about

65% of head and

neck

paragangliomas.

Develop within

the adventitia of

the medial aspect

of the carotid

bifurcation.

3 different types:
Familial
Sporadic
Hyperplastic
The sporadic form is the most common type,

representing approximately 85% of carotid body

tumors (CBTs).

The familial type (10-50%) is more common in

younger patients.

The hyperplastic form is very common in

patients with chronic hypoxia, patients living at

a high altitude, COPD or cyanotic heart disease.




The mean age of onset is 45 years.

Age of onset in the familial group is younger,

in the second to fourth decade.

About 5% of carotid body tumors (CBTs) are

bilateral and 5-10% are malignant.

Risk factors are chronic hypoxic stimulation

and the genetic predisposition.

Defective succinate dehydrogenase has been

postulated to cause an increase in the

intracellular concentration of molecular hypoxia

mediators and the vascular endothelial growth

factor (VEGF) thus resulting in hyperplasia,

angiogenesis, and neoplasia in Familial type.

Chronic hypoxic conditions overburden the

carotid bodies and subsequently lead to

hypertrophy, hyperplasia, and neoplasia of the

chief cells. This condition is seen in the

hyperplastic type of carotid body tumors (CBTs).

CBTs can be occasionally coupled with

syndromes, including MEN type II, von Hippel-

Lindau syndrome, and neurofibromatosis type 1.




composed of 2 cell types that are arranged in

a pseudoalveolar pattern characteristic of

paragangliomas known as "cell balls"

(zellballen):

Type I cells, which are the chief cells that

predominate in carotid body tumors (CBTs)

and contain catecholamine-bound granules

Type II cells, which are the sustentacular

cells located at the periphery, are devoid of

granules

Asymptomatic palpable neck mass in the anterior

triangle of the neck. They are slow-growing tumors.

Typically vertically fixed because of its attachment to

the bifurcation of the common carotid (Fontaine

sign).

Bruit
Approximately 10% of the cases present with cranial

nerve palsy with paralysis of the hypoglossal,

glossopharyngeal, recurrent laryngeal, or spinal

accessory nerve, or involvement of the sympathetic

chain. May be associated with pain, hoarseness,

dysphagia, Horner syndrome, or shoulder drop.

Cause of fever of unknown origin.
In cases of functional CBTs, symptoms similar to

those of pheochromocytoma, such as paroxysmal

hypertension, palpitations, and diaphoresis, are seen.




Check urinary catecholamines in patients who have

any symptoms of a functional carotid body tumor.

Color Doppler USG, which can assess the vascularity

of the neck mass.

CT scanning typically reveals a hypervascular tumor

located between the external and internal carotid

arteries.

MRI imaging is IOC and the tumor has a characteristic

salt and pepper appearance on T1-weighted image.

MRA provides better insight into the vascularity of the

tumor and its feeder vessels.

Angiography shows the typical lyre sign. also helpful

for better visualization of the feeder vessels.

MIBG scans,in patients who have functional tumors




Shamblin describes 3 different types or

stages of carotid body tumors.

Type I consists of a small tumor that is easily

dissected from the adjacent vessels in a

periadventitial plane.

Type II tumors are larger and more adherent

and partially surround the vessel.

Type III tumors are large and completely

surround the carotid bifurcation.




Surgery or radiotherapy.
Choice of treatment, depends on: presence

of other paragangliomas, bilateral carotid

body tumors, the age and the health of the

patient, and the patient's preference.

Preoperative embolization.
Surgery is the treatment of choice for

younger, healthier patients and radiotherapy

is reserved for the elderly, patients who are

poor surgical candidates, individuals with

multiple paragangliomas in whom resection

may be highly morbid.




CH usually affects

the head and neck

(approximately

75%), with a left-

sided predilection.

The posterior

triangle tends to be

most frequently

affected.

Other sites are the

axilla; mediastinum,

groin, and

retroperitoneum.




Failure of lymphatics to connect to the

venous system, abnormal budding of

lymphatic tissue, and sequestered lymphatic

rests that retain their growth potential.

They can arise from trauma (including

surgery), inflammation, or obstruction of a

lymphatic.

More common with Turner syndrome, Down

syndrome, Klinefelter syndrome and trisomy

18 and 13.

Noonan syndrome, Fryns syndrome, multiple

pterygium syndrome, and achondroplasia

Intrauterine alcohol exposure has been

associated with the development of

lymphangiomas.




Are evident at birth, with 80-90% of CHs presenting by age 2

years.

CH can be visualized using abdominal ultrasonography by 10

weeks' gestation.

Elevated alpha fetoprotein levels in amniocentesis fluid
Can involve both the anterior and posterior triangles of the neck.
The cysts are typically large and thick walled. The overlying skin

can take on a bluish hue or may appear normal.

Often present with a sudden increase in size secondary to

infection or intralesional bleeding.

Rarely, children with CH display symptoms of newly

onset obstructive sleep apnea syndrome (OSAS).

Potentially life-threatening airway compromise that manifests as

noisy breathing (stridor) and cyanosis.

Feeding difficulties, as well as failure to thrive___when the lesion

affects structures of the upper aerodigestive tract.

CHs are typically soft, painless, compressible

(doughy) masses.

A CH typically transilluminates.

In children who present with CH of the neck,

closely evaluate for tracheal deviation or

other evidence of impending airway

obstruction.

Closely inspect the tongue, oral cavity,

hypopharynx, and larynx because any

involvement may lead to airway obstruction.




Branchial cleft cyst

Thyroglossal duct cyst

Ranula

Goiter

Soft tissue tumors

Neck abscess

MRI is the study of choice. Contrast can be

used to differentiate hemangiomas from

lymphangiomas.

CT scanning not very good.

Ultrasonography: It is very useful in

demonstrating the relationship of CH to the

surrounding structures.




giguere et al have proposed categorization of

lymphangiomas based on the size of the cystic component,

as follows:

Macrocystic - Cystic spaces at least 2 cm
Microcystic - Spaces less than 2 cm
Mixed lesions
de serres et al have proposed the following system

for staging of CH of the head and neck:

Stage I - Unilateral infrahyoid (17% complication rate)
Stage II - Unilateral suprahyoid (41% complication rate)
Stage III - Unilateral and both infrahyoid and suprahyoid

(67% complication rate)

Stage IV - Bilateral suprahyoid (80% complication rate)
Stage V - Bilateral infrahyoid and suprahyoid (100%

complication rate)




Watchful waiting should be considered only

in patients who are asymptomatic.

Administration of sclerosing agents like OK-

432 (an inactive strain of group

A Streptococcus pyogenes), bleomycin, pure

ethanol, sodium tetradecyl sulfate, and

doxycycline.

An infected CH should be treated with

intravenous antibiotics, and definitive

surgery should be performed once the

infection has resolved

The mainstay of treatment is surgical

excision.

Radiofrequency ablation for intraoral

lymphatic malformations, especially

microcystic lesions.

Magnetic resonance?controlled laser-induced

interstitial thermotherapy.

The ex utero intrapartum treatment (EXIT)

procedure.




PHARYNGEAL

POUCH

Zenker diverticula occur in a muscular

dehiscence that is present most commonly

between the oblique muscle fibers of the

inferior constrictor muscle and the transverse

fibers of the CP muscle. This area is known as

the Killian triangle.







Herniation of the esophageal mucosa posteriorly between

the cricopharyngeus (CP) muscle and the thyropharyngus

part of inferior pharyngeal constrictor muscles.

Hypothetical abnormalities include the following:
Abnormal timing of deglutition resulting in closure of the

CP muscle when ideally it should be opening

Incomplete CP muscle relaxation
Elevated resting tone of the entire upper esophageal

sphincter (UES)

Loss of CP muscle elasticity
CP muscle myopathy or denervation atrophy
Central nervous system (CNS) injury with a focal spastic CP

muscle

CP muscle spasm in response to gastroesophageal reflux

disease (GERD)




Lahey system

Criteria of the Lahey staging system are as

follows:

Stage I - A small mucosal protrusion is

present

Stage II - A definite sac is present, but the

hypopharynx and esophagus are in line

Stage III - The hypopharynx is in line with

diverticulum, and the esophagus is indented

and pushed anteriorly.

Morton system

Criteria of the Morton staging system are as

follows:

Small sacs are less than 2 cm in length

Intermediate sacs are 2-4 cm in length

Large sacs are greater than 4 cm in length




Van Overbeek system

Criteria of the van Overbeek system are as

follows:

Small sacs are less than 1 vertebral body in

length

Intermediate sacs are 1-3 vertebral bodies in

length

Large sacs are greater than 3 vertebral

bodies in length

Dysphagia - Most patients (98%) present with

some degree of dysphagia

Regurgitation of undigested food hours after

eating

Sensation of food sticking in the throat
Special maneuvers to dislodge food
Coughing after eating
Aspiration of organic material
Unexplained weight loss
Fetor ex ore (halitosis)
Borborygmi in the neck




The most common life-threatening complication

in patients with a Zenker diverticulum is

aspiration.

Other complications include massive bleeding

from the mucosa or from fistulization into a

major vessel, esophageal obstruction, and

fistulization into the trachea. Coexistent hiatal

hernia, esophageal spasm, achalasia, and

esophagogastroduodenal ulceration are common.

Squamous cell carcinoma (SCC) within a Zenker

diverticulum is extremely rare, occurring in 0.3%

of Zenker diverticula worldwide.




Barium swallow with videofluoroscopy. This

study provides information about the size,

location, and character of the mucosal lining

of the Zenker diverticulum.

Esophageal manometry

Rigid or flexible esophagoscopy is essential

before surgical management to assess the

nature of the mucosa of the Zenker

diverticulum and to exclude the presence of

SCC or carcinoma in situ.




Patients with diverticula of under 1 cm or in

patients with medical comorbidities

precluding surgery.

Botulinum toxin may be used to provide

temporary relief of dysphagia symptoms.

Zenker diverticula require intervention only if

they produce symptoms.

Small lesions(<2cm) are satisfactorily treated

with a cricopharyngeus (CP) myotomy with or

without an invagination procedure.

Intermediate and large diverticula (ie, 2-6 cm)

are best managed with open diverticulectomy

with CP myotomy or by endoscopic

diverticulotomy.

Very large diverticula (ie, >6 cm) are best

managed with excision with CP myotomy or a

diverticulopexy with CP myotomy, depending on

the health of the patient.




Recurrent laryngeal nerve (RLN) paralysis

Esophageal stenosis

Mediastinitis

Pharyngocutaneous fistula

Hematoma

Esophageal perforation

LARYNGOCELE




Anomalies of the supraglottic larynx.
Result of air or fluid filled dilation of the laryngeal ventricle,

which communicate with the laryngeal lumen.

Classified as "internal" or "external".
Internal laryngoceles, are comprised of a collection of air

or serous fluid and mucous in the anterior portion of the

laryngeal ventricle. Their sac remains within the confines of the

thyroid cartilage.

In contrast, as external laryngoceles enlarge, their sac may

protrude through the thyrohyoid membrane and present as a

anterior neck mass.

Laryngoceles may be congenital and may also be acquired. They

are often seen in glassblowers due to continual forced expiration

producing increased pressures in the larynx which leads to

dilatation of the laryngeal ventricle. It is also seen in people with

chronic obstructive airway disease.




Lateral Compressible Neck Mass that

increases in size with increase in

intralaryngeal pressure, Cough, Hoarseness

and possible airway compromise.

Laryngoceles may also become infected, in

which case they are called Laryngopyoceles.

If infected present with fever, pain,

leukocytosis etc.

Indirect mirror exam.

Flexible fiberoptic laryngoscopy.

CT of the neck with IV contrast.




Internal laryngoceles are managed

endoscopically.

External laryngoceles and combined internal

and external laryngoceles are managed

through an open approach.

All procedures, both open and endoscopic,

typically begin with upper airway endoscopy

to evaluate the lesion completely.




The term ranula is derived

from the Latin

word rana, meaning frog,

and describes a blue

translucent swelling in the

floor of the mouth

reminiscent of the

underbelly of a frog.

Hippocrates described

ranulas and thought that

they were secondary to

inflammation. Par?

thought that ranulas may

represent descent of brain

or pituitary matter.

Congenital ranulas can arise secondary to an

imperforate salivary duct or ostial adhesion.

Posttraumatic ranulas arise from trauma to the

sublingual gland, leading to mucus extravasation

and formation of a pseudocyst.

Plunging ranulas
Also called deep, diving, cervical, or deep

plunging ranula and oral ranula with cervical

extension.

Plunging ranulas generally appear in conjunction

with an oral ranula. Patients present first with an

oral swelling in up to 45% of cases, with

associated oral swelling in 34%, and without any

oral involvement in 21% of cases.




Experimentally, partial severance or ligation of

the sublingual duct leads to ranula formation,

whereas ligation of the submandibular duct does

not. The ligation of the parotid duct ultimately

leads to atrophy.

The difference lies in the fact that the sublingual

gland secretes continuously in the interdigestive

period, whereas the other two major salivary

glands only secrete in response to stimuli, such

as eating. Therefore, with trauma, if a duct is

obstructed, secretory backpressure builds and

acini rupture, leading to mucus extravasation.




Plunging ranulas arise in the neck by 3

mechanisms:

The sublingual gland may project through the

mylohyoid, or an ectopic sublingual gland

may exist on the cervical side of the

mylohyoid..

The cyst may penetrate through the

mylohyoid

A duct from the sublingual gland may join

the submandibular gland, allowing ranulas to

form in continuity with the submandibular

gland.

Bluish cyst located below the tongue

May fill the mouth and raise the tongue.

These are painless masses that do not change in size

in response to chewing, eating, or swallowing.

Plunging ranulas
Plunging ranulas can manifest as neck swelling in

conjunction with or withuot a floor-of-mouth cyst.

Usually found in the submandibular space.

They have been reported to extend into the

submental region, the contralateral neck, the

nasopharynx up to the skull base, the retropharynx,

and even into the upper mediastinum




CT scanning

MRI

Ultrasonography

Lymphadenopathy
Cystic hygroma
Pleomorphic adenoma
Abscess
Thyroglossal duct cyst
Dermoid or epidermoid cyst
Laryngocele
Lipoma
Hemangioma
Cervical thymic cyst
Cysts of the parathyroid or thyroid gland




Marsupialization

Placement of suture or Seton

Sclerosing agents

Carbon dioxide laser

Radiation therapy

Sublingual gland excision

paraesthesia of the lingual nerve

injury to the Wharton duct

obstructive sialadenitis

salivary leakage

recurrence of the ranula




Congenital sequestration dermoid.
Formd by inclusion of ectoderm at fusion line of

first arch.

Thin walled cyst lined by squamous epi.
Lateral and median variety.
Can be supra and inframylohyoid.
Usually seen b\w 10-25 years of age.
C\o of a painless swelling under the tongue or

below the chin.

Pain may be asso with infection.
Tranillumintion is ?ve.
Tt is excision.




STERNOMASTOID

TUMOR

The sternomastoid "tumor" of infancy is a firm, fibrous mass,

appearing at two to three weeks of age, within the substance of

the Sternomastoid muscle and appears as a knot.

It may or may not be associated with torticollis.
Generally, the "tumor" initially grows, then stabilizes, and in

about half the cases recedes spontaneously after a few months. It

may leave a residual torticollis or may be associated with a facial

or cranial asymmetry of a delayed torticollis.

The etiology is unknown, a direct cause and effect relationship to

birth trauma has been largely disproved although approximately

half these children are products of breech deliveries.

The treatment is controversial.
Approximately half of these "tumors" will resolve spontaneously

without sequelae.

Progressive torticollis or development of facial asymmetry are

considered indications for surgery.




CAUSES OF LYMPHADENOPATHY

Infection

Acute

Pyogenic infections

Infectious mononucleosis

Toxoplasmosis

Infected eczema

CMV

Chronic

TB

Sarcoidosis

Syphilis

HIV

CAUSES OF LYMPHADENOPATHY

Malignancy

Primary

Hodgkins lymphoma

Non-Hodgkins lymphoma

CLL

ALL

Secondary

Nasopharngeal

Thyroid

Lung

Breast

Stomach ("Troisier's sign")




TUBERCULAR

LYMPHADENOPATHY

? Enlargementoflymphnodes,typicallytogreaterthan

1.5cmwithchangeintsconsistency,isknownas

? Lymphadenopathy.

Tuberculosisachronicgranulomatousinfection

causedbyMycobacteriumtuberculosi,whichisan

? acid-fastbacil us.

? It com onlypres ntsaspulmonarytuberculosi .

Acom onextrapulmonarymanifestationof

tuberculosislymphadenopathy.






CervicalLN(mostcom on)

InguinalLN,

Axil aryLN,

Mes ntericLN,

Mediastinal& HilarLN,and

Intramam aryLN.

1. Inhalationof rganisminfreshcoughdropletorin

2. dIrniegdes

st put

ion um

.

ofrganisms(duetoselfswallowingof

infectedsputumoringestionofbovinetubercule

3. bIancinlo fr

culoamti

io nf

n ectedmilk.

4. Trans-placental route (rare)




B
? yJones& Campbel

Stage1-Reactivelymphadenitis:Enlarged,Firm

mobilediscretnodeshowingnonspecifcreactive

? hyperplasia.

Stage2-Periadenitis:Largerubberynodesfixedto

? surroundingtis ue(matingtakesplace)

Stage3-Coldabsces:Centralsofteningduetoabsces

formation.

Caseatingnecrosinlymphnodestakesplace.

Stage4-Colarstudabsces :Absces is nde pfascia,it

ruptures&comesinsuperficalfasciabutremainsinside

theskin.

Stage5-Sinus:Blindtractlinedbygranulationtisue.




Stage 4- Collar stud abscess : Bilocular abscess with

one locule deep to the deep fascia and another

locule in superficial fascia.

Stage 5-Sinus tract formation : A blind tract lined

by granulation tissue.

Sinus formation




Reactive lymphadenitis

a)

?LNbecomes

b) Inflam ed

c) Enlarge

d) Palpable

Te
P nd

e er

riadenitis ?

a)
b) MatedLNmas

Slightender

Cold abscess

a)
b)Noriseintemperature

c)Nopain

d)Notendernes

No

Coredne

llar s stud abscess

a)
b)Signsofinflam ationonskin

c)Fluctuation

Sweling




Sinus

a)
b)Openingintheneckorulcer(underminededge)

c)Bluishdiscol urationofskin

Pusdischarge;Caseatingmaterialcomesout.

PYOGENIC ABSCESS

COLD ABSCESS

?

?

?Notsocom on.

?Com onestvarietyof

absces.

Cardinalsignsof

in
? flam ationare

?Allcardinalsigns of

inflam ationpresnt. absent.

?Doesnotproducehot

?Producehot& painful

absces.

Brawnyoedmawith

in

&painfulabsces.

Brawnyinduration,

o
? ed ma& tendernes

? durationpres nt

whenpusisdepseated.

Aresultofprimary

disease.

areabsent.

Almostalwaysasequel

oftubercularinfection.




TREATMENT:

1.Suitableantibotic

started.

TREATMENT:

1.Fullantiubercular

2.Pusisdrainedby

regimestarted.

givngincisonon 2.Pusisdrainedby

mostprominetpart. givnganoblique

incison

A 43-year-old man presents to his GP with a 6-

month history of a painless pulsatile mass at the

angle of the jaw.

A 23-year-old girl complains of intermittent

numbness and paraesthesiae in her right hand

for the past 2 months. On examination there is a

fixed, hard, 1cm2 cm swelling in the right

supraclavicular fossa.

A 3-year-old boy is seen by his GP with a

enlarging midline swelling that has been

present for the past year. It is smooth and

rounded, located just below the hyoid bone,

measuring 2 cm2 cm, and rises on protrusion of

the tongue.


A 32-year-old woman presents to her GP with a

neck lump enlarging for the last 3 years. It

measures 1 cm1.5 cm and is located behind the

junction of the upper and middle thirds of the

left sternocleidomastoid muscle. In the past this

lump has become infected, resolving with oral

antibiotics.

A 23-year-old man presents to his GP with a 2

cm3 cm painless lump at the angle of the jaw;

it has been there for 2 months. He also

complains of weight loss, night sweats and fever,

over the same period. Hepatosplenomegaly is

detected on examination of the abdomen.