boundaries of anterior triangle and posterior triangle
ant: bounded by the lower border of the mandible superiorly, the midline
anteriorly, and the anterior border of the sternocleidomastoid posteriorly
pos: posterior border of the sternocleidomastoid
anteriorly, the anterior border of the trapezius posteriorly, and the clavicle inferiorly
ddx midline lump
- Submental lymph node
- Thyroglossal cyst
- Thyroid nodule in the isthmus
- Sublingual dermoid cyst
- Plunging ranula (retention cyst of the sublingual)
ddx anterior triangle lump
- Lymph node – along anterior border of sternocleidomastoid (levels II, III, IV)
- Thyroid nodule
- Submandibular gland mass (see later section on Salivary gland swellings)
- Branchial cyst + fistula
- Chemodectoma (carotid body tumour)
- Carotid aneurysm
- Pharyngeal pouch
ddx posterior triangle lump
- Lymph node – level V and supraclavicular lymph node groups
- Cystic hygroma
- Cervical rib
- Brachial plexus neuroma/schwannoma
thyroglossal cyst
- what is it
- embryology of thyroid
- tx
A cystic expansion of the remnant thyroglossal tract
embryologic descent of the thyroid from the foramen cecum at the base of the tongue to low anterior neck
Sistrunk procedure – resection of the cyst, its tract and central portion of the hyoid bone
Dermoid cyst
- features/ what is it
- causes
- tx
Cyst lined by epidermis, with evidence of adnexal structures such as hair follicles, sebaceous glands and sweat glands – cystic teratoma
Causes:
- congenital: devt inclusion of epidermis along line of fusion of skin dermatomes (eyebrow, nose, neck)
- acquired: forced inclusion of skin into subcutaneous tissue following injury (fingers)
Mgx: surgical excision
Rannula
- what is it
- types
- causes
- tx
mucous extravasation cyst involving a sublingual gland and is a type of mucocele
simple: confined to floor of mouth
plunging: extend through mylohoid musculature
causes: congenital (imperforate salivary duct), acquired (trauma to sublingual gland)
tx:
- complete resection with Assoc sublingual gland
- else marsupialisation and suture of pseudocyst wall to oral mucosal
branchial cyst
- what is it
- features
- FNA findings
- cx
- mgx
What: congenital epithelial cysts, which arise on the lateral part of the neck from a failure of obliteration of the second branchial cleft in embryonic development.
Features: smooth, firm, ovoid, fluctuant but not transilluminable, a.w branchial fistula
FNA: opalescent fluid with cholesterol crystals under microscopy
cx: recurrent infections – purulent discharge, fixation to surrounding
structures
mgx:
surgical excision of cyst
fistula: perform fistulogram, inject Bonney’s blue dye to delineate tract. tx with abx if infected
location of bifurcation of common carotid artery
- significance?
upper border of thyroid cartilage
- location of carotid body and sinus
- what are paraganglion cells
- types of paraganglionomas
group of non-neuronal cells derived of the neural crest. They are named for being generally in close proximity to sympathetic ganglia.
2 types: - neuroendocrine cells - chromaffin (chromaffin cells) > phaeochromocytomas (adrenals non malignant, extra adrenal - malignant, secrete hormones) - non chromaffin (glomus cells) > carotid body tumours (do not secrete hormones)
Chemodectoma
- location
- risk of malignancy
- features
- ddx
- diagnosis
- tx
carotid body tumour
- @ bifurcation of C carotid art
- usually benign but locally invasive. malignant risk 10% but no histo features, only diagnosed through mets to LN
- solid, firm @ hyoid bone (lvl2 of neck). pulsatile but NOT expansile. move side to side but not up and down.
- carotid artery aneurysm (expansile, bruit, Horner syndrome)
- NO FNAC. use CT/MRI.
CT: homogenous mass with intense enhancement with IV contrast
angiography: gold standard - tx: R/o phaeo.
sx excision with pre-op embolisation. remove enlarged I/L LN.
alt: RT
pharyngeal pouch
- what is it
- features
- cx
- diagnosis
- tx
aka Zenker diverticulum
- A herniation of the pharyngeal mucosa between 2 parts of the inferior
pharyngeal constrictor – thyropharyngeus & cricopharyngeus – weak area situated posteriorly
(Killian‟s Dehiscence)
- c/o cystic swelling in neck, squelching, halitosis, regurgitate, dysphagia, hoarseness, weight loss
- cx: aspiration, diverticular neoplasm
- diagnosis: barium swallow
tx:
- small: leave
- endo: cricothyroid myotomy
- sx: diverticulotomy + cricothyroidotomy or diverticulopexy
cystic hygroma
- what is it
- features
- cx
- mgx
congenital cystic lymphatic malformation. It consists of thin- walled, single or multiple interconnecting or separate cysts which insinuate themselves widely into the tissues at the root of the neck.
- Lobulated cystic swelling that is soft, fluctuant, and compressible. brilliantly transilluminable.
- a.w trisomy 21. may obstruct delivery. compressive problems - SOB, dysphagia
- aspiration/ sclérosant or sx excision
Cervical rib
- features
- diagnosis
- tx
Thoracic outlet syndrome
- Arterial: pallor, gangrene or necrosis of the tips of the fingers
- Venous: oedema, cyanosis
- Neurological: complaints of radicular symptoms (pain, paraesthesia), wasting of the small muscles of the hand
diagnosis: cxr, nerve conduction study, Adson test
tx: PT exercises, analgesia, blood thinners, surgery
Levels of LN in the neck
IA: submental IB: submandibular II: upper jugular III: mid jugular IV: lower jugular Va: posterior triangle Vb: supraclavicular VI: ant compartment
pathophysiology behind Virchow’s node
thoracic duct commences at cisterns chyli > aortic opening > ascend behind oesophagus > at root of neck, enter junction between L IJV and L subclavian veins
virchow node lies between 2 heads of SCM
approach to LN enlargement
1. Infection > bac: TB, strep/staph/klebsiella > viral: EBV, CMV, HIV > fungal/ parasites 2. Neoplastic - lymphoma - mets > H&N Pri: NPC, oral cavity, larynx, thyroid, skin > other Pri: lung, GIT, breast, renal 3. Inflammatory: Kikuchi (female, painful, self-limiting/ acute). Kimura (chronic inflammatory, males, pruritic leisions), SLE, sarcoidosis
B symptoms of lymphoma
fever, night sweats, LOW
Submandibular gland
- significant anatomical relations
- nerve supply
- name of duct
- histology
large superficial part and a small deep part that are continuous with one another around the free posterior border of the mylohyoid
closely related to lingual nerve, submandibular ganglion, hypoglossal nerve.
Nerve: parasympathetic supply. preganglionic from superior salivary nucleus > submandibular ganglion > lingual n (facial n/ chorda tympani)
Wharton (drain into sublingual papilla adjacent to frenulum)
mixed serous and mucinous
Impt structures passing through parotid gland?
- Facial n and branches: temporal, zygomatic, buccal, marginal mandibular, cervical
- retromandibular vein
- external carotid artery > superficial temporal and maxillary artery
Parotid duct
- nerve supply
- duct name, surface marking
- histology
parasympathetic.
pre gang: inferior salivary nucleus > otic ganglion > auriculotemporal n (glossopharyngeal n)
stensen (inter tragic notch to midpoint of philtrum. drain into mouth, opp second molar tooth)
histo: serous
Sublingual
- nerve supply
- histo
superior salivary nucleus > submandibular ganglion > lingual n (facial n/ chorda tympani)
histo: mucous
3 organ sites involved in mumps
parotiditis, orchitis, pancreatitis
Causes of parotid swelling
PARENCHYMAL - neoplasia: benign, malignant, lymphoma/ leukemia - stones: sialolithiasis - infection/ inflammation: mumps, acute sialolithiasis, HIV - autoimmune: Sjögren - infiltration: sarcoidosis - systemic dz: alcoholic liver dz, DM, pancreatitis, acromegaly, malnutrition NON PARENCHYMAL - nodes: mets - blood vessels: AVM, haemangioma - lymphangioma - schwannoma - lipoma
