2. OUTLINE
• ANATOMY OF THE NECK
• CLASSIFICATION OF NECK MASS
• MAIN CAUSES OF NECK MASS
3. ANATOMY OF NECK
Neck is part of the bpdy between occipital and clavicle.
Neck have more than 200 lymph node
4. Surface Anatomy
The prominent landmarks
of the neck are:
• Hyoid bone
• Thyroid cartilage
• Cricoid cartilage
• Trachea
• Sternocleidomastoid
muscles
5. What forms the neck?
● Skin
● Fascia of the neck
- Superficial cervical fascia
- Subcutaneous fat
- Platysma muscle
- Superficial lymph node
- Deep cervical fascia
- Investing layer
- Pretracheal layer
- Prevertebral layer
● Muscles
● Bone-cervical
vertebral
● Viscera of the neck
● Neurovascular
bundles
● Lymphatic system
11. What is in your neck?
Major
triangles
Sub-divisions Content
Anterior Submental Submental LN
Submandibular Submandibular gland and LN,
hypoglossal n, mylohyoid n., parts of
facial artery and vein
Carotid Carotid sinus and body, carotid
sheath (IJV, CCA, vagus n.), ECA,
hypoglossal n, ansa cervicalis
(superior root), spinal accessory n.,
deep cervical LN, branches of cervical
plexus, thyroid gland, larynx, pharynx
Muscular Infrahyoid muscles, thyroid and
parathyroid glands
12. Major
triangles
Sub-divisions Content
Posterior Occipital Transverse cervical artery, EJV,
spinal accessory nerve, post
branches of cervical nerve plexus,
of brachial plexus, cervical LN
Supraclavicular Subclavian artery (3rd part),
subclavian vein, suprascapular
artery, supraclavicular LN
13. • NECK MASS = Defined as any abnormal
enlargement, swelling or growth from the
level of base of skull to clavicles
• Clinically neck masses can be divided into
– Midline
– Lateral (grouped according to triangles of the
neck)
20. BRANCHIAL CYST
• Branchial cleft cysts are 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.
• Common in the 2nd decade of life but can
occur at any age with equal frequency in both
sexes.
21.
22. Pathophysiology
• At the 4th week of embryonic life, the development of
4 branchial (or pharyngeal) clefts results in 5 ridges
known as the branchial (or pharyngeal) 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.
23.
24. Clinical features
• Swelling – upper part of neck, anterior to SCM
• Mass – smooth, round, fluctuant, non-tender, non-
transilluminant
• May be painful and increase in size at the time of URTI
• Anomalies of the 2nd branchial arch are the most common
• May be associated with a sinus or fistula
– External opening at the junction of lower and middle of the
anterior border of sternocleidomastoid, may exude mucoid
discharge
– Internal opening in the tonsillar fossa
– If both external and internal opening present = branchial fistula
25. Investigations
Imaging
• Sonogram
– If a sinus tract exists, radiopaque dye can be injected to delineate the course and to examine
the size of the cyst.
• Ultrasonography
– Delineate the cystic nature of these lesions.
• Contrast-enhanced CT scan
– shows a cystic and enhancing mass in the neck. It may aid preoperative planning and identify
compromise of local structures.
• MRI
– allows for finer resolution during preoperative planning. The wall may be enhancing on
gadolinium scans.
Histopathological
• Fine-needle aspiration
– May be helpful to distinguish branchial cleft cysts from malignant neck masses.
– Fine-needle aspiration and culture may help guide antibiotic therapy for infected cysts.
26. Second branchial cleft cyst. Contrast-
enhanced axial computed tomography scan
at the level of the hyoid bone reveals a large,
well-defined, non-enhancing, water
attenuation mass (m) on the anterior border
of the left sternocleidomastoid muscle(s).
First branchial cleft cyst, type II. Contrast-
enhanced axial computed tomography scan
at the level of the hyoid bone reveals an ill-
defined, non-enhancing, water attenuation
mass (m) posterior to the right
submandibular gland (g).
27. Treatment
Medical
• Antibiotics are required to treat infections or abscesses related to
branchial cleft cysts.
Surgical
• Surgical excision is definitive treatment for branchial cyst.
• A series of horizontal incisions, known as a stairstep or stepladder incision,
is made to fully dissect out the occasionally tortuous path of the branchial
cleft cysts.
• Branchial cleft cyst surgery is best delayed until the patient is at least age 3
months.
• Definitive branchial cleft cyst surgery should not be attempted during an
episode of acute infection or if an abscess is present.
• Surgical incision and drainage of abscesses is indicated if present, usually
along with concurrent antimicrobial therapy.
28. THYROGLOSSAL DUCT CYST
• Thyroglossal duct cysts are the most common
form of congenital neck cyst.
• The cyst is an epithelial remnant of the
thyroglossal tract, and as such is composed of
thick mucous material lined with secreting
columnar or squamous epithelium. A thick
fibrous capsule surrounds the cyst.
• TDC is found in between hyoid bone and the
thyroid cartilage in about 60% of the patients, it is
suprahyoid, supra-sternal and intra-lingual in
about 24%, 13% and 2% respectively.
Moorthy, S. N., & Arcot, R. (2010). Thyroglossal Duct Cyst—More Than Just an Embryological Remnant. Indian Journal of Surgery Indian J Surg, 73(1), 28-31.
29. Pathophysiology
• Thyroglossal duct cysts may arise during the 5th week of embryonic life after the
descent of the thyroid gland from the base of the tongue to its position in the
neck.
• The failure of the tract to involute by the 7th week results in the presence of a
sinus tract and cyst(s) in the midline of the neck.
• If the lower part of the duct alone persists, it prevails as the pyramidal lobe of the
thyroid.
• The foramen cecum, which typifies the ductal opening into the tongue, remains a
small blind pit in the mid line between the anterior two thirds and the posterior
one third of the tongue.
• The cyst can occur anywhere along the thyroglossal duct tract from the foramen
cecum at the base of the tongue to the level of the suprasternal notch.
• The cysts are most commonly located inferiorly to the hyoid bone within 2 cm of
the midline with a close relationship to the hyoid, thyrohyoid membrane, or
thyroid cartilage.
Karmakar S, Saha AM, Mukherjee D; Thyroglossal cyst: an unusual presentation. Indian J Otolaryngol Head Neck Surg. 2013 Jul;65(Suppl 1):185-7. doi: 10.1007/s12070-011-0458-5. Epub 2012 Jan
6.
30.
31. Clinical features
• Cystic midline swelling, usually affecting young children but
can occur at any age.
• Usually rounded with a diameter of 2-4 cm.
• May transilluminate – contains mucoid fluid or blood
• Increases in size with URTI.
• Sometimes it presents as a draining sinus if it has burst due
to infection or has been surgically drained.
• Moves with tongue protrusion - it is attached to the
thyroglossal tract which attaches to the larynx by the
peritracheal fascia.
• (Rare) Can cause swallowing or breathing difficulty in
neonates if it is located at the base of the tongue.
32. Investigations
Imaging
• Ultrasound
– unilocular lesions with thin walls and posterior acoustic enhancement.
• CT scan
– The most helpful features in the differential diagnosis are the midline
location, most often at or below the hyoid bone, and the intimate
relationship of infrahyoid TDCs to the strap muscles.
– Can show capsular enhancement.
– CT better evaluates the potential for thyroglossal duct carcinoma and
is thus preferred in adult patients.
• MRI
– provides a high degree of diagnostic accuracy for TDC but it is rarely
required for the diagnosis.
– Although TDCs are invariably hyperintense on T2-weighted images, T1-
weighted signal intensity is variable.
34. Investigations (cont)
• Thyroid function test
– However, ectopic thyroid gland cannot be ruled out even
in the presence of normal TSH levels and a clinically
euthyroid history.
• Thyroid scanning
– To demonstrate any functioning ectopic thyroid.
– Ectopic thyroid tissue may accompany TGCs in their
location along the line of embryological thyroid descent.
– This can also be used to demonstrate normal thyroid
position and function before removal of any thyroid tissue
which may accompany the cyst.
35. Treatment
Complete surgical excision
• Including with it the
body of hyoid bone and
core of tongue tissue
around the tract in the
suprahyoid tongue base
to the foramen caecum
(Sistrunk’s operation).
• Simple excision of cyst
without removal of its
tract leads to recurrence.
42. • Clinal approach once it is established that the neck
swelling is indeed a thyroid swelling :
1) Diffuse enlargement :
(a) Toxic ( Grave's disease)
(b) Non toxic
- other thyroiditis
( exp : Hashimoto thyroiditis , de Quervain's
thyroiditis)
- simple colloid goitre
45. Papillary Thyroid Carcinoma ( PTC )
• Papillary carcinoma (PTC) is the most common form of
well-differentiated thyroid cancer, 75% to 85% and the
most common form of thyroid cancer to result from
exposure to radiation.
• 20-40 years of age
• Aetiology :
1) Genetic factor : mutation in RET or NTRK1 / RAS , BRAF
oncogene,
2) Exposure to ionizing radiation, particularly during 1st two
decades of life, especially head & neck region
47. Histological findings :
• •Branching papillae (fibrovascular stalk covered by
single to multiple layers of cuboidal epithelial cells)
• •Diagnostic nuclear features → clear or empty
(ground glass or Orphan Annie eye nuclei) or
intranuclear inclusion or intranuclear grooves
• •Psammoma bodies – concentrically lamellated
calcified structures within the cores of papillae
• •Foci lymphatic invasion
48.
49.
50. History
• The most common presentation of thyroid cancer is an
asymptomatic thyroid mass or a nodule that can be felt in the
neck. For any patient with a thyroid lump that has developed
recently, record a thorough medical history to identify any risk
factors or symptoms. In particular, obtain a history regarding
every prior exposure to ionizing radiation and the lifetime
duration of the radiation exposure. Consider a family history of
thyroid cancer.
• Some patients with thyroid cancer have persistent cough,
difficulty breathing, or difficulty swallowing. Pain is seldom an
early warning sign of thyroid cancer. Other symptoms (eg, pain,
stridor, vocal cord paralysis, hemoptysis, rapid enlargement) are
rare, and can be caused by less serious problems.
51. Physical Examination
The clinician should palpate the patient's neck to evaluate
the size and firmness of the thyroid and to check for any
thyroid nodules. The principal sign of thyroid carcinoma is
a palpable nodule, usually solitary, in the thyroid area that
has the following characteristics:
• Painless
• Hard consistency
• Average size of less than 5 cm
• Ill-defined borders
• Fixed in respect to surrounding tissues
• Moves with the trachea at swallowing
52. Investigations
• Thyroid function studies
• TSH suppression test
• Thyroid ultrasound
• Fine-needle aspiration biopsy (FNAB)
• FNAB is considered the best first-line
diagnostic procedure for a thyroid nodule.
53. Management
• Surgery is the definitive management of papillary
thyroid cancer. Approximately 4-6 weeks after surgical
thyroid removal, patients may have radioiodine
therapy to detect and destroy any metastasis and
residual tissue in the thyroid.
• External beam radiotherapy has been used as
adjuvant therapy in patients with papillary thyroid
cancer who were older than 45 years and had locally
invasive disease. Some improvements in 10-year
survival rates have been reported with this approach.
54. • Patients require lifelong thyroid hormone replacement
therapy, especially after total thyroidectomy. Treatment
consists of levothyroxine in a dosage of 2.5-3.5
mcg/kg/d.
http://emedicine.medscape.com/article/282276-overview
http://emedicine.medscape.com/article/2007769-overview
55. Goitre
• A goiter is an enlarged thyroid gland.
• Classification :
a) Simple goitre : - Diffuse hyperplastic
- Multinodular goitre
b) Toxic goitre : - Diffuse ( Graves disease )
- Multinodular
- Toxic adenoma
56. History and Physical examination
A goiter may present in various ways, including the following:
• Incidentally, as a swelling in the neck discovered by the patient or on routine physical
examination
• A finding on imaging studies performed for a related or unrelated medical evaluation
• Local compression causing dysphagia, dyspnea, stridor, plethora or hoarseness
• Pain due to hemorrhage, inflammation, necrosis, or malignant transformation
• Signs and symptoms of hyperthyroidism or hypothyroidism
• Thyroid cancer with or without metastases & proceeds to neck examination.
64. Carotid body tumour
• Arises from the chemoreceptor cells in the
carotid body a.k.a chemodectoma
• Mostly present after 40 y.o, very slow growing
tumour
• About 5% of carotid body tumors are
bilateral and 5-10% are malignant
65. Presentation
• Painless, pulsatile mass in the anterior triangle of
the neck
• Bruit can be heard
• Moves from side to side but not vertically
(attachement to bifurcation of carotid artery )
• May extend into parapharyngeal space and
present in oropharynx
• As the tumor enlarges and compresses the
carotid artery and the surrounding nerves - pain,
tongue paresis, hoarseness, Horner syndrome,
and dysphagia.
66. Investigation
• Simple ultrasonography with color Doppler
– assess the vascularity of the neck mass
• Contrast-enhanced CT & MRI with
gadolinium
– Diagnostic & show extent of the tumor
• MRI angiography : splaying of internal &
external carotid arteries— Lyre’s sign
• FNAC should not be done d/t vascularity of
the tumor
67.
68. Treatment
• Surgical remoral ( <50y/o or tumour extend to
oropharynx causing difficult in speech,
swallow/breathing)
• Radiotherapy (older pt, those unfit/refuse
surgery/metastatic diseases)
73. Lymph Nodes Level of Neck
Level Division
I Submental (1a)
Submandibular (1b)
II Upper Jugular
III Mid Jugular
IV Lower jugular
V Posterior triangle group:
Spinal accessory (Va)
Transverse cervical chain (Vb)
VI Prelaryngeal
Pretracheal
Paratracheal
VII Nodes of upper mediastinum
75. Examination of nodes
• For head and neck malignancies
• Systematic approach
• Better palpated while standing at the back of
patient
• Neck slightly flexed
77. Lymphadenopathy
Neoplasm – Lymphoma
• 1° malignant tumour of lymphatic tissues
• Both Hodgkin’s & non- Hodgkin’s lymphoma
• present with cervical lymphadenopathy
– Can occur at any age
– Presents with painless, rubbery lymphadenopathy often in the
posterior triangle, & sometimes nodes in the axillae & inguinal
areas.
– Systemic symptoms such as fever, night sweats, fatigue, and
weight loss may occur, and hepatosplenomegaly is an associated
finding
• Excision biopsy is often required to confirm dx
Tx : chemo- &/or radiotherapy
78. Secondary metastasis
• Lymph node metastases usually present as a unilateral
progressive swelling of single or multiple nodes.
• Any lymph nodes group can be involved depending on the site of
1° site of primary malignancy:
1. Upper cervical LN :
o Commonly involved in malignancies of upper
aerodigestive tract
2. Accessory chain of nodes in posterior triangle :
o Nasopharyngeal malignancies
3. Nodes in supraclavicular area :
o Possibility of an infraclavicular 1° in lung, breast,
stomach, colon, kidney, ovary & testis
• Principle of management
• Identify primary lesion
• Treat with combination of surgical excision, chemotherapy
and radiotherapy
• Palliative care for terminal cases
80. 80
Lymphadenitis
• Very common, especially during 1st decade
• Marked tenderness, torticollis, trismus, and
dysphagia
• Systemic signs of infection
• Initial treatment - directed antibiotics
• Close follow up
81. 81
Lymphadenopathy
• Failure of antibiotics necessitates biopsy after
complete head and neck work-up
• FNAC indications
– Progressively enlarging nodes
– Solitary, asymmetric nodal mass
– Supraclavicular mass
– Persistent nodes without infectious signs
82. 82
Granulomatous Lymphadenitis
• Develop over weeks and months
• Minimal systemic complaints or findings
• Firm glands, fixation and injection of skin
• Common etiologies
– Typical Mycobacterium tuberculosis (adults)
– Atypical Mycobacterium tuberculosis (children)
– Cat-scratch fever (Bartonella henselae)
(children)
– Actinomycosis, Sarcoidosis
83. 83
Granulomatous Lymphadenitis
• Atypical TB
– Anterior triangle lymph nodes
– Induration and pain
– Usually responds to complete surgical excision
• Typical TB (rarely seen, posterior nodes)
84. Patients with a clinical history of any of the following may be at risk for developing
lymphadenitis:
• Symptoms of an upper respiratory tract infection, sore throat,
earache, coryza, conjunctivitis, or impetigo
• Fever, irritability, or anorexia
• Contact with animals, especially kittens or livestock
• Recent dental care or poor dental health
• Physical examination findings suggestive of infection are as follows:
• Soft
• Fluctuant
• Tender
• Overlying erythema
86. Investigation
Laboratory studies are as follows :
• Gram stain of aspirated tissue - To evaluate bacterial etiologies
• Culture of aspirated tissue or biopsy specimen - To determine the causative
organism and its sensitivity to antibiotics
• Monospot or Epstein-Barr virus (EBV) serologies - To confirm the diagnosis
of infectious mononucleosis
• Bhenselae serologies - To confirm the diagnosis of catscratch disease (if
exposed to cats)
• Skin testing or purified protein derivative (PPD) - To confirm the diagnosis
of tuberculous lymphadenopathy; alternative is interferon-gamma release
assays (IGRA)
• CBC count - Elevated WBC count may indicate an infectious etiology
• Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) - Elevated
ESR and CRP are nonspecific indicators of inflammation
• Liver function tests - May indicate hepatic or systemic involvement; elevated
transaminase levels can be seen in infectious mononucleosis
Imaging Studies
• Ultrasonography may be useful for verifying lymph node involvement and
taking accurate measurements of enlarged nodes.
Treatment
Treatment depends on the causative agent and may include expectant
management, antimicrobial therapy, or chemotherapy and radiation (for
malignancy).
Superficial cervical fascia covered the platysma muscle
important in the body's acute adaptation to fluctuating concentrations of oxygen, carbon dioxide, and pH. The carotid body protects the organs from hypoxic damage by releasing neurotransmitters that increase the ventilatory rate when stimulated.
