Neck Swellings & Neck Dissection😍

Neck Swellings

Dermoid Cyst

• Formed at lines of embryonic fusion.

• Classical site: Post auricular/outer canthus of eye.

• O/E: Fluctuant swelling.

• Imaging → Xray/CT:
• Done prior Surgery.
• To rule out intracranial extension.

• Mx: Surgery.

Implantation Dermoid

• Cause: Occurs due to injury

• Most common: After an ear piercing

• Management: Surgical excision

A. Ameloblastoma
B. Embryogenic dermoid
C. Sequestration dermoid
D. Implantation dermoid

ANS

Implantation dermoid

Angular Dermoid

• located near the medial or lateral canthus of the eye

Tubercular Cervical Lymph Node (Cold Abscess)

 

 

• Features: Collar stud/cold abscess

1. Infection:
1. Tuberculous bacilli infect the cervical lymph node (LN)
• LN involves deep fascia
• Caseous necrosis present

2. Periadenitis:
1. Inflammation around the lymph node
• Leads to matting of lymph nodes

3. Adherence:
1. Lymph nodes become adherent to fascia
• LN coalesce

4. Collar Stud Abscess:
• Cold abscess (no signs of inflammation)
• Forms below the deep fascia and pushes up to involve the superficial fascia

Diagnosis

• Features:
• Cold abscess in cervical region
• Fluctuant swelling

• Confirmation: Anti-gravity aspiration for Ziehl-Neelsen staining
• (Aspirating from below can lead to sinus tract formation)

Management

• Anti-tubercular therapy

• Mx: Anti-gravity aspiration.



• Avoid dependant aspiration.
• To prevent sinus/fistula formation.

Cystic hygroma

Management

• Initial: Aspiration.

• Definitive: Surgery.

• Nerve at Risk during Surgery:
• Spinal accessory nerve.

Features

• A/w in Turners

• Nature: Sequestered lymphatic tissue.

• Most Common Site:
• Posterior triangle of neck.
• Hygroma → Hide Posteriorly

• Characteristics:
• Fluctuant, brilliantly transilluminant
• partly compressible swelling.

Brachial Cyst

Pathophysiology:

• Persistence of cervical sinus

• Formation of cervical sinus due to:
• Fusion of 2nd and 6th branchial arches.

• Normally, this cervical sinus obliterates.

Site (Location):

• Swelling observed over the neck.

• Along the anterior border of the sternocleidomastoid (SCM) muscle.

• Specifically, at the junction of the:
• Upper 1/3rd and
• Middle 1/3rd

Clinical Features:

• Fluctuation (+): Indicating a cystic swelling.

• Transillumination (+): Suggesting fluid content.

Management:

• Fine Needle Aspiration Cytology (FNAC).

• Surgical excision.

Branchial Sinus/Fistula

Formation:

• Results from the failure of fusion between the 2nd and 6th branchial arches.

Site (Location):

• internal orifice → anterior aspect of the posterior faucial pillar just behind the tonsil.

• external orifice → lower third of the neck
• Specifically, between the:
• Middle 1/3rd and
• Lower 1/3rd
• Along the anterior border of the SCM muscle.

Management:

• Surgical excision.

Derivatives of cleft and pouches

Ectodermal cleft	ㅤ
1st	• External acoustic meatus • Outer layer of the tympanic membrane
2nd, 3rd, and 4th	• Obliterate • The 2nd arch overlaps the clefts. Persistence of cervical sinus ↳ Branchial cyst/fistula (Swelling along SCM)
Endodermal Pouches	ㅤ
1st	• Middle ear cavity • Auditory (Eustachian) tube • Inner layer of tympanic membrane
2nd	Epithelium of palatine tonsils ↳ including Crypta Magna
3rd	• Thymus • Inferior parathyroid gland • Mnemonic: Thymus third After formation • Thymus migrates down ↳ carries parathyroid along during migration
4th	Superior parathyroid gland

• Ultimobranchial body → become Parafollicular C Cells
• Derived from NCC (controversy)
• Applied: Medullary Ca Thyroid

Carbuncle

Definition

• Multiple small abscesses coalesce to form a large abscess

Clinical Presentation

• Most common: In diabetics

• Features: Multiple pus points

• Site: Most commonly the nape of the neck

Management

• Drainage with a cruciate incision (to drain all the abscesses)

Lipoma

Clinical Features

• Skin: Can be pinched over swelling (arises from subcutaneous tissue)

• Pseudo fluctuation: Swelling expands only in one axis

• Slip sign: Positive

• Dercum's disease:
• Multiple lipomas/lipomatosis
• Benign condition
• Cum there on Lips

Definition

• Encapsulated collection of fat

• (most common swelling in the body)

Management

• Observation usually sufficient

• Excision:
• If symptomatic (painful)
• If large

• Close observation:
• High potential for sarcomatous change if lipoma is in:
• Retroperitoneum
• Thigh
• Between shoulder blades

Sebaceous Cyst/
Epidermoid Inclusion cyst

Clinical Features

• Sites: Anywhere except palms and soles (no hair follicles)

• Swelling: Skin cannot be pinched over swelling (arises from skin)

• Discharge: Whitish discharge

• Pain: Sometimes present

• Punctum: Characteristic whitish center

Complications

• Inflamed: Infected sebaceous cyst

• Multiple: Seen in scrotum and scalp

• Sebaceous horn: Secretions harden to form a horn-like structure

Management

• Excision of cyst

Cock's peculiar tumor

• Infected sebaceous cyst of the scalp

Encephalocele

Carotid body tumor

• Lyre sign on angiography : Splaying of carotids.

• Highly vascular tumor.

Neck Dissection

• Incision: Mod. Schrodinger incision

Type	Description
Radical ND (Crile)	Removes = 1-5 LNs + SCM, IJV, SAN + Submandibular gland, parotid tail
Modified Radical ND	Removes = 1-5 LNs + Saves ≥ 1 structure (SAN/ IJV/ SCM) Types: • I (SAN saved) • II (SAN + IJV saved) • III (all saved) → Functional Neck Dissection Rest all same as Crile
Selective ND	Central: • Level 6 (Delphian LN); Supraomohyoid: • Levels I-III → (SOHND) Extended: • Levels I-IV → (Extended SOHND)

Type of MRND	Structures Preserved
MRND I	Spinal Accessory Nerve (SAN)
MRND II	SAN + Internal Jugular Vein (IJV)
MRND III	SAN + IJV + Sternocleidomastoid (SCM)

• NOTE: T1/T2 lesions →
• Sentinel lymph node biopsy (SLNB)
• Prophylactic ND (SOHND)
• Both offer Better prognosis.

• Complications:
• Haemorrhage
• Carotid blowout (high mortality)
• Nerve injuries:
• Ramus mandibularis/ Marginal mandibular (drooping of angle of mouth)
• SAN (shoulder dysfunction),
• hypoglossal, ansa cervicalis
• Modified Schoebinger incision
• 2 finger breadth below angle of mandible
• To prevent marginal mandibular N injury

Reconstruction Flaps

Adjuvant Therapy

• Indications:

Risk	Criteria
Major	Extranodal Involvement, Positive margins
Minor	Close margins, Multiple/large LNs, Lymphovascular Invasion, Perineural invasion, T3/T4

• Modalities:

Therapy	Indication
Radiotherapy	1 major or 2 minor risks
Chemo-radiation	Cisplatin for high risk
Immunotherapy	PDL-1 inhibitors for recurrent/metastatic SCC