Benign Neck Disease

56 Benign Neck Disease


56.1 Congenital Neck Masses


56.1.1 Lymphangiomas


• Pathophysiology


figure Normally 2 jugular sacs, 2 posterior sciatic sacs, and 1 retroperitoneal sac develop endothelial outbuddings and extend centrifugally to form lymphatic system


figure Endothelial fibrillar membranes sprout from walls of sacs, penetrate surrounding tissue, canalize it, and produce more cysts


figure Pressure of cysts forces tumour along lines of least resistance into planes or spaces between large muscles or vessels


• Types


figure Simple—thin-walled capillary sized (40%)


figure Cavernous—dilated spaces (35%)


figure Cystic hygroma—various sizes (25%)


• Locations


figure Oral 35%


figure Cervical 50 to 75%


figure Axillary 15%


• Clinical features


figure Equal sex distribution


figure No preponderance to one side


figure Age at presentation:


– 60% birth


– 75% by 1 year


– 90% by 2 years


figure Stridor with tracheal displacement


figure Brachial plexus compression with pain and hyperesthesia


figure Sudden increase in size due to haemorrhage may be fatal


• Management


figure Cryotherapy and sclerosant injection met with limited success


figure Excision required


figure Preop CT to exclude mediastinal involvement


figure Use nerve stimulator to avoid CNs VII, XI, and XII


figure Excise excess skin


figure Multiple excisions may be needed


figure External approach for intraoral lesions


figure Recurrence rate is 10 to 15%; cavernous type most likely to recur


56.1.2 Midline Dermoids


• Characteristic features


figure Always midline in neck


figure Equal sex distribution


• Epidermoid cyst


figure Most common


figure No adnexal structures


figure Contains cheesy keratinous material


• True dermoid cyst


figure Contains skin appendages—hair follicles, etc.


figure Can be acquired through implantation of epidermis in a puncture wound


figure Most occur in the floor of mouth with ¼ involving neck


figure Present as slow-growing lesions


figure Management is surgical excision


• Teratoid cyst


figure Rare


figure May be lined by respiratory epithelium


figure Contains elements from ectoderm, endoderm, and mesoderm


56.1.3 Thyroglossal Cysts


• Embryology


figure Thyroid arises from floor of primitive pharynx between 1st and 2nd pouches


figure Median thyroid anlage loses lumen at 5 weeks and breaks into fragments—lower end divides into 2 portions that become lobes


figure Stalk should atrophy at 6 weeks; if not, it becomes a duct


figure Cysts form when epithelial cells cease to remain inactive


figure Duct runs through hyoid to foramen cecum


figure Fistula results from inadequate treatment


• Presentation


figure Equal sex distribution


figure Mean age 5 (range 4 months–70 years)


figure Midline (90%), lateral (left) 10%


figure 3× more common than branchial cysts


figure 65% infrahyoid, 20% suprahyoid, 15% juxtahyoid


figure Also described intralingual, suprasternal, and intralaryngeal


figure 5% present with infection; 15% present with fistulas


figure Rare familial variants


figure Usually painless and mobile, characteristically move on swallowing and tongue protrusion due to them lying deep to investing layer of deep cervical fascia and relation to hyoid, respectively


figure May present acutely with increasing pain, neck swelling, dysphagia, dysphonia, airway obstruction, fistula, and fever


• Investigation


figure TFTs


figure Suprahyoid cysts—technetium scan ± MRI


figure USS


• Treatment


figure Sistrunk procedure with removal of central core of hyoid; stay medial to lesser cornua to reduce risk of hypoglossal nerve damage


figure 7 to 8% recur


figure Consider removal of core of central tongue musculature in recurrent cases


56.1.4 Thyroglossal Duct Carcinoma


• Suspect if cyst hard or irregular


• 4th decade in women, 6th decade in men


• Local excision and thyroxine suppression


• Adjuvant thyroidectomy and radioiodine may be needed


56.1.5 Branchial Cysts (Fig. 56.1)


• Embryology


figure Remains of branchial clefts/pharyngeal pouches


figure Cervical sinus theory—remains of cervical sinus of His persist


figure Thymopharyngeal duct theory—remnants of original connection between thymus and 3rd branchial pouch


figure Inclusion theory—epithelial inclusions in lymph nodes


figure 1st arch 5 to 25%


figure 2nd arch 40 to 90%


figure 3rd/4th 2 to 8%


• Pathology


figure Stratified squamous epithelium


figure 80% have lymphoid tissue in wall


figure 2 types of 1st-arch anomalies:


– Dorsal—runs medial to conchal cartilage extending posteriorly to retroauricular scalp


– Ventral—presents as sinus/cleft/fistula inferior to cartilaginous EAM


• Clinical features


figure 3 male:2 female


figure Peak age 3rd decade (range 1–70 years)


figure ⅔ on left


figure ⅔ anterior to upper ⅓ SCM


figure Other sites (⅓):


– Middle/lower neck


– Parotid


– Pharynx


– Posterior triangle



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  4. Neck, Laryngeal, and Tracheal Trauma and Stenosis

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Jul 4, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Benign Neck Disease

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