Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS.

Head and NeckSurgery

Dr. Sirwan Abdullah Ali

University of Sulaimani

Faculty of Medical Sciences

School of Medicine

Dr.med.Univ., FACH, ASO, IFSO, FASMBS

Neck LumpsA/ Congenital NL

B/ Infective NL

C/ Tumors of Head & Neck

D/ Thyroid gland disease

E/ Parathyroid gland disease

A/ Congenital Neck Lumps1- Lymphangiomas

2- Midline Dermoid Tumours

3- Thyroglossal duct cysts

4- Thyroglossal duct carcinoma

5- Branchial cysts

6- Laryngocoele

Thyroglossal Duct Cyst

Commonest midline neck cyst

Remnant of the thyroglossal duct

Embryologically arises from the foramen caecum

Can occur anywhere in the area bounded by:

- the foramen caecum above

- the manubrial notch inferiorly

- the anterior border of the sternocleidomastoid muscle laterally




TDC- Pathology

Men & women are equally affeced

Age range is (4 months – 70 years)

90 % are in the midline

10 % are to one side

- Left 95 %

- Right 5 %

TDC- Pathology

Commonest sites of TDC:

- Prehyoid 75 %

- Thyroid cartilage level 15 %

- Suprahyoid 5 %

- Cricoid level 4 %

- Base of tongue 1 %

TDC- Pathology

The duct is always subcutaneous

Spontaneous fistula formation is rare

A fistula is usually the result of- infection

- attempted drainage of misdiagnosed abscess

- inadequate removal of the hyoid bone

Cyst & duct are lined by squamous epith.

Thyroid tissue is rarely found in the wall

TDC- Clinical Features95 % present with a painless cystic lump, which

moves on swallowing or protruding the tongue

5 % present with tenderness & rapid enlargement due to infection

Difficulty in Breathing may happen

Dysphagia

The cyst is mobile in all directions

Translumination is positive

Fistula is present in 15 % of cases, & is usually the result of a previous operation or infection

TDC- Clinical Features

Supra-hyoid cysts may be mistaken for submental lymphadenitis, or a dermoid cyst

Pre-hyoid cysts are nearly always dumb-bell or bar shaped & can push the base of the tongueupwards causing dysrthria

Cysts near the surface of the tongue base must be distinguished from a lingual thyroid or a carcinoma

Cysts low in the neck must be differentiated from a thyroid adenoma by a thyroid scan, from a sebaceous cyst or lipoma

TDC- TreatmentAlthough benign, TDC should be removed

(Sistrunk’s Operation)

Even if symptomless, the cyst should be removed to eliminate the chance of infection or carcinoma

For cosmetic reason

Sistrunk’s procedure:

- Excision of the cyst

- excision of the path (tract)

- Excision of the central part of the hyoid bone (to ensure complete removal of the tract)

Treatment- Sistrunk’s Op

Thyroglossal Duct Carcinoma

Very rarely, a persistent Thyroglossal duct can become cancerous, called thyroglossal duct carcinoma

In this case the cancerous cells are ectopic thyroid tissue that has been deposited along the thyroglossal duct and will present as a papillary carcinoma (always)

Present as a cyst, & diagnosis is only made by histology

There is a slight female preponderance

Thyroglossal Duct Carcinoma

Peak age incidence for women is 30-40 years

Peak age incidence for men is 50-60 years

40 – 50 % Carcinoma arise in an ectopic thyroid tissue

Only 10 % have metastases

Treatment:

- Local excision of cyst

- Thyroidectomy

- Followed by suppressive doses of thyroxine





5- Branchial cysts

6- Laryngocoele

Branchial Cysts

There are 4 theories of the origin of branchial cysts:

1- Branchial apparatus theory

2- Cervical sinus theory

3- Thymo-pharyngeal duct theory

4- Inclusion theories

Branchial Cysts

1/ Branchial apparatus Theory:

Represents remnants of the pharyngeal pouches or branchial clefts, or a fusion of these two elements

2/ Cervical Sinus Theory:

Represents remnants of the cervical sinus of His which is formed by the second archgrowing down to meet the fifth

Branchial Cysts

3/ Thymo-pharyngeal Duct Theory:

Represents remnants of the original connection between the thymus and the third branchial pouch

4/ Inclusion Theories:

Suggests that the cyst epithelium arises from lymph node epithelium, or cysts are the result of epithelial inclusion in lymph nodes

Branchial Cysts

Clinical features:

60 % in men, 40 % in women

Peak age incidence is 3rd decade

75 % on the left side

2 % are bilateral

2/3 are anterior to sternomastoid in the upper third of the neck

Branchial Cysts

Clinical features:

Continuous swelling 80 %

Intermittent swelling 20 %

Pain 30 %

Infection 15 %

Pressure symptoms 5 %

** 70 % are cystic on palpation, 30 % are solid

Branchial Cysts

Treatment:

- Total excision





5- Branchial cysts

6- Laryngocoele

LaryngoceleIs a large air-containing

sac arising from the laryngeal saccule

Incidence 1: 2,5 mil.

Sex 5:1 (men:women)

Peak age incid. 50-60y.

82% occur in Caucasians

85 % are unilateral

30 % external, 20 % internal, 50 % mixed

Laryngocele

Pathology:

It has long been held that laryngocele are due to ,,blowing’’ hobbies or jobs such as trumpet playing or glass blowing but this is untrue

More important is the co-existence of a carcinoma of the larynx which acts as a valve allowing air under pressure into the ventricle

Laryngoceles are lined by columnar ciliated epithelium whereas simple laryngeal cysts are lined by squamopus epithelium

LaryngoceleClinical Features:

The commonest presenting features are hoarseness & swelling in the neck

Stridor which can come on very suddenly over a period of few days or even hours

Dysphagia

Sore throat

Snoring

Pain

Cough

Laryngocele

Clinical Features:

10 % present with infected sacs-pyocele

Because of mix of air & pus on X-ray (gas gangrene)

Plain X-ray is diagnostic (air-filled sac)

All patients with Laryngocele should have Laryngoscopy to exclude carcinoma

Laryngocele

Treatment:

All Laryngoceles should be removed bec. Of the danger of laryngeal obstruction

If patient presents with a pyocele, this should be treated with antibiotics before surgery

Neck LumpsA/ Congenital NL

B/ Infective NL

C/ Tumors of Head & Neck

D/ Thyroid gland disease

E/ Parathyroid gland disease

Infective Neck LumpsAcute cervical lymphadenitis

Retropharyngeal & parapharyngeal abscess

Chronic lymphadenitis

Tuberculous lymphadenitis

Sarcoidosis

Infectious mononucleosis

Toxoplasmosis

Brucellosis

Aids

Tuberculous Cervical Adenitis

The Bacillus reaches the lymph node by direct drainage or haematogenous spread

The incidence of co-existing TB is less than 5 %

50 % of the excised tonsils showed evidence of TB


- Patients give usually long history, & seeks medical advice because The lump have becomes painful

- 20 % have discharging sinuses

- 10 % cold abscess

- Patients usually have negative chest X-ray


90 % are unilateral

90 % involve only one node group, commonest is the deep jugular chain followed by the submandibular group

Diagnosis

- Positive tuberculin skin test

- Demonstration of acid-fast bacilli in biopsy

- Growth of mycobacterium tuberculosis


Treatment:

Excisional biopsy

6-9 months anti-tuberculous chemotherapy

If the nodes are very large & matted, local removal is dangerous since the nodes are often attached to the internal jugular vein

In children it is usually wise to remove & examine histologically the tonsils before removing the nodes

If removal is not followed immediately by chemotherapy a sinus forms with persistent drainage & later ugly scar

Tumours Of The Neck

Tumours of neurogenous origin

- Peripheral nerve Tumours

- Schwannoma - Neurofibroma

- Chemedectomas

- Glomus Vagale Tumours

Malignant neck masses

Peripheral Nerve TumoursNeural Crest

Schwann cell Sympathicoblast

Neurofibroma Schwannoma Paraganglionic cell

Glomus Jugulare T. Ganglionic cell

Carotid B.T. (Chemodectoma) Ganglioneuroma

Peripheral Nerve Tumours

Schwannoma Neurofibroma

Solitary Usually occurs as part of the syndrome of multiple neurofibromatosis

Never associated with (von recklinghausen’s syndrome)

Often associated with (von Recklinghausen’s syndrome)

Painful & tender Asymptomatic

Encapsulated Non-encapsulated

Seldom malignant 8 % malignant

Peripheral Nerve Tumours

Peripheral Nerve TumourClinical Features:

Nerve Tumours are rare, forms only 1 % of all head & neck tumours

These tumours enlarge slowly over years with no symptoms & a painless neck mass as the only sign

The T. remains benign with no interference with nerve function apart from pressure on the sympathetic chain which soon shows as Horner’s syndrome

Even when the tumour becomes malignant & reaches a large size the nerve may still function properly

Horner’s Syndrome

Ptosis (droping of eyelid)

Miosis (constriction of pupil)

Anhidrosis (decreased sweating) of the face on same side

Redness of the conjuctiva

Enophthalmos

Peripheral Nerve Tumour

Diagnosis:

Ultrasonography

CT scan

Angiogram is required

Peripheral Nerve TumoursTreatment:

Total excision

Every effort should be made to preserve the nerve

Postopeartive neuromas must be excised to distinguish them from recurrent cancer

In malignant nerve T., best is to do en bloc excision of the area

Carotid Body Tumour (Chemedectoma)

Nests of non-chromaffin paraganglionic cellderived from the neural crest

Occur on

- Carotid bulb

- Jugular bulb

- Cavity of the middle ear

- Ganglion nodosum of the vagus nerve


Occur on

- Adventitia of the ascending aorta

- Aorta

- Innominate & pulmonary arteries

- Ciliary ganglion of the orbit

Carotid body cells acts as chemoreceptors (chemedectoma)


Pathology:

High incidence in high altitude such as Peru, Colorado & Mexico city (2000-5000 m),

Because of chronic hypoxia leading to carotid body hyperplasia

Average presentation age 35-50 y. (youngest reported case was 12 y. old)

Equal sex incidence

Striking Family history in 10 % of cases


Pathology:

Tendency to bilateral tumours

The tumour is firmly adherent to the bifurcation of the common carotid artery

Seldom grows to more than 4-5 cm

These are non-secreting T.

Metastases are very rare


Clinical features:

All Patients present with with a painless lump in the neck, palpable in the region of the carotid bulb

The lump move from side to side but not up & down

Always a long history (4-5-7 y.) which is helpful in differentiating it from lymphoma or metastatic node

About 30 % present with a pharyngeal mass pushing the tonsil medially & anteriorly (should not be biopsied)

Normal site of growth is from the inner aspect of the notch of the bifurcation


Clinical features:

Normal site of growth is from the inner aspect of the notch of the bifurcation of the carotid artery causing displacement & separation of the internal & external carotid arteries

If the growth occurs mainly on the medial site, a pharyngeal swelling occur with no lateral neck swelling

The T. may grow up the vessels to the base of the skull


Clinical features:

The mass is firm & rubbery & usually demonstrates transmitted rather than expansile pulsation

A bruit may be present

Rarely patients complain of dysphagia or discomfort

Large T. may involve 9th, 10th, 11th & 12th cranial nerves, accasionally the sympathetic chain causing a Horner’s syndrome

Carotid Body TumourDiagnosis:

- History of a longstanding neck mass

- Physical examination

- CT scan

- Carotid angiogram (to see feeding vs., extent of tumour)

Carotid Body Tumour

Treatment:

Surgical removal is indicated:

- Malignant & resectable T.- Patient in a good health, < 60

with a small or medium sized T.

- Those T. which have extended into the pharynx & palate & are interfering with swallowing, breathing & speaking

Carotid Body Tumour

Treatment:

Radiotherapy in:

- Patients who should have surgery but refuse- Poor-risk patients- In metastatic disease

Glomus Vagale Tumour

Extremly rare

Presents as a mass at the angle of the jaw (too high for a branchial cyst, too low for parotid tumour

Some cause pain & discomfort or pharyngeal M.

Dx. by angiography

Removal is much more difficult than carotid B.T. (vascular S.)

Malignant Neck MassesIn the Neck, the main malignant problem to be

considered is secondary carcinoma metastatic to the lymph nodes

Most carcinomas of the head & neck sooner or later metastasize to the lymph nodes of the neck

These LN form a barrier that prevents further spread of the disease for many months

Most common carcinoma of the head region are basal cell ca. & squamous cell ca.

Non-thyroid Neck Masses in an Adult

Neoplastic (85 %)Inflammatory/congenital (15 %)

Malignant (85 %) Benign (15 %)

Metastatic (85%) Primary (15%): lymphoma, salivary g.

Primary cancer site Primary cancer site belowabove clavicle (85 %) clavicle (15 %)

Squamous Cell Carcinoma

Is a cancer of a kind of epithelial cell, the squamous cell which are the main part of the epidermis of the skin

It is one of the major forms of skin cancer, & seen mainly on the lips & mouth

SCC of the skin begins as a small nodule and as it enlarges the center becomes necrotic and sloughs and the nodule turns into an ulcer.


Predisposing Factors:

1- Smoking

2- Alkohol Consumption

3- HPV infection


Clinical Features:

90 % of cases of head and neck cancer (cancer of the mouth, nasal cavity, nasopharynx, throat and associated structures) are due to squamous cell carcinoma

The lesion caused by SCC is often asymptomatic

Ulcer or reddish skin plaque that is slow growing

Intermittent bleeding from the tumor especially on the lip

The clinical appearance is highly variable,usually the tumor presents as an ulcerated lesion with hard, raised edges

The tumor commonly presents on sun-exposed areas

Unlike basal cell carcinoma (BCC), squamous cell carcinoma (SCC) has a substantial risk of metastasis


Clinical Features:

A hoarse voice sometimes present in cases of ulcer in the oral cavity, near the pharynx

Treatment:

1- Surgery ( extensive excision may be necessary)

2- Radiotherapy


Basal Cell Carcinoma

is the most common cancer

It rarely metastasizes

However, because it can cause significant destruction and disfigurement by invading surrounding tissues, it is still considered malignant

Patients present with a shiny, pearly nodule. However, superficial basal-cell cancer can present as a red patch like eczema


Diagnosis:

- is by skin Biopsy

Treatment:

1- Surgical excision: most preffered

2-Chemotherapy: Some superficial cancers respond to local therapy with 5-fluorouracil

3-Immuntherapy: research suggests that treatment using Euphorbia peplus, a common garden weed, may be effective


ReferencesCurrent, Surgical Diagnosis & Treatment, Gerard

M. Doherty

Essential Surgical Practice, A. Cuschieri, G R Giles, A R Moosa

Bailey & Love’s, Short Practice of Surgery, R.C.G. Russell, Norman S. Williams, Christopher J.K. Bulstrode

Clinical Surgery, A. Cuschieri, Thomas P.J. Hennessy, Roger M. Greenhalgh, David I. Rowly & Pierce A. Grace

Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS.

Documents

thyroglossal duct cyst

infection slide

thyroglossal duct cysts

tract slide

laryngocoele slide

fasmbs slide

wall slide

lipoma slide