NECK MASSES AND

FISTULAS
ASHENAFI KEFENI , MD
NOV. 30 , 2005

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 NECK MASSES AND
FISTULAS
 Ninety percent benign
 Most common causes –congenital

-lyphadenopathy
 embryology & anatomy
 Correct Dx _Hx , P/E

size fixation
shape compressibility
site pulsation 2
 Cont’d …
Commonly used Ix ;
Imaging : CXR , U/S , CT / MRI
BIOPSY; - excision
- FNAC ??
THYROID SCAN
 Rx – depends on cause
excision for – congenital
-neoplastic
medical Rx for –infectious causes
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 CONGENITAL CAUSES
 Branchial cleft cysts / sinuses / fistulas
 Thyroglossal cysts / sinuses
 Cystic hygroma
 Toticollis
 Haemangiomas
 Dermoid cysts

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 Branchial cysts / fistulas
 Twenty percent of cervical masses
 Congenital epithelial cysts
 Incomplete obliteration of B.clefts
 Embryology; 4th to 8th week

branchial apparatus –cleft

-arches
-pouches
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 Cont’d, BC..
 Head & neck structures from arches & clefts
 Four pairs of branchial clefts
 1st BC persists –external ear canal
 2nd to 4th BCs obliterates
 PERSISTENCE = BC ANOMALIES

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 Types of branchial cleft cyst
1.first BC cyst ;
-near ext. auditory canal
-inf. & post. To the tragus
-stmes in parotid gland & angle of mandible

2. Second BC cyst;
-most common (95%)
-upper 3rd of SCM –commonest
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 Cont’d, BC….
- the course of 2nd B. fistula
-connects the skin & pharynx
-skin of lateral neck
-b/n int. & ext. carotid artery
-in front of hypogllossal nerve
-end in tonsilar fossa
-ten % bilateral
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Branchial cleft cysts
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 Cont’d , BC….
3. 3rd BC cyst; rare
-same course as 2nd B. fistula
-post. To carotid artery
-located deep to SCM
4. 4th brachial cleft cyst ; extremely rare
-on lateral neck
-parallels the course of RLN
-can arise in madiastinum
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 Cont’d BC …
 Clinical aspects;
-fistulas more common than sinus
-both are more common than cysts
-cysts predominate in adults
-an infected mass could be 1st presentn.
-infection more common in cysts
-cuetaneous opening , skin tag/cartilage
-tract may be palpable
-compression = mucoid discharge
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Branchial cleft
fistula 14
 Cont’d, BC…
DIAGNOSIS;
-glary mucoid discharge
-along border of SCM
-palpable tract
-cysts more difficult to Dx
Ix; -Sinogram –course of the tract & size of the cyst
-U / S -identify deep cyst
-characterize nature of contents
-type & location of cystic structure
-surgical exploration

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 Cont’d, BC…
 DDx; -cystic hygroma -subcutaneous
-transilluminate
-septation on U/s
-adenopathy (infectious/neoplastic)
-parotid lesion
-dermoids

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 Cont’d, BC…
 TREATMENT;
Goal = complete excision
If inflammation / infection;
-difficult dissection
-high chance of recurrence
-change into sinuses
-High risk of neurovascular injury injury
Rx infection first and let inflammation settle
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Excision of branchial cyst
 THYROGLOSSAL DUCT CYST

 Embryonic in origin
 Most common midline neck mass next to thyroid
 Develops from remnants of TGD
 Embryology; 4th to 7th week
TGD
thyroid gland
tongue
hyoid bone
= have intimately related in embryogenesis
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 Cont’d,TGD….
 Foramen cecum = thyroid diverticulum
 Thyroid diverticulum;
1. pharyngeal buds = tongue
2. thyroid g. descends in the neck / TGD
Hyoid bone from 2nd branchial arch
The TGD may pass in front or behind it.
By the 7th wk, thyroid descent complete
TGD obliterates
Failure to obliterate = TGD cyst
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 Cont’d, TGD…
 Clinical Aspects;
Classical site –midline
-at or just below hyoid
Can occur any where from F. cecum
to suprasternal area
Sns&Sxs; –small,soft,round mass on midline
-moves with swallowing
- Sns of inflammation if infected
-a small opening with mucus discharge
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Thyroglossal duct cyst Thyroglossal duct sinus
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 Cont’d, TGD…
 Diagnosis ; generally clinical
Ix ; - Blood tests – assess TFT
- U / S –cystic midline neck mass
-thyroid scan –show physical abnormality
DDx ; sub mental dermoid cysts – superficial
sub mental LN – U / S
Treatment:
First be sure that;
-this is not the only thyroid tissue
-no sign of infection
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 Cont’d, TGD…
 Operation ;
SISTRUNK’S PROCIDURE
-Transverse incision through the cyst
-appearance of cyst dif/t from thyroid
Xic –glary thick mucus with fibrous capsule
-continue dissection cephalad to hyoid bone
-remove central part of hyoid bone
-ligate the base of the tract at the floor of mouth
-close wound in layers
Recurrence 4 to 5 %
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 CYSTIC HYGROMA
 Cavernous lymphangioma
 Multi loculated cystic spaces
 Lined by endothelial cells
 Separated by fine walls = septation
 Inc ; - 1/ 12,000 birth

-50 to 60 % appear at birth

-80 to 90 % by the 2nd year
-75 % occur in the neck more on the Lt.
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 Cont’d ,cystic…
 Embryology ; 6th wk of dev’t
-primitive lymph sac develop (mesoblast)
= jugular lymph sacs
-sequestration of a portion of this sac
= cystic hygroma
 Clinical aspects;
-swelling in the lower third of neck
-progress towards the ear as it grows
-post. Triangle of neck often involved
-intercommunication b/n many compartments
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Cystic Hygroma Cystic hygroma
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 Cont’d, cystic…
-increases in size when coughing or crying
-Xic distinguishing features
= Tran illuminates brilliantly
 Behavior - uncertain / unpredictable
- expand rapidly
-spontaneous regression - rare
-proportional growth – most
-may become infected
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 Cont’d, cystic…
 Diagnosis;
- Hx & P/E usually sufficient
-transillumination
 Ix; CXR – evaluate chest & mediastinum
 U / S – mulitilocular
-predominantly cystic
-septa of variable thickness
CT & MRI – to see relationship of lesion with
surrounding structures

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 Cont’d, cystic…
 Complication ;
-rapid increase in size –trauma
-infection
-bleeding
= respiratory obstruction –aspiration
-tracheostomy
-dysphagia –involvement of hypophx / esoph
-erosion into a major vessel
-dental malocclusion / mandibular abnormality
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 Cont’d, cystic…
 Treatment ;
Depends on -size , location
-complication
Best Rx - complete excision at early age
Rx Cxn -recurrence
-infection
-fistula formation – chylous
-chylothorax , hemorrhage
-damage to neurovascular structures
-mortality 2 to 6 %
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 Cont’d, Cystic…
 Timing of excision ??
-Immediate to avoid Cxn
-wait until 2 to 6mths ? Regression
 Conservative Rx ;
-observation in assymptomatic pts
-if Sxs progress = Immediate Rx
-Aspiration; useful in –large unilocular cyst
-emergency decompression
- I & D to evacuate abscess
-radiotherapy -limited success

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 TORTICOLIS (WRYNECK)
 Abnormal neck posture
 Neurological or muscular
 Causes ; -cervical -congenital
-acquired
-pharyngeal infections
-ocular -squints
-visual field defects
- muscular -contructure of SCM
-habitual -no obvious reason
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 Cont’d, Tort…
 Most common type is due to ;
-Fibromatosis and shortening of SCM
 Xic -face and chin away
-head & neck towards the lesion
-palpable fibrous tissue

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 Cont’d, Tort…
 Diagnosis :
-66% of infants had a tumor in the muscle
-34% had fibrosis but no tumor
-appearance depends on
-severity of the lesion
-distribution of fibrosis
-child’s growth pattern
-with time cranial and facial abnormality
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 Cont’d, Tort…
 Treatment :
-80 % no require surgery
-early recognition & manipulation
-motion & stretching exercises
 Indication for operation;
-dev’t of facial hemihypoplasia
 Operation ; divide the muscle at its
- upper or lower end of SCM or
-both sides or
-middle third –simplest
 Postop physiotherapy-full rotation & extension
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 INFLAMMATORY CAUSES OF
NECK MASSES

 Enlarged LN most common cause

 Majority- non-specific reactive hyperplasia
 Ant. Cervical nodes drain the mouth & phx
 URTI affect this nodes
 Cervical LNs are palpable b/n 2-10yrs
 But uncommon in infants = significant

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 Cont’d, Inflam…
 Causes :
1.acute supurative cervical lymphadenitis
-most common cause
-bacterial infection – oropharynx
-most common organisms;
-PRSA
-strept. Hemolyticus
 Dx ; clinical –hot,tender,fluctuation & fever
 Rx ; - needle aspiration or I & D
-antibiotics
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Acute suppurative lymphadenitis
 Cont’d, Inflam…
2.Chronic lymphadenitis
 nodes enlarged but not inflamed
 fluctuation unlikely or much slower
 two wks course of antibiotics
 if a single dominant LN persist for more
than 6 – 8wks = excise completely
-culture
-histological exam

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Chronic lymphadenitis 43
 Cont’d,Inflam…
3.mycobacterial lymphadenitis
 -caused by M.tbc
-extension from pul. Tbc
-raw milk ingestion
 -usually involves the supraclavicular LN
 Dx ; -family Hx , Sx complex of tbc
 Ix ; -CXR , PPD
 Rx ; -antiTb
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 NEOPLASTIC CAUSES
 Neoplastic neck masses :
benign - lipoma
-goiter -endemic , Graves ds , hashimot’s ds
malignant – primary –neuroblastoma
-rhabdomyosarcoma
-lymphoma (HL & NHL )
-thyroid Carcinomas
- secondary - rare
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 Neuroblastoma (in the neck)
 Firm and solitary
 Difficult to diff/t from cervical LN
 Horner’s syndrome
 May grow from primary mediastinal tumor
 Dx ; -hematology ; CBC , RFT,LFT,
- urinary catecholamines
- CXR , U / S , CT - neck
-thorax
-abdomen
- Biopsy -excisional
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 Cont’d , Neurb…
 Treatment :
As a team – surgeon
-chemotherapist
-radiation therapist
-pathologist
SURGERY plus ADJUVANT Rx
Surgical Rx ; -diagnostic - biopsy
-therapeutic –complete excision
-partial excision
-palliative
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 Rhabdomysarcoma
 Third most common neck tumor after HD & NHL
 Most common malignant STT of H & neck
 Rapidly growing
 Painless neck mass
 Dx ; Biopsy
 Rx ; - excision of as much of the tissue

-followed by -radiation and

-chomotherapy
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 Lymphoma
 Most common malignant T of the neck
 Both HD & NHL affect equally
 Multiple , firm , rubbery cervical LAP
 Dx ; Biopsy
 Rx ; -radiation , for localized disease &

-chemotherapy for systemic or diffuse

-place of surgery ; -Dx - Biopsy
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 Thyroid Masses
 More than 80 % benign
 Benign - endemic goiter

-Hashimoto’s thyroiditis
-Grave’s disease
-follicular adenoma
 Malignant masses – papillary ca

-medullary thyroid ca
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 THANK YOU !!

ASHENAFI KEFENI , MD
NOV. 30 , 2005

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 INFLAMMATORY CAUSES OF
NECK MASSES

 Enlarged LN most common cause

 Majority- non-specific reactive hyperplasia
 Ant. Cervical nodes drain the mouth & phx
 URTI affect this nodes
 Cervical LNs are palpable b/n 2-10yrs
 But uncommon in infants = significant

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 CONGENITAL CAUSES
 Branchial cleft cysts / sinuses / fistulas
 Thyroglossal cysts / sinuses
 Cystic hygroma
 Toticollis
 Haemangiomas
 Dermoid cysts

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 NEOPLASTIC CAUSES
 Neoplastic neck masses :
benign - lipoma
-goiter -endemic , Graves ds , hashimot’s ds
malignant – primary –neuroblastoma
-rhabdomyosarcoma
-lymphoma (HL & NHL )
-thyroid Carcinomas
- secondary - rare
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 REFFERENCES :
1. ASHCRAFT , HOLDER
PEDIATRIC SURGERY –2ND EDITION
2. OXFORD TEXT BOOK OF SURGERY
Peter J. Morris & Ronald A Malt - 1995
3.SABISTON – 15TH EDITION
4. BAILEY & LOVE’S SHORT PRACTICE
OF SURGERY – 23RD EDITION
5. SCHWARTZ PRINCIPLES OF SUGERY
7TH EDITION
6. INTERNATE REVISION
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