Al-Azhar University

Faculty of Medicine
General Surgery
Department
D.D of Mid-line Neck Swellings
 ILOs

By the end of this topic, you have to;

 approach a case of mid-line neck swelling
 Enumerate cystic & solid mid-line neck swellings
 Describe thyroglossal cyst
 Describe dermoid cyst
 Differentiate between thyroglossal & dermoid cyst
 Describe laryngeocle
 Enumerate the mid-line lymph node groups of the neck
 Differentiate the mid-line neck swellings
 Introduction

 Neck lumps are a relatively common presentation, most often due to

lymphadenopathy
 To approach a neck lump you must understand 2 basic factors:
 Anatomy
 Possible pathologies
 History; duration of symptoms is one of the most important points,
progression, pain
 Examination;
 Should include the mass itself, the rest of the neck, the skin of the
head and neck and the ENT system
 The size, consistency, tenderness and mobility of the mass provide
diagnostic clues.
 Investigations; ultrasonography, FNAC, Biopsy, CT, MRI, thyroid
function tests
 Classification
Solid;
 Submental L.Ns enlargement.
 Pre-tracheal & pre-laryngeal L.Ns enlargement.
 Nodule in the isthmus of the thyroid gland
 Median ectopic thyroid tissue
 Lipoma
Cystic;
 Thyroglossal cyst
 Dermoid cyst
 Subhyoid bursitis
 Laryngocele
 Cystadenoma of thyroid isthmus
 Ludwig’s Angina
 Cold abscess
 Pyogenic abscess
 Thyroglossal Cyst
Aetiology; patent part of remnant of thyroglosssal duct
Site; At any point of the thyroglossal track (foramen ceacum to the isthmus).
The commenest site is under the hyoid bone.
Pathology;
 The wall of cyst is lined by columnar epithelium (rich in lymphatic
tissue, so inflammation commonly occurs.
 The cyst contains clear mucoid fluid + cholesterol crystals.
Clinically;
Age; common in children.
Symptoms; mass at midline of the neck. Pain if infected. Fistula if
complicated.
Signs; rounded mass at midline of neck, tense and cystic , moves up & down
with deglutition and protrusion of tongue.
 Thyroglossal Cyst
Complication:
1- Thyroglossal fistula; acquired never congenital, due to infection
of cyst due to high lymphoid tissue or inadequate removal of the
cyst.
Discharge viscid fluid or pus, firm tract: from fistula (below) to
hyoid bone (above), the opening: crescentic due to fibrosis from
infection.
2- As any cyst (infection-rupture- hemorrhage- calcification)
Treatment; Sistrunk operation, elliptical incision over cyst or
fistula, excision of cyst or fistula, removal of entre of hyoid bone to
prevent recurrence of tissue up to foramen caecum of tongue.
 Thyroglossal Cyst
Thyroglossal cyst Infected Fistula
 Dermoid Cyst
It is a cyst lined by stratified squamous epithelium and contains sebaceous material.

Types;
 Sequestration dermoid cyst
 Inclusion demoid cyst; it happens due to inclusion of epidermis during
closure of cavity under it
 Tubulodermoid; it is from distention of remnants of embryonic ducts.
 Implantation dermoid; it is secondary to puncture wound which displace
some epithelial cells into subcutaneous tissue forming cyst

Painless cystic swelling in mid line, child 6-8y, once infected it will be painful,

Treatment; excision
Dermoid Cyst
 Laryngeocele
Def; air sac communicating with the cavity of the larynx which may
bulge outward on the neck, may be congenital or acquired in glass
blowers and singers.
Aetiology; herniation of laryngeal mucosa through thyroid membrane
due to increase intra-laryngeal pressure.
Clinically; hoarseness, stridor, midline cystic compressible resonant
swelling give expansile impulse on cough
Investigation; X-ray, CT, laryngeoscopy
Treatment;
 Laryngoscopy with CO2 laser in internal type
 External excision in external type
 Laryngeocele
Normal anatomy Laryngeocele
 Laryngeocele
X-ray CT Laryngeoscopy
 Cold Abscess
Aetiology; TB
 Complication of TB infection
 Neither cold nor abscess
 May rupture or get infected
 Management: aspiration and anti- TB drugs
Cervical Lymph nodes
Cervical Lymph nodes
 Mid-line Lymphadenopathy
Sub-mental, pre-tracheal & pre-laryngeal L.Ns enlargement
Aetiology;
 Inflammatory; Acute (Pyogenic infections, Infectious mononucleosis,
Toxoplasmosis, Infected eczema, CMV), Chronic (TB, Sarcoidosis, Syphilis,
HIV)
 Neoplastic; Primary (Hodgkins lymphoma, Non-Hodgkins lymphoma),
Secondary (Tip tongue & lip cancer, Nasopharngeal, Thyroid, Lung, Breast,
Stomach (“Troisier’s sign”)

Clinically;
 Inflammatory; swelling is painful, firm, mobile, signs of inflammation
 Neoplastic; swelling is painless, hard, may be fixed, signs of primary cancer
 Thyroid isthmus swellings
Individual isthmus lumps can occur in the thyroid due to:
 Colloid nodules
 Benign hyperplastic nodules
 Thyroid adenomas
 Thyroid cancer
 Thyroid cyst (simple cyst, or degenerative cystadenoma)

Clinically;
 Mid line swelling move up & down with swallowing at the
anatomical site of thyroid gland
Thyroid isthmus swellings
 Quiz
 How to approach a case of mid-line neck swellings?
 Enumerate cystic & solid mid-line neck swellings
 Describe thyroglossal cyst
 Describe dermoid cyst
 Differentiate between thyroglossal & dermoid cyst
 Describe laryngeocle
 Enumerate the mid-line lymph node groups of the
neck
 How to differentiate the mid-line neck swellings?
THANK YOU