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Head and NeckSurgery
Dr. Sirwan Abdullah Ali
University of Sulaimani
Faculty of Medical Sciences
School of Medicine
Dr.med.Univ., FACH, ASO, IFSO, FASMBS
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Neck LumpsA/ Congenital NL
B/ Infective NL
C/ Tumors of Head & Neck
D/ Thyroid gland disease
E/ Parathyroid gland disease
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A/ Congenital Neck Lumps1- Lymphangiomas
2- Midline Dermoid Tumours
3- Thyroglossal duct cysts
4- Thyroglossal duct carcinoma
5- Branchial cysts
6- Laryngocoele
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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
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Thyroglossal Duct Cyst
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Thyroglossal Duct Cyst
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Thyroglossal Duct Cyst
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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 %
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TDC- Pathology
Commonest sites of TDC:
- Prehyoid 75 %
- Thyroid cartilage level 15 %
- Suprahyoid 5 %
- Cricoid level 4 %
- Base of tongue 1 %
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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
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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
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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
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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)
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Treatment- Sistrunk’s Op
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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
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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
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A/ Congenital Neck Lumps1- Lymphangiomas
2- Midline Dermoid Tumours
3- Thyroglossal duct cysts
4- Thyroglossal duct carcinoma
5- Branchial cysts
6- Laryngocoele
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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
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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
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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
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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
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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
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Branchial Cysts
Treatment:
- Total excision
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A/ Congenital Neck Lumps1- Lymphangiomas
2- Midline Dermoid Tumours
3- Thyroglossal duct cysts
4- Thyroglossal duct carcinoma
5- Branchial cysts
6- Laryngocoele
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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
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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
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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
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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
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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
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Neck LumpsA/ Congenital NL
B/ Infective NL
C/ Tumors of Head & Neck
D/ Thyroid gland disease
E/ Parathyroid gland disease
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Infective Neck LumpsAcute cervical lymphadenitis
Retropharyngeal & parapharyngeal abscess
Chronic lymphadenitis
Tuberculous lymphadenitis
Sarcoidosis
Infectious mononucleosis
Toxoplasmosis
Brucellosis
Aids
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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
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Tuberculous Cervical Adenitis
- 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
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Tuberculous Cervical Adenitis
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
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Tuberculous Cervical Adenitis
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
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Tumours Of The Neck
Tumours of neurogenous origin
- Peripheral nerve Tumours
- Schwannoma - Neurofibroma
- Chemedectomas
- Glomus Vagale Tumours
Malignant neck masses
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Peripheral Nerve TumoursNeural Crest
Schwann cell Sympathicoblast
Neurofibroma Schwannoma Paraganglionic cell
Glomus Jugulare T. Ganglionic cell
Carotid B.T. (Chemodectoma) Ganglioneuroma
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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
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Peripheral Nerve Tumours
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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
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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
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Peripheral Nerve Tumour
Diagnosis:
Ultrasonography
CT scan
Angiogram is required
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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
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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
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Carotid Body Tumour (Chemedectoma)
Occur on
- Adventitia of the ascending aorta
- Aorta
- Innominate & pulmonary arteries
- Ciliary ganglion of the orbit
Carotid body cells acts as chemoreceptors (chemedectoma)
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Carotid Body Tumour (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
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Carotid Body Tumour (Chemedectoma)
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
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Carotid Body Tumour (Chemedectoma)
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
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Carotid Body Tumour (Chemedectoma)
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
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Carotid Body Tumour (Chemedectoma)
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
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Carotid Body TumourDiagnosis:
- History of a longstanding neck mass
- Physical examination
- CT scan
- Carotid angiogram (to see feeding vs., extent of tumour)
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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
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Carotid Body Tumour
Treatment:
Radiotherapy in:
- Patients who should have surgery but refuse- Poor-risk patients- In metastatic disease
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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.)
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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.
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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 %)
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Squamous Cell Carcinoma
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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.
Squamous Cell Carcinoma
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Predisposing Factors:
1- Smoking
2- Alkohol Consumption
3- HPV infection
Squamous Cell Carcinoma
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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
Squamous Cell Carcinoma
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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
Squamous Cell Carcinoma
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Basal Cell Carcinoma
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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
Basal Cell Carcinoma
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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
Basal Cell Carcinoma
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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