for PG

1. BENIGN NECK DISEASE
Dr Raju Kafle
3rd year Resident
NMCTH, ORL-HNS Dept.
1

2. Introduction
• Common occurrence
• Congenital or acquired
• FNAC/FNAB ± USG GUIDED : gold standard investigation
Neck masses
Adult
 75% : neoplastic
 80% are metastatic
 75% metastatic neck masses are due to
primary tumor , above clavicle
Children
• 90% are benign
upto 55% : congenital
2

3. LYMPHANGIOMA
• Benign slow growing vascular lesions
• Composed of dilated lymphatic channels or cysts
lined by endothelial cells
1. Simple/ capillary 2. Cavernous
(Painless rubbery swelling)
3. Cystic hygroma
3
Congenital

4. 1. Simple/capillary type
• Thin walled capillary sized lymphatics
• Asymptomatic
• Pale-pinkish, small vesicle like lesions in oral cavity or skin
2. Cavernous type
• 40%
• Dilated lymphatic spaces, often with fibrous adventitia
• Typical location: tongue, cheeks and lips
• Painless diffuse swelling
• If in neck : subcutaneous rubbery like nodules
4

5. 3. Cystic hygroma ( macrocystic LM)
• Collections of large, interconnected lymphatic cysts lined by thin endothelium
• At birth, shortly afterwards, or in adults as recurrence
• large, poorly delimitated, soft mass covered by skin, cystic, transilluminant
• If large: stridor, tracheal displacement or mediastinal widening
• gradually increase in size : suggests internal haemorrhage or infections
• M/c : cervicofacial, axilla and lateral chest wall
• Few mm to several cm
5

6. • Derived from venous system
• 6 primitive sacs ( 2 jugular , 2 posterior sciatic
sacs, Single retroperitoneal and cisterna chyli)
• Endothelial buds from these extend centrifugally
to form peripheral lymphatic system
Theories
1. sequestration of lymphatic tissue
2. Endothelial fibrillar membrane proliferation
6

7. Diagnosis: Clinical grounds + CT and MRI : accurate
size, exact anatomical location, relationship with other
important structures + aids surgical planning.
Treatment:
• Observations: upto 15% - spontaneous regression
• Repeated aspirations : pressure symptoms
• Sclerosing agents : bleomycin , tetracyclines,
alcohol, boric acid ,silver nitrates
• OK-432( PICINABIL): is a lyophilized mixture of
group A S.pyogenes
Surgical : treatment of choice.
7
15 units
1 unit =1mg
0.5mg/kg : upto
10 units at a
time
Price : NRS 700-
1400
OK-432: 0.01-0.05 mg/ml—6-12
weeks apart—4 injection (mostly)

8. OK 432
• 90% resolution after first dose
• 100% after 2nd dose
( Ref: OK-432: an effective sclerosing agent for treatment of lymphangioma of head and neck. D K Baskota et al KUMJ 2007)
8

9. DERMOID CYST
• 3 types: Epidermoid, true dermoid and teratoid cysts
• 20% all dermoid cysts : neck , 28% of all midline neck swelling, M=F
• Epidermoid cysts: M/c , contains only skin , squamous epithelium with or
without keratinous material.
• True dermoid cysts: squamous epithelium, skin and appendages (hair, hair
follicles, sebaceous and sweat glands )
• Teratoid cysts: squamous or respiratory epithelium, all 3 embryological
elements; ectodermal, endodermal and mesodermal (nails, teeth, brain and
glandular tissue)
9

10. AETIOLOGY:
• Ectodermal differentiation of multipotential cells trapped along the lines of fusion,
usually midline
• Other fusion areas: external angular dermoid and nasal dorsum.
CLINICAL FEATURES
• The peak age : second and third decade.
• cystic or solid painless mass, usually in submental region, above or below the
mylohyoid muscle.
• Can be infected.
10

11. DIAGNOSIS AND INVESTIGATIONS
• Diagnosis is suggested by the patient’s age, the clinical location, and nature of
presentation.
• Ultrasound-guided FNAC.
• CT and MRI : extent of large lesions, and aids surgical planning.
TREATMENT
• Complete surgical excision is the treatment of choice.
11

12. • M/c upper neck midline lesion
• Almost 1/3rd of all congenital neck masses.
• Can present as a mass/ lump, at any level b/w
foramen caecum and the upper mediastinum
• Majority presenting about the level of the hyoid
bone.
Thyroglossal cysts
12

13. • Usually sporadic, rare familial variant : AD
• Arise from epithelial cells that must become
inactive— gets active
• stalk usually atrophies during 6th week- If persist :
thyroglossal duct then cysts.
• Courses: up from thyroid gland, then inferiorly,
upwards and in the region of the hyoid bone
• At hyoid : either behind, through or in front of the
hyoid
• Then ends deeply in the junction of the anterior 2/3rd
and posterior 1/3rd of tongue (foramen caecum)
13

14. • A fistula usually arises from spontaneous drainage of an
abscess
• Following attempted drainage of a misdiagnosed midline
neck abscess (most common)
• or as a result of inadequate surgical excision associated
with leaving an intact hyoid bone.
14

15. CLINICAL FEATURES
• Majority (~95%) : asymptomatic cystic mass
• Moves on swallowing and protrusion of the
tongue.
• 5%- infected, 15% - discharging fistula.
• M=F.
• Mean age: 5 years, range: 4 months - old age.
• 90% - midline ; 10% either side -- 95% in left side
• Sb 8th edi: 75% are pre-hyoid with the remaining
25% located above or below the hyoid
2.1%
24.1%
60.9%
12.9%
rare
15

16. INVESTIGATIONS
• TFT
• TSH and T4 levels : thyroid status of the patient.
• USG :
• location and diagnosis of cyst
• confirm the presence of normal thyroid gland.
• FNAC
• cystic contents containing colloid.
• Rule out carcinomas
• Isotope scan (Tc99 or I123)
• presence of lingual thyroid.
• CT or MRI scanning
• If large cysts –to r/o malignancy
• lingual thyroid .
Calcification in thyroglossal duct cyst :
papillary carcinoma
16

17. TREATMENT
• Surgical excision : treatment of choice
• Schlange procedure : Only cyst excision with no hyoid, infection and
recurrence: 85%
• The Sistrunk procedure (1920) and modified sistrunk procedure
• Modified Sistrunk technique : currently employed as standard procedure
• Modified sistrunk procedure vs sistrunk procedure:
1. No need to excise the tongue base epithelium
2. More wide en block resection of TGDC
17

18. 18

19. 19

20. Basis for removing core tongue muscle in sistrunk
procedure
1. Genioglossus
2. Geniohyoid
3. Mylohyoid
20

21. Note:
• Ducic and colleagues indicated that when a branched TGDC occurs, residual tracts
can be left behind while removing the main tract.
• An elliptical excision of the skin surrounding the fistula tract is then required,
followed by dissection carried from the fistula to the area of the hyoid bone
21

22. Carcinoma
• ranges: 6-81 years (mean =39 years)
• 85% papillary ca
• 15% ( follicular adenocarcinoma/adenocarcinoma/scc) : management
• No definitive treatment ; sistrunk + suppressive dose of thyroxine : reasonable
chance of cure
Complications:
unusual
• If present: postoperative hematoma, seroma, or wound infection.
• Inadequate or unsuccessful excision : recurrence ( upto 8% even following after
adequate surgical excision)
22

23. BRANCHIAL CYSTS
• Branchial : gills (branchial apparatus--transient
structure, 4-7 weeks -- mature into well-defined
anatomic structures.
• Incomplete closure of branchial pouches or failure
of obliteration of the branchial grooves
• smooth, firm, nontender mass anywhere from
preauricular region to the supraclavicular fossa
• lateral to the anterior midline of the neck and medial
to the sternocleidomastoid (SCM) muscle
23

24. • 19% of all paediatric cervical masses. M=F, birth-16 years ( mean - 4.1 years)
• Often manifest in young adults : 3rd decade peak, range 1-70 years, M: F =60 - 40%
• 60% -left , 40% - right, few : b/l
• In 90%-lined by stratified squamous epithelium 10% : respiratory epithelium
• 80% have lymphoid tissue in outer wall
• Contain straw-coloured fluid - cholesterol crystals.
24

25. • 3/4th : classical upper neck
• 1/4th : lower neck, parotid, pharynx and posterior triangle
Presenting features:
• Continous swelling -m/c (80%)
• Intermittent -20%
• Pain -30%
• Infection-15%
• Pressure symptoms -5%
Palpation : 70% cystic and 30% firm swelling, well
demarcated
25

26. < 10 %
> 90%
Close to thyroid gland , thyroiditis
26

27. Bailey classification of second branchial cleft cysts
• Defines anatomic location of cysts, from superficial to deep
27

28. Theories
Four theories
1. Branchial apparatus theory : remnant of pharyngeal pouches or branchial clefts,
or a fusion of these two elements.
2. Cervical sinus theory : remnants of cervical sinus of His, which if formed by the
second arch growing down to meet the fifth arch.
3. Thymopharyngeal duct theory : remnants of the original connection between the
thymus and the 3rd branchial pouch from which it takes origin..
28

29. 4. Inclusion theory
• This theory postulates that branchial cysts are epithelial inclusions within a lymph
node.
• This theory is supported by the fact that
1. Most branchial cysts have lymphoid tissue in their wall and have been reported
in the parotid and the pharynx.
2. This theory also explains why most branchial cysts have no internal opening, are
almost unknown in neonates, while the peak age of presentation is much later in
life, compared to that seen for most other congenital lesions.
29

30. INVESTIGATIONS
• USG Guided FNAC : acellular fluid with
cholesterol crystals on microscopy
• If lymph nodes are necrotic, as seen in squamous
cell carcinoma and tuberculosis
• they may be difficult to distinguish
sonographically from a second branchial cleft
cyst
• Ar that time, but FNB is usually helpful.
• CT and MRI scanning is a useful investigation for
large cysts to allow surgical planning
30

31. D/D of branchial cysts
• According to age of patients
New born
• lymphangioma (much more softer, no demarcated edge)
• dermoid cyst (very firm and tesne, well demarcated edge)
Little older child : rhabdomyosarcoma
• If tender : lymhadenititis ( tonsils, teeth, pharyngeal spaces)
15-40 years : most likely adenititis (viral/ bacterial) , TB, lymphoma, neurogenic
tumors (m/c: vagus –parapharyngeal space)
>40 years: Metastatic LN
31

32. TREATMENT
• Surgical excision is the treatment of choice
32

33. BRANCHIAL FISTULAE AND SINUSES
• Branchial sinuses /pits: open along line
b/w tragus and sternoclavicular joint at
anterior border of SCM, no internal
opening.
• Branchial fistula: skin-lined tract, opening
internally depending upon type of
anomalies
• External openings: anterior border of
SCM (middle and lower thirds)
33

34. INVESTIGATIONS
• The diagnosis is made on clinical
grounds.
• A contrast swallow or CT
fistulogram :
• determine the pathway of the
tract, differentiate a sinus
from a fistula
• and aids surgical planning
34

35. TREATMENT
• Surgical excision is the treatment of choice.
• In stepladder fashion :
• removing the mouth of the sinus with an
ellipse of neck skin.
• Then followed upwards as high as possible
and then another transverse cervical or
cervico-facial incision is made.
• Then continued to tonsillar region where the
tract usually disappears
• It should be ligated before it avulses, in order
to minimize recurrence of symptoms
35

36. 36

37. ACQUIRED NECK MASSES
37

38. • Sites bearing sebaceous glands ( hairy skin - esp beard
region and scalp)
• obstruction of duct
• Single or multiple, spherical smooth and well defined
• opening of blocked duct visible : punctum
• Creamy secreted dry material : foul smelling
• may accumulate in the centre : sebaceous horn.
• Rarely investigation needed: USG: non specific ,
FNAC: not necessary
Surgical excision once inflammation subsides/
prophylactic : TOC
SEBACEOUS CYSTS
( Epidermal inclusion cyst/keratin cyst)
38

39. ACQUIRED / IMPLANTATION DERMOID
• usually solitary
• solid and cystic areas containing skin appendages and sebaceous materials.
• penetrating injury / following surgery : resulting in implantation of dermal or
skin structures deep into the subcutaneous tissue.
• present at same site of injury
• Diagnosis made often on clinical grounds
• ultrasound-guided FNAC : If history of injury is not clear.
Surgical excision along with tractis the treatment of choice.
39

40. PILOMATRIXOMA
(calcifying epithelioma of Malherbe)
• benign tumour of prickle cell layer of skin
(Malherbe and Chenantais,1880)
• Most frequently 2nd decade of life
• 2/3rd cases : < 10 years of age , F:M=3:2
• Majority (68%) : head and neck
• Malignant transformation: very rare.
AETIOLOGY
• Unknown
• Thought to be a sequel of episode of local
inflammation or trauma
40

41. • usually solitary
• Firm, nodular superficial lesions measuring up to 3cm
in size.
• Usually no discolouration, but if situated superficially:
reddish blue color
• Diagnosis : based on clinical features.
• FNAC : If suspected
• basaloid and squamous cells, calcium deposits
and foreign body giant cells.
Surgical excision is the treatment of choice
• If the lesion is bothersome
• Doubt about diagnosis.
41

42. LIPOMA
• Benign lesions of adipose layer.
• The adipose cells are organized into large lobules
divided by loose fibrous septa.
• Painless, can be multiple -If painful :Dercum’s
disease.
• Majority : sporadic
• In the neck region: subfascial or arising within the
muscles.
• Very slow growth
• very low risk of malignant transformation.
AETIOLOGY : unknown ? Trauma to adipose layer
42

43. CLINICAL FEATURES
• usually in adults, size variable
• smooth, lobulated surface with well-defined edge
• Soft as they lie below dermis, overlying skin can be
moved above it
INVESTIGATIONS
• Characteristic appearances on USG
• FNAC: not required unless risk of malignant transformation
suspected.
• For large lipomas : CT and MRI : surgical planning.
TREATMENT
• Surgical excision is the treatment of choice
43

44. INFLAMMATORY NECK MASSES
ACUTE CERVICAL LYMPHADENITIS
• common, especially in paediatric populations.
• Due to viral or bacterial infection in upper aerodigestive
tract, ears, skin of the head and neck
• usually painful , may form abscess
• diagnosis : on clinical grounds
• If the infective episode is severe and the child requires
hospital admission
TREATMENT
Treatment is initially empirical, with supportive and broad-
spectrum antibiotic therapy, if a bacterial infection is
suspected or diagnosed.
44

45. 45
1st line 2nd line
Staph aureus Cloxacillin ( 50-100mg/kg/day)
Cefazolin 500mg-1gm TDS
Children: 25-50mg/kg/day TDS
Amoxy-clav (500-1.2gm TDS)
Children: 30-40 mg/kg/day TDS
MRSA Vancomycin IV : m BD
Children: 10-20mg/kg TDS
TMP-SMX + rifampicin ( 2tabs
per day)
Children : 8mg/kg TMP +
40mg/kg SMX BD
Anaerobes Clindamycin 600-1200 mg/day
TDS
Children : 10-20 mg/kg/day
TDS or QID
Amoxy-clav 500 mg TDS
• IV: 1.2gm TDS
Children: 30-40mg/kg/day TDS
Proteus Amoxy-clav 500 mg TDS
• IV: 1.2gm TDS
Children :30-40mg/kg/day TDS
Oral Cephalosporins
Ceftriaxone :IV
• Adults: 2gm OD or 1 gm BD
• Children : 50-75mg/kg/day
OD or BD
Ref : current ENT diagnosis , 2019

46. • Mycobacterium TB : obligate aerobe, non-spore
forming slender rod.
• Humans: only reservoir
• usually acquired through contact from TB infected
patient via air-borne transmission.
• After a short period of replication in the lungs,
silent dissemination occurs through the
lymphohematogenous system to extra-pulmonary
sites including the cervical lymph nodes.
46
TUBERCULOUS ADENITIS
(scrofula)

47. • Common in Asia and Africa, not common is USA or Europe
• 5% cases of TB develops cervical lymphadenitis
• 5-9 years (UK) but in 30% : >25 years
• Coexisting pulmonary TB : <5%
• 90% : unilateral involvement mainly jugular chain lymph nodes,
>submandibular triangle > posterior triangle.
• Lymph nodes : usually firm, painless + characteristic erythematous skin
discoloration.
• Lately : fistulae, obvious discharging sinus, or ‘cold’ abscess.
47

48. INVESTIGATIONS
• CBC :non-specific and can be normal.
• ESR : often elevated.
• Chest X-ray : mandatory, but only 20% : positive
changes.
• Soft-tissue X-rays of the neck : dystrophic
calcification characteristic of TB infection.
• Mantoux and Heaf test : >10mm
• USG : multiple, matted nodes but may be non-
specific.
• CT: peripheral rim enhancement, hyperdense
• FNAC can reveal mycobacteria: 40% of patients
48

49. • FNAC + PCR: quick and accurate diagnosis with high specificity (84%) and
sensitivity (100%)
• Excision biopsy
• Incisional biopsy : if already skin involvement is present.
• Samples: microbiology and histological analysis for definitive diagnosis.
• Microbiology analysis : may take up to 6 weeks to culture mycobacteria, which
may delay treatment.
• HIV testing is advisable in all patients
49

50. TREATMENT
• 9 -12 months of ATT
• Increasing resistance to chemotherapy : so adjusted according to sensitivity
• Surgery has a very limited role
• Only reserved for residual cases
• Or diagnostic tool only
50

51. Non-tuberculous atypical mycobacterial adenitis
(NTAM)
• Increasingly common in Western world,
• Main difference from tuberculous infection: affect otherwise healthy
immunocompetent children.
• Mycobacterium avium and Mycobacterium avium intracellulare
• Route of entry: oropharynx or eye
• from ingestion of contaminated soil
CLINICAL FEATURES
• young healthy children with multiple cervical lymphadenopathy
• without any symptoms or signs of systemic illness.
51

52. INVESTIGATIONS
• Diagnosis based on clinical suspicion
• confirmation : Isolating organism, microbiological swabs, FNAC or incisional
biopsy.
TREATMENT
• Most children: own immunity - period of observation is advisable
• Antibiotic therapy : macrolides- clarithromycin or azithromycin with or without
antituberculous therapy
• Surgical excision
• ultimate treatment of choice
• more effective than antibiotic therapy alone
52

53. INFECTIOUS MONONUCLEOSIS
• Glandular fever : EBV, usually affects adolescents and
younger adults.
• Usually from saliva, replicative infection within the
oropharynx , life-long latent infection of B cells.
• Primary EBV infection generally occurs during early
childhood.
CLINICAL FEATURES
• Primary: Asymptomatic or mild self-limiting illness-
fever, tonsillitis and lymphadenopathy.
• If delayed until adolescence - clinical syndrome of
infectious mononucleosis (fever, pharyngitis,
lymphadenopathy, especially cervical, and malaise )
53

54. • 5% : maculopapular rash
• 50% : palatal petechiae, acute bacterial tonsillitis, splenomegaly and hepatomegaly.
• In severe cases / immunocompromised patients
• AIHA, thrombocytopenia, splenic rupture, encephalitis, cranial nerve paralysis
• And acute upper airway obstruction - tonsillar hypertrophy
• Investigations: Paul Bunnel test, monospot
TREATMENT
• Mainly supportive + mandl’s paint
• Broad-spectrum antibiotic therapy : secondary strep. infections
• Corticosteroid therapy : impending airway obstruction and other complications
• Antivirals: acyclovir or famcyclovir
54

55. CERVICAL NECROTIZING FASCITIS
Rare, but life-threatening infection
• progressive necrosis of the skin and s/c tissues.
• Sources:
• odontogenic or tonsillar bacterial infection
• As a complication following deep space neck
infections or surgery.
• Streptoccocus pyogenes or viridans and mixed
anaerobes (m/c)
• Characteristic features: initial cutaneous cellulitis
with disproportionate pain that progresses to
necrosis of subcutaneous tissues and skin.
55

56. INVESTIGATIONS
• Full blood count
• USG or CT scan
• may show oedema + air pockets in skin : diagnostic
features
TREATMENT
• Early diagnosis and treatment are essential.
• If untreated may be fatal
• In patient basis: IV high-dose antibiotic therapy: aerobic
and anaerobic bacteria
• Plus debridement of all necrotic areas, is mandatory.
56

57. Chronic Cervical Lymphadenitis
• Often associated with systemic symptoms such as malaise, weight loss, anorexia
and night sweats
• Hence the clinical history is very important.
• These conditions include:
• HIV and AIDS
• sarcoidosis
• Toxoplasmosis
• Actinomycosis
• Tuberculosis (TB).
• In all cases, excluding TB, lymph node enlargement may be non-specific, hence
clinical diagnosis may be difficult
57

58. ACTINOMYCOSIS
• Actinomycosis israelii – microaerophilic, gram
+ve, anaerobic
• commensal in healthy oral cavity
• Mandible area: most common site as commensals
• Sources: dental caries and periodontitis.
CLINICAL FEATURES
• Firm to bony hard indurated mass with ill-defined
edges usually lateral to the mandible.
• Multiple sinus : discharge pus and watery fluid
containing characteristic yellowish sulphur
granules. 58

59. INVESTIGATIONS :
• Diagnosis on clinical grounds : usually typical.
• FNAC : may show sulphur granules : diagnostic.
TREATMENT
• IV benzylpenicillin or cephalosporins in high doses :at least 6 weeks.
• Antibiotic treatment for up to 1 year : resistant cases or immunocompromised
patient
59

60. Cat scratch disease
• Very rare outside USA, mainly in children and young
adults, 2 -14 years.
• Rickettsia Bartonella sp. - Bartonella henselae
• Cervical lymphadenopathy is preceded by erythematous
papulae at the site of inoculation with Systemic
symptoms and splenomegaly
• Dignosis: Serological testing and PCR
TREATMENT
• Self limiting or Antibiotics: gentamicin, ciprofloxacin,
especially azithromycin for rapid resolution
60
Rare cause of neck swellings

61. Other infections causing lymphadenopathy
 Brucellosis
• Disease of domestic animals : unpasteurized milk or direct contacts
• Brucella sps
• IP : 2-3 weeks
• Undulating fever + sweats, chills and malaise : classical with 20% cervical and
inguinal lymphadenopathy
• Rx: Doxycycline 200mg or rifampicin 900 mg daily for 6 weeks
 Toxoplasmosis
• T gondii, protozoa : ingestion of cyst excreted in faeces of infected cats,
undercooked beef or lamb
• Isolated lymphadenopathy or general symptoms
• Lab : CBC : lymphocytosis , CSF analysis ; confirmation
• Rx : sulfadimidine, pyrimethamine and folic acid 61

62. 1. Organized haematomas : Blunt or penetrating trauma of the neck
2. Castelman disease: hyperplasia of lymph nodes and capillary proliferation that usually
affects adolescents and young adults, , Kaposi sarcoma gamma herpes virus
Rx: Gancyclovir or Anti CD20 monoclonal antibody
3. Kikuchi disease: histiocytic necrotizing lymphadenopathy of autoimmune origin (
HLA class II) : self limiting disease
4. Kawasaki disease: characterized by fever, bilateral non-exudative conjunctivitis,
erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical
lymphadenopathy
• Rx: high dose aspirin and IVIG
62
Rare cause of neck swellings

63. Rosai Dorfman disease: are disorder characterized by overproduction
and accumulation histiocyte in lymph nodes M/c: neck
Kimura disease : eosionophilic hyperplastic garnuloma
63

64. References
• Scott brown otorhinolaryngology 6th and 8th edition
• Myers operative otorhinolaryngology 2nd edition
• Cummings head and neck surgery 7th edition
• Open atlas of head and neck surgery by lohan fagan
64