neck triangles , swellings and lymphatics

The NeckBy:

Tamer Rushdy EL-AlfyAssistant lecturer of general surgery

Neck triangles .

Neck swellings

Thyroglosal cyst.

Branchial cyst

Lymph nodes of the neck.

AnatomyAnatomy

Each sides of the neck is divided by sternomastoid muscle in to two main triangles :-

1. The anterior triangle.

2. The posterior triangle.

CYSTCYST

Means a swelling consisting of a collection of fluid in a sac which is lined by epithelium or endothelium

FISTULAFISTULA

Is an abnormal communication between two epithelial surface

SINUSSINUS

Is a blind track lined with granulations leading from an epithelial surface in to the surrounding tissues .

Swelling in the carotid triangleSwelling in the carotid triangle Solid :

Deep cervical L.Node.

Enlarge lateral lobe of thyroid gland.

Carotid body tuomour.

Cystic:

Cold abscess.

Brancheal cyst.

Swelling in the posterior triangle Swelling in the posterior triangle Solid :

L.Node enlargement .

Neurofibroma.

Cervical rib.

Cystic:

Cystic hygroma.

Cold abscess.

Pneumatocele.

OthersOthers Swelling of skin & subcutaneous

tissues:

As lipoma .

Sebaceous cyst .

haemangioma.

Carotid body tuomourCarotid body tuomour

Rare .

Slow growing malignant tuomour.

Arise from the chemoreceptor at the bifurcation of carotid artey.

Usually occur at middle age .

Usually smooth but may be lobular.

Move side to side but not vertically.

Exhibit transmitted pulsation from underlying carotid artery.

Thyroglossal duct cyst

The thyroglossal duct cystThe thyroglossal duct cyst

It is a remnant of the diverticulum formed by migration of thyroid tissue from foramen cecum at the base of the tongue through the hyoid bone to its final position around the tracheal cartilage .

The thyroglossal duct cystThe thyroglossal duct cyst

Failure of subsequent closure and obliteration of this tract predisposes to thyroglossal cyst formation.

Is a rare but occasional cause of a benign neck mass.

Almost always in the midline.

site: 20% are suprahyoid. 15% occur at the hyoid . 65% are infrahyoid.

Present by the age of 10 in 50% of cases. but may be found in the older population as well.

No sex predominance .

size: It measure about 0.5-5cm in diameter, and

gradually ↑ in size.

It is painful if increase in size or became infected

Asymptomatic

Hot , red & tender if infection present.

Consistency:

Firm to hard

Movement:

Upward by deglutition, & protrusion

of the tongue.

Diagnosis is usually made clinically.

Thyroglossal fistula Thyroglossal fistula

Are almost always the result of infection with spontaneous or surgical drainage.

It can drain internally , externally or both.

Discharge of mucus & recurrent attack of inflamation is the clinical finding.

Treatment Treatment

Before thyroglossal duct cysts are excised, it is important to demonstrate that normally functioning thyroid tissue is in its usual location.

Thyroid scans and thyroid function studies are ordered preoperatively.

Treatment Treatment

Total surgical excision (sistrunk procedure) including:- The cyst and sinus to the base of the tongue. Whole fistula. Middle third of hyoid bone.

Branchial Cyst:Branchial Cyst:

• ETIOLOGY:

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Persistent cervical sinus

PATHOLOGY:

Lined by stratified squamous epithelium & most have lymphoid

tissue in the wall. Contain straw-coloured fluid rich in

cholesterol crystals.

Branchial Cyst: Branchial Cyst: (cont.)(cont.)• INCIDENCE:

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Most frequently seen in young adultsPeak age: third decade

CLINICAL PICTURE:

Slowly-growing, painless, soft cystic swelling,characteristically under the ant. border of the upper &

middle 1/3 of the SCM muscle. Branchial cysts are not translucent & do not move on

swallowing

Branchial Cyst: Branchial Cyst: (cont.)(cont.)

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Surgical excision(Band?)

INVESTIGATIONS:

TREATMENT:

Lymphatic drainage

Lymphatic drainage of head and neck are particularly important when locating and working up a "neck mass" or possible malignancy.

Lymphatic drainage:Lymphatic drainage:

Superficial nodes: Are few nodes lies superficial to the deep fascia :1. The anterior cervical node along the anterior jugular vein.

2. The superficial cervical nodes along the external jugular vein.

Deep nodes: 1. Vertical chain.

2. Circular chain.

Vertical chain Deep nodes

Is closely related to internal jugular vein.

Types of vertical chains:

1. Superior deep cervical (jugulo-digastric nodes ).

2. Inferior deep cervical (jugulo-omohyoid nodes ).

3. Few nodes in the root of the neck called supraclavicular nodes (virchow’s nodes ), (Troisier’s sign).

Circular chainCircular chain Submental nodes . Submandibular nodes . Buccal or facial nodes . Preauricular (parotid ) nodes . Posterior auricular nodes . Occipital nodes . Retropharyngeal , pretracheal nodes .

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Lymph node levels

• Level I– Refers submental and submandibular nodes– Drains the lip, oral cavity and tongue

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• Level II– Forms upper jugular group of nodes– Drains the oropharynx, larynx, hypopharynx

and parotid

• Level III– Refers to middle jugular node– Drains the larynx and pharynx

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• Level IV– Refers to lower jugular group of nodes– Drains the larynx and hypopharynx

• Level V– Refers to posterior triangle group of nodes– Drains the other lymphatic regions in the neck– Level Va:

• Superior to inf belly of omohyoid• Contains the chain of nodes along the accessory nerve,

which drain the nasopharynx

– Level Vb:• Inferior to inf belly of omohyoid• Contains nodes related to the thyrocervical trunk which

drains the thyroid gland

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• Level VI:– Anterior or central group of nodes– Paratracheal, perithyroidal, Delphian nodes

• Level VII:– Corresponds to the superior mediastinal

tissues