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20 Neck Swellings 20 Neck Swellings Introduction –yPretracheal fascia: It extends in front of the trachea and is attached superiorly to hyoid, and below, it extends In general, the swellings in the neck are skin and soft tissue into the superior mediastinum and merges with the swellings, and specifically, these are from lymph nodes pericardium. y (which are almost half the number of the total lymph nodes – Prevertebral fascia: It extends behind the oesophagus in the body) and embryological vestiges, apart from thyroid and in front of the prevertebral muscles. It is attached swellings. In this chapter, general features and classification superiorly to the base of the skull and extends inferi- of neck swellings have been discussed (excluding thyroid). orly into the posterior mediastinum. The pretracheal fascia and prevertebral fascia join laterally with the general investing deep layer and forms carotid sheath. Between these two fasciae, lie the thyroid gland, Anatomy larynx, trachea, and oesophagus, and so, it is called visceral compartment of the neck. The neck consists of anterior (visceral) and posterior (mus- cular) compartments, separated by extensions of deep fascia Triangles of the Neck of neck, with neurovascular structures on either side of these compartments, which connect the brain and rest of the body. The two key muscles of the neck, sternocleidomastoid and trapezius, divide the neck into triangles of neck for conveni- Fascia of the Neck ence of anatomical location of the swellings (Fig. 20.2). The important anatomical structure in the neck is the deep fascia, which divides the neck into compartments that limit Sternocleid­ General investing layer the spread of infections and, to some extent, neoplasms omastoid (Fig. 20.1). Pretracheal layer It has two layers: Thyroid yySuperficial fascia: gland y – Contains platysma Carotid yyDeep fascia (fascia colli), which has three layers: sheath Prevertebral –yGeneral investing layer: It surrounds the neck and has layer the following attachments: Trapezius 1. Superiorly: Superior nuchal crest, mastoid process, lower border of the mandible, symphysis menti and hyoid bone. It has an extension upwards near angle of the mandible, enclosing the parotid gland. Fig. 20.1 Fascia of the neck. This is called paritedomasseteric fascia, which is attached above to the zygomatic process. 2. Posteriorly: Ligamentum nuchae and cervical spinous processes. Digastric 1: Digastric triangle 3. Inferiorly: It is attached to acromion process, clavi- Trapezius 2: Carotid triangle cle and later splits into two layers to be attached to 3: Muscular triangle the anterior and posterior borders of manubrium Sternocleid­ sterni. The space between these two layers is called omastoid 1+2+3= Anteior triangle space of Burns, which contains anterior jugular vein, areolar tissue, origins of the sternocleidomas- Omohyoid 4: Supraclavicular triangle 5: Suboccipital triangle toid muscles and occasionally a lymph node. 4. Anteriorly, both sides of the fascia are continuous 4+5= Posterior triangle with each other. 5. It encloses two muscles: posteriorly, trapezius and anteriorly sternocleidomastoid, and gives two extensions: prevertebral and pretracheal layers. Fig. 20.2 Triangles of the neck. 252 Chapter 20 yyAnterior: yyLevel VI: Anterior compartment group. –yDigastric. yyLevel VII: Mediastinal group (ultimately, most cervical –yCarotid. nodes communicate with these nodes). –yMuscular. yyPosterior: –ySupraclavicular. General Features of Neck Swellings –yOccipital. yyThe most common neck swelling is the lymph nodal Lymph Nodes of the Neck swelling. yy Lymph nodes of the neck are divided into superficial and About 800 lymph nodes are present in the body, and out deep nodes (Fig. 20.3): of them, about 300 are present in the neck. yyOther swellings are those of the skin and soft tissues. yySuperficial (superficial to the deep fascia of the neck): yyThe key structure in the neck is the sternocleidomastoid –yIn the neck: Along external jugular and anterior jugu- muscle, and the relation of any mass in the neck to this lar veins. muscle should be examined. –yIn the face: Circular chain—occipital, postauricular, parotid, zygomatic, buccal and facial. yyDeep (deep to the deep fascia of the neck): Classification of Neck Swellings –ySubmental and submandibular. –yAlong carotid sheath: yyMidline swellings: 1. Upper jugular (jugulodigastric). –yCystic. 2. Supraomohyoid. –ySolid. 3. Infraomohyoid. –yPulsatile. –ySupraclavicular. yyLateral swellings: –yAlong oesophagus and trachea. –yCystic. –yRetropharyngeal. –ySolid. –yPrelaryngeal and pretracheal. –yPulsatile. –yIn the space of Burns. Midline Swellings Levels of Cervical Lymph Nodes For universal representation of various groups of lymph Above Hyoid nodes in the neck, a system of levels is used to describe them yyCystic: (Fig. 20.4): –yThyroglossal cyst. yyLevel I: Submental and submandibular nodes. –ySublingual dermoid. yyLevel II: Upper jugular group. yySolid: yyLevel III: Middle jugular (supraomohyoid). –yLudwig’s angina. yyLevel IV: Lower jugular (infraomohyoid). –ySubmental lymph nodes. yyLevel V: Posterior triangle group. –yLipoma. Lev el I: Submental and 1: Submental Hyoid bone level 2: Submandibular submandibular nodes 3: Facial Lev el II: Upper jugular 4: Preauricular group 5: Postauricular Lev el III: Middle jugular 6: Occipital (supraomohyoid) 7: Upper jugular (jugulodigastric), Lev el IV: Lower jugular 8: Supraomohyoid (infraomohyoid) 9: Infraomohyoid Lev el V: Posterior triangle 10: Supraclavicular group 11: External jugular (superficial) Lev el VI: Anterior 12: Prelaryngeal and pretracheal compartment group 13: In the space of Burns Lev el VII: Mediastinal group (ultimately most cervical nodes communicate 1,2,3,4,5,6 and 11 are superficial nodes, with these nodes) remaining are deep nodes Cricoid cartilage lower border Fig. 20.3 Lymph nodes of the neck. Fig. 20.4 Levels of lymph nodes. Neck Swellings 253 Below Hyoid Posterior Triangle yyCystic: yyCystic: –ySubhyoid bursa. –yCystic hygroma. –yCystic hygroma. –yCold abscess (it can be from cervical vertebra, lymph –yThyroglossal cyst. nodes, clavicle, sternum or sternoclavicular joint). –yDermoid. yySolid: yySolid: –ySupraclavicular lymph nodes. –ySwelling from isthmus of the thyroid. –yLipoma. –yPyramidal lobe. –yPharyngeal pouch. –yPretracheal and prelaryngeal lymph nodes. –yCervical rib. –yRetrosternal goitre. –yPeripheral nerve tumours from the vagus nerve or bra- –yThymic swelling. chial plexus. –yExtrinsic carcinoma of the larynx. –yPancoast’s tumour. yyPulsatile: Space of Burns –ySubclavian aneurysm. yyCystic: –yDermoid. –yCold abscess. Branchial Cyst and Branchial Fistula yySolid: –yLipoma. Development of Branchial Arches –yLymph nodes. yyThe neck and pharynx are formed from five bars called yyPulsatile: visceral or branchial arches. –yAneurysm of the innominate artery. yyThe internal sides are called the visceral pouches, and the external ones are called the visceral clefts. Lateral Swellings yyEach arch has a plate of cartilage, a muscle, a nerve and Enlarged deep cervical lymph nodes are the most common an artery. swellings. yyEach arch is lined by squamous epithelium on outside and by columnar epithelium on inside. yy Submandibular Triangle Each arch develops into structures and viscera of the neck (Table 20.1). yyCystic: –yCold abscess. Cervical Sinus of His –yDeep or plunging ranula. –yDental abscess. yyThe growth of the second branchial arch is faster, and it –yLymphangioma. overhangs other arches, forming a deep groove called cer- yySolid: vical sinus. –yLipoma. yyThe overgrown II arch fuses with V arch. –yLymph nodes. yyCervical sinus is buried, and later, it disappears entirely. –ySubmandibular salivary gland. yyIf the sinus persists, it forms a cyst called branchial cyst. –yExtension of growth from the jaw. yyIf the II arch fails to fuse with V arch, it forms a fistula called the branchial fistula. Carotid Triangle Branchial Fistula yyCystic: –yBranchial cyst. yyIt is due to failure of fusion of II arch with V arch, causing –yCold abscess. a track between II on outside and III on inside. yySolid: yyHence, it passes between the structures of II, that is, exter- –yLymph nodes. nal carotid and facial nerves, on outside and structures of –yCarotid body tumour. III, that is, internal carotid and IX nerves, on inside. –yBranchiogenic carcinoma. yyPulsatile: Course –yAneurysm of the carotid artery. yyThe external opening of the fistula is situated at the ante- rior border of the sternocleidomastoid in the lower third Muscular Triangle of the neck. yyThyroid swelling. yyIt passes subcutaneously up to the upper border of the yySternocleidomastoid tumour. thyroid cartilage, pierces the deep fascia to pass through 254 Chapter 20 Table 20.1 Branchial arches Arch Structure Muscle Artery Nerve I Mandible Muscles of mastication and Facial Mandibular branch of V Mandibular arch anterior two­third of tongue II Part of hyoid Facial expression, side and Extemal carotid VII Hyoid arch front of neck III Remaining hyoid, Posteior one­third of tongue Internal carotid IX thyroid cartilage IV and V Cartilages of larynx Subclavian on right and arch Superior and recurrent and trachea of aorta on left laryngeal the fork of the carotid and opens on the posterior pillar of Complication the tonsil. yy yyIt is bilateral in 30% of cases. Infection, abscess and sinus in the upper third of the neck. yyBranchiogenic carcinoma. Clinical Features Investigation Mucoid discharge since birth, from a small opening sit- uated at the anterior border
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