20 Neck Swellings

Introduction ––Pretracheal 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. – (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 (muscular) 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 – – Contains platysma Carotid yyDeep fascia (fascia colli), which has three layers: sheath Prevertebral ––General 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. ––Digastric. yyLevel VII: Mediastinal group (ultimately, most cervical ––Carotid. nodes communicate with these nodes). ––Muscular. yyPosterior: ––Supraclavicular. General Features of Neck Swellings ––Occipital. 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 ––In 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. ––In the face: Circular chain—occipital, postauricular, parotid, zygomatic, buccal and facial. yyDeep (deep to the deep fascia of the neck): Classification of Neck Swellings ––Submental and submandibular. ––Along carotid sheath: yyMidline swellings: 1. Upper jugular (jugulodigastric). ––Cystic. 2. Supraomohyoid. ––Solid. 3. Infraomohyoid. ––Pulsatile. ––Supraclavicular. yyLateral swellings: ––Along oesophagus and trachea. ––Cystic. ––Retropharyngeal. ––Solid. ––Prelaryngeal and pretracheal. ––Pulsatile. ––In 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): ––Thyroglossal cyst. yyLevel I: Submental and submandibular nodes. ––Sublingual dermoid. yyLevel II: Upper jugular group. yySolid: yyLevel III: Middle jugular (supraomohyoid). ––Ludwig’s angina. yyLevel IV: Lower jugular (infraomohyoid). ––Submental lymph nodes. yyLevel V: Posterior triangle group. ––Lipoma.

Level I: Submental and 1: Submental Hyoid bone level 2: Submandibular submandibular nodes 3: Facial Level II: Upper jugular 4: Preauricular group 5: Postauricular Level III: Middle jugular 6: Occipital (supraomohyoid) 7: Upper jugular (jugulodigastric), Level IV: Lower jugular 8: Supraomohyoid (infraomohyoid) 9: Infraomohyoid Level V: Posterior triangle 10: Supraclavicular group 11: External jugular (superficial) Level VI: Anterior 12: Prelaryngeal and pretracheal compartment group 13: In the space of Burns Level 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: ––Subhyoid bursa. ––Cystic hygroma. ––Cystic hygroma. ––Cold abscess (it can be from cervical vertebra, lymph ––Thyroglossal cyst. nodes, clavicle, sternum or sternoclavicular joint). ––Dermoid. yySolid: yySolid: ––Supraclavicular lymph nodes. ––Swelling from isthmus of the thyroid. ––Lipoma. ––Pyramidal lobe. ––Pharyngeal pouch. ––Pretracheal and prelaryngeal lymph nodes. ––Cervical rib. ––Retrosternal goitre. ––Peripheral nerve tumours from the vagus nerve or bra- ––Thymic swelling. chial plexus. ––Extrinsic carcinoma of the larynx. ––Pancoast’s tumour. yyPulsatile: Space of Burns ––Subclavian aneurysm. yyCystic: ––Dermoid. ––Cold abscess. Branchial Cyst and Branchial Fistula yySolid: ––Lipoma. Development of Branchial Arches ––Lymph nodes. yyThe neck and pharynx are formed from five bars called yyPulsatile: visceral or branchial arches. ––Aneurysm 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: ––Cold abscess. Cervical Sinus of His ––Deep or plunging ranula. ––Dental abscess. yyThe growth of the second branchial arch is faster, and it ––Lymphangioma. overhangs other arches, forming a deep groove called cer- yySolid: vical sinus. ––Lipoma. yyThe overgrown II arch fuses with V arch. ––Lymph nodes. yyCervical sinus is buried, and later, it disappears entirely. ––Submandibular salivary gland. yyIf the sinus persists, it forms a cyst called branchial cyst. ––Extension 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: ––Branchial cyst. yyIt is due to failure of fusion of II arch with V arch, causing ––Cold abscess. a track between II on outside and III on inside. yySolid: yyHence, it passes between the structures of II, that is, exter- ––Lymph nodes. nal carotid and facial nerves, on outside and structures of ––Carotid body tumour. III, that is, internal carotid and IX nerves, on inside. ––Branchiogenic carcinoma. yyPulsatile: Course ––Aneurysm of the carotid artery. yyThe external opening of the fistula is situated at the anterior 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 two-third of tongue

II Part of hyoid Facial expression, side and Extemal carotid VII Hyoid arch front of neck

III Remaining hyoid, Posteior one-third 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 yy It is bilateral in 30% of cases. Infection, abscess and sinus in the upper third of the neck. yy Branchiogenic carcinoma. Clinical Features Investigation Mucoid discharge since birth, from a small opening situated at the anterior border of the lower third of the Aspiration: Turbid pus-like fluid with shimmering surface sternocleidomastoid. due to lipid content on microscopy shows cholesterol crys- tals secreted by sebaceous glands. Complications Treatment Infection and abscess. Complete excision. Treatment Complete excision by two incisions in the neck. Branchiogenic Carcinoma

Branchial Cyst Aetiology

Aetiology Primary carcinoma in association with branchial cyst. yy Failure of absorption of cervical sinus. Clinical Features yy Entrapment of developing branchial epithelium in the cervical lymph node (recent theory). yy Hard irregular and nodular mass is situated at the place of the branchial cyst (carotid triangle). Pathology yy It cannot be differentiated from metastatic lymph nodes. yy The cyst is lined with squamous epithelium and is a Investigation sequestration dermoid. yy The plane of the cyst is similar to that of the branchial fis- Fine-needle aspiration cytology (FNAC). tula (between second and third branchial arches). ––It is situated at level of the upper border of the thyroid Treatment cartilage and projects deep from anterior border of the sternocleidomastoid. yy Surgery (radical neck dissection). yy Radiotherapy. Clinical Features yy Incidence: Common in early adult life. Carotid Body Tumour yy It presents as a cystic swelling in the upper third of the neck (carotid triangle), partly deep to the sternocleido- Synonyms: Chemodectoma, potato tumour and nonchromaffin mastoid muscle, projecting from its anterior border. paraganglioma.

Differential Diagnosis Cold abscess. Neck Swellings 255

Physiology Clinical Features yyCarotid body is a chemoreceptor organ of about 2-mm yySlow-growing, painless solid lump in the bifurcation diameter located in the bifurcation of the carotid artery. of the carotid, deep to the sternocleidomastoid muscle yyIt contains chemosensitive cells sensitive to lack of oxygen (Fig. 20.5).

(O2), excess of CO2 and hydrogen ion. yyMass is firm and rubbery and exhibits transmitted yyThe chemoreceptors excite nerve fibres that pass along pulsations. with the baroreceptor fibres through Hering’s nerve and yyMay be pulsatile, with a bruit. the glossopharyngeal nerve into the respiratory and vaso- yyMobile from side to side and not vertically. motor centre of the brain stem. yyPressure on the mass may produce syncope and yyWhen there is a rise in the CO2 tension or hydrogen ion bradycardia.

concentration, or fall in the O2 concentration in the arte- yyMay present as a pharyngeal mass pushing the tonsil. rial blood, these chemoreceptors are strongly stimulated, and, in turn, they stimulate the respiratory centre, caus- Differential Diagnosis ing increased respiratory rate and volume. yyThey also cause control of blood pressure by stimulat- yyLymph nodal mass: ing the vasomotor centre whenever blood pressure falls ––Moves in both directions. below a critical level (the chemoreceptors are stimulated ––Pulsations are absent. because diminished blood flow causes decreased oxygen yyAneurysm of the carotid artery: – and excess of CO2 and hydrogen ions). – Expansile pulsations are present.

Pathology Investigations yyCarotid body tumour is a benign tumour arising from the yyDuplex scan. chemoreceptor cells on the medial side of the carotid yyFNAC is contraindicated. bulb. yyMagnetic resonance imaging (MRI) scan. yyIt is rare and is seen in persons living at high altitudes, yyCarotid angiogram (lyre sign): The carotid bifurcation where chronic hypoxia leads to carotid body hyperplasia. is found to be splayed by the carotid body tumour and yyAs it is situated in the bifurcation of the carotid, the appears like the musical instrument lyre. tumour is also situated in the bifurcation of the carotid, deep to the sternocleidomastoid (Fig. 20.5). Treatment yyIt is radioresistant. Incidence yyComplications of surgery are serious, and the tumour is yyAge: 40 to 50 years. benign. Hence, surgery is not done routinely. yyMay be associated with pheochromocytoma. yyIf it is causing difficulty due to its rapid growth or large size, it is removed along with carotid bifurcation. yyPeroperative common carotid to internal carotid artery bypass is done to establish blood flow to the brain during surgery on the carotid bifurcation. yyCarotid fork along with the carotid body tumour is excised, followed by common carotid to internal carotid artery grafting by a Teflon (DuPont Co) graft. Teflon (polytet- Internal carotid artery rafluoroethylene [PTFE] is a synthetic fluoropolymer of Sternocleidomastoid External carotid artery tetrafluoroethylene and is manufactured by DuPont Co.)

Other Chemodectomas yyGlomus jugulare over bulb of the internal jugular vein. yyAortic bodies over the arch of the aorta. yyVagal body tumours from paraganglionic tissue of Carotid body the vagus nerve from base of the skull to the carotid tumour bifurcation.

Peripheral Nerve Tumours

yySchwannomas: ––Commonly from the vagus nerve. ––Rarely from XII cranial nerve, sympathetic chain and Fig. 20.5 Carotid body tumour. brachial plexus. 256 Chapter 20 yyNeurofibroma: Inflammatory Conditions of the Neck ––Solitary. ––Generalised. Ludwig’s Angina These tumours present like solid masses and are usually mis- taken for lymph nodal masses. If excision biopsy is done mis- It is cellulitis of the submandibular and sublingual spaces, takenly for a lymph node, the corresponding nerve may be due to streptococcal infection, and is sometimes associated damaged. Proper clinical examination (lymph node moves in with anaerobic infection. all directions and the nerve tumour moves only perpendic- ular to the axis of the nerve and may produce paraesthesia) Pathology before biopsy of a mass in the neck is essential. Source of Infection yyOdontogenic. Pancoast’s Tumour yySubmandibular salivary abscess. yyOccasionally from oral cancer. Pathology yyIt is a bronchogenic carcinoma of the apex of the lung. Spread of Infection yyAs the tumour spreads locally, it infiltrates the first rib, yyInfection in the submandibular space causes oedema on lower trunk of the brachial plexus and cervical sympa- both sides of mylohyoid, leading to oedema of the floor thetic chain or stellate ganglion or its preganglionic fibres. of mouth, causing the tongue to be displaced upwards and backwards, producing dysphagia and respiratory Clinical Features obstruction. yyIf the infection is not controlled, inflammatory exudate yyCough, haemoptysis, chest pain and breathlessness in a passes along the tunnel of the stylohyoid muscle to sub- chronic smoker. mucosa of the glottis or along facial planes of the neck, yyA hard, irregular and fixed mass may be felt in the pos- causing oedema of glottis and laryngeal obstruction. terior triangle of the neck. The lower margin of the mass cannot be felt. Clinical Features

Pancoast’s Syndrome yyHigh pyrexia, with elevated tongue and oedematous floor of the mouth. yyPancoast’s tumour. yyBrawny induration of the submandibular region. yyErosion of the first rib (detected on X-ray of the neck). yyParalysis of the lower trunk of the brachial plexus (C8 and Treatment T1). yyHorner’s syndrome (due to involvement of stellate yyAntibiotics. ganglion): yyIf no relief in 48 hours, incision and drainage of the sub- ––Miosis. mandibular space and decompression of the space deep ––Enophthalmos (regressed eyeball). to the mylohyoid muscle. yy ––Pseudoptosis. Tracheostomy if laryngeal oedema develops. ––Anhidrosis on the affected side.

Investigations Torticollis (Wry’s Neck) yyX-ray of chest, including the thoracic inlet: Upper lobe It is leaning of head to one side, with chin turned to the opacity, with erosion of the first rib. other side because of contraction of the sternocleidomastoid yyComputed tomographic (CT) scan: It demonstrates the muscle. tumour with infiltration to the surrounding structures. yySputum for malignant cells. Aetiology yyFibreoptic bronchoscopy. yyGuided FNAC. yyFracture dislocation of cervical spine. yySternocleidomastoid tumour. Treatment yyTuberculosis of cervical spine. yyAcute suppurative cervical lymphadenitis. Palliative radiotherapy. yyPostburn contracture of the neck. Neck Swellings 257

Clinical Features where muscle fibres are replaced by a mass of fibrous tissue, probably due to trauma to the muscle during yyAcute: child’s birth. ––Neck is bent to one side, with chin turned to the opposite side. ––Restricted movements of the neck. Clinical Features yy yyChronic: It presents at 3 to 4 weeks after birth. yy ––On the affected side (bent side), the following will The chin is turned to opposite side, with facial occur: asymmetry. 1. Atrophy of face. yyIn long-standing cases, features of chronic torticollis 2. The distance between the outer canthus of the eye manifest. and the angle of mouth is small. 3. Cheek is less full. Differential Diagnosis 4. Eyebrow is less arched. From other causes of torticollis. Treatment Treatment The cause is treated. yyWatchful expectancy. yyIf no relief, tenotomy of the sternocleidomastoid muscle at its origin, followed by use of torticollis harness for 6 to Sternocleidomastoid Tumour 12 months. Aetiology yyBirth injury causing contraction and swelling of the ster- Lymph Nodal Swellings nocleidomastoid muscle. yyThough it is called as sternocleidomastoid tumour, it is Please refer to Chapter 14 Diseases of Lymphatics and Lymph not a neoplasm. It is caused by fibromatosis of the muscle, Nodes.

Neck Swellings

yyThe deep fascia of the neck has general investing layer, prevertebral fascia and pretracheal fascia. Sternocleidomastoid muscle is the key muscle in the neck, and every swelling in the neck should be examined in relation to this muscle. yyThe most common swelling in the neck is lymph nodal swelling, and hence, it should be considered first in the diagnosis. yyA cystic swelling in the neck can be due to cold abscess from the lymph nodes, cervical vertebra, mandible, sternum or clavicle. The other cystic swellings are branchial cyst, cystic hygroma, plunging ranula and, in the midline, dermoid, thyroglossal cyst and cyst from isthmus of the thyroid (cystic hygroma and ranula are translucent). yyA solid swelling is most commonly due to lymph nodal enlargement, and other causes are lipoma, submandibular salivary gland swelling, carotid body tumour, jaw tumour and, in the midline, thyroid swellings. Rarely, it can be due to branchiogenic carcinoma, Pancoast’s tumour, cervical rib or neuroma of the brachial plexus or vagus nerve. yyA pulsatile swelling in the neck is due to aneurysm of the carotid, subclavian or innominate artery. yyThe branchial cyst and fistula are due to sequestration of the ectoderm owing to the overgrown second branchial arch to meet fifth branchial arch. The branchial cyst presents as a cyst without transillumination, projecting from undercover of the upper one-third of the anterior border of the sternocleidomastoid muscle. It is situated between structures formed from II arch (external carotid and facial nerve) and III arch (internal carotid and glossopharyngeal nerve). It is treated by complete excision. yyCarotid body tumour arises from chemoreceptor cells of the carotid bulb and presents as a slow-growing, smooth, firm swelling in the fork of bifurcation of the carotid artery, with transmitted pulsations. It is diagnosed by duplex scanning and MRI carotid.