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SURGERY OTHER NECK SURGERIES CST CFA Mary Sutton, , Severalof surgical the procedures Head are per- usually and smooth, nontender Neck masses locat- formed for specific benign process- ed between the preauricular area and the es in the neck, including branchial cleft supraclavicular area of the neck. How- and thyroglossal duct cysts, and Zenk- ever, these cysts may form a sinus tract er’s diverticulum. This article will also extending to the skin. review three surgeries of various sali- The maj ority of branchial cleft cysts vary glands and conclude with an over- arise from the second branchial arch. view of tracheotomy. Indications for surgery to remove a branchial cleft cyst include: recurrent BRANCHIAL CLEFT CYST infections, increase in size, and for cos- Between the fourth and sixth week of metic reasons. In removing the branchi- gestation, five paired swellings occur al cleft cyst, it is important to remove in the head of the embryo. These swell- the cyst, any sinus tract, and any tis- ings, or branchial arches, have a corre- sue surrounding the cyst that may have sponding internal pouch and are sepa- been involved in attempts to drain the Editor’s Note: This is rated by four grooves or clefts external- infected cyst. the fourth and final ly. Inside each branchial arch are devel- Instruments for a branchial cleft cyst insta ll ment in th is oped specific anatomic features, such as excision are contained in the standard seri es. P l ease refer to cranial nerves, arteries, and cartilage. neck set. Any special instrumentation past issues for an over- During natural development, the pouch- needed depends on the location of the view of norma l anat- omy for thi s reg i on. es should close and the grooves dissolve. cyst. Supplies are similar for any neck Anatomi ca l vari at i ons When these pouches and grooves do not dissection and include a bipolar forceps specific to a procedure follow their natural course, an anoma- and cord. The surgeon will likely use a will be di scussed with ly occurs. Branchial cleft remnants are headlight. its descri pt i on. SEPTEMBER 2005 The Surgical Technologist 9 261 SEPTEMBER 2005 2 CE CREDITS The patient can choose between general anesthe- sue descends anteriorly to the pharynx. The tis- sia or local injection with monitored anesthesia sue has two lobes with a stalk-like attachment to care depending on the size and location of the the base of tongue. The hyoid bone divides the cyst. Most patients undergo the procedure with tract into upper and lower segments. When the general anesthesia. The patient is placed on the thyroid settles into its final position, the tract operating table in the supine position with the should be resorbed. When it is not resorbed, a neck extended and the head turned away from thyroglossal duct cyst may form. the affected side. A patient with a thyroglossal duct cyst pres- The surgeon will make a horizontal inci- ents with a midline mass, which moves upon sion in the nearest skin crease of the neck. If a swallowing or with movement of the tongue. sinus tract is present, it is incorporated through Dysphagia and/or a choking sensation, and rare- an elliptical incision. The sinus tract is part of ly upper respiratory obstruction may also occur. the specimen. Skin and tissue flaps are dissect- Indications for thyroglossal duct cyst excision ed around the cyst to protect any major struc- are an undiagnosed midline mass, history of tures that may lie in the area. The cyst is identi- infection in the mass, the possibility of malig- fied and dissected from the surrounding tissue. nant degeneration into cancer, and cosmetic Care is taken not to rupture the cyst, as the con- appearance, as the mass may increase in size. Ttents could contaminate the wound. The cyst is A standard neck set is required for a thyro- carefully dissected from the carotid sheath and glossal duct cyst excision. A bone cutter should hypoglossal nerve. also be available, as most surgeons remove part Once the cyst is dissected fully, the tract is of the hyoid bone. Supplies are the same as for a followed superiorly, usually between the internal branchial cleft cyst. As with any similar proce- and external carotid arteries, to rule out a sec- dure, a headlight is needed. ond branchial cleft cyst. The tract then runs past Excision of a thyroglossal duct cyst is called the posterior digastric belly to the pharynx. If the Sistrunk procedure. Walter Sistrunk first no internal connection to the pharynx is estab- performed the surgery in 1920. He had excellent lished, the tract can be ligated and removed with results with a recurrence rate of about 1.5% to 4%. the cyst. If it is connected to the pharynx, the The Sistrunk procedure includes the excision of whole tract must be removed. The wound is irri- the mass with the midportion of the hyoid bone gated and a drain is placed. The wound is closed and the block of muscle that theoretically con- and dressed appropriately. tains the thyroglossal duct remnant. The drain is removed 24 to 48 hours post- The patient undergoes general anesthesia and operatively. If there is spillage in the wound or is placed in the supine position on the operating communication with the pharynx, the patient table with the neck extended. The incision is made is given prophylactic antibiotics for 48 hours. in a skin crease in the upper midline of the neck. If Complications are rare, but include hematoma, the skin is adhered to the cyst as a result of recur- seroma, and infection. rent infection, that skin is excised with the mass via an elliptical incision. A superior flap is dissect- Thyroglossal duct cyst ed to the hyoid bone. The strap muscles are iden- Thyroglossal duct cyst is an upper-midline cer- tified and retracted. The cyst is dissected free on vical mass, with a common presentation next to all sides. The hyoid bone is grasped, usually with a the hyoid bone and the thyrohyoid membrane. It Lahey clamp or a Kocher, and the muscle and soft is the most common mass in the midline of the tissue are dissected from the body of the hyoid neck. bone. The body of the hyoid bone is transected The surgeon’s k nowledge of embr yolog- with bone cutters or a curved Mayo scissors. ical and developmental anatomy of the thy- A large cur ved retractor is placed in the roid is important. Embryologically, thyroid tis- mouth to push the base of the tongue into the 10 The Surgical Technologist SEPTEMBER 2005 Stensen’s duct Buccinator muscle Parotid gland Mandible Masseter muscle Sublingual gland Wharton’s duct Submandibular gland neck wound. The stalk of the cyst is followed mittent cervical dysphagia that becomes pro- FIGURE 1 upward and cut out of the muscle of the tongue gressively worse. The patient may hear a gurgling base. The wound is irrigated, a drain is placed, sound when swallowing and have excessive sali- Major salivary and the wound is closed. An appropriate dress- va, which can lead to aspiration. Halitosis, or bad ing is placed, if necessary. Complications of thy- breath, is a frequent symptom. glands and roglossal duct cyst excision are hematoma, sero- In patients with a Zenker’s diverticulum, ma, and wound infection. food gets caught in the diverticulum instead of surrounding going down to the stomach. The food caught in Zenker’s diverticulectomy the diverticulum can be expelled into the air- anatomy. Zenker’s diverticulum is a pharyngoesophageal way causing aspiration. Patients with advanced pouch that is formed by forces within the mus- cases of Zenker’s diverticulum may have recur- cles of the esophagus acting against an area of low rent pulmonary infections due to aspiration and resistance. The diverticulum was first described weight loss. Patients rarely feel a mass, as the by Frederick Albert Von Zenker in 1877. Patients diverticulum is located deep within the neck. with Zenker’s diverticulum present with inter- Indirect laryngoscopy in the doctor’s office often SEPTEMBER 2005 The Surgical Technologist 11 shows pooling of secretions in the hypopharynx. ach for postoperative feeding until healing is A barium esophagram is used to determine the complete. This reduces the risk of pharyngocu- size and exact location of the diverticulum. taneous fistula. The cut muscle is not closed to Instrumentation for the excision of a Zenk- prevent stricture. A drain may be placed in the er’s diverticulum is a standard neck set and wound before the wound is closed. A pressure an esophagoscopy set, which includes a light dressing may be applied. source. There will be two fields, one clean and Complications of Zenker’s diverticulecto- one sterile. Supplies are the same for a branchi- my are recurrent laryngeal nerve injury, hypo- al cleft cyst, but should also include something pharyngeal stricture, or pharyngocutaneous fis- to pack the diverticulum: either plain gauze or tula. These complications are rare but must be Vaseline® gauze (surgeon’s preference). Some explained to the patient. surgeons may use a linear stapler (30 or 55 mm) to remove the diverticulum and close the esoph- Submandibular gland excision agus in one step. The surgeon will likely wear a The submandibular gland is one of three paired headlight. Separate suction sets are needed for salivary glands that drain into the oral cavity each field. (Figure 1). The gland lies under the mandible in The patient undergoes general anesthesia and what is called the submandibular triangle. The is placed in the supine position on the operat- marginal mandibular nerve passes right above ing table with the neck extended.

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