congenital neck masses

7/23/2019 Congenital Neck Masses

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CONGENITAL NECK MASSES


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In the changing pattern of this specialty it is essential

that every otolaryngologist should e fa!iliar "ith

diagnosis and !anage!ent of !asses in the nec#$


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LA% O&T

'$ Thyroglossal duct cysts

($ )ranchial cysts $

*$ Ly!phangio!as$

+$ Lingual thyroid$

,$ -e!angio!as

.$ Laryngocele$

/$ 0lunging ranulas$

1$ Terato!as

2$ 3er!oid cyst

'4$ Thy!ic cysts$

''$ Sternocleido!astoid tu!ors of infancy$'($ 0araganglio!as and nerve sheath tu!ors$

'*$ )ronchial cysts


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T-%5OGLOSSAL 3&CT C%STS


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INT5O3&CTION

Most co!!on cystic lesion in the nec# $

'6*rdof all congenital nec# !asses $

&p to ,47 "ill present in adulthood $ Over *47 presenting efore '4 years of age $

E8ual !ale to fe!ale incidence $


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EM)5%OLOG%

Thyroid pri!ordiu! develops in the floor of pri!itive pharyn9$

:ora!en caecu! $

Thyroid gland !igrates through the tounge tissue$ Anterior to hyoid one to lie in the anterior nec# $

Thyroglossal duct $

:ailure of involution of the tract $


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05ESENTATION

Mostly present as !idline !asses ( ; * c! in dia!eter in


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0AT-OLOG%

Lined y colu!nar epitheliu! "ith s!all glands containing

thyroid colloid fre8uently$ 3ecalcification of hyoid one indicates that tract passes through

it $


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IN=ESTIGATIONS

3iagnosis is clinical$

&ltrasound nec# $

:NAC if !ass is suprahyoid $ 5adionuclide scanning is reserved for patients "ith nor!al

thyroid glands cannot e locali>ed $


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T5EATMENT

Infected cyst ? Should e aspirated for !icroiological culture and to

avoid incision into the cyst $

Surgery

'$ Si!ple cyst e9cision $($ Sistrun#@s operation $

. 5ecurrence rate is + '4 7$

. 5ecurrence rate are significantly less "ith Sistrun#@s operation$

.

Thyroid carcino!a !ay present in thyroglossal cyst $247 of the! arepapillary carcino!a $

. 5E=IEB :5OM SLONE KATTE5ING $


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LATE5AL CE5=ICAL O5 )5ANC-IAL C%STS


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INT5O3&CTION

Most fre8uently present in late childhood and early adulthood $

Can present at any age occasionally $ E8ual !ale to fe!ale incidence$


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COM0ONENTS

a. Branchial arch covered y ectoder! e9ternallyD lined internally y endoder!D core of

arch for!ed y !esenchy!eDeach arch has a specific nerve that innervate$

b. Branchial groove (Pharyngeal cleft) ectoder!al e9ternalF cleft et"een ad


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)ranchial ApparatusOuter notched ectoder!

Inner pouched;out

endoder! Me!ranes "here they

!eet

Mesoder!al core of!uscle and vascularendotheliu!

Neural crest!esenchy!e


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:I5ST )5ANC-IAL CLE:T )ECOMES EHTE5NAL A&3ITO5% MEAT&S $

:I5ST )5ANC-IAL MEM)5ANE )ECOMES T%M0ANIC MEM)5ANE$


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EM)5%OLOG%

Cervical sinus nor!ally closes y si9 "ee#s leaving a cervical

vesicle$

This trapped ectoder! for!s lateral cervical cysts in youngadults $

They arise fro! failure of pharyngoranchial ducts to oliterate

during fetal develop!ent $


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CLASSI:ICATION

:irst )ranchial cleft cysts Incidence is less than '7$

&sually appear on face or near the auricle $

T%0E '?These are duplication ano!alies of EAC $ Co!posed of ectoder!ally derived tissue $

May pass into parotid gland and close to facial nerve


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T%0E (

May co!prise ectoder!ally and !esoder!ally derived

tissue $

0resent elo" the angle of !andile pass through the parotid

gland and close to facial nerve $ End in E9ternal auditory cannal$


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SECON3 )5ANC-IAL CLE:T C%STS

Most co!!on of three types $

3iscrete rounded !ass elo" the angle of !andile and at the

anterior order of sternocleido!astoid $ Tract of the associated sinus passes 3EE0to e9ternal carotid

artery and S&0E5:ICIAlto internal carotid artery $

Open into tonsillar fossa$


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T%0ES

Type I:

Located along the anterior !argin of sternocleido!astoid !uscle at the


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T-I53 )5ANC-IAL CLE:T C%STS

0resent anterior to sternocleido!astoid !uscle ut lo"er in the

nec# than first or (nd

ranchial cysts $ These cysts are 3EE0to CN IH internal carotid artery and

S&0E5:ICIALto CN H$


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AETIOLOGICAL T-EO5IES

Origin fro! a ranchial pouch re!nant $

Origin fro! cervical sinus $ Origin fro! ly!ph node degeneration $


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05ESENTATION

Cystic often tender oval !ass + .c! in dia!eter anterior to

sternocleido!astoid !uscle $

3evelops fairly 8uic#ly $ S"elling !ay e inter!ittent

Infected cyst presents "ith overlying erythe!a and pain $

5ecent upper respiratory tract infection is descried $


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3I::E5ENTIAL 3IAGNOSIS

IN EA5L% A3&LT-OO3 ? 5eactive ly!phadenopathy

IN C-IL35EN ?

'$ 3er!oid cyst

($ 5hado!yosarco!a

. IN %O&NG A3&LTS ?

'$ Ly!pho!a

($ Tuerculosis

*$ Nerve sheath tu!ors

. O=E5 *, %EA5S ?

'$ Cervical !etastasis fro! a head and nec# pri!ary leision $


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0AT-OLOG%

Lined "ith s8ua!ous epithelliu! "ith transitional type

pseudostratified epithelliu! $

Cyst presenting in younger age groups are !ore li#ely to e

lined "ith respiratory epithelliu! $


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IN=ESTIGATIONS

:NAC

I!aging is not usually necessary to !a#e the diagnosis $

&ltrasound scan$ CT scan $


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T5EATMENT

Aspiration of the contents $

I6= antiiotics $

Incision and drainage procedures should e avoided ut they!ay e necessary for treating acute acess$

Surgical e9cision of the cyst $


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)ENIGN L%M0-ATIC LESIONS


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INT5O3&CTION

T-5EE T%0ES ?

'$ CA00ILA5% L%M0-ANGIOMA

($ CA=E5NO&S L%M0-ANGIOMA

*$ C%STIC -%G5OMA. One third of lesions are found in oral cavity and chee# and

aout a 8uarter in the nec# $

. =ery unco!!on only , cases per *444 ad!issions to a

pediatric hospital $


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EM)5%OLOG%

Ly!phatics fail to connect in the nor!al "ay to the venous

channels$

There are large fluid spaces occupying the tissue and e9panding

tissue planes $

0AT-OLOG% Macrocystic lesions ? large co!pressile and fre8uently

!ultilocular and have "ell defined !argins $

Co!!only referred to as cystic hygro!a $ Microcystic lesions ? S!aller and fir!er$


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CA0ILLA5% L%M0-ANGIOMA

Co!prise of capillary li#e ly!phatic vasculature $

Confined to superficial s#in or oral cavity$

0ale s!all vesicle li#e lesions $ &sually asy!pto!atic$

No treat!ent is necessary$


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CA=E5NO&S L%M0-ANGIOMA

Co!posed of dilated ly!phatic channels $

Occur in tongue chee#s and lips causing diffuse s"elling $ They account for +47 of all ly!phangio!as $


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C%STIC -%G5OMA

Si!ilar to cavernous ly!phangio!a histologically $

Co!posed of thin "alled sinuses and cysts that are lined y flat

endothelial cells containing eosinophils and acellular ly!ph

fluid $

There are large cystic !asses "hich co!!unicate "ith each

other or re!ain isolated $


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05ESENTATION

S!ooth soft tissue s"elling filled "ith fluid

fluctuantnontenderco!pressile and transillu!inated "ith

distinct !argins $

0osterior triangle of nec# $

Involve chee# parotid oral cavity !ediastinu! and a9illa $

:atal air"ay ostruction $

5ecurrent upper respiratory infections$

Intra oral lesions !ay leed $


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IN=ESTIGATIONS

Clinical diagnosis $

M5I

CT Scan

0renatal ultrasound 0renatal M5I

:NAC if !alignancy is suspected $


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T5EATMENT

I: LESION IS SMALL Cos!etically and functionally acceptale

then no treat!ent is needed only oservation $

MAC5OC%STIC 3ISEASE ? it is a!enale to aspiration and

intralesional in


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S&5GE5%

S&5GICAL 5ESECTION ? 5eserved for !icrocystic lesionsand !acrocystic lesions not a!enale to sclerotherapy $

Co!plete e9tirpation !ay e i!possile$

CO0EN-EGAN 5E=IEB?

'$ ,4 7 of patients had residual disease$

($ ++7 had i!pair!ent of speech s"allo"ing and reathing $

*$ *. 7 had cos!etic defor!ity $

.

5ecurrence rates are very high$May occur rapidly or after !anyyears $


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STAGING S%STEM TO 05E3ICT S&5GICAL O&TCOME


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LING&AL T-%5OI3


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INT5O3&CTION

A !ass on the ase of the tongue in infancy or childhood

leading to dysphagia or air"ay ostruction $

It is e9tre!ely rare$

In a revie" of thyroid anor!ality in (2444 autopsies only +

lingual thyroids "ere identified $


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EM)5%OLOG%

Thyroid pri!ordiu! fails to descend in the nec# $

Thyroid tissue re!ains at fora!en caecu! $

No thyroid tissue at usual pretracheal site $ All the thyroid gland is represented at fora!en caecu! $


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05ESENTATIONS

3ysphagia

Air"ay co!pro!ise 5arely it !ay present acutely as a result of leeding into ectopic

thyroid tissue $


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IN=ESTIGATIONS

M5I

CT SCAN

5adio active Iodine scanning Thyroid function tests? &sually de!onstrate hypothyroidis! $


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T5EATMENT

S!all lingual thyroid causing no sy!pto!s ? Oral thyro9ine

Advice of EN3OC5INOLOGIST $

Large Lesion causing dysphagia 6air"ay ostruction ? Surgical

e9cision


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-EMANGIOMAS


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INT5O3&CTION

-e!angio!as are !alfor!ations of vascular tissue

0resent in first fe" !onths of life and gro" rapidly during first

year $

Involute at '1 (+ !onths "ithout any therapy $

Classification ?

'$ Capillary he!angio!as

($ Cavernous 6 Juvenile he!angio!as


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05ESENTATION

5ed or luish soft !ass $

Mass is co!pressile and increase in si>e "ith straining and

crying $

)ruit !ay so!eti!es auscultated over the lesion


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IN=ESTIGATIONS


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IN=ESTIGATIONS CT SCAN

M5I

T5EATMENT Involute spontaneously $

Conservative !anage!ent and oservation $

Surgical intervention needed if there is

'$ Air"ay co!pro!ise($ S#in ulceration

*$ 3ysphagia

+$ Thro!ocytopenia

,$ Cardiac failure

. Syste!ic corticosteroids

. Surgical laser e9cision $


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LA5%NGOCELE


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3E:INITION

An anor!al dilation or herniation of the saccule of laryn9 $

LA5%NGO0%OCELE ? Secondary infection of laryngocele is

called laryngopyocele$


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CLASSI:ICATION

INTE5NAL LA5%NGOCELE? if the dilation lies "ithin the li!its

of thyroid cartilage $

EHTE5NAL LA5%NGOCELE ? if the dilation e9tends eyond the

thyroid cartilage and protrude through the thyrohoid !e!rane

producing a lateral nec# !ass

COM)INE3 LA5%NGOCELE ? if there are oth internal and

e9ternal co!ponents $


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05ESENTATION

-oarseness

Cough

3yspnea

3ysphagia

:oreign ody sensation

Any co!ination of aove !entioned sy!pto!s$


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IN=ESTIGATION

LA5%NGOSCO0% ? 5eveals a s!ooth dilation at the level of

false cords involving oth the false cords and aryepiglottic

folds$

CT SCAN$


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T5EATMENT

SMALL LESIONS ? Laryngoscopic deco!pression $

LA5GE LESIONS ?

'$ Surgical e9cision through e9ternal approach $

($ Laser endoscopy


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SACC&LA5 C%STS

Si!ilar to laryngocele $

Anor!al dilation or herniation of saccule of the ventricle of the

laryn9$

It occurs in infants and young children $

It differs fro! laryngocele in that there is no opening into the

laryn9 and id filled "ith !ucus instead of air $

0rotrudes into the laryngeal air"ay et"een true true and false

cords $

Treat!ent ? Surgical e9cision $


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TE5ATOMAS

INT5O3&CTION

Originate fro! pluripotent cells$

Contain ele!ents fro! all three ger! layers $

0resent as fir! nec# !asses$

Most co!!only present at irth or "ithin first year of life $

(4 7 associated incidence of !aternal polyhydra!nios$


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05ESENTATION ?


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'$ Bhen large enough cause respiratory co!pro!isedue to

tracheal co!pression

($ 3ysphagiasecondary to esophageal co!pression $*$ 3isruption of deglutition$

. IN=ESTIGATIONS ?

'$ CT SCAN

($ M5I

. S&5GICAL EHCISION is the treat!ent of choice $


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3E5MOI3 C%ST

INT5O3&CTION

Originate fro! ectoder! and !esoder! $

-ead and nec# is the !ost co!!on site to find the! $

They can present at any age ut !a


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05ESENTATION

Midline non tender !oile nec# !ass in the su!ental region$

They can also present lateral to su!andiular gland $

Occur in sucutaneous tissue and contain s#in appandages li#e hair folliclesseaceous

glands and s"eat glands

They can also occur fro! i!plantation secondary to puncture "ounds $

T5EATMENT

S&5GICAL EHCISION


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T-%MIC C%ST

E!ryology ? Third ranchial cyst gives rise to thy!us during . th"ee# of fetal life $itelongates in the pharyn9 and then descends into !ediastinu! $

05ESENTATION ?'$ Mostly Slo" gro"ing

($ May e asy!pto!atic*$ )eco!e painful if infected $

+$ 5arely gro" rapidly and cause dyspnea and dysphagia $

. IN=ESTIGATIONS ?'$ CT SCAN

($ M5I

*$ 3efinitive diagnosis is !ade y presence of -ASSEL@S corpuscles histlologicaly $


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T5EATMENT

S&5GICAL EHCISION


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STE5NOCLEI3OMASTOI3 T&MO5S O: IN:ANC%

0resent as nec# !asses $

3ense firous tissue$

Asence of striated !uscles$

5elated to congenital torticollis$

0resentation


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:ir! painless discrete !asses "ithin the STM !uscle $

Slo"ly increase in si>e for ( * !onths and then regress for + 1 !onths$

T5EATMENT

Eighty 7 cases resolve spontaneously $

Only physical therapy to prevent restrictive torticollis $

Surgical e9cision for persistent cases $


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0L&NGING 5AN&LAS

These are !ucoceles or retention cysts of the floor of !outh $

0resent as slo" gro"ing painless su!ental !ass$

Arise fro! sulingual gland and e9tend into nec# y passing

through !ylohyoid !uscle $

T5EATMENT ? E9cision of the lesion in continuity "ith sulingual

gland$


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)5ONC-IAL C%STS

&nco!!on lesions occur in suprasternal notch $

More co!!only they occur in thoracic cavity or !ediastinu! $

More co!!on in !ales

Associating "ith discharging sinus $

Surgical e9cision$


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0A5AGANGLIOMAS

congenital neck masses

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