• Slide 1
  • Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS
  • Slide 2
  • Neck Lumps A/ Congenital NL B/ Infective NL C/ Tumors of Head & Neck D/ Thyroid gland disease E/ Parathyroid gland disease
  • Slide 3
  • A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele
  • Slide 4
  • Thyroglossal Duct Cyst Commonest midline neck cyst Remnant of the thyroglossal duct Embryologically arises from the foramen caecum Can occur anywhere in the area bounded by: - the foramen caecum above - the manubrial notch inferiorly - the anterior border of the sternocleidomastoid muscle laterally
  • Slide 5
  • Thyroglossal Duct Cyst
  • Slide 6
  • Slide 7
  • Slide 8
  • TDC- Pathology Men & women are equally affeced Age range is (4 months – 70 years) 90 % are in the midline 10 % are to one side - Left95 % - Right5 %
  • Slide 9
  • TDC- Pathology Commonest sites of TDC: - Prehyoid75 % - Thyroid cartilage level15 % - Suprahyoid5 % - Cricoid level4 % - Base of tongue1 %
  • Slide 10
  • TDC- Pathology The duct is always subcutaneous Spontaneous fistula formation is rare A fistula is usually the result of - infection - attempted drainage of misdiagnosed abscess - inadequate removal of the hyoid bone Cyst & duct are lined by squamous epith. Thyroid tissue is rarely found in the wall
  • Slide 11
  • TDC- Clinical Features 95 % present with a painless cystic lump, which moves on swallowing or protruding the tongue 5 % present with tenderness & rapid enlargement due to infection Difficulty in Breathing may happen Dysphagia The cyst is mobile in all directions Translumination is positive Fistula is present in 15 % of cases, & is usually the result of a previous operation or infection
  • Slide 12
  • TDC- Clinical Features Supra-hyoid cysts may be mistaken for submental lymphadenitis, or a dermoid cyst Pre-hyoid cysts are nearly always dumb-bell or bar shaped & can push the base of the tongueupwards causing dysrthria Cysts near the surface of the tongue base must be distinguished from a lingual thyroid or a carcinoma Cysts low in the neck must be differentiated from a thyroid adenoma by a thyroid scan, from a sebaceous cyst or lipoma
  • Slide 13
  • TDC- Treatment Although benign, TDC should be removed (Sistrunk’s Operation) Even if symptomless, the cyst should be removed to eliminate the chance of infection or carcinoma For cosmetic reason Sistrunk’s procedure: - Excision of the cyst - excision of the path (tract) - Excision of the central part of the hyoid bone (to ensure complete removal of the tract)
  • Slide 14
  • Treatment- Sistrunk’s Op
  • Slide 15
  • Thyroglossal Duct Carcinoma Very rarely, a persistent Thyroglossal duct can become cancerous, called thyroglossal duct carcinoma In this case the cancerous cells are ectopic thyroid tissue that has been deposited along the thyroglossal duct and will present as a papillary carcinoma (always) Present as a cyst, & diagnosis is only made by histology There is a slight female preponderance
  • Slide 16
  • Thyroglossal Duct Carcinoma Peak age incidence for women is 30-40 years Peak age incidence for men is 50-60 years 40 – 50 % Carcinoma arise in an ectopic thyroid tissue Only 10 % have metastases Treatment: - Local excision of cyst - Thyroidectomy - Followed by suppressive doses of thyroxine
  • Slide 17
  • A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele
  • Slide 18
  • Branchial Cysts There are 4 theories of the origin of branchial cysts: 1- Branchial apparatus theory 2- Cervical sinus theory 3- Thymo-pharyngeal duct theory 4- Inclusion theories
  • Slide 19
  • Branchial Cysts 1/ Branchial apparatus Theory: Represents remnants of the pharyngeal pouches or branchial clefts, or a fusion of these two elements 2/ Cervical Sinus Theory: Represents remnants of the cervical sinus of His which is formed by the second archgrowing down to meet the fifth
  • Slide 20
  • Branchial Cysts 3/ Thymo-pharyngeal Duct Theory: Represents remnants of the original connection between the thymus and the third branchial pouch 4/ Inclusion Theories: Suggests that the cyst epithelium arises from lymph node epithelium, or cysts are the result of epithelial inclusion in lymph nodes
  • Slide 21
  • Branchial Cysts Clinical features: 60 % in men, 40 % in women Peak age incidence is 3 rd decade 75 % on the left side 2 % are bilateral 2/3 are anterior to sternomastoid in the upper third of the neck
  • Slide 22
  • Branchial Cysts Clinical features: Continuous swelling80 % Intermittent swelling20 % Pain30 % Infection15 % Pressure symptoms5 % ** 70 % are cystic on palpation, 30 % are solid
  • Slide 23
  • Branchial Cysts Treatment: - Total excision
  • Slide 24
  • A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele
  • Slide 25
  • Laryngocele Is a large air-containing sac arising from the laryngeal saccule Incidence 1: 2,5 mil. Sex 5:1 (men:women) Peak age incid. 50-60y. 82% occur in Caucasians 85 % are unilateral 30 % external, 20 % internal, 50 % mixed
  • Slide 26
  • Laryngocele Pathology: It has long been held that laryngocele are due to,,blowing’’ hobbies or jobs such as trumpet playing or glass blowing but this is untrue More important is the co-existence of a carcinoma of the larynx which acts as a valve allowing air under pressure into the ventricle Laryngoceles are lined by columnar ciliated epithelium whereas simple laryngeal cysts are lined by squamopus epithelium
  • Slide 27
  • Laryngocele Clinical Features: The commonest presenting features are hoarseness & swelling in the neck Stridor which can come on very suddenly over a period of few days or even hours Dysphagia Sore throat Snoring Pain Cough
  • Slide 28
  • Laryngocele Clinical Features: 10 % present with infected sacs-pyocele Because of mix of air & pus on X-ray (gas gangrene) Plain X-ray is diagnostic (air- filled sac) All patients with Laryngocele should have Laryngoscopy to exclude carcinoma
  • Slide 29
  • Laryngocele Treatment: All Laryngoceles should be removed bec. Of the danger of laryngeal obstruction If patient presents with a pyocele, this should be treated with antibiotics before surgery
  • Slide 30
  • Slide 31
  • Neck Lumps A/ Congenital NL B/ Infective NL C/ Tumors of Head & Neck D/ Thyroid gland disease E/ Parathyroid gland disease
  • Slide 32
  • Infective Neck Lumps Acute cervical lymphadenitis Retropharyngeal & parapharyngeal abscess Chronic lymphadenitis Tuberculous lymphadenitis Sarcoidosis Infectious mononucleosis Toxoplasmosis Brucellosis Aids
  • Slide 33
  • Tuberculous Cervical Adenitis The Bacillus reaches the lymph node by direct drainage or haematogenous spread The incidence of co-existing TB is less than 5 % 50 % of the excised tonsils showed evidence of TB
  • Slide 34
  • Tuberculous Cervical Adenitis - Patients give usually long history, & seeks medical advice because The lump have becomes painful - 20 % have discharging sinuses - 10 % cold abscess - Patients usually have negative chest X-ray
  • Slide 35
  • Tuberculous Cervical Adenitis 90 % are unilateral 90 % involve only one node group, commonest is the deep jugular chain followed by the submandibular group Diagnosis - Positive tuberculin skin test - Demonstration of acid-fast bacilli in biopsy - Growth of mycobacterium tuberculosis
  • Slide 36
  • Tuberculous Cervical Adenitis Treatment: Excisional biopsy 6-9 months anti-tuberculous chemotherapy If the nodes are very large & matted, local removal is dangerous since the nodes are often attached to the internal jugular vein In children it is usually wise to remove & examine histologically the tonsils before removing the nodes If removal is not followed immediately by chemotherapy a sinus forms with persistent drainage & later ugly scar
  • Slide 37
  • Tumours Of The Neck Tumours of neurogenous origin - Peripheral nerve Tumours - Schwannoma- Neurofibroma - Chemedectomas - Glomus Vagale Tumours Malignant neck masses
  • Slide 38
  • Peripheral Nerve Tumours Neural Crest Schwann cellSympathicoblast NeurofibromaSchwannomaParaganglionic cell Glomus Jugulare T.Ganglionic cell Carotid B.T. (Chemodectoma)Ganglioneuroma
  • Slide 39
  • Peripheral Nerve Tumours SchwannomaNeurofibroma SolitaryUsually occurs as part of the syndrome of multiple neurofibromatosis Never associated with (von recklinghausen’s syndrome) Often associated with (von Recklinghausen’s syndrome) Painful & tenderAsymptomatic EncapsulatedNon-encapsulated Seldom malignant8 % malignant
  • Slide 40
  • Peripheral Nerve Tumours
  • Slide 41
  • Peripheral Nerve Tumour Clinical Features: Nerve Tumours are rare, forms only 1 % of all head & neck tumours These tumours enlarge slowly over years with no symptoms & a painless neck mass as the only sign The T. remains benign with no interference with nerve function apart from pressure on the sympathetic chain which soon shows as Horner’s syndrome Even when the tumour becomes malignant & reaches a large size the nerve may still function properly
  • Slide 42
  • Horner’s Syndrome Ptosis (droping of eyelid) Miosis (constriction of pupil) Anhidrosis (decreased sweating) of the face on same side Redness of the conjuctiva Enophthalmos
  • Slide 43
  • Peripheral Nerve Tumour Diagnosis: Ultrasonography CT scan Angiogram is required
  • Slide 44
  • Peripheral Nerve Tumours Treatment: Total excision Every effort should be made to preserve the nerve Postopeartive neuromas must be excised to distinguish them from recurrent cancer In malignant nerve T., best is to do en bloc excision of the area
  • Slide 45
  • Carotid Body Tumour (Chemedectoma) Nests of non-chromaffin paraganglionic cellderived from the neural crest Occur on - Carotid bulb - Jugular bulb - Cavity of the middle ear - Ganglion nodosum of the vagus nerve
  • Slide 46
  • Carotid Body Tumour (Chemedectoma) Occur on - Adventitia of the ascending aorta - Aorta - Innominate & pulmonary arteries - Ciliary ganglion of the orbit Carotid body cells acts as chemoreceptors (chemedectoma)
  • Slide 47
  • Carotid Body Tumour (Chemedectoma) Pathology: High incidence in high altitude such as Peru, Colorado & Mexico city (2000-5000 m), Because of chronic hypoxia leading to carotid body hyperplasia Average presentation age 35-50 y. (youngest reported case was 12 y. old) Equal sex incidence Striking Family history in 10 % of cases
  • Slide 48
  • Carotid Body Tumour (Chemedectoma) Pathology: Tendency to bilateral tumours The tumour is firmly adherent to the bifurcation of the common carotid artery Seldom grows to more than 4-5 cm These are non-secreting T. Metastases are very rare
  • Slide 49
  • Carotid Body Tumour (Chemedectoma) Clinical features: All Patients present with with a painless lump in the neck, palpable in the region of the carotid bulb The lump move from side to side but not up & down Always a long history (4-5-7 y.) which is helpful in differentiating it from lymphoma or metastatic node About 30 % present with a pharyngeal mass pushing the tonsil medially & anteriorly (should not be biopsied) Normal site of growth is from the inner aspect of the notch of the bifurcation
  • Slide 50
  • Carotid Body Tumour (Chemedectoma) Clinical features: Normal site of growth is from the inner aspect of the notch of the bifurcation of the carotid artery causing displacement & separation of the internal & external carotid arteries If the growth occurs mainly on the medial site, a pharyngeal swelling occur with no lateral neck swelling The T. may grow up the vessels to the base of the skull
  • Slide 51
  • Carotid Body Tumour (Chemedectoma) Clinical features: The mass is firm & rubbery & usually demonstrates transmitted rather than expansile pulsation A bruit may be present Rarely patients complain of dysphagia or discomfort Large T. may involve 9 th, 10 th, 11 th & 12 th cranial nerves, accasionally the sympathetic chain causing a Horner’s syndrome
  • Slide 52
  • Carotid Body Tumour Diagnosis: - History of a longstanding neck mass - Physical examination - CT scan - Carotid angiogram (to see feeding vs., extent of tumour)
  • Slide 53
  • Carotid Body Tumour Treatment: Surgical removal is indicated: - Malignant & resectable T. - Patient in a good health, < 60 with a small or medium sized T. - Those T. which have extended into the pharynx & palate & are interfering with swallowing, breathing & speaking
  • Slide 54
  • Carotid Body Tumour Treatment: Radiotherapy in: - Patients who should have surgery but refuse - Poor-risk patients - In metastatic disease
  • Slide 55
  • Glomus Vagale Tumour Extremly rare Presents as a mass at the angle of the jaw (too high for a branchial cyst, too low for parotid tumour Some cause pain & discomfort or pharyngeal M. Dx. by angiography Removal is much more difficult than carotid B.T. (vascular S.)
  • Slide 56
  • Malignant Neck Masses In the Neck, the main malignant problem to be considered is secondary carcinoma metastatic to the lymph nodes Most carcinomas of the head & neck sooner or later metastasize to the lymph nodes of the neck These LN form a barrier that prevents further spread of the disease for many months Most common carcinoma of the head region are basal cell ca. & squamous cell ca.
  • Slide 57
  • Non-thyroid Neck Masses in an Adult Neoplastic (85 %)Inflammatory/congenital (15 %) Malignant (85 %)Benign (15 %) Metastatic (85%)Primary (15%): lymphoma, salivary g. Primary cancer sitePrimary cancer site below above clavicle (85 %)clavicle (15 %)
  • Slide 58
  • Squamous Cell Carcinoma
  • Slide 59
  • Is a cancer of a kind of epithelial cell, the squamous cell which are the main part of the epidermis of the skin It is one of the major forms of skin cancer, & seen mainly on the lips & mouth SCC of the skin begins as a small nodule and as it enlarges the center becomes necrotic and sloughs and the nodule turns into an ulcer. Squamous Cell Carcinoma
  • Slide 60
  • Predisposing Factors: 1- Smoking 2- Alkohol Consumption 3- HPV infection Squamous Cell Carcinoma
  • Slide 61
  • Clinical Features: 90 % of cases of head and neck cancer (cancer of the mouth, nasal cavity, nasopharynx, throat and associated structures) are due to squamous cell carcinoma The lesion caused by SCC is often asymptomatic Ulcer or reddish skin plaque that is slow growing Intermittent bleeding from the tumor especially on the lip The clinical appearance is highly variable,usually the tumor presents as an ulcerated lesion with hard, raised edges The tumor commonly presents on sun-exposed areas Unlike basal cell carcinoma (BCC), squamous cell carcinoma (SCC) has a substantial risk of metastasis Squamous Cell Carcinoma
  • Slide 62
  • Clinical Features: A hoarse voice sometimes present in cases of ulcer in the oral cavity, near the pharynx Treatment: 1- Surgery ( extensive excision may be necessary) 2- Radiotherapy Squamous Cell Carcinoma
  • Slide 63
  • Basal Cell Carcinoma
  • Slide 64
  • is the most common cancer It rarely metastasizes However, because it can cause significant destruction and disfigurement by invading surrounding tissues, it is still considered malignant Patients present with a shiny, pearly nodule. However, superficial basal-cell cancer can present as a red patch like eczema Basal Cell Carcinoma
  • Slide 65
  • Diagnosis: - is by skin Biopsy Treatment: 1- Surgical excision: most preffered 2-Chemotherapy: Some superficial cancers respond to local therapy with 5-fluorouracil 3-Immuntherapy: research suggests that treatment using Euphorbia peplus, a common garden weed, may be effective Basal Cell Carcinoma
  • Slide 66
  • References Current, Surgical Diagnosis & Treatment, Gerard M. Doherty Essential Surgical Practice, A. Cuschieri, G R Giles, A R Moosa Bailey & Love’s, Short Practice of Surgery, R.C.G. Russell, Norman S. Williams, Christopher J.K. Bulstrode Clinical Surgery, A. Cuschieri, Thomas P.J. Hennessy, Roger M. Greenhalgh, David I. Rowly & Pierce A. Grace
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Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS.

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  • Slide 1
  • Head and Neck Surgery Dr. Sirwan Abdullah Ali University of Sulaimani Faculty of Medical Sciences School of Medicine Dr.med.Univ., FACH, ASO, IFSO, FASMBS
  • Slide 2
  • Neck Lumps A/ Congenital NL B/ Infective NL C/ Tumors of Head & Neck D/ Thyroid gland disease E/ Parathyroid gland disease
  • Slide 3
  • A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele
  • Slide 4
  • Thyroglossal Duct Cyst Commonest midline neck cyst Remnant of the thyroglossal duct Embryologically arises from the foramen caecum Can occur anywhere in the area bounded by: - the foramen caecum above - the manubrial notch inferiorly - the anterior border of the sternocleidomastoid muscle laterally
  • Slide 5
  • Thyroglossal Duct Cyst
  • Slide 6
  • Slide 7
  • Slide 8
  • TDC- Pathology Men & women are equally affeced Age range is (4 months – 70 years) 90 % are in the midline 10 % are to one side - Left95 % - Right5 %
  • Slide 9
  • TDC- Pathology Commonest sites of TDC: - Prehyoid75 % - Thyroid cartilage level15 % - Suprahyoid5 % - Cricoid level4 % - Base of tongue1 %
  • Slide 10
  • TDC- Pathology The duct is always subcutaneous Spontaneous fistula formation is rare A fistula is usually the result of - infection - attempted drainage of misdiagnosed abscess - inadequate removal of the hyoid bone Cyst & duct are lined by squamous epith. Thyroid tissue is rarely found in the wall
  • Slide 11
  • TDC- Clinical Features 95 % present with a painless cystic lump, which moves on swallowing or protruding the tongue 5 % present with tenderness & rapid enlargement due to infection Difficulty in Breathing may happen Dysphagia The cyst is mobile in all directions Translumination is positive Fistula is present in 15 % of cases, & is usually the result of a previous operation or infection
  • Slide 12
  • TDC- Clinical Features Supra-hyoid cysts may be mistaken for submental lymphadenitis, or a dermoid cyst Pre-hyoid cysts are nearly always dumb-bell or bar shaped & can push the base of the tongueupwards causing dysrthria Cysts near the surface of the tongue base must be distinguished from a lingual thyroid or a carcinoma Cysts low in the neck must be differentiated from a thyroid adenoma by a thyroid scan, from a sebaceous cyst or lipoma
  • Slide 13
  • TDC- Treatment Although benign, TDC should be removed (Sistrunk’s Operation) Even if symptomless, the cyst should be removed to eliminate the chance of infection or carcinoma For cosmetic reason Sistrunk’s procedure: - Excision of the cyst - excision of the path (tract) - Excision of the central part of the hyoid bone (to ensure complete removal of the tract)
  • Slide 14
  • Treatment- Sistrunk’s Op
  • Slide 15
  • Thyroglossal Duct Carcinoma Very rarely, a persistent Thyroglossal duct can become cancerous, called thyroglossal duct carcinoma In this case the cancerous cells are ectopic thyroid tissue that has been deposited along the thyroglossal duct and will present as a papillary carcinoma (always) Present as a cyst, & diagnosis is only made by histology There is a slight female preponderance
  • Slide 16
  • Thyroglossal Duct Carcinoma Peak age incidence for women is 30-40 years Peak age incidence for men is 50-60 years 40 – 50 % Carcinoma arise in an ectopic thyroid tissue Only 10 % have metastases Treatment: - Local excision of cyst - Thyroidectomy - Followed by suppressive doses of thyroxine
  • Slide 17
  • A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele
  • Slide 18
  • Branchial Cysts There are 4 theories of the origin of branchial cysts: 1- Branchial apparatus theory 2- Cervical sinus theory 3- Thymo-pharyngeal duct theory 4- Inclusion theories
  • Slide 19
  • Branchial Cysts 1/ Branchial apparatus Theory: Represents remnants of the pharyngeal pouches or branchial clefts, or a fusion of these two elements 2/ Cervical Sinus Theory: Represents remnants of the cervical sinus of His which is formed by the second archgrowing down to meet the fifth
  • Slide 20
  • Branchial Cysts 3/ Thymo-pharyngeal Duct Theory: Represents remnants of the original connection between the thymus and the third branchial pouch 4/ Inclusion Theories: Suggests that the cyst epithelium arises from lymph node epithelium, or cysts are the result of epithelial inclusion in lymph nodes
  • Slide 21
  • Branchial Cysts Clinical features: 60 % in men, 40 % in women Peak age incidence is 3 rd decade 75 % on the left side 2 % are bilateral 2/3 are anterior to sternomastoid in the upper third of the neck
  • Slide 22
  • Branchial Cysts Clinical features: Continuous swelling80 % Intermittent swelling20 % Pain30 % Infection15 % Pressure symptoms5 % ** 70 % are cystic on palpation, 30 % are solid
  • Slide 23
  • Branchial Cysts Treatment: - Total excision
  • Slide 24
  • A/ Congenital Neck Lumps 1- Lymphangiomas 2- Midline Dermoid Tumours 3- Thyroglossal duct cysts 4- Thyroglossal duct carcinoma 5- Branchial cysts 6- Laryngocoele
  • Slide 25
  • Laryngocele Is a large air-containing sac arising from the laryngeal saccule Incidence 1: 2,5 mil. Sex 5:1 (men:women) Peak age incid. 50-60y. 82% occur in Caucasians 85 % are unilateral 30 % external, 20 % internal, 50 % mixed
  • Slide 26
  • Laryngocele Pathology: It has long been held that laryngocele are due to,,blowing’’ hobbies or jobs such as trumpet playing or glass blowing but this is untrue More important is the co-existence of a carcinoma of the larynx which acts as a valve allowing air under pressure into the ventricle Laryngoceles are lined by columnar ciliated epithelium whereas simple laryngeal cysts are lined by squamopus epithelium
  • Slide 27
  • Laryngocele Clinical Features: The commonest presenting features are hoarseness & swelling in the neck Stridor which can come on very suddenly over a period of few days or even hours Dysphagia Sore throat Snoring Pain Cough
  • Slide 28
  • Laryngocele Clinical Features: 10 % present with infected sacs-pyocele Because of mix of air & pus on X-ray (gas gangrene) Plain X-ray is diagnostic (air- filled sac) All patients with Laryngocele should have Laryngoscopy to exclude carcinoma
  • Slide 29
  • Laryngocele Treatment: All Laryngoceles should be removed bec. Of the danger of laryngeal obstruction If patient presents with a pyocele, this should be treated with antibiotics before surgery
  • Slide 30
  • Slide 31
  • Neck Lumps A/ Congenital NL B/ Infective NL C/ Tumors of Head & Neck D/ Thyroid gland disease E/ Parathyroid gland disease
  • Slide 32
  • Infective Neck Lumps Acute cervical lymphadenitis Retropharyngeal & parapharyngeal abscess Chronic lymphadenitis Tuberculous lymphadenitis Sarcoidosis Infectious mononucleosis Toxoplasmosis Brucellosis Aids
  • Slide 33
  • Tuberculous Cervical Adenitis The Bacillus reaches the lymph node by direct drainage or haematogenous spread The incidence of co-existing TB is less than 5 % 50 % of the excised tonsils showed evidence of TB
  • Slide 34
  • Tuberculous Cervical Adenitis - Patients give usually long history, & seeks medical advice because The lump have becomes painful - 20 % have discharging sinuses - 10 % cold abscess - Patients usually have negative chest X-ray
  • Slide 35
  • Tuberculous Cervical Adenitis 90 % are unilateral 90 % involve only one node group, commonest is the deep jugular chain followed by the submandibular group Diagnosis - Positive tuberculin skin test - Demonstration of acid-fast bacilli in biopsy - Growth of mycobacterium tuberculosis
  • Slide 36
  • Tuberculous Cervical Adenitis Treatment: Excisional biopsy 6-9 months anti-tuberculous chemotherapy If the nodes are very large & matted, local removal is dangerous since the nodes are often attached to the internal jugular vein In children it is usually wise to remove & examine histologically the tonsils before removing the nodes If removal is not followed immediately by chemotherapy a sinus forms with persistent drainage & later ugly scar
  • Slide 37
  • Tumours Of The Neck Tumours of neurogenous origin - Peripheral nerve Tumours - Schwannoma- Neurofibroma - Chemedectomas - Glomus Vagale Tumours Malignant neck masses
  • Slide 38
  • Peripheral Nerve Tumours Neural Crest Schwann cellSympathicoblast NeurofibromaSchwannomaParaganglionic cell Glomus Jugulare T.Ganglionic cell Carotid B.T. (Chemodectoma)Ganglioneuroma
  • Slide 39
  • Peripheral Nerve Tumours SchwannomaNeurofibroma SolitaryUsually occurs as part of the syndrome of multiple neurofibromatosis Never associated with (von recklinghausen’s syndrome) Often associated with (von Recklinghausen’s syndrome) Painful & tenderAsymptomatic EncapsulatedNon-encapsulated Seldom malignant8 % malignant
  • Slide 40
  • Peripheral Nerve Tumours
  • Slide 41
  • Peripheral Nerve Tumour Clinical Features: Nerve Tumours are rare, forms only 1 % of all head & neck tumours These tumours enlarge slowly over years with no symptoms & a painless neck mass as the only sign The T. remains benign with no interference with nerve function apart from pressure on the sympathetic chain which soon shows as Horner’s syndrome Even when the tumour becomes malignant & reaches a large size the nerve may still function properly
  • Slide 42
  • Horner’s Syndrome Ptosis (droping of eyelid) Miosis (constriction of pupil) Anhidrosis (decreased sweating) of the face on same side Redness of the conjuctiva Enophthalmos
  • Slide 43
  • Peripheral Nerve Tumour Diagnosis: Ultrasonography CT scan Angiogram is required
  • Slide 44
  • Peripheral Nerve Tumours Treatment: Total excision Every effort should be made to preserve the nerve Postopeartive neuromas must be excised to distinguish them from recurrent cancer In malignant nerve T., best is to do en bloc excision of the area
  • Slide 45
  • Carotid Body Tumour (Chemedectoma) Nests of non-chromaffin paraganglionic cellderived from the neural crest Occur on - Carotid bulb - Jugular bulb - Cavity of the middle ear - Ganglion nodosum of the vagus nerve
  • Slide 46
  • Carotid Body Tumour (Chemedectoma) Occur on - Adventitia of the ascending aorta - Aorta - Innominate & pulmonary arteries - Ciliary ganglion of the orbit Carotid body cells acts as chemoreceptors (chemedectoma)
  • Slide 47
  • Carotid Body Tumour (Chemedectoma) Pathology: High incidence in high altitude such as Peru, Colorado & Mexico city (2000-5000 m), Because of chronic hypoxia leading to carotid body hyperplasia Average presentation age 35-50 y. (youngest reported case was 12 y. old) Equal sex incidence Striking Family history in 10 % of cases
  • Slide 48
  • Carotid Body Tumour (Chemedectoma) Pathology: Tendency to bilateral tumours The tumour is firmly adherent to the bifurcation of the common carotid artery Seldom grows to more than 4-5 cm These are non-secreting T. Metastases are very rare
  • Slide 49
  • Carotid Body Tumour (Chemedectoma) Clinical features: All Patients present with with a painless lump in the neck, palpable in the region of the carotid bulb The lump move from side to side but not up & down Always a long history (4-5-7 y.) which is helpful in differentiating it from lymphoma or metastatic node About 30 % present with a pharyngeal mass pushing the tonsil medially & anteriorly (should not be biopsied) Normal site of growth is from the inner aspect of the notch of the bifurcation
  • Slide 50
  • Carotid Body Tumour (Chemedectoma) Clinical features: Normal site of growth is from the inner aspect of the notch of the bifurcation of the carotid artery causing displacement & separation of the internal & external carotid arteries If the growth occurs mainly on the medial site, a pharyngeal swelling occur with no lateral neck swelling The T. may grow up the vessels to the base of the skull
  • Slide 51
  • Carotid Body Tumour (Chemedectoma) Clinical features: The mass is firm & rubbery & usually demonstrates transmitted rather than expansile pulsation A bruit may be present Rarely patients complain of dysphagia or discomfort Large T. may involve 9 th, 10 th, 11 th & 12 th cranial nerves, accasionally the sympathetic chain causing a Horner’s syndrome
  • Slide 52
  • Carotid Body Tumour Diagnosis: - History of a longstanding neck mass - Physical examination - CT scan - Carotid angiogram (to see feeding vs., extent of tumour)
  • Slide 53
  • Carotid Body Tumour Treatment: Surgical removal is indicated: - Malignant & resectable T. - Patient in a good health, < 60 with a small or medium sized T. - Those T. which have extended into the pharynx & palate & are interfering with swallowing, breathing & speaking
  • Slide 54
  • Carotid Body Tumour Treatment: Radiotherapy in: - Patients who should have surgery but refuse - Poor-risk patients - In metastatic disease
  • Slide 55
  • Glomus Vagale Tumour Extremly rare Presents as a mass at the angle of the jaw (too high for a branchial cyst, too low for parotid tumour Some cause pain & discomfort or pharyngeal M. Dx. by angiography Removal is much more difficult than carotid B.T. (vascular S.)
  • Slide 56
  • Malignant Neck Masses In the Neck, the main malignant problem to be considered is secondary carcinoma metastatic to the lymph nodes Most carcinomas of the head & neck sooner or later metastasize to the lymph nodes of the neck These LN form a barrier that prevents further spread of the disease for many months Most common carcinoma of the head region are basal cell ca. & squamous cell ca.
  • Slide 57
  • Non-thyroid Neck Masses in an Adult Neoplastic (85 %)Inflammatory/congenital (15 %) Malignant (85 %)Benign (15 %) Metastatic (85%)Primary (15%): lymphoma, salivary g. Primary cancer sitePrimary cancer site below above clavicle (85 %)clavicle (15 %)
  • Slide 58
  • Squamous Cell Carcinoma
  • Slide 59
  • Is a cancer of a kind of epithelial cell, the squamous cell which are the main part of the epidermis of the skin It is one of the major forms of skin cancer, & seen mainly on the lips & mouth SCC of the skin begins as a small nodule and as it enlarges the center becomes necrotic and sloughs and the nodule turns into an ulcer. Squamous Cell Carcinoma
  • Slide 60
  • Predisposing Factors: 1- Smoking 2- Alkohol Consumption 3- HPV infection Squamous Cell Carcinoma
  • Slide 61
  • Clinical Features: 90 % of cases of head and neck cancer (cancer of the mouth, nasal cavity, nasopharynx, throat and associated structures) are due to squamous cell carcinoma The lesion caused by SCC is often asymptomatic Ulcer or reddish skin plaque that is slow growing Intermittent bleeding from the tumor especially on the lip The clinical appearance is highly variable,usually the tumor presents as an ulcerated lesion with hard, raised edges The tumor commonly presents on sun-exposed areas Unlike basal cell carcinoma (BCC), squamous cell carcinoma (SCC) has a substantial risk of metastasis Squamous Cell Carcinoma
  • Slide 62
  • Clinical Features: A hoarse voice sometimes present in cases of ulcer in the oral cavity, near the pharynx Treatment: 1- Surgery ( extensive excision may be necessary) 2- Radiotherapy Squamous Cell Carcinoma
  • Slide 63
  • Basal Cell Carcinoma
  • Slide 64
  • is the most common cancer It rarely metastasizes However, because it can cause significant destruction and disfigurement by invading surrounding tissues, it is still considered malignant Patients present with a shiny, pearly nodule. However, superficial basal-cell cancer can present as a red patch like eczema Basal Cell Carcinoma
  • Slide 65
  • Diagnosis: - is by skin Biopsy Treatment: 1- Surgical excision: most preffered 2-Chemotherapy: Some superficial cancers respond to local therapy with 5-fluorouracil 3-Immuntherapy: research suggests that treatment using Euphorbia peplus, a common garden weed, may be effective Basal Cell Carcinoma
  • Slide 66
  • References Current, Surgical Diagnosis & Treatment, Gerard M. Doherty Essential Surgical Practice, A. Cuschieri, G R Giles, A R Moosa Bailey & Love’s, Short Practice of Surgery, R.C.G. Russell, Norman S. Williams, Christopher J.K. Bulstrode Clinical Surgery, A. Cuschieri, Thomas P.J. Hennessy, Roger M. Greenhalgh, David I. Rowly & Pierce A. Grace
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