Neck Mass- Cysts and Fistula

Branchial Cleft Remnants 

Typically presents as lateral neck  mass (swelling) in toddlers. All branchial cleft remnants are present at birth, often not recognized until later. Sinus, fistula and cartilaginous rests are most common in infants . Cyst on neck: Most common in older children and adolescents.

Branchial Cyst 

Vestigial remnants of the second branchial cleft. Lined by squamous epithelium and contains thick, turbid fluid. Upper neck in early or middle adulthood. Junction of the upper third and middle third of the sternomastoid muscle at its anterior border. Fluctuant  neck swelling that may transilluminate. Difficult to palpate, If infected, cause erythema and tenderness. May pass the bifurcation of the common carotid artery as far as the pharyngeal constrictors. Superficial to the XI & XII CN . >40 years – r/o malignancy with necrotic node.

Branchial Fistula

Unilateral or bilateral. Represent a persistent second branchial cleft. External orifice is nearly always situated in the lower third of the neck near the anterior border of the Sternocleidomastoid. Internal orifice is located on the anterior aspect of the posterior faucial pillar just behind the tonsil . Lined by ciliated columnar epithelium. Same path as a branchial cyst and requires complete excision to avoid recurrence

Cystic Hygroma

Usually present in the neonate or in early infancy.  Multiple local aged cystic neck mass lined by endothelial cells. Caused by sequestration of jugular lymph sac from lymphatic system. Filled with clear lymph. Associated with: Turner’s Syndrome. Most common site: Posterior Triangle - Check, axilla, groin and mediastinum are other less frequent sites for a cystic hygroma. Soft and partially compressible, visibly increasing in size when the child coughs or cries. Brilliantly translucent. Can cause airway obstruction, other complication are infection and haemorrhage.

IOC: MRI. Definitive treatment involving complete excision of the cyst on neck at an early stage is best if possible. Injection of a sclerosing agent is an alternative strategy – commonly multicystic and therefore, complete resolution is a challenge. May become infected and rupture onto the skin of the neck presenting as a discharging sinus / fistula.

Sistrunk’s Operation 

Excision of the whole thyroglossal tract. Removal of the body of the hyoid bone and. The suprahyoid tract through the tongue base to the vallecula at the site of the primitive foremen caecum

Ludwig’s Angina

Consist of brawny neck swelling of the submandibular. Inflammatory oedema of the mouth. Accompanying putrid halitosis.

Thyroglossal Cyst

The thyroid gland descends early in fetal life from the base of the tongue of the level 2nd and 3rd rings of trachea. Track of the descent of the thyroid gland is variable, passing front, through or behind the hyoid. Thyroglossal duct cysts represent a persistence of this track in midline from the tongue base to the thyroid isthmus. Rarely it may be only functioning thyroid tissue. Classically, the cyst on neck moves upwards on swallowing and with tongue protrusion – also occurs like dermoid attached to hyoid.

Cause : Virulent streptococcal infection associated with anaerobic infection, tracks deep to the mylohyoid muscle. The tongue is displaced upwards and backwards, giving rise to dysphagia. May extend beneath the deep fascial layers of the neck to involve the larynx . Broad spectrum antibiotics with anerobic cover. I & D of submental region to drain submandibular areas.

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Cervical Adenitis

 Acute enlarged and tender pyrexia, anorexia and general malaise. Rx directed to primary focus of infection.

Chronic Adenitis

Chronic - Tuberculosis in young children or adults, secondary to malignant disease, most commonly from a squamous cell carcinoma. Others: HIV & Lymphoma.

Cause Of Cervical Lymphadenopathy

Inflammatory: Reactive hyperplasia, Infective, Viral: for example, infectious mononucleosis, HIV: Bacterial- Streptococcus, Staphylococcus, Actinomycosis Tuberculosis Brucellosis. Protozoan: Toxoplasmosis, Neoplastic Malignant: Primary (e.g. lymphoma) Secondary carcinoma) Known primary Occult primary.

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Tuberculosis Adenitis

MC children / young adults. Entry from ipsilateral tonsil. In 80% of patients, the tuberculous process is confined to nodes Need to r/o pulmonary TB. Unilateral lymph nodes in neck liquefy and form a Cold Abscess. Collar stud abscess Abscess extends to subcutaneous tissue – may lead to sinus formation.

Management 

FNAC- AFB Staining, CXR, Mantoux .Recent test – GeneXpert for MTB (PCR based) . In selected patients, r/o HIV. Rx is by ATT after appropriate Biopsy to establish diagnosis. Surgery for drainage of abscess or sinus / resection of residual nodes that are persistent after ATT.

Chemodectoma (Carotid Body Tumor) 

Higher incidence in areas people live at high altitudes. Chronic hypoxia leading to carotid body hyperplasia. 5th decade; 10% are familial, usually benign. Association with Phaeochromocytoma. Arise from the chemoreceptor cells on the medial side of the carotid bulb- adherent to carotid wall here. Long history of a slowly enlarging, painless lump at the carotid bifurcation. 1/3 Pharyngeal neck mass pushing tonsil medially. Firm, rubbery, pulsatile, mobile from side to side but not up and down. Emptied by firm pressure, after which it slowly refills in a pulsatile manner- may have a bruit. A carotid angiogram can be carried out to demonstrate the carotid bifurcation, splayed- “Lyre Sign” and a blush, outlines the tumour. Rx is Surgery with provision of bypass / graft.

Nodal Metastasis

MC from SCC / Nasopharyngeal tumors – Npx, Tongue.

Check for tonsil, Pyriform Fossa, Supraglottis to r/o Occult Primary by Pan – endoscopy & Directed Biopsies.

Diagnosis by FNAC – rarely needs Core biopsies.

Rx- Surgical along with Primary or Resection of residue after CT / RT.

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