1. Neck masses Prof. Fuad Ammari
Thyroid neoplasms
Thyroglossal cyst
Salivary gland swelling
Branchial cyst
Cystic Hygroma
Chemodectoma
Lymph node enlargement th

2. Thyroglossal Cyst
It is present in any part of thyroglossal tract. The most common sites are beneath the hyoid, over the thyroid cartilage. It contain thyroid tissues in about 60% of cases The initial presentation often follow upper resp. infection

3. CT thyrogl.cyst

4. Thyroglossal Cyst
It occupies the mid line except in the region of thyroid cartilage where thyroglossal tract is pushed usually to the left.
It moves upward on swallowing and an protrusion of the tongue.

5. Site of th.gl.cyst

8. Infection may occur  fistula. Rec. after surgery  fistula
Thyroglossal Cyst
Infection may occur  fistula.
Rec. after surgery  fistula
discharges clear fluid or pus.
Treatment: Cistrunk operation: Excision with part of body of the hyoid bone.
A cyst over 1cm in size should be excised because infection is inevitable

9. Salivary glands Paired salivary glands: Parotid & Submandibular
Minor salivary glands: Widely distributed in the mucosa of
The lips, cheeks, hard & soft palate, uvula, floor of the mouth, tongue & peritonsillar area
A few are found in the nasoph., paranasal sinuses, larynx, trachea, bronchi & lacrimal glands.

10. Salivary gl.

11. Facial n. & parotid

12. Diseases of the salivary glands
INFLY: Acute parotitis, TB., Mumps, Actinomycosis, cat scratch disease
OBST. : Sialolithiasis, Sjogren’s, stricture.
NEOPLASMS: I. Epithelial tumours
A. Adenomas: pleomorphic (mixed) & monomorphic e.g. basal cell adenoma, oncocytoma & adeno-lymphoma.

13. Sal. Gl. neoplasms B. Mucoepidermoid C. Acinic cell tumour
D.Carcinoma: Carcinoma in a mixed t., adenocarcinoma, undifferentiated ca., adenoid cystic ca., & epidermoid ca. high grade mucoepidermoid ca.
II. Nonepithelial tumours

14. Acute suppurative sialadenitis
-It is an ascending infection (Staph. Aureus & strept. viridans) from the oral cavity Predisposed by a reduction in salivary flow or partial obstruction
-Following major surgical operations due to dehydration & poor oral hygiene

15. Sialadenitis
During deblitating illnesses e.g Cholera or Typhoid fever.
Following radiotherapy
Sjogren’s syndrome.

16. Ac. Sup. Sial. Clinically:
Brawny swelling on the side of the face, in advanced cases the skin becomes dusky red.
Taking the shape of the parotid gl.
It raises the lobule of the ear.
Temp. is usually well above 37.8’C.

17. Ac. Sup. Sial.
Fluctuation occurs only after pus has penetrated the dense fascia of the parotid sheath.
Pus can be expressed from the parotid duct and taken for C&S.
Sialogram following resolution of symptoms to asses salivary function
Meticulous oral hygiene. .

18. Sialadenitis Dentures are worn only at meal time
Improve the general state of the patient.
Antibiotics “broad spectrum antibiotics”.
Soft diet & plenty of fluids are taken as chewing is painful.
Message the gland, if not improved incision & drainage is essential.

19. Ranula A sialocele of the floor of the mouth Types
Circumscribed - obstruction and cystic dilatation of sublingual gland or submandibular duct.
Plunging - extravasations of saliva into tissues of the floor of the mouth. May extend deep into floor of the mouth

20. Ranula

21. Ranula

22. CT

23. Ranula
Signs and Symptoms - cystic sub mucosal mass in the floor of the mouth; may periodically shrink with discharge of contents into mouth
Treatment
Circumscribed cyst may be excised, along with involved gland or glands
Plunging ranulas cannot be excised and should be marsupialized

24. Salivary calculi
The submandibular (SM) calculi are the most common 80% radio-opaque.
Parotid stones 20% usually radiolucent
Swelling and pain; dull ache radiate to the ear, before or during eating last through the meal.
Pain goes away before swelling.
Recurrent painful swelling at mealtime especially lemon

25. Salivary calculi
Hx of symptoms on the other side due to bilateral calculi
Pressure on the gland may give foul tasting saliva (purulent saliva)
Acute & subacute infection may be the first indication of a stone.
Persistent obstruction damages the gland making it harder and tender

26. Salivary calculi
The SM gland lies beneath the horizontal ramus of the mandible on the mylohyoid muscle anterior to the anterior border of the sternomastoid
Skin is red, edematous ,hot and tender if infected

27. Calculi
Bimanual palpation one finger inside the mouth and others on the skin over the lump
Plain Xray
Sialography to demonstrate the lumen of the ducts for stone, tumor, or stricture.

28. Calculi
Calculi within the duct may be removed through the floor of the mouth
Excision of the gland where the stone is within the gland or the gland is severely damaged by chronic infection.

29. Salivary neoplasms
Tumors of the salivary glands3-6% of all head and neck neoplasms.
Parotid gl % of all salivary t.,
80% are benign and 80% of the benign are pleo-morphic ad.
Sub mand. gl % of all salivary t., 60% are benign and 95% of the benign are pleomorphic ad.
Minor salivary gl % of all salivary t., 80% are malignant.

30. Pleomorphic adenoma The most common salivary tumor,
Appear well circumscribed and slowly growing benign tumor but strands or lobules of the tumor tends to penetrate the thin capsule “pseudopodia” and extend beyond the main limits of the mass (enucleation is inadequate).

31. Pleomorphic adenoma Histopathology:
Epit.cells proliferate in strands or duct like
Myoepith. cells proliferate in sheets with the production of a mucoid material which separate the cells producing a myxomatous appearance cartilage like.

32. Pleom. ad.
Cystic areas may appear due to excessive mucoid accumulation.
After many years ( 10-30) few tumors may exhibit malignancy(ca in pleom. ad.)
Treatment of benign t. is by superficial parotidectomy.

33. Adenolymphoma (Warthin’s tumor)
A benign tumor, dominant in males
Common in Asians and smokers
Occurs in almost exclusively in the parotid gl.
Slowly enlarging soft or fluctuant swelling
It is formed of a double layered epithelium.
Spaces or cysts, with papillary like app.

34. Adenolymphoma The stroma contains lymphoid tissues and follicles
usually toward the lower pole (10% of parotid t.),
can be multiple and bilateral 10-20%.
It form a hot spot in a 99mTc-pertechnetate
Treated by superficial parotidectomy

35. Malignant tumors most common in the major salivary glands are:
mucoepidermoid carcinoma,
acinic cell carcinoma
adenoid cystic carcinomas.
Among the minor salivary glands adenoid cystic ca. is the most common.
Malignant tumours are designated :
Low-grade:
Acinic cell tumours: represent 1% of all salivary gland neoplasms. 95% arise in the parotid gland.
Mucoepidermoid carcinoma (grades I or II).

36. Malignant tumors Mucoepidermoid carcinoma (grade III)
High-grade:
Mucoepidermoid carcinoma (grade III)
Adenocarcinoma - poorly differentiated carcinoma and anaplastic carcinoma; represents 2-3% of salivary tumours.
Squamous cell carcinoma.
Malignant mixed tumours.
Adenoid cystic carcinoma

37. Mucoepidermoid tumor
It is composed of sheets and masses of epidermoid cells and cystic spaces lined by mucus secreting cells (no cartilage like app)
They are of varying speed of growth and degree of differentiation.
Mostly they are slow growing and invade local tissues to a limited degree.
Only occasionally grow rapidly and metastasize to lymph nodes, lungs or skin- Grade III.

38. Mucoep. t.
Mucoepidermoid carcinoma is the most common malignancy of the parotid and is the second most common of the submandibular gland (after adenoid cystic carcinoma). It represents about 8% of all parotid tumours.
Clinically they are usually harder than mixed t., yet become fixed when large.
Mostly they do not cause facial paralysis
FNA
Superficial parotidectomy and radiotherapy may be advisable

39. Adenoid cystic carcinoma
Adenoid cystic carcinoma is the most common in submandibular & minor salivary glands.
Perineural spread
Skip lesions are common -↑rec.rate
May remain symptom free years followed by sudden and aggressive recurrence and lung mets are common.
Total excision with safety margin
Radiotherapy

40. Carcinomas
It tends to produce obvious clinical signs of malignancy at an early stage
Hard, rapidly growing infiltrating mass
Fixation, resorption of adjacent bone & ulceration
Pain, anesthesia, muscle spasm and later paralysis in the case of parotid ca.

41. Carcinoma FNA cytology CT scan. Radical excision, block dissection
Post-operative radiotherapy in extra-glandular dis., Peri-neural invasion, regional spread and high grade histology

42. Branchial cyst
Vestigial remnant of the second branchial cleft, is lined sq. epith & filled with thick turbid fluid full of cholesterol crystals
It presents in early or middle adulthood
In upper neck at ant. border of sternomast.
Soft, fluctuant & may transilluminate
Infection may occur red & tender D.D TB
Diag. US & FNA
Treatment Complete excision

43. Branch. Fistula Branchial fistula: unilat or bilateral
External opening in the lower neck at ant. Border of sternomastoid
Internal opening in oropharynx or end blindly
It requires complete excision
Branchogenic carcinoma: It is rare.
It is due to cystic degeneration in a LN. with sq.carcinoma the primary carcinoma in the nasoph. tongue or oroph or larynx. It needs full scanning to diagnose the primay

44. Cystic Hygroma
It is a sequestration of a part of the jugular lymph sac “between the jugular and subclavian veins from the lymphatic system” it is filled with lymph
It presents in neonate & infancy or at birth
It may be bilateral, it may involve tongue, parotid & floor of the mouth, less common site cheek, axilla, groin & mediastinum
It is soft, compressible, translucent, increases in size on crying or coughing

45. Cystic Hyg.
The behaviour is uncertain, it may expand rapidly with respiratory distress - aspiration to reduce pressure
Infection red & painful & regression may occur
Definitive treatment is complete excision at an early stage
Sclerotherapy “picibanil” inside the cysts

46. Carotid Body Tumor “Chemodectoma”
It arises from chemoreceptors in carotid body at carotid bifurcation in the neck.
It occurs as a consequence of chronic hypoxia in high altitudes as in Peru & Mexico .
It occurs in 50th decade
Familly history in 10% of cases
Association with pheochromocytoma
Usually benign except in few cases
Inactive “no hormone secretion”

47. Chemodect -Slowly enlarging painless lump for several years
-The mass is firm, rubbery, pulsatile, is mobile from side to side, it can be emptied under pressure to slow refil again
-It pushes the tonsil medially, bruit may be present
- Carotid angiogram & MRI diagnostic
-It should not be biopsied
Treatment: Avoid surgery in elderly as it is a benign T.
If small and dissection is possible. If large bypass equipment should be ready.

48. Secondary Carcinoma in the neck
-It is common from primary sites in the head and neck, FNA for diagnosis
-It is treatment as the primary lesion
-Primary lesion excise and local dissection of lymph node
-Radiotherapy as a first line of treatment

49. Acute Lymphadenitis a Enlarged group of LN Pyrexia, anorexia, malaise
Usually there is a primary focus of infection e.g. tonsillitis
Treatment : antibiotics and antipyretics

50. Tuberculous Lymphadenopathy
-It is a common cause of cervical lympha-denopathy, it occurs at different ages
-TB. Bacillus gain entrance through the tonsils.
-A primary focus in the lung must be suspected and investigated, In 80% it is limited to the affected group
-FNA is necessary to exclude malignancy.
-A cold abscess is formed & a discharging sinus
- TB chemotherapy for 6-9 months

51. Lymphoma of the head & Neck
-Hodgkin’s or non-Hodgkin’ lymphoma
-Upper deep cervical lymph node enlargement
-Night fever at advanced stage
-CT for staging
-FNA or lymph node biopsy for diagnosis
-Radiotherapy & chemotherapy

52. Painful neck mass THYROIDAL CAUSES Acute thyroiditis
Subacute thyroiditis
Acute thyroid cyst (hemorrhage into cyst or nodule)
Rapidly enlarging thyroid carcinoma
Painful Hashimoto’s thyroiditis
Radiation thyroiditis