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Occipital headache as referred pain from tight scalene
muscles.
Weakness in forearm, hand.
Vascular symptoms
Claudication, ischaemic ulcers, gangrene.
Signs
Scalene muscle tenderness.
Pulsatile swelling in supraclavicular region with thrill and
bruit (25%).
Bony mass above clavicle.
Adson’s test (+ve), Roos test (+ve).
Elevated arm stress test (+ve).
SRB's Manual of Surgery
Costoclavicular compression
manoeuvre.
Hyperabduction manoeuvre.
Poor capillary refilling.
Absence or feeble pulse.
reveals feeble/absence of
radial pulse due to compres-
}
sion of the subclavian artery.
(Please refer Chapter on Arterial Diseases for details of tests).
Investigations: X-ray of the neck and cervical spine to check
cervical rib, cervical spine pathology. Arterial Doppler of upper
limb and neck; Subclavian CT angiogram; MRI neck; nerve
conduction studies of upper limbs; electromyography are other
investigations needed. Blood tests for sugar, lipid profile, vasculitis should be done.
Types (Refer Fig. 5.4)
1. Complete bony: Cervical rib is radio-opaque, anteriorly ends
over the first rib or manubrium.
2. Combined: Partly bony partly fibrous.
3. Complete fibrous: Cannot be demonstrated radio logically.
4. Partial bony: With free end expanding as bony mass, which
is felt in the neck.
Fig. 5.4: Cervical rib types.
Note:
7 types of cervical ribs are identified. Type III is the commonest which is
a band extending from C7 vertebra to scalene tubercle of 1st rib elevating
the neurovascular bundle upwards causing compression.
Treatment
Conservative—if nerve velocity is >60 m/second
Surgical—if nerve velocity is <60 m/second
CONSERVATIVE TREATMENT FOR TOS
B
x Exercises—neck stretching, postural and breathing exercises
x Drugs—analgesics, muscle relaxants, antidepres sants
x Avoid weight lifting
x Physiotherapy
SURGICAL TREATMENT OF TOS
B
x Transaxillary (ROOS)—mainly for first rib excision and also
cervical rib
x Supraclavicular approach for cervical rib and soft tissue excision,
scalenotomy, neurolysis, arterial reconstruction
x Cervical sympathectomy may be needed
CERVICAL RIB
Denition
It is an extension of costal element (anterior part) of trans-
verse process of C7 vertebra more than 2.5 cm (normal).
Syndrome caused by it is called as cervical rib syndrome,
thoracic-inlet syndrome, thoracic-outlet syndrome, scalene
syndrome.
It is 0.5% common; common in females; more frequent on
right side.
It can be unilateral or bilateral (>50%) can be asymptomatic
or symptomatic (15–20%).
Pathology
Cervical rib narrows the scalene triangle (bounded by scalenus
anterior, scalenus medius and first thoracic rib below).
Compression of subclavian artery; C8 and T1 nerve roots due
to cervical rib.
↓
Angulation of subclavian artery occurs.
↓
Causes constriction of artery at the site where artery
crosses the cervical rib
↓
‘Eddie’s current’ created in the blood flow causes
sudden release of pressure distal to the narrowing.
↓
Poststenotic dilatation → Venturi phenomenon
(due to vessel wall ischaemia)
↓
Stasis of blood occur
↓
Thrombosis → Embolus
↓ ↓
Features of ischaemia in the hand and forearm.
Later digital gangrene occurs.
Neurological (95%)—Compression of C8 and T1 causes
tingling and numbness along its distribution, i.e. in the little
finger, medial side of hand and forearm.
Venous—(rare—4%): Paget–Schroetter (‘Effort’ axillary—
subclavian vein thrombosis) syndrome is subclavian vein
compression by cervical rib in costoclavicular space. It is rare.
Arterial compression is very rare (2%) but when it occurs
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more dangerous. Rarely thrombus may extend proximally into
the subclavian artery causing vertebrobasilar insufficiency.
Double crush syndrome – TOS with carpal tunnel syndrome
(CTS).
A
B
2.
Vascular manifestations:
¾
Pain is due to ischaemia in the muscle. It is more during
work, exercise, and is relieved by rest.
¾
Upper limb claudication usually is observed in forearm
and arm more obvious after usage of limb. Pain (dull
pain) in posterior triangle of neck may be due to presence rib mass. Ischaemic pain in the digits and hand
may be present.
¾
Vasomotor changes with cyanosis, cold fingers, excessive sweating may be observed.
¾
Roos test: The patient raises his arms at 90° of abduction at shoulder with the arms fully externally rotated and
the elbows at 90° of flexion. The hands are kept in this
position for up to 3 minutes. The test is positive if the
patient is unable to hold the arms up for 3 minutes, or
if the patient feels pain, heaviness or paraesthesia in the
shoulder, arm or hand.
¾
Elevated arm stress test (EAST): Both shoulders (arms)
are abducted to 90° with arms fully externally rotated and
the elbows braced backwards. Patient will open and close
(clench and unclench) the hands rapidly for 5 minutes.
Normal individual can do this without any discomfort
and pain. Patient with thoracic outlet syndrome develops
pain, fatigue, paraesthesia of forearm with tingling and
numbness of fingers which gradually progresses. Patient
will not be able to continue the test for 5 minutes. This
test can also differentiate thoracic outlet syndrome from
cervical disc prolapse disease.
¾
Adson’s test: The hand is raised above after feeling the
radial pulse. The patient is asked to take a deep breath
and turn the head to the same side. Any change in pulse,
i.e. either becoming feeble or absent, is noted.
417
CHAPTER 5 Neck
C
Figs. 5.5A to C: Anatomy of cervical rib and its relation to subclavian
artery and vein and brachial plexus. Note the Eddie’s current, poststenotic dilatation due to arterial compres sion by cervical rib. X-ray
shows left-sided complete cervical rib.
Clinical Features
Majority of patients are asymptomatic—(80%).
1. Neurological features is due to compression of T1 and C8
causing tingling and numbness in the little finger, medial side
of hand and forearm.
¾
Pain, on the medial side, weakness on the medial side of
hand and anaesthesia may be evident.
¾
Card test for interossei muscle weakness, Froment’s sign/
test to detect weakness in adductor pollicis are positive.
Wasting may be due to neurological cause also.
Fig. 5.6: Adson’s test—after palpating radial pulse, elbow with stretched
hand is slightly raised; neck is turned to same side; deep breath is taken;
feeble or pulse becoming absent may be obvious in positive Adson's.
¾
Modified Adson’s test is same as Adson’s, but neck is
turned towards the opposite side.
¾
Costoclavicular compression manoeuvre (Falconer test):
While palpating the radial pulse of the patient, he is asked
to move his shoulder backwards and downwards (exag-
gerated military position) which may cause absence/
feeble radial pulse and a bruit may be heard while auscultating the supraclavicular region—military attitude test.
Nothing dies quicker than a new idea in a closed mind.
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This is due to compression of subclavian artery between
clavicle and first rib. Similary Halstead manoeuvre is done
by 45° abduction and extension of arm with downward
pushing of the shoulder with neck turned opposite side
to cause radial pulse feebly palpable.
¾
Hyperabduction manoeuvre (Wright’s test): While
palpating the radial pulse, arm on the diseased side is
passively hyperabducted causing feeble or absence of
radial pulse. This is due to compression of artery by
pectoralis minor tendon (pectoralis minor syndrome).
An axillary bruit may be heard on auscultation.
¾
SRB's Manual of Surgery
Allen’s test: It is used in hand to find out the patency
of radial and ulnar arteries. Both radial and ulnar
arteries of the patient is felt and pressed firmly at the
wrist. Patient clinches his hand firmly (often repeated
clinching) and holds it tightly. After 1 minute clinch
is released to open the palm of the hand which looks
pale. Pressure on radial artery in the wrist is released
to see area of distribution of the radial artery. Normally,
it becomes flushed with pink color. If there is block
in radial artery, the area will remain white. Test is
repeated again. This time pressure on the ulnar artery
is released to check the patency of ulnar artery. Area
will be pale and blanched after releasing in case of ulnar
artery block. Otherwise it becomes pink after release in
normal individual.
Fig. 5.8: Upper limb ischaemia showing ischaemic ulcers and
gangrene of finger tips.
Note:
• Mostcommonpresentationisneurological.
• Mostproblematicpresentationisvascularwhichrequiressurgery.
DIFFERENTIAL DIAGNOSIS
B
x Cervical spondylosis—to differentiate, X-ray neck—lateral view
should be taken
x Carpal tunnel syndrome
x Tumours or swellings compressing over the vessel or nerves
in the neck
x Other causes of digital gangrene like atherosclerosis, Raynaud’s
syndrome, collagen diseases, diabetes mellitus, and embolism
x Syringomyelia, motor neuron disease
x Pancoast tumour.
Fig. 5.7: Allen’s test done upper limb ischaemia to look for perfusion
of hand.
¾
Wasting of thenar, hypothenar and forearm muscles.
¾
Often digital gangrene, ischaemic ulcers in digits, oedema
of fingers and hand are observed.
¾
Limb is colder and paler than the opposite side.
3. Features in the neck:
¾
Hard, fixed, bony mass in the supraclavicular region.
¾
Palpable thrill above the clavicle in the subcla vian artery.
¾
Bruit on auscultation.
Investigations
Chest X-ray PA view and lateral view including neck—only
(radio-opaque) bony rib can be identified.
Nerve conduction studies to confirm neurological compres-
sion and also to rule out carpal tunnel syndrome or cervical
spondylosis.
Arterial Doppler of subclavian artery and of the upper limb.
CT scan neck and thorax and CT angiogram of subclavian
artery are ideal investigations. MRI of neck is useful.
Other relevant investigations like blood sugar, lipid profile,
cardiac assessment.
MR neurography is newer method used now.
Scalene muscle block by injecting 5 ml of bupivacaine with
1 mL of betamethasone into the scalenus muscle to observe
for relief of symptoms.
Treatment
Conservative
It is aimed at increasing the space and reducing the compres-
sion.
Proper posturing; correction of wrong posture; muscle
strengthening exercises; strengthening the shoulder girdles;
avoiding hyperextension of the neck and hyperabduction of
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the limb.
NSAIDs; muscle relaxants; ultrasonography with ionatopho-
rosis; transcutaneous electric nerve stimulations (TENS).
Limb elevation; compression garments; phonopheresis; limb
massage.
Surgical
Indications: Failure of conservative treatment beyond 2 months;
subclavian arterial compression; progressive neurological deficit;
nerve conduction velocity <60 m/s.
In symptomatic cervical rib without arterial compression
(subclavian artery), along with scalenotomy (cutting scalenus
anterior muscle), extraperiosteal resection of cervical rib
and resection of first rib is done to increase the thoracoaxillary channel and so as to reduce arterial compression and
recurrence.
In symptomatic cervical rib with significant subclavian artery
compression along with scalenotomy, extraperiosteal resection of cervical rib, resection of first rib, subclavian artery
reconstruction with or without a graft is done.
Along with scalenotomy, extraperiosteal resection of cervical
rib, resection of first rib, reconstruction of subclavian artery,
cervical sympathectomy is also done to improve the circulation to the ischaemic upper limb.
Amputation toes when they are gangrenous.
In pectoralis minor syndrome, pectoralis minor tendon is
released (tenotomy) from its insertion to coracoid process.
In subclavian compression with thrombosis, thrombectomy,
catheter directed thrombolysis or venous bypass may be
needed.
Anticoagulant therapy with unfractionated heparin or low
molecular heparin; later oral anticoagulants is used in case
of vascular compression.
COMPLICATIONS OF SURGERY
B
x Nerve injury—phrenic, brachial plexus, long thoracic nerve of
Bell, intercostobrachial
x Vascular injury—subclavian vessels
x Pleural—pneumothorax, hemothorax
x Thoracic duct—chylous fistula, chylothorax
x Recurrence (10%)—It is due to postoperative scarring; due to
inadequate postoperative exercises; also occasionally due to
incomplete scalenotomy and incomplete excision of the first rib.
Recurrence usually occurs within 3 months of surgery. It requires
reexploration, reexcision of the first rib, completion scalenotomy,
adequate neurolysis, vasculolysis, completion of first rib excision
and partial 2nd rib excision also with cervical sympathectomy.
Resurgery is always done through posterior high thoracoplasty
approach.
BRANCHIAL CYST
It arises from the remnants of second branchial cleft.
Normally, 2nd, 3rd, 4th clefts disappear to form a smooth
neck. Persistent 2nd cleft is called as cervical sinus (of His)
which eventually gets sequestered to form branchial cyst.
Epithelial infusion within lymph node may be the other
cause as branchial cyst contains lymphoid tissues in their
wall.
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CHAPTER 5 Neck
APPROACHES
B
x Supraclavicular—mainly used when vascular reconstruction is
needed. It gives wide exposure and adequate resection of cervical
rib and first rib; brachial plexus neurolysis is also easier.
x Transaxillary (Roos)—it is through axillary crease hair line, at 3rd
rib level. Both first rib resection and scalenotomy can be achieved.
It is cosmetic; less blood loss; anomalous ligaments and bands
can be transected properly. But vascular reconstruction and
brachial plexus neurolysis is difficult; often there will be difficult
to expose scalene triangle.
x Infraclavicular—useful for exposure of subclavian artery and vein
for reconstruction and embolectomy; but outlet is not exposed
with poor view of posterior part of the first rib.
x Posterior—rib resection and cervical sympathectomy is easier;
but vascular reconstruction is not possible.
x Thoracoscopic first rib resection using 3 ports—one at anterior
part of 3rd intercostals space; second at lateral part of 5th intercostals space; third at lateral part of 6th intercostals space.
A
Figs. 5.9A and B: Branchial cyst. It is only occasionally transilluminant.
Figs. 5.10A and B: (A) Branchial cyst—both sides; (B) Positions of
Everything big starts with something little.
B
BA
branchial cyst and fistula.
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Features
It is 20% of all neck masses.
Swelling in the neck beneath the anterior border of upper third
of the sternomastoid muscle. It is smooth, soft, fluctuant,
often transilluminant with a sensation of ‘Half-filled double
hot water bottle’.
It is equal in both sexes. Even though congenital, it is seen
in late adolescents and early 3rd decade.
In 3% cases, it is bilateral; it can be familial also.
Usually painless unless it is infected.
It contains cholesterol crystals which is from the lining of
SRB's Manual of Surgery
mucous membrane which contains sebaceous gland. Cheesy
toothpaste like material is typical.
Histologically, it is lined by squamous epithelium. Occasion-
ally it contains ciliated columnar epithelium. Cyst wall shows
plenty of lymphoid tissue.
It may get infected to form an abscess.
FNAC shows cholesterol crystals.
MRI allows for finer resolution during preoperative planning.
Complications: Recurrent infection. Rupture may cause
acquired branchial fistula at upper third of sternocleidomastoid muscle.
Differential diagnosis: Cold abscess, lipoma neck; Lymph
cyst; Chronic lymphadenitis.
Treatment: Excision under general anaesthesia.Cyst is in
relation to carotids, hypoglossal nerve, glossopharyngeal
nerve, spinal accessory nerve, posterior belly of digastric
and pharyngeal wall. Medially it is close to the posterior pillar
of tonsils. During dissection, all these structures should be
taken care of. Step ladder approach using two parallel incisions is better.
Complications of surgery: Injury to major structures; Infec-
tion; Recurrence/fistula formation due to incomplete removal
of the track.
CHOLESTEROL CRYSTALS ARE SEEN IN:
B
x Branchial cyst x Dentigerous cyst x Hydrocele
Note:
• SclerotherapywithOK-432(picibanil)hasbeeneffective,oftendone
underUSguidance.
• Infish,branchialcleftsdevelopintogills.BranchiainGreekmeans
gills.
• Sixbranchialarcheswith fivepharyngealpouches(endoderm
lining)inside andfivepharyngealclefts (ectodermlining)outside
arepresentduringdevelopment.
• Branchialcleftcystcanarisefromcleft1,2,3and4;fromcleft2is
commonest(90%).
BRANCHIAL FISTULA
Branchial fistula is commonly a congenital lesion. It is due
to persistent precervical sinus between 2nd branchial cleft
and 5th branchial cleft having opening in the skin at lower
1/3rd of neck on the inner margin of sternocleidomastoid
muscle, often ends as a sinus just proximal to the posterior
pillar of fauces behind tonsil which is also the site of inner
A
B
Figs. 5.11A and B: Branchial fistula in two different patients. Note the
location and discharge (Courtesy: Professor Kishore
ENT
Surgeon and Head of the Department and Dr Sampath, ENT
Surgeon, KMC, Mangaluru)
Chandra Prasad,
opening when presents as fistula. Fistula runs between the
structures related to 2nd and 3rd branchial arches (2nd
arch artery is E
CA, nerve is facial; 3rd arch artery is ICA,
nerve glossopharyngeal). From external opening at skin
below, it runs in subcutaneous plane to pierce deep fascia
at level of thyroid cartilage; to travel between ECA and ICA;
behind posterior digastric belly and stylohyoid; outer to IJV,
stylopharyngeus, hypoglossal and glossopharyngeal nerves;
perforates superior constrictor to reach the internal opening.
Occasionally acquired branchial fistula can occur due to
rupture of or after drainage of infected branchial cyst or
incomplete excision of the cyst track. This type of fistula is
located outside at skin at the level of upper third of sternomastoid muscle.
Often it is bilateral (30%).
External orifice of the fistula is situated in the lower third of the
neck near the anterior border of the sternomastoid muscle.
Internal orifice is located on the anterior aspect of the poste-
rior pillar of the fauces, just behind the tonsils.
Sometimes fistula ends internally as blind end.
Track is lined by ciliated columnar epithelium with patches of
lymphoid tissues beneath it, causing recurrent inflammation.
It usually presents at birth. It is common in children and early
adolescent period. Equal in both sexes.
External orifice is very small with a dimple which becomes
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more prominent on dysphagia with tuck in appearance.
Discharge is mucoid or mucopurulent.
Investigations: Discharge study, fistulogram, MR/CT fistu-
logram.
A
(oblique fibres) and cricopharyngeus (transverse fibres) of the
inferior constrictor muscle of the pharynx.
Thyropharyngeus is supplied by pharyngeal plexus from
cranial accessory nerve. Cricopharyngeus is supplied by
external laryngeal nerve.
Pharyngeal pouch is a pulsion diverticulum. It starts in the
midline of posterior pharyngeal wall. Once it expands and
reaches the vertebra, it deviates towards left side of the neck
because of resistance of vertebra.
Imperfect relaxation of the cricopharyngeus increases the
pressure in the pharynx, mainly during swallowing which
leads to protrusion of mucosa through the Killian’s dehiscence causing pharyngeal pouch.
The protrusion is usually towards left.
Large pouch which is visible in the neck as a globular swelling
often tender, smooth and soft. Swelling is below the level of
the thyroid cartilage and behind sternocleidomastoid muscle
and can be emptied on pressure. Opening of the pouch is not
vertical but horizontal. They present with dysphagia, features
of respiratory infection like pneumonia and lung abscess,
weight loss and cachexia. Pouch may itself get infected
and may form an abscess. Often the pouch may descend
downward and enter the superior mediastinum. Gurgling
sound in the neck is observed.
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CHAPTER 5 Neck
B
Figs. 5.12A and B: Branchial fistula is usually operated using two
transverse parallel incisions with step ladder dissection (Courtesy: Dr
Ganesh Pai, MCh).
Treatment
Always surgery:
Under general anaesthesia, methylene blue is injected into
the track. Probe is passed into the fistulous track. Through
circumferential/elliptical incision around the fistula opening,
entire length of the track is dissected until the internal orifice.
Care should be taken to safeguard carotids, jugular vein,
hypoglossal nerve, glossopharyngeal nerve and spinal accessory nerve. Entire track should be excised.
Step ladder dissection is done using two parallel incisions
one below at lower part another above at upper part of the
neck, will make dissection easier and complete.
STAGES
B
x Small diverticulum pointing towards vertebra. It is asymptomatic
and incidentally diagnosed by barium meal X-ray. Foreign body
sensation in pharynx may be present.
x Large, globular diverticulum with vertical mouth/opening causing
regurgitation, violent cough, dysphagia, respiratory infection.
Regurgitation is more after meals and while turning the neck.
PHARYNGEAL POUCH (ZENKER'S)
It is a protrusion of mucosa through Killian’s dehiscence, a weak
area of the posterior pharyngeal wall between thyropharyngeus
Fig. 5.13: Pharyngeal pouch (Zenker’s diverticulum).
There is only one degree difference between hot water and steam.
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PROBLEMS IN PHARYNGEAL POUCH
B
x Progressive dysphagia
x Respiratory problems like pneumonia, and lung abscess
x Abscess in the neck due to infection in the pouch
x Weight loss and cachexia
x Carcinoma may develop in the pouch rarely
Features
Treatment
Antibiotics and nutritional support initially.
Surgery
INDICATIONS FOR SURGERY
B
x Progressive symptoms; recurrent aspirations; persistent
dysphagia.
Pain, dysphagia, recurrent respiratory infection, swelling in
the neck on the left side which is smooth, soft and tender.
SRB's Manual of Surgery
Regurgitation during night while turning neck, smooth, soft,
tender swelling in the posterior triangle of the left side of the
neck; typical gurgling noise while swallowing—are typical
features. It is common in males.
Swelling is deep to sternocleidomastoid muscle below the
level of thyroid cartilage; initially soft and emptying; impulse
on coughing may be evident unless opening of the pouch is
blocked due to recurrent inflammation.
Halitosis from decayed food in the pouch is not uncommon.
Dyspnoea and change in voice can also occur.
Differential diagnosis:
Branchial cyst; Lymph cyst; Cold
abscess in the neck; Haemangioma neck; Other causes of
dysphagia like carcinoma, webs and stricture.
Investigations
Barium swallow—lateral view shows pharyngeal pouch—
Diverticulectomy with cricopharyngeal myotomy: It is done
in large lesion. After general anaesthesia, oesophagoscope is
passed and pouch is packed with acriflavine gauze. Nasogastric tube is passed under vision through the oesophagus.
Oblique or horizontal incision in the neck is made; sternocleidomastoid muscle is cut; diverticula is excised; oesophagopharyngeal wall is closed after doing cricopharyngeal
myotomy (Circular muscle fibers are cut at posterior midline
without opening the mucosa) is done to relieve the spasm;
drain is placed in the neck; nasogastric tube is kept in situ
for 7 days.
Inversion or diverticulopxey are other procedures.
COMPLICATIONS OF SURGERY
B
x Infection, either mediastinitis or lung infection (Pneumonia or
lung abscess)
x Pharyngeal fistula; Abscess in the neck
x Oesophageal stenosis and recurrence
x Recurrent laryngeal nerve palsy.
videofluoroscopy.
Chest X-ray shows pneumonia.
CT neck is very useful—ideal.
Indirect laryngoscopy may show pooling of saliva in pyriform
fossa.
Endoscopic minimally invasive technique
Dohlman’s approach – Pouch is excised using double lipped
endoscopy. Cautery or laser is used. It is quicker procedure
with shorter duration of anaesthesia; with faster recovery.
Stapling of the diverticula.
Note:
Friedrich Albert von Zenker (1851) was a German physician and pathologist. Zenker’s pharyngeal pouch; Zenker’s muscle degeneration; Zenker’s
peroneal nerve paralysis.
Fig. 5.14: Barium study showing pharyngeal pouch.
Note:
Oesophagoscopy should be gentle or avoided as scope may enter the
friable pharyngeal pouch and can cause perforation and life threatening
mediastinitis.
LARYNGOCELE
It is a unilateral narrow necked, air-containing diverticulum
resulting from herniation of laryngeal mucosa.
It occurs in professional trumpet players, glass blowers and
in people with chronic cough. It is common in males.
Laryngocoele is an abnormal dilatation of the appendage of
the laryngeal ventricle of Morgagni forming an airsac lined
with pseudostratified ciliated, columnar epithelium (air-filled
dilated saccule). Laryngeal ventricle of Morgagni is an elliptical recess between false and true vocal cords. Anterosuperior blind pouch of it is called as appendage of the ventricle
which normally communicates with the laryngeal ventricle
through a normal stalk.
It can be congenital or acquired (common). It may be often
associated with laryngeal carcinoma.
TYPES
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B
1. External: It is situated in the anterior third of the laryngeal
ventricle, between the false cords and thyroid cartilage, herniates
through the thyrohyoid membrane where it is pierced by superior
laryngeal nerve (25%).
Internal: Confined within the larynx, presents as a distention of
2.
false cords (30%).
3.
Combined (45%).
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CHAPTER 5 Neck
A
Fig. 5.15: Laryngocele.
Features
Swelling in the neck in relation to larynx, adjacent to
thyrohyoid membrane which is smooth, soft, resonant and
is more prominent while blowing, coughing and Valsalva
manoeuvre.
It moves upwords during swallowing with expansile impulse
on coughing.
Infection is quite common in the sac of laryngocele,
leading to the blockade of opening of the sac causing an
abscess.
Pus often may be discharged into the pharynx repeatedly.
Hoarseness and cough, sudden dyspnoea is often evident.
If large, causes obstruction to larynx.
Sudden compression and asphyxia can occur when it is
infected.
Bryce sign: In combined laryngocele, neck mass when
compressed from outside will cause hissing sound of air
escaping into the larynx.
Diagnosis: X-ray neck, laryngoscopy, CT scan neck.
Differential diagnosis: Saccular cyst which does not
communicate with larynx and contains mucus so dull on
percussion.
B
Treatment
External laryngocoele: Excision through neck incision. Neck of
the sac should be ligated. Thyrohyoid membrane is repaired
using 3 zero nonabsorbable polypropylenes sutures.
Every sunset gives us one day less to live; but every sunrise gives us one day more to hope.
C
Figs. 5.16A to C: Typical laryngocoele in the neck which becomes
prominent after blowing. X-rays (AP and lateral) show radiolucent air
in the neck.
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Internal laryngocoele: Marsupialisation, with the help of laryngoscope.
COMPLICATIONS OF SURGERY FOR LARYNGOCELE
B
x Laryngeal oedema causing airway obstruction
x Subcutaneous emphysema
x Laryngocutaneous fistula
x Injury to superior/internal laryngeal nerve
x Recurrence
CYSTIC HYGROMA (CAVERNOUS
SRB's Manual of Surgery
L
YMPHANGIOMA)
It is a cystic swelling due to sequestration of a portion of
jugular lymph sac from the lymphatic system, during the
developmental period in utero.
Present at birth and so may cause obstructed labour. Occa-
sionally present in early infancy.
Lymphatics fail to communicate to venous system; abnormal
budding of lymphatics is seen.
Often it is associated with Turner’s, Down’s, klinefelter
syndromes and trisomy 18 and 13.
It is also called as hydrocoele of the neck.
Cyst will not communicate with normal lymphatics and so
existing lymph gets absorbed and cyst will be filled with
clear watery mucous derived from endothelial lining of the
cyst wall. Cyst even though is subcutaneous; it commonly
extends into deeper planes across many anatomical planes
and barriers. Cyst is multilocular. Often extension may occur
across two or more lymphatic regions; example—involvement of both neck and axilla.
Lymphangioma circumscripta (<5 cm), lymphangioma
diffusum (>5 cm) and lymphangioma ab agne (reticulate
pattern) are different variants. For detail refer chapter
‘Swelling’.
Fig. 5.17: Cystic hygroma in newborn baby.
Features
Swelling is present at birth in the posterior triangle of neck
causing obstructed labour.
Swelling is smooth, soft, fluctuant (cystic), partially compres-
sible, brilliantly transilluminant. It is not reducible completely.
During crying swelling often increases in size.
Disfigurement of face of the child which is more worrying
factor for the parents.
Swelling may rapidly increase in size causing respiratory
obstruction—dangerous sign.
It may get infected forming an abscess which is a tender,
warm, soft swelling. It may cause septicaemia which may
be life threatening.
Rupture with lymph ooze can occur.
SITES
B
x Posterior triangle of the neck—75%—most common site. Eventu-
ally may extend upwards in the neck
x Axilla—20%
x Tongue—lymphangiogenetic macroglossia
x Cheek; Groin; Mediastinum; Often multiple sites
Pathology
It contains aggregation of cysts looking like soap bubbles.
Cysts have mosaic appearance with larger cysts near the
surface and smaller cysts in the deeper planes. Each cyst
contains clear lymph with endothelial lining. Fluid does not
coagulate.
Fig. 5.18: Cystic hygroma.
Treatment
https://t.me/medicina_free
Features
425
Aspiration of the contents. Later once the sac or capsule gets
thickened by fibrous tissue, it is excised.
Care should be taken to have meticulous dissection across
all planes including deeper muscular one to clear entire cyst
wall; otherwise recurrence will occur.
When it causes respiratory obstruction, aspiration and
tracheostomy is done.
Under proper antibiotics coverage, drainage of abscess is
done. Later sac is excised.
Preoperative injection of sclerosants (OK–432, PICIBANIL
recently used) and later once fibrosis develops excision of
entire aggregation of cysts. In olden days injecting boiling
water into the cyst as a sclerosant used to be popular. OK–
432 is an inactive strain of group A Streptococcus pyogenes.
Pure ethanol, interferon α 2a, doxyclycline are other sclerosants often used.
COMPLICATIONS
B
x Respiratory distress
x Infection → Abscess → Septicaemia
x Surgery itself may cause torrential haemorrhage
x Chylous fistula, chylothorax
x Recurrence of cyst – 15%
LUDWIG’S ANGINA
LUDWIG’S ANGINA (German physician, Wilhelm Friedrich von
Ludwig, 1836) (Angere means choking [Latin]; strangle [Greek]).
It is an infective, acute inflammatory oedema with cellulitis
of submandibular region and floor of the mouth (sublingual
space), commonly due to streptococcal infection.
It causes diffuse swelling and brawny oedema of the subman-
dibular region. It is common in severely ill or in advanced
malignancy, causing trismus, laryngeal oedema. Extension
of infection into parapharyngeal space may lead to dreaded
internal jugular vein thrombosis. As the infection is deep to
the deep fascia in a closed fascial plane, it spreads very fast
causing dangerous complications. Involvement of carotid
sheath (20%), retropharyngeal space (70%), mediastinum,
aspiration pneumonia can lead into fatal outcome with more
than 5% mortality.
Bilateral and more than one neck space involvement; spread
by continuity across connective tissues and muscles but not
through gland.
It contains gangrenous serosanguinous fluid which is
spreading. But there is no lymphatic spread.
PRECIPITATING FACTORS
B
x Caries teeth (80%); Oral or other malignancy; Submandibular
salivary infection/calculi; Chemotherapy; Chronic diseases like
diabetes mellitus; Cachexia of any cause
Brawny oedema/diffuse swelling of submandibular and
submental region.
Intraoral oedema in floor of the mouth with putrid halitosis,
drooling of saliva, earache.
Severe toxicity, fever, dyspnoea, dysphagia, may cause
laryngeal oedema, trismus, septicaemia, extension of sepsis
into other spaces in the neck.
Investigations: X-ray shows—Thumb sign on epiglottis
indicating laryngeal edema; US neck is very useful. Total
count, blood sugar, serum creatinine, chest x-ray, are other
investigations needed.
Complications: Laryngeal oedema and respiratory distress,
septicaemia, mediastinitis, IJV/cavernous sinus thrombosis,
aspiration pneumonia, empyema, lung abscess.
Differential diagnosis: Lymphadenitis, angioneurotic oedema,
sialadenitis, sublingual hematoma.
Treatment
Airway maintenance is most important part which is either
awake fibreoptic nasal intubation, tracheostomy, etc. Often
critical care with ventilator support may be needed.
Antibiotics must be given intravenously penicillins, cloxacillin
or higher generations.
Hydration by intravenous fluids, catheterization, nasogastric
tube placement, often central line placement (based on individual patient) may be required. Nutritional supplements,
management of diabetes, critical care, electrolyte management are also essential.
Surgical Decompression of the submandibular region is
done, by making bilateral deep transverse incisions (and also
midline submental incision) extending into the deep fascia and
also splitting both the mylohyoid muscles by blunt dissection
(mylohyoid can also be transected to decompress); infected
fluid is collected for culture; penrose drains are placed in all
spaces after thorough warm saline irrigation. Either wound
is left open and delayed suturing is done (better option) or it
is loosely sutured. Often small multiple transverse incisions
are made deeply (one on each side) and drains are placed
into the deeper planes through this, which is becoming more
acceptable and popular.
LUDWIG’S ANGINA
B
x Bilateral wood like swelling; double chin appearance; airway
obstruction; elevation and protrusion of the tongue
x Streptococci Viridans, streptococci, staphylococci, bacteroides—
common organisms
x USG neck is very useful
x Air way management is very crucial (awake fibreoptic nasal
intubation, nasal intubation, tracheostomy)
x Adequate antibiotic therapy
x Surgical decompression either single deep transverse incision
or multiple small deep incisions with placement of the drains.
CHAPTER 5 Neck
It is better to aim at good things and miss it , than to aim at a bad thing and hit it.
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