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Surgery is recommended for most branchial cleft cysts, to prevent infective complications. The aim of surgical excision is to resect both the cyst and ligate the tract as proximally as possible. If the cyst is not palpable, ultrasound may be useful to mark the location of the cyst.

Patients often present with a unilateral, progres­sive, soft swelling in the oor of mouth and sub­mandibular region. Most ranulas are greater than 2cm at presentation, and as they increase in size, they typically have a blue appearance. They may be ‘reduced’ from the neck to cause an increase in swelling in the oor of mouth. Rarely, as they increase in size they may be associated with dif­culties with speech and swallowing; however, the size may uctuate over time [15].

The ranula appears as a hypoechoic cystic mass and may contain internal echoes, and if extending to the submandibular space, the dehiscence in the mylohyoid muscle can often be seen, which is a diagnostic feature. US is also useful to assess the submandibular gland and identify any suspicious features related to the cyst, which may warrant further investigation.

Management of ranulas varies with a range of approaches and techniques described in the liter­ature. As the vast majority of cases are related to the sublingual gland, treatment focuses on the removal of this gland often through an intraoral approach.

Tracheal neoplasms are inherently uncommon, with an estimated incidence of 2–3in 1,000,000 people per year. Accounting for just over 0.2% of all respiratory tract malignancies and 0.02–0.04% of all recorded malignancies, malignancies of the larynx and bronchi 40 and 400 times more com­mon respectively. In adults, tracheal malignan­cies may be either primary or secondary, with over 90% of all primary tracheal neoplasms being malignant. Squamous cell carcinoma (SCC) and adenoid cystic carcinoma (ACC) are the most common subtypes of primary tracheal malignan­cies [1]. Secondary tracheal tumours are more common than primary tracheal malignancy and predominantly arise from direct invasion of tumours of surrounding structures (such as the thyroid and oesophagus), with distant metastasis to the trachea is considerably rarer.

of disease (tumour location, size, locoregional spread and metastases) and the patient’s own co­morbidities, with treatment regimens necessitating multidisciplinary input involving shared airway management, complex resection, reconstruction and potential adjuvant therapy in the form of radiotherapy and chemotherapy.

This chapter seeks to focus primarily on the workup and management of malignant diseases of the trachea (primary and secondary), relevant adjuvant therapy, surgically relevant anatomy and tracheostomy.

At its upper border, the cricotracheal ligament facilitates the trachea’s superior attachment to the lower border of the cricoid. In adults, as the tra­chea passes inferiorly towards the thorax, it runs progressively deeper as it approaches the thoracic inlet; from a lateral viewpoint, it dives from anteri­orly (subcutaneously) at the neck to posteriorly in the chest. It enters the thoracic inlet at midline, posterior to the manubrium, to bifurcate into the main bronchi at the carina, which is usually at the level of T4, right of midline and just below the lower border of the manubrium. From the carina, the right main bronchus continues more vertically, with the left main bronchus taking a more horizon­tal, acute angle with respect to the trachea.

In adults, over 90% of all primary tracheal neo­plasms are malignant, with squamous cell carci­noma (SCC) and adenoid cystic carcinoma (ACC) being the most common subtypes.

Tracheal masses pose a diagnostic challenge, with their slow growth and vague symptomatol­ogy leading to a delayed presentation to a pri­mary care clinician in the rst instance, and secondarily a delayed diagnosis due to early symptoms being mild and attributed to common, benign pathology such as pneumonia, chronic obstructive pulmonary disease (COPD) and adult-onset asthma. As such, early diagnosis of tracheal malignancy requires an extremely high index of suspicion and a thorough elucidation of potential red ags on history and examination (see Table10.5).

for presenting with haemoptysis. Patients typi­cally do not experience signicant breathlessness until the lumen of their airway is considerably narrowed, with exertional dyspnoea usually not evident until the airway narrowed by 50%, with dyspnoea at rest only apparent narrowing of greater than 70%. Patients reporting these early, non-specic symptoms of dyspnoea and cough frequently undergo a workup with a chest radio­graph and pulmonary function testing. The chest x-ray is likely to miss an obstructive tracheal lesion in up to 75% of cases, with pulmonary function testing demonstrating a similar obstruc­tive pattern and responsiveness to bronchodilators found in asthma. Patients are prescribed a regi­men of bronchodilators and steroids; and it is only when this medical therapy begins to fail, do these patients undergo a CT which reveals the tracheal malignancy. A subset of patients will present with dysphonia as their primary complaint, as a result of direct invasion of the trachea from a thyroid primary malignancy. This is readily seen on naso­endoscopy, which should be a routine component of the workup of thyroid malignancy.