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CHAPTER 5 Head and neck surgery
222
Thyroglossal cyst, sinus, and fi stula
Key facts
• Thyroglossal cyst is a fl uid-fi lled sac resulting from incomplete closure
of the thyroglossal duct.
• Thyroglossal sinus results from persistence of the whole duct.
• Incidence <1%; ♂:♀, 1:1.
Anatomy (see Fig. 5.1)
The thyroglossal duct arises embryologically between the fi rst and second pharyngeal pouches. It runs as a hollow tube from the foramen
caecum on the dorsal surface of the tongue, becoming a solid cord of
cells migrating through the tongue and into the midline of the neck. The
tract usually passes in front of the hyoid bone and then loops up behind
it before descending in the midline of the neck where the cells divide to
form the two lobes of the thyroid gland either side of the midline. The
duct normally atrophies in the sixth week of gestation.
Clinical features
• Usually presents in children or young adults.
• Ninety per cent present as a painless midline cyst.
• Ten per cent appear on one side of the midline, usually the left.
• Seventy-fi ve per cent appear in front of the hyoid bone and the
majority of the rest at any point to the root of the neck.
• The cyst elevates on protruding tongue if attached to hyoid or if
attached to isthmus of thyroid elevates on swallowing.
• Five per cent become infected presenting as a painful, red neck
swelling.
• Fifteen per cent have a fi stula to the skin (due to infection or
incomplete excision).
• Papillary carcinoma of the thyroglossal ductal cells is rare. Treatment is
by excision.
Diagnosis and investigations
• Ultrasound scan is investigation of choice.
• CT scan will often reveal a well circumscribed cyst related to the
midline of the hyoid bone.
• Fine needle aspiration may reveal a cloudy infected fl uid or a straw-
coloured fl uid.
Treatment
Infected thyroglossal cyst
• Majority respond to antibiotics.
• Surgical drainage if abscess formed or failure to respond to antibiotics.
• Elective excision of the cyst once acute infection has resolved.
Surgery
• Excision is recommended for most cysts.
• Remove through a transverse midline incision in a skin crease.
THYROGLOSSAL CYST, SINUS, AND FISTULA
t
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• Divide the platysma muscle and excise the cyst using sharp and blunt
dissection.
• On the deep surface, it is attached to the hyoid bone; excise
approximately 1cm of the bone in midline, removing any underlying
thyroglossal duct epithelium. This is Sistrunk’s procedure.
• Close the wound in layers with a suction drain.
• If there is a fi stula or sinus in the neck, excise it through a transverse
elliptical incision. Again use blunt dissection and remove the middle
part of the hyoid bone (‘Sistrunk procedure’).
Complications These are usually very few. Remove the drain the next
day and discharge the patient.
The important structures that must be considered when operating on
the thyroid gland include:
• Recurrent laryngeal nerve.
• Superior laryngeal nerve.
• Parathyroid glands.
• Trachea.
• Common carotid artery.
• Internal jugular vein (not depicted).
223
Superior
laryngeal
nerve
Vagus nerve
Left lobe of
thyroid gland
Superior
hyroid artery
Superior
parathyroid
glands
Inferior
thyroid artery
Inferior
parathyroid
glands
Recurrent
laryngeal
nerve
Fig. 5.1 The anatomy of the region of the thyroid gland. Reproduced with
permission from Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine,
7th edn. Oxford University Press, Oxford.
Posterior
Thyroid
cartilage
Superior
laryngeal
nerve
Right lobe of
thyroid gland
Recurrent
laryngeal
nerve
Lateral
CHAPTER 5 Head and neck surgery
224
Branchial cyst, sinus, and fi stula
Key facts
• Disputed aetiology. Theories include:
Cystic degeneration of epithelial derivatives of the fi rst, second, or •
third branchial clefts.
Cystic degeneration of epithelial elements in a cervical lymph node.•
• A branchial fi stula is a tract running from the neck skin through to the
posterior pillar of the fauces; these are very rare.
• A branchial sinus occurs when the lower part of this tract remains
open on to the neck skin surface.
• A branchial abscess is an infected branchial cyst.
Clinical features
• Presents as a neck lump, usually painless.
• They typically present in early adulthood.
• Sixty to seventy per cent are anterior to the upper third of the
sternomastoid muscle with the posterior border lying beneath the
sternomastoid. Other sites include:
Parotid gland.•
Anterior to the lower two-thirds of the sternomastoid.•
Anterior to the pharynx.•
In the posterior triangle of the neck.•
• Two-thirds occur on the left side; 2% are bilateral.
• May present with an acute branchial cyst abscess causing pain,
increased swelling, and occasionally, pressure symptoms (diffi culty
swallowing or breathing).
Diagnosis and investigation
For branchial cyst or abscess
• Ultrasound scan is fi rst investigation of choice. CT/MRI for complex
cases.
• Fine needle aspiration biopsy:
Abscesses• . Purulent fl uid is obtained that may culture organisms.
Cysts• . Straw-coloured fl uid containing cholesterol crystals.
Treatment
Branchial abscess
• Drain via a transverse incision in the neck at the point of maximum
convexity.
• Suture a Yeates type drain.
• Give antibiotics and make no attempt to remove the cyst until the
infection has resolved completely.
Branchial cyst
• Most cysts are excised to achieve a diagnosis and prevent symptoms
or complications.
• Place a transverse incision over the cyst, preferably in a transverse skin
crease, long enough to match the size of the cyst.
BRANCHIAL CYST, SINUS, AND FISTULA
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• Divide the platysma and the deep fascia over the anterior border of
the sternomastoid and retract the muscle posteriorly.
• Remove the cyst, usually by blunt/sharp dissection.
• Use suction drainage and close the wound in layers.
• If the cystic lesion is in the parotid gland and cannot be distinguished
from any other parotid lesion, extend a preauricular incision into the
neck as for a superfi cial parotidectomy.
Branchial fi stula
• Excise a sinus of fi stula through a horizontal elliptical incision around
the neck opening.
• Blunt and sharp dissection of sinus tract as far as possible.
• If the upper end of the tract cannot be reached, make a further
transverse incision at a higher level (‘stepladder’ incisions).
• Sometimes the tract runs between the internal and external carotid
arteries and sometimes up to the pharyngeal wall in the region of the
middle constrictor.
• Close the wounds in layers with suction drainage.
Complications
A branchial cyst at any site often lies near important nerves. Previous
infections causing fi brosis will increase the risk of damaging them. The
following nerves are at risk:
• Hypoglossal nerve (tongue deviates to affected side on protrusion).
• Mandibular branch of the facial nerve (movement of lower lip).
• Great auricular nerve (numb ear).
• Accessory nerve (paralysis of trapezius: weakness of arm abduction,
asymmetry, and chronic pain).
225
CHAPTER 5 Head and neck surgery
226
Salivary calculi
Key facts
• Salivary gland calculi occur most commonly within the submandibular
ductal tree (80%), 20% in the parotid.
• Composed of calcium phosphate and carbonate; may be related to
sialadenitis (infl ammation of a salivary gland).
• Most common in adults.
• No proven relationship with other calculi, e.g. renal.
Clinical features
• Pain and swelling of the affected gland on eating and drinking.
• If there is partial obstruction of the duct, the swelling can last minutes
to several hours.
• Complete obstruction leads to persistent swelling and infection.
• The patient may also experience colicky pain in the duct when eating.
Points in the examination of the submandibular gland
• Examine the gland from behind and feel the swelling by running the
fi nger backwards under the jaw. If you cannot feel a lump, ask the
patient to suck a sour sweet and re-examine them
• Examine the duct orifi ce from the front. Ask the patient to open
their mouth wide and point their tongue upwards. The ducts lie near
the midline at the root of the tongue. Are they red? Is there pus?
Can you see an impacted stone?
• Examine the gland bimanually from the front. Wear gloves and place
the fi nger of one hand over the gland. The index of the other hand is
placed in the mucosal surface of the mandible and the gland palpated
between the two.
Diagnosis and investigations
• Radiographs of the submandibular gland, parotid gland, and ducts are
helpful. Twenty per cent of submandibular and 80% of parotid calculi
are radiolucent.
Lower occlusal X-ray of the teeth will show a stone in the distal •
portion of submandibular duct.
A lateral oblique X-ray or orthopantomogram (OPT) of the •
mandible will show a calculus in the submandibular gland.
• Submandibular duct radiography (sialography) is technically diffi cult
and rarely done.
• Parotid sialography may show a fi lling defect. Sialectasis is often seen.
May provide therapeutic benefi t due to fl ushing out of debris in the
ductal tree.
• Ultrasound scanning of parotid and submandibular glands is often the
choice of investigation by head and neck radiologists.
SALIVARY CALCULI
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Treatment
• Stones in the intra-oral part of the ducts can be removed under local
anaesthesia. Steady the stone with a Babcock’s forceps and incise
directly over it. Remove the stone; leave the duct marsupialized.
• Stones within the submandibular gland require removal of the gland
itself.
• Removal of a calculus from the parotid gland is a rare operation. Most
calculi are at the distal end of parotid duct (as it does an ‘S’ bend
through buccinator muscle) and can be released by intra-oral incision
of parotid duct papilla.
• Most parotid gland obstructive/infl ammatory disease is treated
conservatively with sialogogues and intermittent massage of the gland
towards the duct. Duct dilation using lacrimal probes is useful as most
strictures/obstruction occur at the ‘S’ portion noted above.
Key revision points—anatomy and physiology of
salivary glands
• Salivary glands produce: saliva-containing water; electrolytes
(especially K
+
and HCO
• The parotid is a pure serous gland. It responds to salivary stimuli, e.g.
–
); varying amounts of mucus and enzymes.
3
food in mouth, smell. There is little resting fl ow. The submandibular
is mixed with serous and mucous acini, responds to salivary stimuli,
and has a resting fl ow, which contributes along with sublingual and
minor glands to maintain mouth moisture.
• Saliva functions to lubricate, aid mastication, aid taste, suppress oral
bacteria, initiate starch digestion.
• Submandibular duct is palpable in the fl oor of the mouth and enters
mouth from gland on the sublingual papilla near the midline.
• Parotid duct is palpable over the anterior border of masseter and
enters the mouth on the medial wall of the cheek after passing
through buccinator muscle via an ‘S’ bend.
• The facial nerve trunk lies between the deep and superfi cial parts of
the parotid gland and divides into fi ve branches (pes anseris) within
the superfi cial portion.
227
CHAPTER 5 Head and neck surgery
228
Acute parotitis
Key facts
• Parotitis is infl ammation of the parotid gland. Causes include:
Acute or chronic obstruction (now commonest cause).•
Bacterial (ascending parotitis), less common.•
Viral infection, e.g. paramyxovirus (mumps), HIV.•
Infl ammatory disorders, e.g. Sjögren’s syndrome, sarcoidosis.•
Any cause of infl ammation of lymph nodes within the parotid gland.•
• Most patients develop this condition as an acute episode of a chronic
obstructive sialadenitis.
Clinical features
• Obstructive parotitis occurs more commonly in adults.
• Presents as an acutely painful preauricular swelling.
• There is often a history of recurrent, intermittent swelling of the gland.
• The gland is usually tender on palpation.
• The patient may be toxic with fever and raised WCC, and pus may
exude from the opening of the parotid duct opposite the crown of the
second upper molar tooth.
• Elderly, debilitated, dehydrated patients with poor oral hygiene or who
are on anticholinergic drugs are at greatest risk.
Diagnosis and investigations
• Plain X-rays to determine whether radio-opaque calculi are present in
the duct or gland.
• Ultrasound or CT scanning may help differentiate between stones,
infl ammation, and tumour.
• If pus is present, take a bacteriology swab and send it to the lab. The
commonest infecting organism is Staphylococcus aureus.
Treatment
Acute parotitis
• Most patients respond to antibiotics:
Give amoxicillin 500mg tds, IV if necessary.•
Rehydrate dehydrated and debilitated patients.•
Good oral nursing care with chlorhexadine mouth rinses.•
• Review patients by clinical examination after the infection has subsided
to make sure that the obstruction was not due to a parotid tumour.
• If a parotid abscess develops, it should be drained surgically:
Make an incision over the abscess under general anaesthetic where •
it appears to be pointing, parallel to the branches of the facial nerve
to avoid damaging them.
Open the abscess with sinus forceps and place a Yeates drain in the •
wound.
Recurrent parotitis
• Teach patients with recurrent parotitis to massage the gland in order
to express saliva from the duct.
• Dilatation of the duct with lacrimal probes can assist drainage.
ACUTE PAROTITIS
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• Remove radio-opaque calculi, if possible.
• Advise the patient to keep an emergency supply of antibiotics at home.
• If recurrent parotitis persists for months or years, a total
parotidectomy is curative.
229
CHAPTER 5 Head and neck surgery
230
Salivary gland tumours
Key facts Salivary gland tumours are rare, accounting for 0.4% of all
malignant tumours; 80% arise in the parotid gland.
Clinical features Most patients present with a slow-growing lump in
the affected gland. Pain, paraesthesia (e.g. lingual nerve in submandibular
gland), facial palsy (parotid gland) imply malignancy. Salivary tumours of
minor glands in upper aerodigestive tract (UADT) present as a lump. Fifty
per cent of these are malignant.
Clinicopathological features
Pleomorphic adenoma
• Eighty per cent of benign parotid tumours.
• ♂:♀, 1:1.
• Peak incidence 30–50y.
• Composed of epithelial and mesothelial cells that form a mucous
matrix, often with chondromatous components.
• The tumour grows slowly and has no true capsule so that strands of
tumour cells protrude into normal surrounding tissue. Local extension
may be widespread with recurrence if excision is incomplete.
• Malignant change (adenocarcinoma) occurs in 20% after 10y and is
seen in asymptomatic deep lobe parotid tumours.
Warthin’s tumour (adenolymphoma)
• Usually affects men >50y; 10% are bilateral.
• Benign and presents as a slow-growing soft swelling.
• Successfully treated by wide local excision.
Malignant tumours
Mucoepidermoid tumour
• Low grade malignancy, though variable behaviour.
• Most grow slowly, invading locally and eventually metastasizing to neck
lymph nodes, lung, and skin.
Adenoid cystic carcinoma
• A slow growing malignant tumour with indolent behaviour.
• Perineural invasion propensity and facial palsy common with extension
through stylomastoid foramen. Lung metastasis common.
• Often regarded as incurable, but individuals can lead a normal life over
20–30y before succumbing.
• Treatment is extensive wide local excision, with nerve/organ
preservation where possible. Post-operative radiotherapy has a role.
Radiotherapy also has a role in controlling lung symptoms if they arise.
Acinic cell carcinoma
♀ > ♂; slow-growing, but may metastasize unexpectedly. Surgery is the
treatment of choice.
Squamous cell carcinoma, adenocarcinomas, and undifferentiated
carcinomas
• Generally high grade malignant tumours.
SALIVARY GLAND TUMOURS
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• Often rapid local invasion into extraparotid tissues and infratemporal
fossa, leading to pain and trismus.
• There may be skin fi xation or ulceration with facial nerve palsy
and invasion of the external auditory canal; incurable; palliative
radiotherapy.
Diagnosis and investigations
• Clinical examination is still of great importance in assessing extent.
• CT scanning may help differentiate between stones, infl ammation, and
tumour.
• MRI scanning offers the most sensitive investigation for assessment of
local invasion and involvement of surrounding structures.
• PET CT is useful for assessing metastases.
Treatment
Benign parotid tumours
• Excise the parotid gland superfi cial to the facial nerve (superfi cial
parotidectomy). Deep lobe tumours should have a facial nerve-sparing
total parotidectomy.
• Enucleation is inadequate and often leads to local recurrence that is
diffi cult to manage.
Benign tumours in other salivary glands
Excision of the entire gland (e.g. simple submandibulectomy).
Malignant tumours
• Radical local excision (to sacrifi ce or preserve the facial nerve in
parotid tumours is controversial).
• May be accompanied by neck dissection, especially in parotid tumours.
Complications of parotid surgery
• Facial nerve injury (risk varies according to procedure: lowest in
primary surgery for benign tumours < redo surgery < surgery for
malignancy). Seventy-fi ve per cent neurapraxia with complete or
extensive recovery of function; 25% neurolysis with little or no
recovery (may be treated by nerve interposition grafting).
• Frey’s syndrome:
Late complication of surgery in up to 25% of patients.•
Facial fl ushing and sweating of the skin innervated by the •
auriculotemporal nerve when the patient salivates.
Caused in this case by division of the parasympathetic •
secretomotor fi bres that innervate the parotid gland: they may
regenerate erratically to control cutaneous secretomotor functions.
Subcutaneous botox injection is useful.•
Prognosis
• Recurrence of benign tumours. May develop 20y after surgery,
especially in the patient where enucleation, rather than superfi cial
parotidectomy has been performed.
• Five-year survival rate for all malignancies approximately 60%.
231
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