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314
Manipal Manual of Surgery
Clinical Features
• Majority of patients are between 20 and 50 years.
• A round to oval swelling in the dorsum of the hand,
with smooth surface and round borders. Skin over
the swelling is normal.
• The swelling is tensely cystic and fluctuant. Trans-
illumination is negative. It is mobile in the transverse
direction.
• When the tendons are put into contraction, the
mobility of the swelling gets restricted.
• Ganglion is not connected with the joint space.
Sometimes, it gives an impression of becoming small
due to slipping away between bones.
Treatment
1. Asymptomatic ganglion is better left alone.
2. Aspiration of the ganglion and injection of sclerosants
may reduce the size of ganglion.
. Sometimes, rupture of the cyst due to trauma may
3
result in permanent cure.
4. Surgical excision can be done. However, recurrence
rate is high.
Differential Diagnosis (DD)
1. Implantation dermoid cyst, when it occurs in the feet
or hand.
. Exostosis of the bone, has to be considered, if swelling
2
is very hard.
3. Bursa (vide infra)
COMPOUND PALMAR GANGLION
Aetiology
• Tuberculous tenosynovitis of the tendon sheaths
affecting the flexor tendons. This is a common cause
in India (Key Box 34.7).
• Rheumatoid arthritis with involvement of multiple
joints causing thickening of synovial membrane—
common cause in Western countries.
• Soft, cystic, fluctuant, transillumination—negative
swelling situated above and below the flexor retinaculum.
• Cross-fluctuation test between these two swellings
is positive, which is diagnostic of compound palmar
ganglion.
• Restricted mobility of the fingers due to matting of
the tendons.
• Wasting of the small muscles of the hand.
• Paraesthesia due to compression on median nerve.
Investigations
1. The ESR may be increased, if it is due to tuberculosis.
. Aspiration of the swelling and fluid can be sent for
2
acid-fast bacilli.
3. Synovial biopsy.
Treatment
. Antituberculous treatment (ATT) in case of tubercular
1
pathology. If the response rate is not satisfactory—
exploration, decompression, synovectomy and
release of matted tendons is the treatment.
2. Control of rheumatoid arthritis, with complete
excision of the synovial sheath, in cases due to
rheumatoid arthritis.
Summary of Compound Palmar Ganglion
• Tuberculosis and rheumatoid arthritis—common
causes.
• Synovial thickening will clinch the diagnosis.
• Cross-fluctuation test is an important clinical finding.
• Antituberculous treatment, if it is due to tuberculosis.
• Decompression or synovectomy may be required in
both conditions mentioned above.
GLOMUS TUMOUR (Key Box 34.7)
• This is also called glomangioma or angioneuromyoma.
• Glomus is a specialised organ.
Pathology
As a result of tuberculous tenosynovitis, typical caseous
material collects within the flexor tendon sheaths. The
tendons get matted, a swelling develops in the palm
and another swelling develops in lower aspect of
forearm. The thickening of synovial membrane, fibrin
particles in the fluid and melon seeds are characteristic
of this condition.
Clinical Features
• Majority of patients are below 40 years of age.
Section II • General Surgery
• Concavity of the palm is obliterated.
Key Box 34.7
Glomus Tumour
Rare and benign tumour
The most painful tumour
The smallest benign tumour, does not turn malignant.
Nail bed is the commonest site.
Histologically, it is an angioneuromyoma.
It is radioresistant.
Excision gives permanent cure.
Function of glomus is concerned with heat regulation.
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
315
Structure of Glomus (Glomus Body)
Abundant arteriovenous anastomosis surrounded by
large clear cells (glomus cells) and medullated and
non-medullated nerve fibres in between the cells is
characteristic of glomus.
Clinical Features of Glomus Tumour
(Figs 34.19 and 34.20)
. Typical site: Under the nail beds of hands and feet.
1
2. It is purple red in colour, usually single, the size does
not exceed 1 cm in diameter.
3. Glomus tumour is usually seen in the 5th decade.
4. Excruciating pain either at rest or on movement of
the finger or on pressure is pathognomonic feature
of this tumour. Pain is due to compression of the
nerve fibres by dilated glomus vessels.
5. The tumour is compressible.
Treatment
Surgical excision results in permanent cure.
Differential Diagnosis
1. Subungual melanoma: Painless and pigmented
. Granuloma pyogenicum: Mild pain, bleeds on touch
2
and evidence of infection is present.
3. Chronic infection with granuloma.
BURSA
• Bursa means a sac or a sac-like cavity containing
fluid lined by endothelium. It is meant to reduce
the friction between tendons of the muscle and the
bone.
• Bursitis refers to inflammation of a bursa resulting
in accumulation of excessive fluid inside the bursa.
This results in a swelling in the anatomical sites of
normal bursa.
• The causes of chronic bursitis include constant
pressure, constant irritation or minor injuries.
• Some examples of bursitis are given in Table 34.2.
Clinical Features
• A cystic swelling in a known anatomical site of
a bursa is a chronic bursitis unless proved otherwise.
• Bursitis produces a soft, cystic, circumscribed or oval
swelling with fluctuation.
• As majority of bursitis contain inflammatory fluid,
they do not show transillumination.
• In a few cases, signs of inflammation may be pre-
sent.
Complications
1. Secondary infection may result in an abscess.
. Frequent friction may result in ulceration.
2
3. Cosmetic deformity.
Treatment
• Excision is indicated only in the presence of
Figs 34.19 and 34.20: Glomus tumour: The most painful
condition in the finger. (Courtesy: Prof Bhaskarananda Kumar
and Dr Anil Bhat, Department of Orthopaedics, KMC, Manipal)
Table 34.2 Bursae and bursitis
Anatomical site Popular nomenclature
1. Prepatellar bursa Housemaid’s knee
2. In front of patella tendon (infrapatellar) Clergyman’s knee
3. Olecranon bursa Student’s elbow
4. Under the insertion of tendons of sartorius, gracilis and Bursa anserina (extension of the bursa along the sides of
semitendinosus muscle tendon—resembles goose’s foot)
5. Between the tendon of the semimembranosus and the Semimembranosus bursitis
medial condyle of tibia
symptoms such as pain or complications mentioned
above.
• Chances of recurrence are high.
Section II • General Surgery
316
Manipal Manual of Surgery
SEMIMEMBRANOSUS BURSA (Figs 34.21 to 34.23)
This is the commonest swelling in the popliteal space.
It presents as a tensely cystic swelling when the knee is
extended and it becomes flaccid on flexion of the knee.
It is not compressible as it does not communicate with
the joint.
The differential diagnosis for semimembranosus
bursitis is Morrant-Baker’s cyst, which is a herniation
of the synovial membrane. The differences between
these two swellings are given in Table 34.3.
ADVENTITIOUS BURSAE
• This refers to a cyst which develops in an anatomical
area where no bursa is present. These also occur due
to constant pressure or friction. They are summarised
below.
1. Tailor’s ankle: Above the lateral malleolus
2. Porter’s shoulder: Between clavicle and skin
3. Weaver’s bottom: Between gluteus maximus and
ischial tuberosity
4. Bunion: Between prominent head of the first
metatarsal and skin due to hallux valgus.
• The complications and treatment of adventitious
bursae are similar to chronic bursitis (Fig. 34.22).
TRANSILLUMINANT SWELLINGS IN THE BODY
These are the cystic swellings containing clear fluid
characterised by fluctuation and transillumination.
1. Lymphangioma
2. Ranula
3. Meningocele
4. Epididymal cyst
5. Vaginal hydrocele
LYMPHANGIOMA (Figs 34.24 to 34.26)
• Failure of one of the lymphatics to join the major
lymph sac of the body results in a lymphangioma.
Hence, it occurs in places where lymphatics are
abundant.
A
Fig. 34.22: Constant pressure on the
lateral aspect of foot resulting in bursa due
to the habit of ‘
picture is showing the bursa with pigmen-
Fig. 34.21: Popliteal fossa swelling
Table 34.3 Comparison of semimembranosus bursa and Baker’s cyst (Fig. 34.21)
1. Aetiology Friction or pressure Rheumatoid or osteoarthrosis of knee joint
2. Age Young patients Middle aged
3. Location in the popliteal fossa Higher up and more medial Below and midline
4. On flexion of the knee Disappears Increases
5. On extension of the knee Appears and is tense (Figs 34.23A and B) Diminishes
6. Patellar tap Absent Present
7. Compressibility Absent Present partially
8. Knee movements Normal Restricted
Section II • General Surgery
tation all around
Semimembranosus bursa Baker’s cyst
squatting position’. Second
B
Figs 34.23A and B: (A) Semimembranosus
cyst and (B) cyst disappears on flexing
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
Fig. 34.24: Lymphangioma
involving chest wall. Brilliantly
transilluminant
Fig. 34.25: Lymphangioma
involving neck and axilla.
Cross-fluctuation was positive
• They are dilated lymphatics that project onto the skin
surface.
• Common sites: Posterior triangle of the neck, axilla,
mediastinum, groin, etc. (Key Box 34.8).
317
• Typical locations—lateral aspect of neck (posterior
triangle), groin, buttocks.
• Soft, cystic, fluctuant, partially compressible swelling.
Lymphangioma is a multilocular swelling consisting
of aggregation of multiple cysts. These cysts may
intercommunicate and may occasionally insinuate
between muscle planes. Hence, it gives the sign of
compressibility! However, complete reducibility is
not a feature.
• The swelling is brilliantly transilluminant because
it contains clear fluid (watery lymph) (Key Box 34.9).
Key Box 34.9
Transillumination Test
Should be done in a dark room
Avoid surface transillumination
Transillumination may be negative because of infection,
sclerotherapy and haemorrhage
Key Box 34.8
Lymphangioma Sites
Jugular lymph sac Neck
Posterior lymph sac Groin
Cisterna chyli Retroperitoneum
• In the neck, it is called cystic hygroma of the neck.
As the sac has no communication with lymphatics
by the time swelling appears, the lymph is absorbed
and is replaced by thin watery fluid (mucus) secreted
by endothelium. Hence, it is also called hydrocele of
the neck.
• When it is largely confined to subcutaneous plane, it
is called cystic hygroma.
Types of Lymphangioma
Lymphangioma circumscriptum: If it is less than
1.
5 cm across.
2. Lymphangioma diffusum: If they are more wide-
spread.
3. Lymphoedema ab igne: If they form a reticulate
pattern of ridges.
Treatment
Surgical excision is the treatment of choice. All the loculi
or cysts should be removed. Careful search has to be
made for the extension of lymphangioma through the
muscle planes so as to avoid recurrence (Figs 3
4.26 and
34.27). Sclerotherapy was being used earlier for
lymphangioma. Since, tissue planes are distorted by
sclerosants, dissection becomes difficult. Thus, injection
type of treatment is not favoured at present.
Fig. 34.26: Lymphangioma twice excised—residual lesion. It can
be left alone if it is asymptomatic
Clinical Features
• Usually, cystic hygroma presents during infancy or
early childhood. Occasionally, present since birth and
rarely before birth. They can also present as small
vesicles.
• When the child cries or strains the swelling increases
in size and becomes prominent due to increased intrathoracic pressure which is transmitted through root
of the neck.
Fig. 34.27: Lymphangioma. Multiple pockets at surgery. All those
extensions have to be removed to prevent local recurrence
Section II • General Surgery
318
Manipal Manual of Surgery
Differential Diagnosis
1. Haemangioma: Posterior triangle of the neck is one
of the common sites for haemangioma. Haemangioma
is soft, cystic and fluctuant but transillumination is
negative and the sign of compressibility is positive.
2. Lipoma: This is a soft lobular swelling with fluctuation
because fat behaves like fluid at body temperature.
However, the edge slips under the palpating fingers.
Both transillumination and compressibility tests are
negative with lipoma.
3. Cold abscess (details follow in a later page).
Complications
1. In neonates and infants, lymphangioma can cause
difficulty in breathing due to its large size.
. Occasionally, secondary infection can occur.
2
3. Lymphangioma in the mediastinum can give rise to
dyspnoea, dysphagia due to compression on the
trachea/oesophagus.
RANULA
Ranula is a cystic swelling arising from sublingual
salivary gland and from accessory salivary glands which
are present in the floor of the mouth called glands of
Blandin and Nuhn.
The word ranula is derived from the resemblance of
the swelling to the belly of frog—Rana hexadactyla.
Aetiology
1. Ranula occurs due to obstruction to the ducts secreting mucus. Hence, it is an example for retention cyst.
. Some surgeons consider it as an extravasation cyst.
2
Clinical Features
• Seen in young children and adults.
• The swelling is typically located in the floor of the
mouth or under surface of the tongue, to one side of
the midline.
• Soft, cystic, fluctuant swelling, which gives brilliant
transillumination.
• It is covered by thin mucosa containing clear, serous
fluid. Hence, it is bluish in colour (Fig. 34.28).
• Surface is smooth, borders are diffuse, nontender
swelling.
• Plunging ranula: It is an intraoral ranula with cervical
extension, where it passes on the side of mylohyoid
muscle and produces a swelling in the submandibular
region. Thus, one swelling in the floor of the mouth
and the other in the neck gives rise to plunging
ranula. The diagnosis is confirmed by cross-
Section II • General Surgery
fluctuation test (Key Box 34.10).
A B
Figs 34.28A and B: Ranula—observe the bluish colour and
swelling in the floor of the mouth (Courtesy: Dr Adarsh Kudwa,
MCODS Manipal)
Key Box 34.10
Cross-fluctuation Test
Indicated when a cyst has two interconnected compo-
nents
When gentle pressure is applied on one component,
impulse is felt on the other component
Demonstrated by bidigital palpation
Plunging ranula, compound palmar ganglion, iliopsoas
abscess, hydrocoele en bisac—cross-fluctuation can be
felt
Treatment
Complete excision of the ranula is the treatment
1.
of choice in plunging ranula. Since the cyst wall
is very thin, it should be carefully dissected and
removed.
2 Marsupialisation is indicated in simple ranula. The
ranula is incised and the wall of the cyst is sutured to
the mucosa of the floor of the mouth, so as to leave
an opening to the exterior (marsupials, e.g. kangaroo).
• After 5–10 days, the cyst gets collapsed, fibrosis
occurs and the entire cavity gets obliterated.
• Marsupialisation avoids surgical dissection and
chances of injury to the submandibular duct.
• Plunging ranula can be excised by intraoral
approach. Once the intraoral dissection is
completed, the cervical extension can be mobilised
by the same incision dissecting close to the cyst
wall. However, rupture and chances of leaving
behind a portion of the cyst wall are high.
Differential Diagnosis
• Sublingual dermoid cyst is a thick-walled cyst,
whitish in colour and not transilluminant.
• Mucus cyst.
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
319
Complications
1. Rupture of the cyst decreases the size but it can
reappear at a later date.
. When the swelling is big, the tongue is pushed
2
upwards and may cause difficulty in speech or
swallowing.
MENINGOCELE
Meningocele is a herniation of the meninges through a
weak point in the spine (neural arch) where the bony
fusion has not taken place effectively (Fig. 34.29 and
Key Box 34.11). The swelling is covered by pia mater
and arachnoid mater without a dural covering. The
swelling contains cerebrospinal fluid (CSF). Meningocele
is an example of spina bifida cystica.
Clinical Features
• The swelling is present since birth.
• Soft, cystic, fluctuant with brilliant transillumina-
tion are the typical features of the swelling.
• Sign of compressibility is present due to displace-
ment of CSF.
• When the child cries or coughs, an expansile impulse
is present.
• On palpating the edge of the swelling, a bony defect
is usually found.
Treatment (Key Box 34.12)
• CT scan is done to look for hydrocephalus. If it is
present, a ventriculoperitoneal shunt is done which
will reduce the meningocele.
Key Box 34.12
Excision of Meningocele
Surgery: As early as possible after birth
Early closure prevents infection
Transverse elliptical incision
Excision of the sac
Closure of the defect by plication
Approximation of the muscles
• Excision of the meningocele should be done as early
as possible to prevent the rupture and secondary
infection.
Complications
• Skin covering the swelling is very thin and so is prone
to ulceration. Due to ulceration, secondary infection
and meningoencephalitis can occur.
• Haemorrhage.
SPINA BIFIDA OCCULTA
• In this condition, the neural arch is defective
posteriorly. There is no visible swelling.
• It can be suspected when there is a tuft of hair, lipoma,
naevus, pigmented patch of skin overlying the
lumbosacral region.
• Child is normal at birth. Neurological symptoms such
as weakness, sciatica-like pain may start appearing
at puberty (neurogenic talipes equinus—club foot).
• During this time, because of growth, there may be
traction on the spinal cord by a ligament called
membrane reuniens.
• X-ray can demonstrate the bifid spine.
• Surgical excision of the membrane gives permanent
cure to the patient, if there are symptoms.
Fig. 34.29: Meningocele
Key Box 34.11
Meningocele: Sites
Lumbosacral: The commonest
Occipitocervical: Second common
Root of the nose: Rare
Types of Spina Bifida Cystica
. Meningocele
1
2. Meningomyelocele
}
See Table 34.4 for comparison.
• Protrusion of meninges, with nerve root of spinal
cord or disordered spinal cord results in meningomyelocele.
• Neurological deficit such as foot drop, talipes,
trophic ulcer of the foot (S
root) may be present.
1
• Surgical excision may be followed by residual
neurological deficit.
3. Syringomeningomyelocele
• In this condition, in addition to the meninges,
the central canal of spinal cord is also herniated
out.
Section II • General Surgery
320
Table 34.4 Comparison of meningocele and meningomyelocele
Meningocele Meningomyelocele
Contents Membranes Membranes with nerve roots
Consistency Soft and cystic Soft to firm
Transillumination Brilliant Partially transilluminant
Longitudinal furrow Absent Present due to adherence of the nerve roots to the skin
Neurological deficit Absent Trophic ulcers, bladder and bowel incontinence, locomotor
Prognosis after repair Good Residual neurological deficit is present
Manipal Manual of Surgery
problems are present
LUDWIG’S ANGINA
• This is an inflammatory oedema of the floor of the
mouth. It spreads to the submandibular region and
submental region.
• Tense, tender, brawny, oedematous swelling in the
submental region with putrid halitosis is characteristic of this condition.
Fig. 34.30: Encephalocele. (Cour
Paediatric Surgeon, KMC, Manipal)
tesy: Prof Vijaykumar,
• Most of the children are stillborn.
• Very difficult to treat, if the child survives.
Encephalocele (Fig. 34.30): It is also known as cranium
bifidum. It is a neural tube defect characterised by saclike protrusion of brain and meninges through an
opening in the skull.
DIFFERENTIAL DIAGNOSIS OF MIDLINE SWELLINGS
IN THE NECK
MIDLINE SWELLINGS (From Above Downwards)
. Ludwig’s angina
1
2. Enlarged submental lymph nodes
3. Sublingual dermoid cyst
4. Subhyoid bursitis
5. Thyroglossal cyst
6. Enlarged isthmus of thyroid gland
7. Pretracheal and prelaryngeal lymph nodes
8. Retrosternal goitre
9. Thymic swelling
10. Swelling in the suprasternal space of Burns:
Section II • General Surgery
Lipoma/cold abscess/aneurysm.
ENLARGED SUBMENTAL LYMPH NODES
The three important causes of enlargement:
1. Tuberculosis: Matted submental nodes, firm in
consistency, with enlarged upper deep cervical lymph
nodes, with or without evening rise of temperature,
are suggestive of tuberculosis.
2. Non-Hodgkin’s lymphoma can present with sub-
mental nodes along with other lymph nodes in the
horizontal group of nodes such as submandibular,
upper deep cervical, pre-auricular, post-auricular
and occipital lymph nodes (external Waldeyer’s
ring). Nodes are firm or rubbery, discrete without
matting.
3. Secondaries in the submental lymph nodes can arise
from carcinoma of the tip of the tongue, floor of the
mouth, central portion of the lower lip. The nodes
are hard in consistency and sometimes, fixed.
SUBLINGUAL DERMOID CYST
• It is a type of sequestration dermoid cyst which
occurs due to sequestration of the surface ectoderm
at the site of fusion of the two mandibular arches.
Hence, such a cyst occurs in the midline, in the floor
of the mouth (Key Box 34.13).
• When they arise from 2nd branchial cleft, they
are found lateral to the midline. Hence, lateral
variety.
• The cyst is lined by squamous epithelium and
contains hair follicles, sebaceous glands and sweat
glands. It does not contain hair.
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
321
Key Box 34.13
Sublingual Dermoid Cyst
Origin: At the site of fusion of 2nd branchial arches
Site: Midline—common; Lateral—uncommon
Supraomohyoid variety is common
Bidigital palpation for demonstration of fluctuation
Soft, cystic, fluctuant, transillumination negative swelling
Differential diagnosis
Ranula: Transillumination is positive
Thyroglossal cyst: Moves with deglutition
Clinical Features
1. Young children or patients between the age of 10 and
20 years present with painless swelling in the floor
of mouth.
. Swelling is soft and cystic. Fluctuation test is positive.
2
Bidigital palpation gives a better idea about fluctuation with one finger over the swelling in the oral
cavity and the other finger in the submental region.
3. Transillumination test is negative as it contains
thick, cheesy, sebaceous material.
• It moves up with deglutition.
• Soft, cystic, fluctuant and transillumination negative
swelling (turbid fluid).
• The swelling may be tender as it contains inflam-
matory fluid.
Treatment
Complete excision
Complication
It can develop into an abscess.
Differential Diagnosis
1. Thyroglossal cyst is a vertically placed oval swelling,
whereas subhyoid bursitis is transversely placed
oval swelling (Fig. 34.32).
• Thyroglossal cyst moves on protrusion of the
tongue outside (subhyoid bursitis does not).
. Pretracheal lymph node swelling.
2
3. Ectopic thyroid enlargement.
Differential Diagnosis
. Ranula: When a sublingual dermoid cyst is in the
1
midline in the floor of the mouth and above the
mylohyoid muscle, ranula is considered as differential
diagnosis. However, ranula is bluish in colour,
brilliantly transilluminant.
2. Thyroglossal cyst should be considered as
differential diagnosis when the sublingual dermoid
cyst is below the mylohyoid muscle. Thyroglossal
cyst moves up with deglutition, whereas a
sublingual dermoid cyst does not.
Treatment
Through intraoral approach, excision can be done for
both types of sublingual dermoid cyst.
SUBHYOID BURSITIS
• Accumulation of inflammatory fluid in the subhyoid
bursa results in a swelling and is described as
subhyoid bursitis.
• The bursa is located below the hyoid bone and in front
of thyrohyoid membrane.
Fig. 34.31: Subhyoid bursitis: Transversely placed oval swelling
Clinical Features
• The swelling is in front of the neck, in the midline
below the hyoid bone (Fig. 34.31).
• The swelling is oval in the transverse direction.
Fig. 34.32: Thyroglossal cyst: Vertically placed oval swelling
Section II • General Surgery
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Manipal Manual of Surgery
MIDLINE SWELLINGS IN THE NECK (Figs 34.33 to 34.40)
Fig. 34.33: Submental lymphadenitis:
Caused by tuberculosis—not a common
site
Fig. 34.36: Incompletely treated thyroglossal
cyst. Recurred, about to rupture and form
thyroglossal fistula
Fig. 34.34: Submental swelling of
30 years duration. (Courtesy: Prof. KK
Rajan, Calicut Medical College)
Fig. 34.37: Thyroid nodule: Common
swelling—moves with deglutition
Fig. 34.35: Intraoral examination of patient
(Fig. 16.36) reveals swelling also in the floor
of mouth—sublingual dermoid cyst
Fig. 34.38: Pretracheal lymph nodes and
upper neck nodes: Case of non-Hodgkin’s
lymphoma
2008: MS Examination
short case, KMC, Manipal.
(Courtesy: Professor BH
Ananda Rao, Department
of Surgery)
Fig. 34.39: Cold abscess in the suprasternal space of Burns:
Section II • General Surgery
One of the common sites of cold abscess
2008: MS Examination
short case, Govt. Medical
College, Goa. (Courtesy:
Prof. Dilip Amonkar, Head,
Department of Surgery)
Fig. 34.40: Aneurysm of innominate artery. Atherosclerosis is
the cause. Before incising a cold abscess in this location, make
sure that it is not an aneurysm
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
THYROGLOSSAL CYST
• This is an example for tubuloembryonic dermoid
cyst.
• It arises from thyroglossal tract/duct which extends
from foramen caecum at the base of the tongue to
the isthmus of the thyroid gland. Hence, the thyroglossal cyst can develop anywhere along this duct.
Four anomalies are shown in Fig. 34.41.
• It is lined by pseudostratified, ciliated, columnar or
squamous epithelium which produces desquamated
epithelial cells or mucus at times.
Sites of Thyroglossal Cyst (Fig. 34.42)
. Subhyoid: The most common type
1
2. At the level of thyroid cartilage: 2nd common site
3. Suprahyoid: Double chin appearance
4. At the foramen caecum: Rare
5. At the level of cricoid cartilage: Rare
6. In the floor of the mouth
323
Fig. 34.42: Sites of thyroglossal cyst (see the text)
Clinical Features
• Even though congenital, thyroglossal cyst appears
around the age of 15–30 years.
• They are more common in females who present with
painless, midline swelling. However, in the region
of thyroid cartilage, the swelling is slightly deviated
to the left side.
• The cyst is soft, cystic, fluctuant, transillumination-
— negative swelling (very rarely, it can give rise to
transillumination). It can be firm, if the tension within
the cyst is high.
• Mobility: Thyroglossal cysts exhibit 3 types of
mobility which are characteristic of this condition:
The cyst moves with deglutition.
–
– Moves with protrusion of the tongue (Fig. 34.43
and Key Box 34.14): Hold the thyroglossal cyst with
the finger and thumb and ask the patient to
protrude the tongue outside. The movement of the
cyst upwards is described as a tug because of its
attachment with the hyoid bone.
– The swelling moves sideways but not vertically as
it is tethered by the thyroglossal duct.
Fig. 34.41: Anomalies/fate of thyroglossal tract
Fig. 34.43: Thyroglossal cyst: It moves upwards with protrusion
of the tongue
Section II • General Surgery