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324
Key Box 34.14
Manipal Manual of Surgery
Movement on Protrusion of the Tongue
The cyst is attached to the hyoid bone. Hence, it gives
a classical tug
Not always present, cyst below the thyroid cartilage—
tug is absent
Better appreciated on holding the swelling
Examination of thyroglossal cyst
Cyst proper, mobility
Base of the tongue to rule out lingual thyroid and
lymph nodes
Fig. 34.44: Thyroglossal fistula
Treatment
• Before excision of cyst, a thyroid scan is mandatory
since it may be the only functioning thyroid tissue.
• Sistrunk operation: Excision of the cyst along with
the entire thyroglossal tract which may include part
of the hyoid bone, is the recommended treatment.
The intimate relationship of hyoid bone can be
explained by its development from 2nd and 3rd
branchial arches.
Complications
1. Recurrent infection: The wall of the thyroglossal cyst
sometimes contains lymphoid tissue which can get
infected, resulting in an abscess. If it ruptures or is
incised, it results in thyroglossal fistula (Key Box 3
4.15).
2. Rarely, a papillary carcinoma can occur in the thyro-
glossal cyst.
3. Fistula.
Key Box 34.15
Recurrent Abscess: Rupture Fistula or Sinus
Thyroglossal fistula
Osteomyelitis
Stitch abscess
Pilonidal sinus
Median mental sinus
Cold abscess
Umbilical sinus
Key Box 34.16
Thyroglossal Fistula
Always acquired
Fistulous opening is in the midline
Semilunar sign or hood sign
It gets pulled up with protrusion of the tongue
1. Infected thyroglossal cyst rupturing into the skin.
2. Inadequately drained infected thyroglossal cyst.
3. Incompletely excised thyroglossal cyst.
• The track is lined by columnar epithelium.
Clinical Features
• Previous history of swelling in front of the neck,
which is now painful, red and ruptured resulting in
discharging pus. Once the pus is drained, the opening
closes. However, after an interval of time, the ‘pain
and discharge’ reappear.
• When there is no infection, the fistula discharges
only mucus and the surrounding skin is normal.
Infected fistulae are tender, discharging pus and the
skin is red hot.
• Majority of the patients presenting are young in the
age group of 10–20 years.
• A fistulous opening in the centre of neck which is
covered by a hood of skin can occur due to increased
growth of the neck, when compared to that of fistula.
This is described as semilunar sign or hood sign.
Do not forget to feel base of the tongue for lingual thyroid/
ectopic thyroid. Whenever a patient has one congenital
anomaly, examine thoroughly for ‘more’ associated anomalies.
THYROGLOSSAL FISTULA
Thyroglossal fistula is never congenital. It is always
acquired due to the following reasons (Fig. 34.44 and
Key Box 34.16):
Section II • General Surgery
Treatment
• Infection is controlled with antibiotics.
• Surgical excision should include the fistula with
removal of the entire tract up to the foramen caecum.
Otherwise, recurrence will occur.
• The central portion of the hyoid bone is removed
due to close proximity of the fistula.
• An elliptical incision is preferred as it gives a neat
scar.
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
325
• This operation is called Sistrunk’s operation.
Key Box 34.17 for details about Sistrunk’s operation.
Key Box 34.17
Sistrunk’s Operation
Fistula with entire thyroglossal tract is excised.
Central portion of the hyoid bone and lingual muscle
are removed.
Removal is facilitated by pressing the posterior 1/3rd
of the tongue.
Do not perforate thyrohyoid membrane.
Incomplete removal results in recurrence.
ANOMALIES OF THYROGLOSSAL DUCT
• Thyroglossal duct extends from foramen caecum to
thyroid cartilage.
• Various anomalies have been given in Key Box 34.18.
• However, thyroglossal cyst is common. Lingual thyroid
and ectopic thyroid tissue are uncommon swellings.
• They have to be kept in mind as a differential diag-
nosis of the swellings in the midline of the neck.
Key Box 34.18
Thyroglossal Duct Anomalies
Lingual thyroid
Levator glandulae thyroidae
Ectopic thyroid tissue
Thyroglossal cyst
SWELLINGS IN THE SUPRASTERNAL SPACE OF BURNS
1. Lipoma: Soft and lobular,
edge slips under the palpating finger.
2. Sequestration dermoid
cyst is a midline, soft, cystic,
fluctuant swelling.
3. Gumma produces a firm
swelling with evidence of
syphilis elsewhere in the
body.
4. Thymic swellings, an
aneurysm of innominate
or
subclavian artery, are the
other causes (Fig. 34.45).
Fig. 34.45: Aneurysm
A lady of 65 years presented with swelling in the suprasternal space (Fig. 34.82). Candidate gave the diagnosis of
lymph node swelling—probably cold abscess. He failed. It
had expansile pulsations. It was a case of aneurysm of
innominate artery. M.S. exam case 2008, JNMC, Belgaum.
(Courtesy: Professor Ashok Godhi, Head, Dept. of Surgery)
DIFFERENTIAL DIAGNOSIS OF
LATERAL SWELLINGS IN THE NECK
Before we discuss the swellings in the lateral side of the
neck, it is essential to know the various triangles in
the neck. These are discussed below.
SWELLING ARISING FROM ISTHMUS
OF THE THYROID GLAND
Almost all the diseases of the thyroid gland result in
enlargement of the isthmus. However, a solitary nodule
and cysts can occur in relation to isthmus. The swelling
moves with deglutition. However, it does not move on
protrusion of the tongue.
PRETRACHEAL AND PRELARYNGEAL LYMPH NODES
These lymph nodes produce nodular swelling in the
midline. One or two discrete nodes are palpable. They
can enlarge due to the following conditions:
1. Acute laryngitis: The nodes are tender, soft.
2. Papillary carcinoma of thyroid: The nodes are firm
without matting, with or without evidence of thyroid
nodule.
3. Carcinoma of the larynx: The nodes are hard in
consistency.
4. In India, tuberculosis should be considered as a
possible diagnosis when other diseases are ruled out.
Triangles of the Neck
Each side of the neck is a quadrilateral space subdivided
by sternocleidomastoid into anterior triangle and
posterior triangle. They are further subdivided as given
below (Fig. 34.46).
Fig. 34.46: Triangles of the neck
Section II • General Surgery
326
Manipal Manual of Surgery
Anterior Triangle
1. Submental triangle
. Digastric (submandibular) triangle
2
3. Carotid triangle
4. Muscular triangle
Posterior Triangle
1. Occipital triangle
2
. Supraclavicular triangle
SWELLINGS IN SUBMANDIBULAR TRIANGLE
• The submandibular triangle is a part of anterior triangle.
• This is bounded inferiorly by anterior and posterior
belly of digastric muscles with their tendon, superiorly
by the attachment of deep fascia to the whole length
of mandible.
• This triangle is covered by deep fascia.
• The floor is formed by mylohyoid muscle which
arises from mylohyoid line of the mandible, thus
closing the space.
• Swellings in the submandibular triangle are
(Fig. 34.47):
. Enlarged submandibular lymph nodes—common
1
2. Submandibular salivary gland enlargement—
common
3. Plunging ranula—not uncommon
4. Ludwig’s angina—not uncommon
5. Lateral sublingual dermoid cyst—rare
6. Tumours of the mandible—rare
ENLARGED SUBMANDIBULAR LYMPH NODES
They form a nodular swelling which is deep to deep
fascia. They are palpable only in the neck (not
intraorally). The nodes can get enlarged due to the
following conditions:
1. Acute lymphadenitis: Very often, poor oral hygiene
or a caries tooth produces painful, tender, soft
enlargement of these lymph nodes. Extraction of the
tooth or with improvement of oral hygiene, lymph
nodes regress.
2. Chronic tuberculous lymphadenitis can affect these
nodes along with upper deep cervical nodes. The
nodes are firm and matted.
3. Secondaries in the submandibular lymph nodes arise
from carcinoma of the cheek, tongue, palate. The
nodes are hard with or without fixity.
4. Non-Hodgkin’s lymphoma can involve sub-
mandibular lymph nodes along with horizontal
group of nodes in the neck. The nodes are firm or
rubbery in consistency.
SUBMANDIBULAR SALIVARY GLAND ENLARGEMENT
(Key Box 34.19)
The various causes of submandibular salivary gland
enlargement have been discussed under the salivary
gland chapter. The common causes are chronic
sialadenitis with or without a stone, tumours of the
salivary gland or enlargement due to autoimmune
diseases. They form irregular or nodular swelling. The
diagnosis is confirmed by bidigital palpation of the
gland. Enlarged submandibular gland is bidigitally
palpable because the deep lobe is deep to mylohyoid
muscle.
Key Box 34.19
Submandibular Salivary Gland Enlargement
Calculus
Chronic sialoadenitis
Cancer
Chronic diseases: Autoimmune
Fig. 34.47: This swelling in the submandibular triangle was
bidigitally not palpable. However, it exhibited a doubtful sign of
movement with deglutition. It turned out to be an ectopic thyroid
swelling. (Courtesy: Prof Sampath Kumar, Dept. of Surgery, KMC,
Manipal)
Section II • General Surgery
DIFFERENTIAL DIAGNOSIS OF SWELLINGS
IN THE CAROTID TRIANGLE
The carotid triangle has the following boundaries
(Fig. 34.48): Laterally by sternomastoid muscle, superomedially by digastric muscle and stylohyoid muscle and
inferomedially by omohyoid muscle.
Some important swellings in this triangle are as follows:
1. Branchial cyst
2. Lymph node swelling (cold abscess)
3. Aneurysm of carotid artery
4. Enlargement of the thyroid gland
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
327
5. Carotid body tumour—
rare
6. Laryngocele—rare
7. Sternomastoid tumour—
rare
8. Neurofibroma of the
vagus
BRANCHIAL CYST
Aetiology
Fig. 34.48: Carotid triangle
• Branchial cyst arises from vestigeal remnants of 2nd
branchial arch.
• The cyst is lined by squamous epithelium and
contains desquamated epithelial cells which slowly
forms a toothpaste-like material.
Clinical Features
• Even though congenital, majority of patients are
young between the age group 15 and 25 years.
• The swelling is typically located in the anterior
triangle of the neck partly under cover of the upper
1/3rd of anterior border of sternomastoid. This can
be explained because of the development of sternomastoid muscle from the myotome in the ridge of second
branchial arch (Fig.
34.49).
• The swelling has smooth surface and round borders.
It is soft, cystic, fluctuant and transillumination
1
negative.
The consistency is that of a rubber bag half
filled with water. The swelling is very often firm due
to thick inspissated content. In such situations, it is
very difficult to elicit fluctuation. The mobility of the
swelling is also restricted because of its adherence to
the sternomastoid muscle.
• Sternomastoid contraction test: The swelling
becomes less prominent.
• If contents are aspirated, it contains cholesterol
crystals (Key Box 34.20).
• No other lesion is found in the neck (lymph nodes).
Key Box 34.20
Swellings Containing Cholesterol Crystals
Branchial cyst
Dental cyst
Dentigerous cyst
Hydrocele
Treatment
• Excision of the cyst along with its entire epithelial lining
with a curved incision centred over the swelling. One
must ensure that epithelial lining should be removed
completely or else recurrence will occur.
• Sometimes cyst may grow backwards in between
‘fork’ of common carotid artery as far as pharyngeal
constrictors.
Complication
Since the wall is rich in lymphatic tissue, it can undergo
secondary infection with pain and swelling. Hence, the
swelling has to be excised (Fig. 34.50).
Differential Diagnosis (Fig. 34.51)
There is no differential diagnosis in a classical case of
branchial cyst. However, a few swellings have to be
considered as differential diagnosis.
1. Cold abscess occurs in young patients due to tuber-
culosis of jugulodigastric nodes. Presence of multiple
lymph nodes in the neck with or without fever gives
clue to the diagnosis.
AB
Figs 34.49A and B: (A) Branchial cyst, (B) excised specimen.
(Courtesy: Dr Dayananda Nooli, Senior Consultant Surgeon,
Chikodi, Belgaum)
1
Branchial and thyroglossal cysts rarely give rise to transillumination, if contents are clear and unless the cyst is small, it is difficult to elicit
fluctuation. These cysts can be firm or hard swellings also.
Fig. 34.50: Swelling mimicked branchial cyst. However, it was a
subcutaneous swelling with lobularity—it turned out to be lipoma.
(Courtesy: Dr P Rajan, Calicut Medical College, Calicut, Kerala)
Section II • General Surgery
328
Manipal Manual of Surgery
Key Box 34.21
Internal carotid artery
Internal jugular vein
Hypoglossal nerve
Glossopharyngeal nerve
Stylopharyngeous muscle
Pierces superior constrictor muscle and opens on
posterior pillar of the fauces behind tonsil.
of tonsils (Fig. 34.52). The tract is lined by ciliated
squamous epithelium and discharges a mucopurulent discharge. Sometimes, the upper end is blind
resulting in a sinus.
• The patient may complain of a dimple, discharging
mucus and the dimple becomes more obvious when
the patient is asked to swallow.
• Usually seen in growing adults (30% of cases).
• Can be unilateral or bilateral, equally common
males and females.
• It is also called lateral fistula
glossal fistula is called median fistula of the neck.)
Branchial Fistula Passes Superficial
to following Structures
Derivatives
of 3rd arch
in
of the neck. (Thyro-
Fig. 34.51: Branchial cyst—one example of diagnosing a case
using clinical methods. It is important that each clinical method
elicited carefully, gives a clue to the diagnosis
2. Lymphangioma is a brilliantly transilluminant,
partially compressible swelling. However, anterior
triangle is not a common site for lymphangioma.
3. Lipoma can also occur in the neck, though it is an
uncommon site (Fig. 34.50).
BRANCHIAL FISTULA (Key Box 34.21)
• This is always congenital and occurs due to persistent
2nd branchial cleft.
1
• External opening is
situated at the junction of
middle 1/3rd and lower
1/3rd of sternomastoid
(Fig. 34.52).
• The tract from the skin
passes through the fork of
common carotid artery
deep to the accessory and
hypoglossal nerve and
opens in the anterior
aspect of posterior pillars
Fig. 34.52: Sites of branchial
fistula—commonly bilateral
Treatment
Fistulogram can be done by injecting methylene
blue into the external opening and defining the tract
(Fig. 34.53). This is followed by exploration of the tract.
At surgery, it should be carefully dissected up to the
internal opening and then excised. May have to be done
by two different incisions: Upper incision at upper
border of thyroid cartilage and lower incision encircling
fistula and dissecting upwards.
Complication
Recurrent infection of the fistula.
Fig. 34.53: Contrast study demonstrating fistulous tract
1
Section II • General Surgery
Persistent first branchial cleft results in external auditory meatus.
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
329
COLD ABSCESS DUE TO TUBERCULOSIS
• In India, this is the commonest cystic swelling in the
carotid triangle. The cold abscess occurs as a result
of caseation necrosis of the lymph nodes. This forms
a soft, cystic, fluctuant swelling with negative transillumination. Presence of other lymph nodes in the
neck or sinuses in the neck gives the clue to the
diagnosis.
• Loss of appetite, weakness and fever with chills may
be other features.
ANEURYSM OF THE COMMON CAROTID ARTERY
• Atherosclerosis is the most common cause of
aneurysm. This weakens the vessel walls uniformly
and produces fusiform dilatation of the blood vessel.
Hypertension is another factor which adds to the
aneurysm.
• Abdominal aorta is the commonest site for aneurysms
followed by popliteal artery.
Types
A.Fusiform: Atherosclerosis, hypertension (Fig. 34.54
A).
B. Saccular: Due to injury (Fig. 34.54B).
C. False: In this condition, there is a sac lined by cellular
tissue which communicates with the artery through
an opening in its wall (Fig. 34.54C).
Causes (Key Box 34.22)
Key Box 34.22
Aneurysm: Causes
Congenital: Berry aneurysm in the circle of Willis
Traumatic
Degenerative: Atherosclerosis
Rare causes:
Syphilis: Endarteritis obliterans
Mycotic: Infective emboli
Subacute bacterial endocarditis
Marfan’s syndrome
Polyarteritis
Clinical Features of Aneurysm
1. Elderly patients are commonly affected.
2
. Evidence of atherosclerosis in the form of thick-
walled vessel is present.
3. Tensely cystic (feels firm), fluctuant, transillumination
negative swelling with expansile pulsation (when the
fingers are kept over the aneurysm, they are not only
elevated but they are also separated).
4. Compressibility is positive.
5. On exerting pressure proximally the swelling diminishes
in size—classically it happens in a case of popliteal
aneurysms on compression of the femoral artery.
6. Bruit/thrill is characteristic of this condition.
Classical signs of an aneurysm described above may be absent,
if thrombus is present within it.
Treatment of Aneurysm
• Angiography to confirm the diagnosis followed by
repair of aneurysm with graft—PTFE graft (poly-
Fig. 34.54A to C: (A) Fusiform, (B) saccular, (C) false aneurysm
Figs 34.55A to F: Different methods of operation for aneurysm. (A) Excision and end-to-end graft, (B) excision and end-to-side graft,
(C) excision and side-to-side graft, (D) excision and bypass grafting, (E and F) matas aneurysmorrhaphy
tetrafluoroethylene graft, Fig. 34.55).
Section II • General Surgery
330
Manipal Manual of Surgery
CAROTID BODY TUMOUR (CHEMODECTOMA)
Introduction
• This is a benign tumour arising from chemoreceptors
in the carotid body (Key Box 34.23). They are situated
in the tunica adventitia at the bifurcation of common
carotid artery (Fig. 34.56).
• Hence, such a tumour is called chemodectoma.
• Function of the carotid body is regulation of pH.
Key Box 34.23
Chemoreceptors: Sites
The carotid body
The aortic body
Brain stem
Pulmonary receptors
Myocardial receptors
Hormonally not active cells
• The patient gives long history of painless, slow-
growing swelling for many years.
• Typical location: In the upper part of the anterior tri-
angle o
f the neck, at the level of the hyoid bone, beneath
the anterior edge of the sternomastoid muscle (Fig. 34.57).
• Surface is smooth or lobulated, borders are round,
and is an oval, vertically placed swelling. Consistency
is firm to hard. Hence, called classical potato tumour.
• Horner’s syndrome and unilateral vocal cord para-
lysis can occur due to involvement of the nerves.
• Pressure on the tumour gives rise to syncopal attack due
to decrease in the pulse rate (carotid body syndrome).
• Moves in the transverse direction.
• Carotid artery is stretched over the swelling and so,
transmitted pulsations are felt (Fig. 34.58).
• Intraoral examination shows prolapse of ipsilateral
tonsil, unless it grows in parapharyngeal space.
Shamblin classification
Class I: Localized—minimal vascular attachment.
Class II: Partially surrounds carotids.
Class III: Encase carotids—resection difficult and may
need temporary interruption of cerebral circulation.
Fig. 34.56: Location of
carotid body
Fig. 34.57: Carotid body tumour—
classical site
• It may be associated with phaeochromocytoma.
• Chronic hypoxia can lead to carotid body hyper-
plasia. Hence, there is a higher incidence of chemodectoma in people living at higher altitudes.
Clinical Features (Key Box 34.24)
• Middle-aged or elderly patients are affected
(5th decade).
Key Box 34.24
Carotid Body Tumour
Rare tumour
Rarely malignant
Rarely bilateral
Rarely grows fast
Rarely patient presents early
Rarely metastasises
Experience of a general surgeon with this tumour is
Section II • General Surgery
very, very rare
Diagnosis
• Carotid angiography (Fig. 34.59A) should be done,
if there are neurological symptoms, such as syncopal
attack. It may demonstrate separation of the carotid
bifurcation.
• Lyre sign: Splaying of carotid artery can be seen
(Fig. 34.59B).
Fig. 34.58: Carotid body tumour in a 45-year-old lady—duration
5 years. (Courtesy: Dr MR Srivatsa, Prof. and Head, Prof. Bagali
Babasaheb, Prof. Bharathi, Dr Srikar Pai, Department of Surgery,
MS Ramaiah Medical College and Hospital, Bangalore)
Figs 34.59A and B: Carotid angiography—observe separation
of internal and external carotid artery by the tumour (A) and
vascular blush (B)
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
331
• Incision biopsy is dangerous.
• Colour Doppler should be the first investigation.
Treatment
• Excision of the tumour with reconstruction
• No role for radiotherapy.
It is important to preserve cerebral circulation during surgery.
Vascular surgeon’s help is necessary.
Complications
Very rarely, it can turn into a malignant carotid body
tumour with lymph nodal metastasis.
Precautions
• Do not biopsy from within mouth—carotid body
tumour can displace tonsil medially.
• Should not do FNAC.
• Should not do open biopsy.
• When you feel some pulsations over a lymph node in
the carotid triangle—remember carotid body tumour.
STERNOMASTOID TUMOUR
Key Box 34.25
Laryngocele
Very rare
Increased laryngeal pressure
Expansile impulse on cough
Treatment: Ligation of its neck and division of the
whole sac.
Fig. 34.60: Laryngocele
• When it enlarges within the larynx, it may displace
vocal cord, produce hoarseness and is called internal
laryngocele.
• This is not a tumour, it is a misnomer.
• Injury to the sternomastoid during birth causes
rupture of a few fibres and haematoma. Later, healing
occurs with fibrosis, resulting in a swelling in the
middle of sternomastoid muscle.
• The other possible theory is that this is a congenital
anomaly—short sternomastoid muscle.
Clinical Features
• This is seen in infants or children. Firm to hard, 1–2 cm
swelling in the middle of the sternomastoid muscle.
• Tender and mobile sideways. Medial and lateral
borders are distinct but superior and inferior borders
are continuous with the muscle.
• Many cases are associated with torticollis.
Treatment
• Gentle manipulation of child’s head
• Physiotherapy to stretch the shortened sternomastoid
muscle.
• Division of lower attachment of sternomastoid from
clavicle and sternum with or without removal of lump
is the surgical treatment.
LARYNGOCELE (Key Box 34.25)
• It occurs due to herniation of the laryngeal mucosa
(Fig. 34.60, external laryngocele)
Causes
• Glass blowers, musicians, wind instruments and
trumpet players are commonly affected.
• Chronic cough may be one of the predisposing factors.
Clinical Features
• Smooth, oval, boggy swelling which moves upwards
on swallowing, in relation to thyrohyoid membrane
(subhyoid position).
• Swelling becomes prominent when the patient is
asked to cough or blow (Valsalva manoeuvre).
• Expansile cough impulse is present.
• Tympanitic note on percussion (resonant)
Treatment
• Excision of the sac—in external laryngocele
• Marsupialisation—in internal laryngocele.
Differential Diagnosis
Other cystic swellings, such as branchial cyst and
lymphangioma, should be ruled out.
Complications
Secondary infection results in laryngopyocele. The
opening in the thyrohyoid membrane may be blocked
by mucopus in such cases.
Section II • General Surgery
332
Manipal Manual of Surgery
PHARYNGEAL POUCH
• Herniation or protrusion of mucosa of the pharyn-
geal wall through Killian’s dehiscence.
• Killian’s dehiscence is
a potential area of
weakness in between
the two parts of the
inferior constrictor
muscle (Fig. 34.61): (A)
Upper oblique fibres
(thyropharyngeus)
and (B) Lower horizontal fibres (cricopharyngeus).
Aetiopathogenesis
Fig. 34.61: Pharyngeal pouch
Due to increase in the intrapharyngeal pressure, mucous
membrane bulges in between parts of inferior
constrictor muscles due to neuromuscular imbalance.
Hence, it is a pulsion diverticulum.
Course of the Diverticulum
Pulsion diverticulum deviates to one side mostly to the
left because of the rigid vertebral column in the midline,
posteriorly.
Diagnosis
• Initially foreign body sensation is present in the
throat. Later, gurgling sound, regurgitation of food
on turning to one side, sense of suffocation, cough or
dysphagia are present.
• Aspiration may cause dyspnoea later.
Pharyngeal pouch is a swelling behind sternocleidomastoid
below the level of thyroid cartilage—soft swelling which can
be emptied.
Treatment
• Barium swallow followed by excision of the
pouch
• Cricopharyngeal myotomy may also be done.
SCHWANNOMA OF THE VAGUS NERVE (Fig. 34.62)
Fig. 34.62: Schwannoma of the vagus nerve. (Courtesy:
Prof. P Rajan, Calicut Medical College, Kerala. This swelling was
not moving with deglutition—candidate offered thyroid nodule
as diagnosis—MS exam case 2007)
DIFFERENTIAL DIAGNOSIS OF SWELLINGS
IN THE POSTERIOR TRIANGLE
The posterior triangle (Key Box 34.26) is an interesting
area as far as swellings are concerned. It is the
commonest area of metastasis in lymph nodes from
occult primary. Lymphangiomas, haemangiomas, cold
abscess, lymphomas commonly occur here. Interesting
cases of cervical rib, Pancoast’s tumour, aneurysms also
occur here.
Key Box 34.26
Boundaries of Posterior Triangle
Anteriorly : Sternomastoid (posterior border)
Laterally : Trapezius (anterior border)
Above : Mastoid process
Below : Clavicle
Most of the swellings have been discussed under
appropriate chapters. Haemangioma, metastasis in the
cervical lymph nodes and Pancoast’s tumour have been
discussed below.
CLASSIFICATION (Table 34.5)
Common swellings in the posterior triangle are given
below.
HAEMANGIOMA
Definition
This is a swelling due to congenital malformation of
blood vessels. It is an example of hamartoma.
• This condition produces swelling in the carotid
triangle in the region of thyroid swelling.
• It is a vertically placed oval swelling
• It is firm to hard in consistency
• On pressure over the swelling, dry cough and in some
Section II • General Surgery
cases bradycardia may occur.
Classification
. Depending on the Origin
A
• Capillary
• Cavernous
• Arterial
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
Table 34.5 Swellings in the posterior triangle
Solid swellings Cystic swellings Pulsatile swellings
1. Metastasis in the lymph nodes Lymphangioma Subclavian artery aneurysm
2. Tuberculosis Haemangioma Vertebral artery aneurysm
3. Lymphoma Cold abscess
4. Lipoma
5. Cervical rib
6. Pancoast’s tumour
B. Depending on Behaviour of the Lesion
Terms in common use
I. Involuting haemangioma
• Superficial Strawberry naevus
Capillary haemangioma
• Deep Cavernous
• Combined (superficial + Strawberry naevus
deep)
Capillary haemangioma
Cavernous haemangioma
II. Noninvoluting
• Port-wine stain Port-wine stain
Fig. 34.63: Capillary haemangioma. (Courtesy: Prof. Pramod
Kumar, Head, Department of Plastic Surgery, KMC, Manipal)
Capillary haemangioma
Naevus flammeus
• Cavernous haemangioma
• Arteriovenous fistula
333
CAPILLARY HAEMANGIOMA (Key Box 34.27)
It consists of dilated capillaries and proliferation
of endothelial cells. Hence, it commonly occurs in the
skin (Figs 34.63 and 34.64). It can be of the following
types:
1. Salmon patch is a bluish patch over the forehead, in
the midline, present at birth and disappears by 1 year
of age. Hence, no treatment is required.
2. Port-wine stain is an extensive intradermal haeman-
gioma. This is bluish purple in colour, commonly
affects the face or other parts of the skin, is present
at birth, usually progresses and does not regress
(Key Box 34.28).
Key Box 34.27
Capillary Haemangioma
Skin and soft tissue involvement
Salmon patch: Midline forehead
Port-wine stain: Head and neck
Strawberry angioma: Compressible
Wait and watch policy is the best
Fig. 34.64: Capillary haemangioma of the nose
Key Box 34.28
Port-wine Stain
Port-wine colour even though to start with it is red in
colour.
Occurs usually in the face, can also occur on the
shoulder and trunk.
Regression does not occur.
Treatment: Pulsed dye laser, photocoagulation, derma-
brasion.
Worrying because it becomes more keratotic and
nodular as age advances.
Injection of sclerosants may be needed.
Noninvoluting haemangioma is its another name.
Extensive intradermal capillary dilatation
Remember as PORT-WINE
Section II • General Surgery