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SECTION IX — Clinical Methods in ENT and Neck Masses
THYMIC CYST
Thymus develops from the third pharyngeal pouch and
then descends through the neck to the mediastinum.
Thymic remnants may persist anywhere in its path from
angle of the mandible to the midline of neck. Swelling is
either cystic or solid. Unlike a cystic hygroma, a cyst is
always unilocular. It can occur in children or adults and
presents as a neck mass anterior and deep to middle third
of sternocleidomastoid muscle. It is a very rare condition.
Treatment is surgical excision. Sternotomy is required if it
also extends into the mediastinum.
BRANCHIAL CYST
It is common in the second decade of life but can occur at any age with equal frequency in both sexes. Cyst
presents as a swelling in the upper part of the neck anterior to sternocleidomastoid muscle. Mass is smooth,
round, fluctuant, nontender and nontransilluminant. A
painful increase in size at the time of upper respiratory
infection can occur. Anomalies of the second branchial arch are the most common. A branchial cyst may
be associated with a sinus or a fistula. A second arch
branchial sinus has an external opening at the junction
Figure 77.2. Lateral swellings of neck as seen in different triangles of neck.
Figure 77.3. Thyroglossal cyst.
Figure 77.4. Sites of thyroglossal duct cysts. 1. Base of tongue, 2.
Suprahyoid, 3. Subhyoid (most common), 4. On the thyroid cartilage
and 5. In front of cricoid.
Figure 77.5. Left-sided branchial sinus discharging pus.
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of lower and middle of the anterior border of sternomastoid and may exude mucoid discharge. It may have
an internal opening in the tonsillar fossa. When both
internal and external openings are present, it is called a
branchial fistula.
Treatment of branchial cyst is surgical excision along
with its tract, if present.
Chapter 77 — Neck Masses
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CAROTID BODY TUMOUR
It arises from the chemoreceptor cells in the carotid body,
hence also called chemodectoma. Mostly presents after
40 years. It is a very slow-growing tumour and the history
of mass in the neck may extend into several years. It presents as a painless swelling which is pulsatile. Bruit can
be heard with a stethoscope. It moves from side to side
but not vertically. It may extend into the parapharyngeal
space and present in the oropharynx (Figure 77.6).
Contrast-enhanced CT and MRI with gadolinium are diagnostic and also show the extent of the tumour. MRI angiography shows splaying of internal and external carotid arteries (Lyre’s sign). Some tumours are functional and secrete
catecholamines. Hence serum catecholamines and urinary
metanephrines and vanillylmandelic acid (VMA) should be
estimated. Fine-needle aspiration cytology (FNAC) or biopsy should not be done because of the vascularity of tumour.
Treatment is surgical when the patient is younger
than 50 years and surgically fit, or when the tumour extends into the oropharynx causing difficulty in speech,
swallowing or breathing.
Radiotherapy is also effective and is used in older patients and those unfit for surgery or those who refuse surgery or have a metastatic disease.
BRANCHIAL SINUS OR FISTULA
(FIGURE 77.5)
A second arch fistula has a typical course, the knowledge
of which can help in the total surgical extirpation of the
tract. It has:
1. An external opening along the anterior border of sternocleidomastoid muscle.
2. A tract which ascends just deep to deep cervical fascia
along the carotid artery.
3. The tract passes deep to second arch structures, i.e.
external carotid artery, stylohyoid and posterior belly
of digastric but superficial to third arch structure, i.e.
internal carotid artery (the tract passes between internal
and external carotid arteries). It also runs superficial to
hypoglossal nerve.
4. Pierces the pharyngeal wall and ends in the tonsillar
fossa.
Complete excision of the tract can be accomplished by
step-ladder incisions.
Third branchial cleft sinus is uncommon. Its external
opening is at the same place as second cleft sinus but internal opening is situated in pyriform sinus. Tract passes
behind both internal and external carotid vessels but is superficial to vagus and hypoglossal nerves.
PLUNGING RANULA
It is a pseudocyst caused by extravasation of mucus from
obstruction to sublingual salivary gland. It presents as an
isolated swelling in the submandibular area and is transilluminant. Sometimes plunging ranula coexists with a
ranula in the floor of mouth. Treatment is total excision
along with removal of sublingual salivary gland.
PARAPHARYNGEAL TUMOURS
These tumours present in the upper neck near the angle
of mandible or retromandibular area.
They may also be seen intraorally displacing the tonsil,
lateral pharyngeal wall and soft palate medially. Though
majority of these tumours are of salivary gland origin
(pleomorphic adenomas being the most common) others
like schwannoma, neurofibroma, lipoma, haemangioma,
paraganglioma or lymph node metastasis in parapharyngeal nodes are also seen. Diagnosis can be established by
imaging techniques and FNAC.
CYSTIC HYGROMA
Also called lymphangioma or cavernous lymphangioma, it
occurs most commonly in the posterior triangle of the
neck (Figure 77.7). It arises from obstruction or sequestration of the jugular lymph sac.
It may be seen in the neonate, early infancy or childhood. Ninety per cent are seen before 2 years of age.
When present at birth, they cause difficulty in labour.
Most commonly cystic hygroma is seen in the supraclavicular region and may extend to involve the whole
of posterior triangle or extend into the axilla and mediastinum. Other common sites are axilla and groin. It may
occur in the tongue and floor of mouth.
Cystic hygroma is soft, cystic, multilocular, partially
compressible and brilliantly transilluminant. It may involve
several tissue planes and neural and vascular structures. It
may extend to involve laryngeal or pharyngeal structures
to cause stridor, respiratory difficulty or feeding problems.
When inflamed due to infection, it becomes painful and
increases in size. Spontaneous regression is unpredictable.
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SECTION IX — Clinical Methods in ENT and Neck Masses
Figure 77.6. (A) A 23-year-old female patient with carotid body tumour where surgery was earlier attempted. (B) MRI neck showing the tumour.
(C) MRI angiography. Note splaying of the external carotid artery (ECA) and internal carotid artery (ICA). This is also called Lyre’s sign. (D) Tumour
after removal. (E) Histopathology of tumour showing a Zellballen pattern having chief cells and sustentacular cells (H&E, x200).
Treatment is surgical excision with preservation of
neural and vascular structures. Complete excision may
not be possible in a single operation. Bipolar diathermy
is useful. Rupture of cyst makes dissection difficult. Recurrence rate after surgical excision is only 5% if whole
tumour is removed macroscopically but it is 50% if some
part is left. Cystic hygroma causing respiratory distress
may be aspirated or may require tracheostomy to relieve
respiratory obstruction.
Injection of sclerosing agents is not favoured as it
makes later dissection more difficult.
TUBERCULAR LYMPH NODES
Mass due to tubercular lymph nodes in the neck is very
common in India. Any lymph node group can be involved. It can occur in any age or sex. Involved lymph
Figure 77.7. (A) Cystic hygroma neck in a 27-year-old male. (B) CT scan neck of the same point.
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Figure 77.8. Multiple tubercular nodes in the neck.
Chapter 77 — Neck Masses
Diagnosis is usually made by FNAC or lymph node biopsy which reveals a granulomatous lesion. Sometimes
acid fast bacilli (AFB) can be demonstrated. AFB from the
aspirated or biopsy material can be cultured and sensitivity established, to be prepared for multidrug resistant
lesions.
X-ray chest, skin test and work-up for other nodal
group involvement should be done. Tuberculosis is also
becoming more common due to AIDS.
Treatment consists of initial 2 months course of four
drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) followed by 4 months course of rifampicin and
isoniazid. Nodes may initially increase in size during
treatment before they finally subside. Surgical excision
of lymph node mass or abscess is occasionally required
when drug treatment fails.
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node may be single, multiple or matted due to periadenitis. Tubercular abscess may form when node(s) caseate. It may become adherent to the skin and underlying
structures or a draining tubercular sinus may develop
(Figures 77.8 and 77.9).
Figure 77.9. (A) Caseating tubercular suprasternal node forming abscess. (B) Tubercular nodes in supraclavicular area (same patient).
METASTATIC LYMPH NODES
Any lymph node group can be involved depending on the
site of primary malignancy. Upper cervical lymph nodes
are commonly involved in malignancies of upper aerodigestive tract. Nasopharyngeal malignancies spread to accessory chain of nodes in the posterior triangle. In many
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SECTION IX — Clinical Methods in ENT and Neck Masses
cases primary malignant lesion is not discernible (occult
primary), and in such cases the most common sites are
tonsil, base of tongue, nasopharynx and pyriform sinus.
Node(s) in supraclavicular area should alert the surgeon
to the possibility of an infraclavicular primary in the
lung, breast, stomach, colon, kidney, ovary and testis.
LYMPHOMAS
Both Hodgkin and non-Hodgkin lymphomas may present with cervical lymphadenopathy. Other lymphatic
structures of the Waldeyer ring may also be involved and
cause symptoms of dysphagia, serous otitis media or respiratory obstruction. In such cases, other lymph nodes
in the axilla, groin and abdomen should be examined in
addition to spleen and liver enlargement.
CERVICAL RIB
Occasionally an extra rib may arise from the seventh cervical vertebra and end anteriorly by attaching to the first
rib. This rib may produce a bony hard lump in the supraclavicular region. Most often it is seen on the right but
may be present on the left bilaterally.
Subclavian artery and brachial plexus which normally
pass between anterior and middle scalene muscles over the
first rib have now to pass over the cervical rib (a vertebral
space higher) and thus get compressed. It produces neurological or vascular symptoms. Patient may complain of
tingling sensation or numbness along the upper side of
forearm and hand due to compression of the lower part
of brachial plexus. When subclavian artery is compressed,
hand becomes cold and numb with intermittent claudication of upper limb. Due to arterial compression an aneurysm may develop mural thrombus which may shoot emboli to the distal arterial system of the upper limb. Cervical
rib, if asymptomatic, does not require treatment but symptomatic ones are excised by supraclavicular or transaxillary
approach.
STERNOMASTOID TUMOUR
Mostly seen in the newborns due to birth trauma. Fibrosis
and later shortening of the sternocleidomastoid muscle
causes torticollis. Face is turned to opposite side but the
head is tilted on the ipsilateral shoulder. A mass can be
palpated in the sternocleidomastoid muscle on physical
examination. In long-standing cases, asymmetry of face
and head can develop as a sequel.
Treatment is passive exercises of the neck in early
stages. Surgery is done when the condition is persistent
and likely to cause facial hemihypoplasia. It consists of
division of sternomastoid muscle.
SECTION X
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Operative Surgery
S e c t i o n o u t l i n e
78 Myringotomy (Syn. Tympanostomy), 453
79 Ear Surgery and Approaches, 455
80 Cortical Mastoidectomy, 457
81 Radical Mastoidectomy, 459
82 Modified Radical Mastoidectomy, 461
83 Myringoplasty, 463
84 Proof Puncture (Syn. Antral Lavage), 465
85 Intranasal Inferior Meatal Antrostomy, 467
86 Caldwell–Luc (Anterior Antrostomy) Operation, 469
87 Submucous Resection of Nasal Septum (SMR Operation), 471
88 Septoplasty, 473
89 Diagnostic Nasal Endoscopy, 475
90 Endoscopic Sinus Surgery, 477
91 Direct Laryngoscopy, 481
92 Bronchoscopy, 483
93 Oesophagoscopy, 485
94 Tonsillectomy, 487
95 Adenoidectomy, 491
96 Some Imaging Techniques in ENT, 493
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Chapter 78
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Myringotomy (Syn. Tympanostomy)
It is incision of the tympanic membrane with the purpose
to drain suppurative or nonsuppurative effusion of the
middle ear or to provide aeration in case of malfunctioning
eustachian tube. Ventilation tube (grommet) may also be
required in the latter case.
INDICATIONS
1. Acute suppurative otitis media.
(a) Severe earache with bulging tympanic membrane.
(b) Incomplete resolution with opaque drum and per-
sistent conductive deafness.
(c) Complications of acute otitis media, e.g. facial pa-
ralysis, labyrinthitis or meningitis with bulging
tympanic membrane.
(d) Recurrent acute otitis media.
2. Otitis media with effusion.
3. Aero-otitis media (to drain fluid and “unlock” the eustachian tube).
4. Atelectatic ear (grommet is often inserted for longterm aeration).
Figure 78.1. (A) Circumferential incision used in acute suppurative
otitis media. (B) Radial incision used in serous otitis media.
ANAESTHESIA
In infants and children, always use general anaesthesia.
For adults, general anaesthesia is used only when tympanic membrane is acutely inflamed. If there is no inflammation, myringotomy can be done under local anaesthesia or no anaesthesia at all.
STEPS OF OPERATION
1. Ear canal is cleaned of wax and debris.
2. Operation is ideally performed under operating microscope using a sharp myringotome and a good suction
apparatus.
3. In acute suppurative otitis media, a circumferential incision is made in the posteroinferior quadrant of tympanic membrane, midway between handle of malleus
and tympanic annulus, avoiding injury to incudostapedial joint (Figure 78.1A).
4. In otitis media with effusion, a small radial incision is
made in the posteroinferior or anteroinferior quadrant
and all the effusion sucked out.
When the ventilation tube is to be inserted, incision
should be just enough to admit the tube and is preferably
placed in the anterosuperior quadrant for longer retention (Figure 78.2).
Figure 78.2. Grommet in right tympanic membrane.
PITFALLS OF MYRINGOTOMY
1. When tympanic membrane is thick, incision may remain only in the superficial layers of drum head without cutting through its entire thickness.
2. Incision in the posterior meatal wall. This may happen
when distinction between drum head and posterior
meatal wall is lost, when both are inflamed.
3. Beware of vascular anomalies of the middle ear such
as high jugular bulb, aberrant carotid artery or glomus
tympanicum.
POSTOPERATIVE CARE
Daily mopping of ear discharge will be required in cases
of acute suppurative otitis media. In serous otitis media,
just leave a wad of cotton wool for 24–48 h.
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SECTION X — Operative Surgery
Drum incisions usually heal rapidly. No water should
be permitted to enter the ear canal for at least 1 week,
and if a grommet has been inserted, entry of water is prevented so long as grommet is in position.
COMPLICATIONS
1. Injury to incudostapedial joint or stapes.
2. Injury to jugular bulb with profuse bleeding, if jugular
bulb is high and bony floor of the middle ear dehiscent.
3. Middle ear infection.
GROMMET
It is a ventilation tube placed in the tympanic membrane
for drainage or ventilation of the middle ear. It has also
been called pressure-equalizing or tympanostomy tube
and is made of Teflon or medical-grade silicon which are
biocompatible. Some grommets are made of gold or titanium.
Complications of ventilation tube include:
(a) Blockage due to blood or secretions.
(b) Middle ear infection.
(c) Extrusion.
(d) Persistent perforation after extrusion or removal.
(e) Granuloma formation.
(f) Tympanosclerosis.
For long-term ventilation or when grommets are
repeatedly extruded, a T-tube can be used.
Chapter 79
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Ear Surgery and Approaches
INTRODUCTION TO EAR AND MASTOID
TERMINOLOGY FOR OPERATIONS
PERFORMED FOR CHRONIC EAR
INFECTIONS
Myringoplasty
It is an operation in which reconstructive procedure is
limited to repair of tympanic membrane perforation.
Tympanoplasty without Mastoidectomy
(Tympanum=middle ear)
It is an operation to eradicate disease in the middle ear
and to reconstruct the hearing mechanism without mastoid surgery, with or without tympanic membrane grafting. This means ossicular reconstruction only or ossicular
reconstruction with myringoplasty.
Tympanoplasty with Mastoidectomy
It is an operation to eradicate disease in both the mastoid and middle ear cavity, and to reconstruct the hearing mechanism with or without tympanic membrane
grafting.
Cortical Mastoidectomy (Simple
Mastoidectomy or Schwartz Operation)
It is an exenteration of all accessible mastoid air cells preserving the posterior meatal wall.
Modified Radical Mastoidectomy
It is an operation to eradicate disease of the attic and
mastoid, both of which are exteriorized into the external auditory canal by removal of the posterior meatal and
lateral attic walls. Tympanic membrane remnant, functioning ossicles and the reversible mucosa and function
of the eustachian tube are preserved. These structures are
necessary to reconstruct hearing mechanism at the time
of surgery or in a second-stage operation.
Radical Mastoidectomy
It is an operation to eradicate disease of the middle ear
and mastoid in which mastoid, middle ear, attic and the
antrum are exteriorized into the external ear by removal
of posterior meatal wall. All remnants of the tympanic
membrane, ossicles (including malleus and incus but not
the stapes), chorda tympani and the mucoperiosteal lining are removed, and the opening of the eustachian tube
is closed by packing a piece of muscle or cartilage into it.
Meatoplasty
Meatoplasty is an operation in which a crescent of conchal
cartilage is excised to widen the meatus. It is invariably
combined with all canal wall down procedures, i.e. modified radical and radical mastoidectomies for easy access
to mastoid cavity for periodic inspection and cleaning. It
is also done as an isolated procedure in a sagging auricle
seen in older people. Sagging auricle obstructs the ear canal and causes hearing loss and retention of wax.
Mastoid Obliteration
It is an operation to eradicate mastoid disease, when present, and to obliterate the mastoid cavity. Obliteration of
mastoid cavity is done with pedicled temporalis muscle
or musculofascial tissue raised as flaps.
SURGICAL APPROACHES TO THE EAR
AND INCISIONS
1. endomeatal or transcanal approach. It is used
to raise a tympanomeatal flap in order to expose the middle ear. Rosen’s incision is the most commonly used for
stapedectomy. It requires the meatus and canal to be wide
enough to work. It consists of two parts: (i) a small vertical incision at 12 o’clock position near the annulus and
(ii) a curvilinear incision starting at 6 o’clock position to
meet the first incision in the posterosuperior region of
the canals, 5–7 mm away from the annulus (Figure 79.1)
Posterior meatal canal skin is raised in continuity with
tympanic membrane, after dislocating the annulus from
the sulcus. It gives a good view of the middle ear and
ossicles. Stapes, if still covered by posterosuperior overhang of bony meatus, can be exposed by removing this
part of the overhang. This incision is also used commonly for exploratory tympanotomy to find cause for
conductive hearing loss, inlay myringoplasty or ossicular
reconstruction.
2. endaural approach. It is used for:
(a) Excision of osteomas or exostosis of ear canal.
(b) Large tympanic membrane perforations.
(c) Attic cholesteatomas with limited extension into the
antrum.
(d) Modified radical mastoidectomy where disease is lim-
ited to attic, antrum and part of mastoid.
Endaural approach is made through Lempert’s incision
(Figure 79.2). It consists of two parts:
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