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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана
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R. Mehta et al.
intracranial extension along the left jugular
foramen.
On MR imaging with contrast, there was evidence of a large altered signal intensity spaceoccupying lesion of size of approximately
4.7×3.8×2.6cm seen in the neck region on the
left side in the carotid space and anterior to the
Fig. 11 MRI imaging: axial cuts showing a lesion present in the left parapharyngeal space
Fig. 12 MRI images:
sagittal cuts showing a
lesion present in the left
parapharyngeal space
with lesion extending
intracranially through
the jugular foramen, and
a dumbbell shape of the
lesion can be
appreciated
prevertebral muscle. It shows likely intracranial
extension through the jugular foramen up to the
ninth and tenth nerve complex.
Preoperative radiological imaging, intraoperative steps of surgery and postoperative follow-up
images are shown in Figs.11, 12, 13, 14, 15, 16,
17, 18, 19, 20, 21, 22, 23, 24, 25, and 26.
Fig. 13 MRI scan: coronal cuts showing a lesion in the left parapharyngeal space
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Fig. 14 Diffuse swelling appreciated in the left infraauricular region; the ramus of the mandible is overlying
the anterior border of the swelling
Fig. 15 Surface marking of skin incision, mastoid tip and
angle of the mandible
Fig. 17 Surgical eld after removal of the submandibular
gland
Fig. 18 Baring of the left hemi-mandible and marking
for parasymphyseal mandibulotomy and horizontal mandibulotomy over the body of the mandible and ramus of
mandible, respectively
Fig. 16 Elevation of the upper and lower skin ap
Fig. 19 Plates and screws are placed over the planned
mandibulotomy site
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Fig. 20 Lifting mandibulotomy done to improve the
access of the tumour; the tumour now can be accessed
anteriorly and superiorly till the jugular foramen. Major
vessels and nerves secured and isolated using vessel loops
Fig. 21 The internal jugular vein is displaced laterally to
facilitate dissection of the distal aspect of the vagus nerve
Fig. 23 Surgical wound after excision of the tumour and
repositioning the mandible in place with plates and screws
Fig. 24 Gross specimen of the tumour after surgical excision of the lesion
Fig. 22 After the removal of the tumour, the surgical eld
shows intact carotid bifurcation and adjacent cranial
nerves
Fig. 25 Surgical wound after closure
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Fig. 26 Follow-up after 6 months with a well-healed scar
on the left side of the neck
5 Thymoma
5.1 Introduction
Thymomas are uncommon tumours with a slow
growth rate, making it simple to confuse them
with benign growth [79]. Myasthenia gravis is
associated with one-third of them, and in certain
cases, removing them signicantly improves the
symptoms of the disease. A thymoma should be
removed as soon as it is discovered due to its likelihood of being cancerous. Complete resection,
the cornerstone of therapy, has a great cure rate
[79].
Of the tumours in the anterior mediastinum,
they make up 47% [80, 81]. There is a surge
between the ages of 35 and 70, yet they affect
persons of all ages. Thymoma affects both sexes
roughly equally, while older women are somewhat more likely to get it [82]. Patients with
myasthenia gravis are often a bit younger, peaking between the ages of 30 and 60 [79, 82].
Nearly 40% of patients experience local
symptoms. They often include chest discomfort,
a cough and shortness of breath brought on by
myasthenia gravis’ neuromuscular effects or airway constriction. Less frequently, rapidly
expanding tumours can cause superior vena cava
syndrome and weight loss [83]. Local symptoms
are seen in around 40% of individuals. They often
include coughing, shortness of breath and chest
discomfort due to airway constriction or the neuromuscular consequences of myasthenia gravis.
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Rapidly growing tumours less frequently experience superior vena cava syndrome and weight
loss [81, 84].
Thymomas rst often present as well-dened
round or oval lumps. Areas of low attenuation,
many calcications and uneven margins are indicators of an invasion [81, 85]. They can wrap
around these structures but are often anterior to
the major vessels [86]. The use of CT is crucial in
determining whether a tumour is easily resectable or not, as well as if nearby tissues might also
need to be removed. In addition, CT is helpful for
identifying recurrence following the prior
resection.
5.2 Surgical Resection
Given that thymoma has the potential to become
cancerous, they should be removed in otherwise
healthy people. It should be attempted to completely remove all thymic cells. In the surrounding tissue, thymic cells are located in little nests.
Today, the majority of centres conduct an en-bloc
excision of the whole thymus gland and the surrounding areolar tissue [79]. Every effort should
be taken to perform a full resection, which has
repeatedly been proven to be of substantial prognostic signicance in the treatment of thymomas
at every stage [79, 87]. It could involve the excision and repair of crucial organs like the aorta or
superior vena cava. Even in individuals with
myasthenia gravis, if one phrenic nerve is
affected, it should be sacriced unless the patient
has a considerably diminished pulmonary
reserve. For a successful resection, careful surgical planning is essential.
5.3 Operative Technique
The common method is a median sternotomy
[79]. The whole thymus is removed, including all
four lobes. Except for a little quantity surrounding the phrenic nerves, all pericardial fat should
be eliminated. Any attached structure should be
removed in its entirety rather than being just
adjacent.
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If excision of nearby structures such as the
superior vena cava or phrenic nerve is necessary,
an open approach is advised [88]. The sternotomy method of oncologically sound resection is
substantially simpler.
5.4 Case 1
A 43-year-old woman with no prior history of
breathing, swallowing or voice changes arrived
with swelling in front of her neck on the left side
for 3 months. A contrast-enhanced CT scan was
performed on her, and the results revealed a welldened hyperdense lesion in the lower region of
her neck that had spread into her anterior mediastinum. A transcervical and sternotomy technique
was then planned for the patient’s excision.
Preoperative radiological imaging, intraoperative steps of surgery and wound closure images
are shown in Figs.27, 28, 29, 30, 31, 32, 33, 34,
35, and 36.
Fig. 28 Surface marking of the hyoid bone, skin incision
and sternal notch with the superior part of the lesion on
the left side of the lower part of the neck
Fig. 27 Contrast-enhanced CT scan: coronal and sagittal section showing a well-circumscribed hyperdense lesion in
the lower part of the neck with the lesion extending into the anterior mediastinum
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Fig. 31 Retraction of sternocleidomastoid muscles laterally to expose the anterior part of the neck
Fig. 29 Surface marking of the sternotomy incision
Fig. 30 Elevation of the upper and lower skin ap
Fig. 32 Soft tissue dissection done to expose the superior
part of the lesion which is present in the neck
Fig. 33 Sternotomy done to expose the lesion which
extends into the anterior mediastinum
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Fig. 34 Surgical eld after excision of the lesion
Fig. 35 Entire surgical specimen after excision
Fig. 36 Surgical wound after the closure of the neck and
sternotomy wound
6 Branchial Cyst
6.1 Embryology
The branchial arches, which are divided apart
externally by grooves and inside by pharyngeal
pouches, are where the neck’s tissues originate.
The branchial arches’ internal pouches, which
are covered with the ectoderm on the exterior, are
made of foregut endoderm. The interlayer region
contains the tissue that is developed from the
mesoderm [89]. When two nearby arches are
poorly or inadequately fused, a branchial cleft
anomaly results [90]. Fistulas (an open tract
between the skin and throat), sinuses (connecting
the skin or pharynx to a blind pouch in the neck)
and cysts are a few examples of these abnormali-
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ties (isolated epithelial-lined structures lacking
connection to the skin or pharynx). Their positions vary depending on the arch from which they
emerge and how close they are to muscles, arteries and nerves [91].
6.2 First Arch Anomaly
The rst branchial arch accounts for 8% of the
cervical sinus tracts and cysts [92]. Despite the
fact that some people with these rst arch anomalies show no symptoms, others complain of neck,
parotid or ear pain. Around the mandibular angle,
there might be a pit-like depression that, if
infected, could lead to drainage.
6.2.1 Type 1 First Arch Cyst
Type I rst arch cysts typically open in the pre- or
postauricular areas. The sinus tract may adhere to
the tympanic membrane or the skin of the external auditory canal. The external auditory canal
and the sinus tract normally run side by side [89,
90]. Type I lesions are lateral to the facial nerve.
6.2.2 Type II First Arch Cyst
Type II rst arch cysts, on the other hand, appear
medial to the facial nerve [89]. They are located
in the anterior neck, above the hyoid. The type II
rst arch sinus typically goes via the parotid
gland and encircles the facial nerve as it moves
anterior to the hyoid [90].
6.3 Second Arch Anomaly
The most common type of cervical cyst, second
branchial arch cysts, accounts for 90 to 95% of
all cases [89, 90]. If these anomalies come from
the second branchial pouch, they may lead to stulous tracts that connect the palatine tonsil to
the lateral neck skin at the anterior edge of the
sternocleidomastoid muscle. Examination
reveals that there is a skin pit in this location. As
they approach the supratonsillar fossa, they can
alternatively pass near to the glossopharyngeal
and hypoglossal nerves if they originate from the
second branchial cleft. If these pits are bilateral,
it is important to check the newborn for branchiooto- renal syndrome since it may potentially indicate kidney and hearing issues. These cysts can
occasionally be detected near to the carotid
sheath, between the internal and external carotid
arteries [89]. If a skin pit is present, it is at the
anterior edge of the sternocleidomastoid muscle.
Patients, usually suffering from an upper respiratory tract infection, may develop acute cyst
enlargement or superinfection. Depending on its
location and size, this enlargement may result in
dysphagia, torticollis or a compromised respiratory system [89].
6.4 Third andFourth Arch
Anomaly
Cysts, which are incredibly uncommon, make for
less than 2% of anomalies in the third and fourth
branchial arches [90]. Before terminating in the
pyriform fossa, the sinus tracts of these cysts frequently penetrate far into the thyroid gland and
anterior cervical structures. If children develop
secondary infections, these problems may present in the form of suppurative thyroiditis in young
children. If they spread fast due to infection, they
can potentially result in tracheal constriction or
airway compression in young infants [89].
The mainstay of treatment for all of these
cysts is surgical removal. Preoperative imaging
is often used to plan the surgical approach and
anticipate potential problems. Sinuses and cysts
that are left untreated present a high risk of
infection. Greater recurrence rates might also
result from incomplete resection [89]. Certain
surgical safety precautions can be necessary due
to their anatomical positioning. For instance, in
order to thoroughly remove the cyst and sinus
and avoid damaging the facial nerve, a supercial parotidectomy may be required for type II
rst branchial arch cysts. Finding the internal
sinus entry, which is often on the left side, for the
third and fourth branchial arch cysts requires
endoscopic assessment of the pyriform fossa
[90]. Ipsilateral hemithyroidectomy is required
for the fourth arch anomalies in order to remove
the whole tract [89].
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6.5 Case 1
A 30-year-old female presented with swelling on
the left side of her neck since childhood; the
swelling is non-progressive in size with no compressive symptoms. On examination, a swelling
of 4×3cm is present on the left side of the neck
along the anterior border of the neck in the middle one-third. On FNAC, aspirates yield abundant
viscous uid, which contains mature squamous
Fig. 37 Surface marking of the swelling along with
marking the external jugular vein
cells and keratinous debris. Further characterization of the swelling was done by contrastenhanced CT scan. The patient was posted for
excision of the lesion.
Preoperative radiological imaging, intraoperative steps of surgery and surgical specimen
images are shown in Figs.37, 38, 39, 40, 41, 42,
and 43.
6.6 Case 2
A 22-year-old female presented with swelling on
the right side of her neck since childhood; the
swelling is non-progressive in size with no compressive symptoms. On examination, a swelling
of 7×6cm is present on the right side of the neck
along the anterior border of the neck in the middle one-third. On FNAC, aspirates yield abundant
viscous uid, which contains mature squamous
cells and keratinous debris. Further characterization of the swelling was done by contrastenhanced CT scan. The patient was posted for
excision of the lesion.
Fig. 38 Contrastenhanced CT scan
coronal section showing
a homogenous
hypodense lesion
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Fig. 39 Contrast-enhanced CT scan axial images showing a well-dened hypodense lesion in the left side of the neck
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