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158
CHAP TER5 The front oftheneck
• Hodgkin’s disease in 80% of cases involves cer vical lymphnodes.
• Some patients present with systemic symptoms such as weight loss,
fever, and night sweats (type B symptoms).
• Diagnosis is conrmed by biopsy (often excision biopsy is necessary
after initial FNA cytology).
Secondary:metastatic disease
• Metastatic cervical lymph nodes, secondar y to head and neck
malignancy are quite common.
• In approximately 90% of cases spread to the cervical lymph nodes
occurs in a predictable fashion (superior neck nodes being involved
before inferior nodes).
• Pattern and extent of cer vical lymph node involvement dictates the
nature of treatment.
• Neck nodal involvement is the single most important prognostic
factor in determining patients’ survival.
• Factor s of prognostic importance are the level, numbers, and size of
nodal involvement and presence (or absence) of extr acapsular spread.
Treat neck nodes seriously. Regard the solitary node as a malignancy until
ruled out. Refer accordingly.
bThyroid/ thyroglossal cyst/ thymus
The enlarged thyroidgland
The thyroid gland lies in the midline of the lower third of the neck behind
the pre- tr acheal fascia. It consists of two pear- shaped lobes connected
by an isthmus in the middle. A normal thyroid gland weighs approximately 20 g in adults. Posterior to the thyroid gland are superior and
inferior parathyroid glands (calcium homeostasis).
Assessment of a thyroid lesion essentially involves answering the following questions:
• What is the patient’s thyroid status— normal, over- or under- active?
• Is it a generalized enlargement of the gland or a solitary nodule?
• Can this be malignant? Both solitary and multinodular goitres can be
benign or malignant.
bGoitres
A goitre is an enlarged thyroid gland. The term goitre is generally used to
refer to any enlargement without reference to thecause.
Dierent types ofgoitres
• Physiological (usually diuse goitre):seen during pregnancy, at
puberty and in conditions of iodine deciency (now uncommon).
• Inammatory (usually diuse but can be multinodular):De Quervain’s
thyroiditis, Hashimoto’s thyroiditis, Riedel’s thyroiditis.
• Toxic (usually diuse goitre):Gr aves’ disease.
• Nodular:this is a simple benign enlargement of the thyroid gland.
Anodular goitre can be a solitary nodule or multinodular. This only
requires treatment if the patient is thyrotoxic, concerned with its
appearance, or has symptoms of compression of adjacent structures
(e.g. dysphagia or dyspnoea).
THYROID/THYROGLOSSAL CYST/THYMUS
Key questions
• Rate of growth ofgoitre
• Pressure symptoms:hoarseness, pain, dysphagia
• Symptoms of hypo- or hyperthyroidism
• Radiation exposure, family history of thyroid disorders/ cancers.
Investigations
• Thyroid function tests:TSH, freeT4.
• FNA.
• Thyroid r adionucleotide scintigraphy:to determine function, or
identify ectopic thyroid tissue (retrosternal, lingual, and metastasis).
• Ultrasound:denes lumps from cyst s and guidesFNA.
• CT/ MRI:evaluates substernal goitre, nodal involvement, airway and
vascular displacement, tumour invasion.
• CXR:metastasis work- up, tracheal displacement .
Indications forthyroidectomy
• Excision may be required if there is suspicion of malignant change
(rapid increase in size of goitre, lymph node enlargement , or
hoarseness from recurrent laryngeal ner ve involvement).
• Compression symptoms (airway compromise, dysphagia).
• Extension into the mediastinum (substernal goitre).
• Cosmesis.
• Failed medical management for Gr aves’ disease or hyperthyroidism.
bThe solitary thyroid lump (nodule)
These have several causes:
• Cystic:this is usually a degenerative part of a nodular goitre although
true cysts are also seen. Haemorrhage into the cyst is common and
will present with pain and rapid enlargement.
• Adenoma:this may produce thyrotoxicosis if functioning. Subdivided
histologically:papillary, follicular, embryonal, and hurtlecell.
• Carcinoma:4 – 10% of solitary nodules can be malignant.
Dierent types ofthyroid cancers
• Papillary adenocarcinoma:seen in younger age groups; low grade and
rarelyfat al.
• Follicular adenocarcinoma:a malignancy of middle age; bony
metastases are common.
• Anaplastic carcinoma:an aggressive malignancy of the elderly;
metastatic disease at presentation is common.
• Medullary carcinoma:seen in all age groups with equal sex incidence;
moderate malignant potential spreading to lymphnodes.
• Malignant lymphoma:may occur in lymphatic tissue within the thyroid
gland or as secondar ies.
• Secondary:direct spread from adjacent malignancies or metastatic
spread, most commonly from brea st, renal, colon, andlung.
Risks factors forthyroidcancer
Extremes of age, nodule >5cm, previous radiation therapy, autoimmune
thyroiditis (develop lymphomas).
159
160
CHAP TER5 The front oftheneck
bThyroglossal ductcyst
Failure of complete obliteration of thyroglossal duct results in a midline
painless neck mass. The cyst is attached to the hyoid bone so elevates
with tongue protr usion. Patients may have dysphagia. Cysts can get
infected. Malignant potential is rare. Refer for surgical excision
bThymiccysts
• Pathophysiology:remnant of third pharyngeal pouch between angle
of mandible to midlineneck.
• Symptoms:midline neck mass at lowerneck.
• Diagnosis:biopsy, serum calcium (associated parathyroid disorders,
DiGeorge’s syndrome), CT, andMRI.
• Treatment is surgical excision.
bCarotid bodytumour
Carotid body tumours (chemodectomas) are rare, slow- growing lesions
arising in the carotid bifurcation, distorting and encasing the carotid vessels. Chronic hypoxia has been repor ted as a causal factor (high incidence in high- altitude areas). A familial tendency in 10%, and 10% are
bilateral. Left untreated about 5 – 10% will develop metastases within
10years. May also become locally invasive.
Clinical features
• These usually present in patients over 50years of age as solitary or
bilateral lumps at the level of carotid bifurcation (Figure5.5).
• They transmit the carotid pulse rather than being pulsatile itself.
Figure5.5 CT showing bilateral carotid body tumours.
BRANCHIAL CYSTS/SINUSES/FISTULAE
• Most can be moved laterally (displacing the carotid pulse) but not
vertically (Fontainesign).
• Occasionally pressure on the carotid sinus by tumour may cause
fainting attacks.
Management
Surgical excision is the management of choice in the young patient. In
elderly, frail patients, follow- up only is required.
bBranchial cysts/ sinuses/ fistulae
bBranchialcyst
After the thyroglossal cyst, the branchial (lateral cervical) cyst is the
second most common congenital swelling in the neck. It is thought that
branchial cyst s develop from remnants of the second branchial cleft. In
some ca ses tract s are found running from the deep surface of the cyst to
the pharyngeal wall. However, it has also been postulated that they are
a result of cystic degeneration in cer vical lymphatic tissue (Figure5.6).
Clinical features
Most lesions present in the third decade of life. Patients complain of an
enlarging mass arising along the junction of the upper and middle thirds
of the SCM muscle. Frequently the cyst may appear as a swelling during
an upper respiratory tract infection, which may be painful and persist
after the infection has been treated. Recurrent infections can result in a
rm, xed mass adherent to surrounding structures such as the jugular
vein, proving dicult to excise surgically.
161
Figure5.6 Branchialcyst.
162
CHAP TER5 The front oftheneck
Investigations
Diagnosis is usually made on the ba sis of the history and the site of the
swelling. However, FNA biopsy can prove useful by producing an opalescent uid containing cholesterol cr ystals or frank pus. CT or MRI helps
dene its size anddepth.
Management
Surgical excision of the lesion is the treatment of choice following management of infections with appropriate antibiotics. All of the cyst lining
should be removed as any remaining remnants may result in recurrence
or a chronic discharging sinus from thewound.
bBranchial sinus/ branchial stula
A branchial sinus is a small opening found over the anterior border of the
SCM, which may discharge a mucous secretion. They are generally present at birth but may present in later life as a consequence of a ruptured,
chronically infected branchial cyst. The sinus can extend superomedially
between the internal and external carotid ar teries to open onto the lateral wall of the pharynx forming a br anchial stula .
Summary ofbranchial cleft anomalies
• Pathophysiology:developmental alterations of the branchial
appar atus results in cysts, sinuses (single opening to skin), or stulas
(opening to skin and digestive tract).
• Symptoms:neck mass in anterior neck (anterior to SCM), stulas and
sinuses may express mucoid discharge; secondary infections cause
periodic uctuation of size, tenderness, and purulent drainage.
• Diagnosis:CT with contrast (may consider injecting contrast into
stula), laryngoscopy to visualize internal opening.
• Histopathology:lined by squamous epithelium.
bPlungingranula
Congenital ranulas arise secondary to an imperforate salivary duct .
These are ver y rare and spontaneously resolve. More commonly, ranulas arise from minor trauma to the sublingual gland, leading to mucus
extravasation and formation of a pseudocyst. Partial obstruction of the
sublingual duct leads to formation of an epithelial- lined retention cyst.
Plunging ranulas can manifest as neck swellings usually in conjunction
with swelling in the oor of themouth.
Investigations
CT scan may show a unilocular hypodense lesion within the sublingual
space. Plunging ranulas are occasionally noted on CT scanning to have
a small tail extending into the sublingual space and this nding is almost
pathognomonic. Ultrasound and MRI may be useful but not routinely
ne ce ssary.
DERMOID CYSTS AND TERATOMAS
Treatment
Observation for spontaneous resolution of congenit al ranulas is usually
all that is required. Surgical treatment for acquired ranulas includes marsupialization or excision via the mouth orneck.
bDermoid cysts and teratomas
Dermoidcysts
These are considered the most common for m of teratoma and are characterized by a predominance of ectodermal content. Most dermoids in
the head and neck occur in the region of the oor of the mouth. They
are believed to be caused by epithelial rests trapped during embr yological development. Clinically, they manifest as slow- growing lesions that
produce symptoms when their cystic lumens become lled with keratin
debris. Sebaceous material may also be found in the cyst, alluding to its
ectodermal origin.
Management
The management of these cysts is surgical excision.
bCervical teratomas
These are extremely uncommon lesions of the head and neck with prevalence of 1 in 16,000 bir ths. In the neck, they most often occur in the midline
and may manifest clinically with severe respiratory distress and dysphagia
due to compression of the trachea and oesophagus. These lesions are
known to often grow into a large size (as far as 12 cm) and histologically,
may contain any combination of tissues from the three germ layers. They
are sometimes classied in relation to proximity to the thyroid gland as
follows:(1)teratomas of the thyroid gland, deriving its blood supply from
thyroid arteries; (2) teratomas adjacent to the thyroid gland, in which a
denitive blood supply cannot be identied; and (3)teratomas of theneck.
Management
Cervical teratomas are managed with surgical excision. Untreated cases
risk possible malignant degeneration. The prognosis in non- neoplastic
cases is excellent . The ex utero intrapartum treatment (E XIT) procedure
is a technique that allow par tial fetal delivery via Caesarean section, with
establishment of a safe fetal airway. This may be necessary if there is fet al
airway obstruction diagnosed by prenat al scanning.
163
When examining a salivar y gland swelling, assess the following:
• Palpation (mobility, size, consistency)
• Bimanual palpation, with gland massage and inspection of any saliva
expressed
• Tenderness (inammatory process)
• Facial nerve dysfunction (suggests malignancy)
• Lingual and hypoglossal nerve dysfunction with submandibular
gland tumours
• Parapharyngeal space (tonsil) displacement with parotidlumps
• Cervical lymphadenopathy.
164
CHAP TER5 The front oftheneck
The salivaryglands
There are three pairs of major salivary glands and several hundred minor
salivary glands distributed throughout the upper aerodigestive tract. The
parotid is the largest gland and produces predominantly serous saliva.
Submandibular and sublingual glands secrete mucoserous saliva. Salivary
stones are more common in the submandibular gland because of its high
mucinous content. Minor salivary glands are concentrated on palate,
lips, and pharyngeal mucosa and secrete predominantly mucinous saliva
which helps to keep mouthmoist.
Swellings of the glands may present as a swelling in the neck, mouth,
or side of the face. It is unusual for the sublingual gland to produce a true
neck swelling except with a plunging ranula. The causes of salivary gland
swelling are in essence threefold:obstructive, infective, and neoplastic. These
may occur in isolation although they may coexist, e.g. a stone may result
in infection.
cObstruction
Obstruction of any par t of the duct system may result in a build- up of
salivary secretions and swelling. With recurrent bouts of obstr uction,
infection may supersede due to stagnation of secretions. The classic history is of swelling associated with meal times— the patient may repor t
that the swelling settles a few hours af ter the end of eating (Figure5.7).
Salivary calculi form as a result of calcium deposition around a nidus of
organic material. 80% occur in the submandibular gland. Of the submandibular stones, 20% are radiolucent. In these cases sialography is indicated to locate them. Stones in the oor of the mouth may be removed
through a local incision under local anaesthetic. However, recurrent
damage to the gland may necessitate its removal.
Figure5.7 Acute submandibular obstruction.
THE SALIVARYGL ANDS
Duct strictures can also form as a result of chronic trauma or iatro-
genic injur y or may be caused by ulceration around a salivar y calculus.
Fibrosis leads to duct stenosis and obstructive symptoms.
Neoplasia may occasionally present with obstructive symptoms.
cInfections
Infec tion in a major salivary gland usually presents with a painful, red,
warm, tender swelling. The regional lymph nodes may be enlarged and
tender, and pus may be seen to exude from the duct orice on gently
massaging the gland. Infection of the submandibular gland may present
as a painful lump in the neck . Infection of the parotid gland tends to present as a painful swelling on the side of the face. Infections of the sublingual gland and minor salivary glands are generally rare and present with
symptoms within themouth.
Mumps
Both bilateral and unilateral painful parotid swelling is commonly due to
a paramyxovirus infection. This is highly infectious, generally aecting
children, with an incubation period of 21days. Immunity is long- lasting
after an attack. Treatment is symptomatic (analgesia and applying a warm
or cool compress to help relieve pain). Complications of mumps include
pancreatitis, meningitis, oophoritis, and orchitis (especially in adults).
Suppurative parotitis
This is seen in debilitated patients, particularly following major surgery,
as a result of xerostomia secondary to dehydration. Oral ora ascends
along the duct into the gland which becomes infected. Management
includes rehydration and appropriate antibiotic therapy.
Chronic sialadenitis
Usually a complication of recurrent duct obstruction.
bTumours
70– 80% of all salivary gland tumours arise in the parotid. Of these,
approximately 80% are pleomorphic adenomas and 10– 15% are malignant (Figure5.8).
The classication of salivar y gland tumours is complex. This includes
(not an exhaustivelist):
• Benign epithelial tumours (pleomorphic and monomorphic
adenomas, myoepitheliomas, and Warthin’s tumours)
• Malignant epithelial tumour s (acinic cell, mucoepidermoid, and
adenoid cystic carcinomas, salivary duct carcinomas)
• Soft tissue tumours (lymphangiomas, haemangiomas, and
lymphomas)
• Metastatic tumours (skin cancers metastasizing to parotid nodes).
Lumps need urgent refer ral to a head and neck specialty (ma xillofacial/
ENT etc.). Imaging is usually required (CT/ MRI or ultrasound). The role
of FNA is controversial. Management is surgical removal.
165
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CHAP TER5 The front oftheneck
Figure5.8 Parotid tumour.
bSalivary gland dysfunction
Xerostomia (drymouth)
There are many causes for this including primary salivary disorders
(Sjögren’s disea se), medication induced (especially tricyclic antidepressants, antihistamines, antimuscarinic drugs, antiepileptic drugs, antipsychotics, beta- blockers, and diuretics), radiotherapy, dehydration,
and mouth breathing from nasal obstruction. Treat with ar ticial saliva,
sugar- free chewing gum, or pilocarpine. Ask about dry/ gritty eyes. If pres-
ent, this could be Sjögren’s syndrome. Discuss with ophthalmology
regarding ocular assessment.
Ptyalism (drooling)
True overproduction of saliva is very rare (causes include intraoral
infections, foreign bodies such as new dentures, and mercury poisoning). More commonly patients just don’t swallow normal amounts eectively. Causes include Parkinson’s disease, epilepsy, and other swallowing
disorders. It also occurs during pregnancy. Treatment includes scoline
patches or in severe cases chorda tympani transec tion, ductal rerouting,
ligation of Stenson’s duct, or gland excision.
Some usefulfacts
• Mumps is the commonest cause of acute parotid swelling, whether it
is unilateral or bilateral.
• Most parotid lumps are benign. Malignancy is more likely in
submandibular/ sublinguallumps.
• Alump associated with ner ve dysfunction (facial, lingual, hypoglossal)
suggests inltrative pathology (i.e. tumour).
• Not all stones show up on plain X- rays.
• Ask about dry grit ty eyes, joint symptoms, and ra shes in anyone
complaining of severe dry mouth or recurrent salivar y symptoms.
HOARS E VOICE (DYSPHON IA)/LOSS OFVO ICE
• HIV can aect the salivary glands.
• Heer fordt’s syndrome is sarcoidosis resulting in parotid enlargement,
fever, anterior uveitis, and facial nervepalsy.
• Anxiet y and medication are the commonest causes of a drymouth.
cHoarse voice (dysphonia)/ loss ofvoice
Dysphonia is a common condition and in most cases the underlying cause
is benign and self- limiting. However, persistence of symptoms requires care-
ful evaluation:it can be an early sign of malignancy.
Components ofspeech
• Respiration:source of energy from inhalation/ exhalation
• Phonation:production of voice by vocal fold vibration
• Resonation:oral/ nasal speech balance determined by velopharyngeal
musculature and resonance of the sinuses, nasopharynx, nasal cavity,
and oralcavity
• Articulation:speech sounds using muscles of lips, tongue, andjaw
Assessment ofa patient withdysphonia (usually asan
outpatient)
Character ofdysphonia
Onset and dur ation, time course (acute vs chronic), periodicit y (morning
hoarseness with GORD and evening hoarseness with voice abuse).
Contributing factors
Voice abuse, recent URTI, fever, sore throat, cough, congestion; tobacco
or alcohol abuse; PMH of neuromuscular disorders, hypothyroidism,
psychological stressors, previous lar yngeal trauma, surgery, or airway
manipulation.
Associated symptoms
Dysphagia, aspiration, weight loss, hearing loss, heartburn.
Assess perceptual quality ofvoice
Abnormally high pitched or low pitched, abnormally loud orsof t.
Examination
Indirect or direct laryngoscopy (mirror, exible nasopharyngoscopy,
videostroboscopy); assess vocal fold motion, examine laryngeal lesions
and appearance of vocal folds, assess glottic competence. Neck masses,
thyroid masses, neurological examination.
Videostroboscopy
Examines the vocal fold mucosa for general health, vocal fold anatomical
defects, vocal fold disturbances, and mucosal wave dynamics.
Aerodynamic studies and laryngealEMG
Measures airow, pressures, and pat ter n of vibration of the vocalfolds.
167