21 neck swellings
TRANSCRIPT
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Neck Swellings
Dr. Vishal Sharma
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Neck Triangles
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Anterior Triangle
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Boundaries: Anterior = midline of neck
Posterior = S.C.M. anterior border
Superior = lower border of mandible
Floor = deep layer of deep cervical fascia
Roof = Superficial layer of deep cervical fascia
Subdivision: by digastric & omohyoid muscles into
submental, submandibular, carotid, muscular
Contents: carotid arteries, internal jugular vein, vagus,
recurrent laryngeal nerves, submandibular gland,
Levels I, II, III, IV & VI lymph nodes
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Posterior Triangle
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Boundaries:
Posterior: Trapezius anterior border
Anterior: S.C.M. posterior border
Inferior: Middle 1/3rd of clavicle
Floor: deep layer of deep cervical fascia
Roof: Superficial layer of deep cervical fascia
Subdivision: occipital & supra-clavicular by omohyoid
Contents: subclavian artery, brachial plexus, spinal
accessory nerve, level V lymph nodes
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Neck Lymph Nodes
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Sloan Kettering ClassificationLevel I: Submental + submandibular nodes
Level II: Upper jugular nodes (upper 1/3 of IJV)
Level III: Middle jugular nodes (middle 1/3 of IJV)
Level IV: Lower jugular nodes (lower 1/3 of IJV)
Level V: Posterior triangle nodes
Level VI: Anterior compartment nodes
Level VII: Superior mediastinal nodes
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Submental Lymph nodes (Level Ia):
Lateral: Anterior digastric belly (both sides)
Inferior: Body of hyoid
Submandibular Lymph nodes (Level Ib)
Posterior: Posterior digastric belly
Anterior: Anterior digastric belly
Superior: Body of mandible
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Anterior Posterior Superior Inferior
II Lateral
border of
sterno-
hyoid
Posterior
border of
sterno-
cleido-
mastoid
Skull base Carotid
bifurcation
or hyoid
III Carotid
bifurcation
or hyoid
Cricoid
IV Cricoid Clavicle
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Level V: Posterior triangle nodes
Posterior: Trapezius anterior border
Anterior: S.C.M. posterior border
Inferior: Middle 1/3rd of clavicle
Level VI: Anterior compartment nodes
Superior: Body of hyoid bone
Inferior: Supra-sternal notch
Lateral: Lateral border of sterno-hyoid
Level VII: Superior mediastinal nodes
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Classification of neck swelling according to position
• Ubiquitous neck swellings
• Midline neck swellings
• Anterior triangle neck swellings
• Posterior triangle neck swellings
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Ubiquitous neck swellings• Sebaceous cyst
• Lipoma
• Neurofibroma, schwannoma
• Hemangioma
• Dermoid cyst
• Teratoma
• Hydatid cyst
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Midline swellings
Lymph node (submental, Delphian, suprasternal)
Ludwig’s angina Sublingual dermoid
Thyroglossal cyst Subhyoid bursitis
Thyroid swelling (isthmus & pyramidal lobe)
Laryngeal tumors Cold abscess
Sternal tumor Thymus tumors
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Submandibular triangle swellings
• Lymph node (level 1b)
• Cold abscess
• Submandibular salivary gland enlargement (deep
lobe is bimanually
ballotable)
• Plunging ranula
• Mandibular tumor
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Carotid + muscular triangle swellings
Branchial cyst Branchiogenic cancer
Laryngocoele (external) Thyroid lobe swelling
Lymph node (II, III, IV) Cold abscess
Carotid body tumour Carotid aneurysm
Sternomastoid tumor of newborn
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Posterior triangle swellings
Cystic hygroma
Pharyngeal pouch (Zenker’s diverticulum)
Lymph node (level V)
Cold abscess
Cervical rib
Clavicular tumour
Subclavian artery aneurysm
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Classification by etiology
• Congenital / Developmental
• Infectious / Inflammatory
• Neoplastic: Benign / Malignant
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Congenital neck swellings
a. Cystic
Sebaceous cyst Dermoid cyst
Branchial cyst Thyroglossal cyst
Thymic cyst
b. Solid: Ectopic thyroid
c. Vascular
Hemangioma Lymphangioma
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Inflammatory neck swellings• Lymphadenitis
– Viral
– Bacterial
– Granulomatous
• Sialadenitis
– Parotid
– Sub-mandibular
• Deep neck space abscess
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Neoplastic neck swellings
• Skin: Squamous cell Ca, Malignant melanoma
• Soft tissue:
– Benign: Lipoma, Fibroma, Schwannoma
– Malignant: Rhabdomyosarcoma
• Lymph node: Lymphoma, Metastasis
• Thyroid: Benign / Malignancy
• Vascular: Carotid body tumor, Angioma
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Hemangioma & lipoma
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Cervical Lymphadenopathy
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A. Inflammatory hyperplasia
1. Acute lymphadenitis 2. Chronic lymphadenitis
3. Granulomatous lymphadenitis
Bacterial: tuberculosis, secondary syphilis
Viral: infectious mononucleosis, AIDS
Parasitological: toxoplasmosis
Non-specific: sarcoidosis
B. Neoplastic: lymphoma, lymphosarcoma, metastatic
C. Lymphatic leukemia
D. Autoimmune: systemic lupus erythematosus
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Lymph node consistency
• Firm, rubbery: lymphoma
• Soft : infection or cold abscess
• Multiple, firm, shotty: syphilis, viral
• Matted (connected): tuberculosis , sarcoidosis,
malignant
• Rock hard, immobile, fixed to skin: metastatic
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Tuberculous lymphadenitis
• Involves upper deep cervical chain &
posterior triangle lymph nodes
• Development of peri-adenitis → matted
nodes
• Development of caseation → cold abscess
• Abscess tracking down to skin forms
subcutaneous collection → collar stud
abscess
• Abscess bursts spontaneously →
tuberculous sinus
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Tuberculous lymphadenopathy
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LymphomaMore common in children & young adults
60 - 80% children with Hodgkin’s have neck mass
Signs & symptoms:
• Fever + malaise
• Night sweats
• Weight loss
• Pruritus
• Rubbery lymph nodes
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Metastatic lymph node
• Seen in older patients
• Level 1: oral cavity
• Level 2, 3, 4: larynx, oropharynx, hypopharynx,
thyroid
• Level 5: nasopharynx
• Left supraclavicular fossa: lung, stomach, testis
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Unknown Primary Lesion (UPL)
Synonym: 1. metastasis of unknown origin
2. occult primary
Definition: metastatic lymph node with primary site
hidden or undetected
Primary malignancy sites (as per frequency):
1. Nasopharynx 2. Oropharynx (base of tongue)
3. Hypopharynx (pyriform fossa) 4. Larynx 5. Thyroid
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Investigations for UPL
1. Fibreoptic nasopharyngoscopy + laryngoscopy
2. Rigid panendoscopy
3. Excision biopsy of I/L tonsil + blind biopsy of
tongue base, pyriform fossa, fossa of Rosenmuller,
tonsilo-lingual sulcus, retro molar trigone
4. CT scan from skull base to superior mediastinum
5. Excision biopsy of metastatic lymph node
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Ranula
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Introduction
• Rana means frog (blue translucent swelling in
floor of mouth looks like underbelly of frog)
• Simple ranula: Bluish cyst located in floor of
mouth. Painless mass, does not change in size in
response to chewing, eating or swallowing
• Plunging ranula: Sub-mandibular neck swelling
with or without cyst in floor of mouth
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Simple Ranula
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Plunging ranula
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Plunging ranula
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Etiology• Simple ranula: partial obstruction or severance of
sublingual duct leads to epithelial-lined retention
cyst. Commonly traumatic.
• Plunging ranula: 1. sublingual gland projects
through or behind mylohyoid muscle
2. ectopic sublingual gland on
cervical side of mylohyoid muscle
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TreatmentMarsupialization: un-roofing of cyst & suturing of
cyst margin to adjacent tissue. Failure = 60-90%
Sclerosing agents: intra-lesional injection of
Bleomycin or OK-432
Intra-oral excision: of ranula alone (failure = 60%) or
ranula + sublingual gland (failure = 2 %)
Trans-cervical approach for plunging ranula:
complete removal of cyst + sublingual gland
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Marsupialization
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Intra-oral excision
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Ranula specimen
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Thyroglossal cyst
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Embryology• Thyroid appears as epithelial proliferation in floor
of mouth. Thyroid descends in front of pharynx
as bi-lobed diverticulum, connected to tongue by
thyroglossal duct.
• The duct normally disappears later. Thyroglossal
cysts are cystic remnant of thyroglossal duct.
• Commonest congenital anomaly of thyroid
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Location
• Cyst may lie at any point along migratory pathway
of thyroid gland
• Commonest site: sub-hyoid (50%)
• Second common site: supra-hyoid
• Other common sites: base of tongue, at level of
thyroid cartilage, sublingual
• Least common site: at level of cricoid cartilage
.
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Location
1 = base of tongue
2 = sublingual
3 = supra-hyoid
4 = sub-hyoid
5 = in front of thyroid
cartilage
6 = in front of cricoid
cartilage
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Clinical features• Commonly seen in early childhood
• Midline, round swelling, 2-4 cm in diameter
• Swelling moves up with swallowing
• Swelling moves up with protrusion of tongue
• Swelling mobile horizontally but not vertically
• Cyst increases in size with URTI
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Neck swelling moving with swallowing
• Thyroid swelling
• Thyroglossal cyst (mobile horizontally)
• Subhyoid bursitis (oval, long axis horizontal)
• Pre-laryngeal & pre-tracheal lymph nodes
• Laryngocele
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Midline neck swelling
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Ultra-sonography
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CT scan axial cut
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MRI sagittal cut
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Sistrunk’s operation
Consists of complete surgical excision of cyst &
its tract along with body of hyoid bone & core of
tongue tissue around suprahyoid tongue base up
to foramen caecum
Thyroid scan mandatory before cyst excision as
cyst may contain only functioning thyroid tissue
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Patient position & incision
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Exposure of cyst + tract
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Exposure & cutting of hyoid bone
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Removal of tongue tissue
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Removal of cyst + tract
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Complications1. Infection of cyst & abscess formation
2. Throglossal fistula 3. Malignancy (1%)
Infected cyst
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Thyroglossal fistula
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Branchial cleft cysts
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Embryology
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Branchial anomalies
• Cyst: remnant of branchial clefts or pouch without
internal or external opening
• Sinus: persistence of cleft with skin opening
• Fistula: persistence of both cleft + pouch with
openings in skin & pharynx
• Fistula tract lies caudal to structures derived from its
arch & dorsal to structures of following arch
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Branchial anomalies
• In children, fistulas are more common than
sinuses, which are more common than cysts
• In adults, cysts predominate
• Branchial cleft anomalies + biliary atresia +
congenital cardiac anomalies = Goldenhar's
complex
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First branchial cleft cyst
• Type I: Contains only ectodermal elements without
cartilage or adnexal structures. Present as
duplication of external auditory canal.
• Type II: Contains both ectoderm & mesoderm.
Present as abscess below angle of
mandible.
• Fistula ends internally around Eustachian tube
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Second branchial cleft cyst• Commonest branchial anomaly
• Painless, fluctuant mass along anterior border of
middle 1/3rd of sternocleidomastoid muscle
• Fistula tract opens externally along lower 1/3rd of
SCM, passes deep to 2nd arch structures (external
carotid, stylohyoid muscle, posterior belly of
digastric); superficial to internal carotid (3rd arch);
ends internally in tonsillar fossa
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Second branchial cleft cyst
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Second branchial cleft cyst
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• Painless, fluctuant mass along anterior border of
lower 1/3rd of sternocleidomastoid muscle
• Fistula tract opens externally along lower 1/3rd of
SCM, passes deep to 3rd arch structures (internal
carotid, glossopharyngeal nerve); superficial to
superior laryngeal nerve (4th arch): opening internally
in base of pyriform fossa
Third branchial cleft cyst
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Fourth branchial cleft cyst
• Presents as mass along anterior border of lower
1/3rd of stenomastoid or as recurrent thyroiditis
• Fistula tract opens externally along lower 1/3rd of
SCM, passes deep to 4th arch structures (superior
laryngeal nerve ); superficial to recurrent laryngeal
nerve (6th arch); opening internally in apex of
pyriform fossa
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CT scan 1st branchial cyst
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CT scan 2nd branchial cyst
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CT scan 3rd branchial cyst
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Coronal MRI Sagittal MRI Axial MRI
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Treatment
• Abscesses treated first with incision & drainage +
broad-spectrum antibiotics
• Elective surgical excision of cyst with its tract
traced up to its origin in pharyngeal wall done
after infection resolves
• Branchial fistula excised with 2 horizontally
placed incisions (stepladder incision)
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Excision of branchial cyst
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Branchial fistula excision
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Laryngocoele
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• Arises from expansion of saccule of laryngeal
ventricle due to ed intra-luminal pressure in
larynx or congenital large saccule
Causes of ed intra-luminal pressure in larynx:
• Occupational (?): trumpet players, glass blowers
• Coexistence of larynx cancer
• Male : female 5:1, Peak age = 6th decade,
Unilateral in 85 % cases, 1% contain carcinoma
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Swelling enlarges on Valsalva
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Types of laryngocoele• Internal (20%): contained entirely within endolarynx
with bulge in false vocal fold & aryepiglottic
fold
• External (30%): only neck swelling without visible
endolaryngeal swelling
• Combined (50%): Also extends into anterior triangle of
neck through foramen for superior laryngeal nerve &
vessels in thyrohyoid membrane. Dumbbell shaped.
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89
Types of laryngocoele
Internal External Combined
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Clinical Features• Hoarseness
• Stridor in large endolaryngeal laryngocoele
• Neck swelling
• Manual compression of neck swelling results in
escape of fluid / gas into airway (Boyce’s sign)
• 10% cases are pyocele: sore throat, cough
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91
Flexible laryngoscopy
▪Swelling of false vocal
folds & ary-epiglottic fold
▪Swelling easily emptied
▪Escape of purulent fluid
into airway = pyocoele
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92
X-ray neck AP view
X-ray soft tissue neck AP
view during Valsalva
maneuver shows air-
filled radiolucent
swelling
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CT scan: mixed laryngocoele
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Treatment• No symptom: no treatment
• Infected laryngocoele: aspiration & antibiotics
• Internal laryngocoele: endoscopic marsupialization
• External laryngocoele: Excision by external
approach. Cyst exposed by removing upper half of
thyroid cartilage. Cyst incised at its neck & stitched.
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Endoscopic marsupialization
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External approach
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Carotid body tumor• Pulsating, compressible mass in carotid triangle
• Mobile only horizontally not vertically
• Angiography: vascular mass b/w external &
internal carotid arteries (Lyre’s sign)
• Rx: Radiation or close observation in elderly.
Surgical resection for small tumors in young
patients with hypotensive anesthesia & pre-
operative measurement of catecholamines.
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Lyre sign
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Sternomastoid tumor of infancy
• Firm mass of SCM, becomes prominent when chin
turned away & head tilted towards the mass
• Due to birth trauma causing infarction / hematoma
with subsequent fibrotic replacement
• Rx: Physical therapy. Myoplasty of SCM for
refractory cases.
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Hypopharyngeal pouch
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Introduction• Hypopharyngeal pouch is an acquired pulsion
diverticulum caused by posterior protrusion of
mucosa through pre-existing weakness in
muscle layers of pharynx or esophagus
• In contrast, congenital diverticulum like Meckel's
diverticulum is covered by all muscle layers of
visceral wall
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Weak spots b/w muscles
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Origin of Zenker’s diverticulum
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Etiology1. Tonic spasm of cricopharyngeal sphincter:
C.N.S. injury Gastro-esophageal reflux
2. Lack of inhibition of cricopharyngeal sphincter
3. Neuromuscular in-coordination between thyro-
pharyngeus & cricopharyngeus
4. Second swallow against closed cricopharynx
These lead to increased intra-luminal pressure in
hypopharynx & mucosa bulges out via weak areas
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Clinical features1. Entrapment of food in pouch: sensation of food
sticking in throat & later dysphagia
2. Regurgitation of entrapped food: leads to foul taste
bad odor nocturnal coughing choking
3. Hoarseness: due to spillage laryngitis or sac
pressure on recurrent laryngeal nerve
4. Weight loss: due to malnutrition
5. Compressible neck swelling on left side: reduces with
a gurgling sound (Boyce sign)
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Complications
1. Lung aspiration of sac contents
2. Bleeding from sac mucosa
3. Absolute oesophageal obstruction
4. Fistula formation into:
trachea major blood vessel
5. Squamous cell carcinoma within Zenker
diverticulum (0.3% cases)
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Investigations
• Chest X-ray: may show sac + air - fluid level
• Barium swallow
• Barium swallow with video-fluoroscopy
• Rigid Oesophagoscopy
• Flexible Endoscopic Evaluation of Swallowing
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Barium swallow
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Barium swallow with Video-fluoroscopy
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Rigid Esophagoscopy
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Staging
Lahey system:
• Stage I: Small mucosal protrusion
• Stage II: Definite sac present, but hypo-pharynx
& esophagus are in line
• Stage III: Hypopharynx is in line with pouch
& esophagus pushed anteriorly
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Stage 1
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Stage 2
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Stage 3
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Surgical Treatment
1. Cricopharyngeal myotomy: combined with others
2. Diverticulum invagination: Keyart
3. Diverticulopexy: Sippy-Bevan
4. External or open Diverticulectomy: Wheeler
5. Rigid Endoscopic Diverticulotomy
Cautery (Dohlman) Laser Stapler
6. Flexible Endoscopic Diverticulotomy with Laser
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Treatment Protocol
1. Small sac (< 2cm):
Cricopharyngeal (CP) myotomy + invagination
2. Large sac (2-6 cm):
Open Diverticulectomy with CP myotomy
or Endoscopic Diverticulotomy with CP myotomy
3. Very large sac (> 6 cm):
Open Diverticulectomy with CP myotomy
or Diverticulopexy with CP myotomy
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Cricopharyngeal myotomy
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Diverticulum invagination Diverticulum pushed into hypopharynx lumen &
muscle + adjacent tissue are oversewn.
CP myotomy is usually combined with this.
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External diverticulectomy
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Endoscopic diverticulotomy
Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum
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View through diverticuloscope
Cautery, laser, or stapling device used to divide
common party wall between pouch & esophagus
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View through diverticuloscope
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Endoscopic diverticulotomy
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Dohlman’s instruments
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Diverticulopexy Sac mobilized & its fundus fixed to sternocleido-
mastoid muscle in a superior, non-dependent position. CP myotomy is also done.
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Cystic hygroma
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• Synonym: cystic lymphangioma
• Definition: congenital, benign, multi-loculated,
lymphatic lesion classically found in
posterior triangle of neck
• Other sites: axilla, mediastinum, groin & retro-
peritoneum
• Etiology: failure of lymphatics to connect to
venous system; abnormal budding of lymphatic
tissue; sequestered lymphatic cell rests
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Clinical Features
• 50-65% cases present at birth, 80-90% by 2 years
• Soft, painless, compressible trans-illuminant mass
present in posterior triangle of neck. Overlying skin
can be bluish or normal . Sudden se in size due to
infection or intra-cystic bleeding.
• Look for tracheal deviation, airway obstruction,
cyanosis, feeding difficulty, failure to thrive
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Stage Clinical Features Complication rate
Stage I U/L infrahyoid 20%
Stage II U/L suprahyoid 40%
Stage III U/L infrahyoid + suprahyoid 70%
Stage IV B/L suprahyoid 80%
Stage V B/L infrahyoid + suprahyoid 100%
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Cystic hygroma
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Investigations• USG: used to detect CH in utero
• CT scan: Contrast helps to enhance cyst wall
visualization & relationship to surrounding blood
vessels. CH appears isodense to CSF.
– Macrocystic: cystic spaces > 2 cm
– Microcystic: cystic spaces < 2 cm
• MRI: Best investigation. CH appears hyperintense
on T2 & hypointense on T1-weighted images.
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MRI: CH causing airway compression
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Treatment• Asymptomatic: 1. watchful waiting
2. sclerosing agents: OK-432 (Picibanil),
bleomycin, ethanol, doxycycline, Interferon, fibrin
sealant
• Infected cases: intravenous antibiotics & drainage;
definitive surgery after 3 months
• Surgical excision: mainstay of treatment. Done
with Cautery, Laser,
Radiofrequency
• Acute stridor: aspiration, emergency tracheostomy
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Kawasaki syndrome• Etiology: idiopathic multisystem vasculitis
• Diagnosis (presence of any 5): 1. Fever > 5 days.
2. Conjunctival injection. 3. Red / desquamated
palm / sole. 4. Injected oral cavity 5.
Polymorphous rash. 6. Cervical lymph node
enlargement
• Permanent cardiac damage in 20% untreated cases
• Rx: high dose aspirin & immunoglobulin
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135
Thank You