Neck

Question 1

Cervical rib - Definition and types

Answer 1

Definition - Extension of the anterior part of the transverse process of the C7 vertebrae >2.5cms
Types - 1) Completely bony - the entire rib id radiologically opaque and extends upto the sternum or 1st rib
2)Combined - both fibrous and bony present together
3) Fibrous - The entire rib goes radiologically undetectable
4) Partial bony - free and expanding bony mass - felt in the neck

Question 2

Pathology of cervical rib

Answer 2

1) Narrowing of the scalene triangle due to the presence of the cervical rib
2) compression of subclavian artery
3) Post-stenotic dilatation - VENTURI PHENOMENON ; which causes stasis of blood
4) thrombus or embolus formation - pain due to ischemia in the forearm and hand

Question 3

Paget - Schroeter syndrome

Answer 3

Compression of the subclavian vein by cervical rib which may cause upper limb DVT

Question 4

Clinical features of cervical rib- Vascular `

Answer 4

1) Pain - due to ischemia of the muscle
2) Upper limb claudication in forearm and arm ; more obvious after usage of the muscle
3) Tests like ROOS test, ELEVATED ARM STRESS TEST ( EAST).
4) ADSON’s test and MODIFIED ADSON’s test
5) Costoclavicular compression test ( EXAGGERATED MILLITARY TEST)
6) HALSTEAD MANOUVRE and HYPERABDUCTION MANOUVRE
7) ALLEN’s test

Question 5

Clinical features of cervical rib - neurological and features seen in the neck

Answer 5

Neurological - compression of C8 and T1 - Numbness and tingling sensation in the little finger and medial aspect of hand and forearm ; POSITIVE CARD TEST( palmar interossei) AND FROMENT’S SIGN (pen-holding test for adductor pollicis)
In the neck - may see an HARD , BONY MASS seen in the supraclavicular region and a PALPABLE THRILL in the subclavian artery and BRUIT on auscultation.

Question 6

Cervical rib - Treatment

Answer 6

1) In symptomatic patients with no compression of subclavian artery - Scalenotomy with extraperiosteal resection of the cervical rib and 1st rib .- to increase circulation in the thoracoaxillary channel and reduce compression.
2) In symptomatic patients with compression of subclavian artery- Above with subclavian artery construction with or without sympatectomy - to improve circulation in the ischemic limb

Question 7

Branchial cyst - definition

Answer 7

Persistent 2nd Branchial cleft - forms SINUS OF HIS which obliterates to form Branchial cyst
Also there is epithelial infusion with lymph node - cause for branchial cyst having lymphoid tissue

Question 8

Clinical features of branchial cyst

Answer 8

1) Swelling in the upper third of ant. border of SCM - smooth , soft , fluctuant and transilluminant
2) Gives a sensation of HALF FILLED DOUBLE WATER BOTTLE

Question 9

Histology of branchial cyst

Answer 9

1) Lined by squamous epithelial , maybe sometimes lined by columnar epithelium
2) Containes Cholesterol crystals from the the mucous membranes which are lined by sebaceous cysts
3) Cheesy toothpaste like material - typical

Question 10

Complications and treatment of branchial cyst

Answer 10

Complications - Infection leading to abscess formation and when it ruptures it may form a fistula in the upper third of SCM.
Treatment - excision under GA with care for 9,11 and 12th CN , posterior belly of digastric and pharyngeal wall.

Question 11

Cholesterol crystals is seen in

Answer 11

Branchial cyst
Hydrocele
Dentigerous cysts

Question 12

Branchial fistula - openings

Answer 12

Congenital
External opening - lower one-third of the neck in the anterior border of SCM.
The external opening appears as a dimple which becomes more prominent during dysphagia (tuck in appearance)
Internal opening - Anterior part of the posterior pillar of tonsillar fossa
It sometimes can also be a blind sac

Question 13

Structures that the branchial fistula has to pass through

Answer 13

Structures of the 2nd pharyngeal pouch (ECA and facial nerve ) and 3rd pharyngeal pouch (ICA and glossopharyngeal nerve )

Question 14

Main difference between acquired and congenital branchial fistula

Answer 14

Congenital - External orifice is in the lower third of the neck in the anterior border of SCM
Acquired - 2ndary to Branchial cyst getiing infected and ruptures to open in the upper third of the neck in the anterior border of SCM

Question 15

Treatment of branchial Fistula

Answer 15

Stain the fistula with methyl blue - Fistulectomy
Circumferential or elliptical incision around the opening of the fistula OR
Step ladder dissection

Question 16

Cystic hygroma - What is it ?

Answer 16

Cystic swelling due to sequestration of a portion of the jugular lymph sac from the lymphatic system

Question 17

Common sites of Cystic hygroma

Answer 17

Posterior triangle of the neck - most common
Axilla
Cheek
Tongue - Lymphangiogenetic macroglossia

Question 18

Variants of Cystic hygroma

Answer 18

Lymphangioma circumscripta ( <5cm)
Lymphangioma diffisale (>5cms )
Lymphangioma ad agne (reticulate pattern)

Question 19

Clinical features of Cystic hygroma

Answer 19

1) Smooth , soft , partially compressible , not reducible , fluctuant and BRILLANTLY TRANSILLUMINANT
2) Increases in size of crying
3) facial disfigurement

Question 20

Complications of Cystic hygroma

Answer 20

1) Increase in size - compression symptoms - dyspnea
2) Infected - abscess
3) Rupture of the abscess to form chylous fistula and chylothorax
4) surgery can cause torrential haemorrhage
5) recurrence

Question 21

Cystic hygroma - AKA

Answer 21

Hydroecele of the neck

Cavernous lymphangioma

Question 22

Ludwig’s angina - Risk factors

Answer 22

Oral caries 
MAlignancies oral or elsewhwhere
Chemotherapy 
Cachexia of any cause
Submandibular infection and calculi 
Chronic diseases like DM

Question 23

Ludwig’s angina - Special features

Answer 23

Brawny edema/ diffuse swelling in the submandibular or submental region
Intraoral edema
Putrid halitosis
Severe toxicity
Dyspnea / dysphagia
Septicemia , Laryngeal edema and spread to other spaces

Question 24

Treatment of Ludwig’s angina

Answer 24

iv Antibiotics
Incision - deep incision extending into the deep fascia cutting the mylohyoid muscles (from one angle of mandible to the other)

Question 25

Layers of pharynx

Answer 25

mucosa 
Submucosa 
pharyngobasilar fascia 
Muscles ( 3 constrictors , stylohyoid and palatopharyngeas)
Buccopharyngeal fascia

Question 26

Retropharyngeal abscess Acute and chronic differences

Answer 26

Acute- due to suppuration of lymph nodes ; Paramedian or eccentric swelling the posterior pharyngeal wall; Incision can be both intraoral or neck incision
Chronic - TB of cervical spine ; Midline swelling in the posterior pharyngeal wall ; Incision is always in the neck (never intraoral)

Question 27

Carotid body tumour AKA

Answer 27

Potato tumour
Chemodectoma
Non chromaffin paraganglioma

Question 28

Carotid body tumour -2 types of classification

Answer 28

A)Sporadic - most common
Familial multiple
Hyperplastic - in chronic hypoxia like in high altitutde ,COPD or congestive heart disease
B) Shamblin’s Classification:
Type 1 - Localised easily resectable
Type 2 - Adherent; Partially surrounding the carotids
Type 3 - Completely adherent; encasing the carotids

Question 29

Carotid body tumour- blood supply

Answer 29

Ascending pharyngeal artery and ECA

thro MEYER’S Ligament on the posteromedial aspect of the carotid body

Question 30

Carotid body tumour - HP findings

Answer 30

1) Pseudoalveolar pattern of cells - ZALLBALLEN type
Type1 cells - chief cells with catecholamine granules
Type 2 cells sustentacular cells without granules

Question 31

Chemoreceptors in the body

Answer 31

Carotid body
Aortic bodies in the arch of aorta
Jugular bulb in the internal jugular vein
ganglion nodosum of vagus nerve

Question 32

3 main signs in Carotid body tumour

Answer 32

Pulsatility ( transmitted pulsations as the tumor overlies the carotid artery)
Fontaine’s sign positive - mobility only from side to side but not in vertical direction
Lyre sign on angiography - due to splaying of the carotids with tumour blush

Question 33

Tuberculous lymphadenitis - Stages

Answer 33

Lymphadenitis 
Periadenitis which causes matting
Caseation and cold abscess (deep to deep fascia)
Collar stud abscess
Sinus Formation

Question 34

Important features of collar stud abscess

Answer 34

Cross fluctuation and adherent to skin

Question 35

Important features of Cold Abscess

Answer 35

Deep to deep fascia
Not adherent to skin 
No signs of inflammation - hence the name
Smooth soft non-tender and fluctuant
Contains cheesy caseating material

Question 36

Treatment of cold Abscess

Answer 36

ATT
Incision in the NON DEPENDENT PORTION of the abscess
Drainage using a wide bore needle in a ZIG-ZAG pattern to prevent the formation of sinus

Question 37

Types of Tuberculous lymphadenitis

Answer 37

Acute type - in children below 5 yrs
Caseating type - 80%
Hyperplastic type 20%
Atrophic type