Neck Flashcards
To learn the characteristics of different swellings in the neck - Surgery
Cervical rib - Definition and types
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
Pathology of cervical rib
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
Paget - Schroeter syndrome
Compression of the subclavian vein by cervical rib which may cause upper limb DVT
Clinical features of cervical rib- Vascular `
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
Clinical features of cervical rib - neurological and features seen in the neck
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.
Cervical rib - Treatment
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
Branchial cyst - definition
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
Clinical features of branchial cyst
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
Histology of branchial cyst
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
Complications and treatment of branchial cyst
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.
Cholesterol crystals is seen in
Branchial cyst
Hydrocele
Dentigerous cysts
Branchial fistula - openings
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
Structures that the branchial fistula has to pass through
Structures of the 2nd pharyngeal pouch (ECA and facial nerve ) and 3rd pharyngeal pouch (ICA and glossopharyngeal nerve )
Main difference between acquired and congenital branchial fistula
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
Treatment of branchial Fistula
Stain the fistula with methyl blue - Fistulectomy
Circumferential or elliptical incision around the opening of the fistula OR
Step ladder dissection
Cystic hygroma - What is it ?
Cystic swelling due to sequestration of a portion of the jugular lymph sac from the lymphatic system
Common sites of Cystic hygroma
Posterior triangle of the neck - most common
Axilla
Cheek
Tongue - Lymphangiogenetic macroglossia
Variants of Cystic hygroma
Lymphangioma circumscripta ( <5cm) Lymphangioma diffisale (>5cms ) Lymphangioma ad agne (reticulate pattern)
Clinical features of Cystic hygroma
1) Smooth , soft , partially compressible , not reducible , fluctuant and BRILLANTLY TRANSILLUMINANT
2) Increases in size of crying
3) facial disfigurement
Complications of Cystic hygroma
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
Cystic hygroma - AKA
Hydroecele of the neck
Cavernous lymphangioma
Ludwig’s angina - Risk factors
Oral caries MAlignancies oral or elsewhwhere Chemotherapy Cachexia of any cause Submandibular infection and calculi Chronic diseases like DM
Ludwig’s angina - Special features
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
Treatment of Ludwig’s angina
iv Antibiotics
Incision - deep incision extending into the deep fascia cutting the mylohyoid muscles (from one angle of mandible to the other)
