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In The Name of God

In The Name of God. Congenital Neck Masses. D r. Babak Saedi otolaryngologist imam Khomeini hospital.

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In The Name of God

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  1. In The Name of God

  2. Congenital Neck Masses Dr. Babak Saedi otolaryngologist imam Khomeini hospital

  3. Neck Masses - Considerations • Age • Location • Lateral – branchial cleft cysts and laryngoceles • Midline – thyroglossal duct cyst, dermoid cyst, thymic cyst, and teratoma • Exceptions – hemangiomas and vascular malformation lesions

  4. Thyroglossal Cyst • Painless, cystic midline swelling in the region of the hyoid bone • Most common congenital midline mass • Can occur any age most common up to 12 years • F/M: 1 • Commonly at the level of the hyoid • Become symptomatic through inflammation – Pain and swelling • Moves up on swallowing and protrusion of the tongue

  5. Thyroglossal Duct Cyst Cyst is a portion of the thyroglossal duct, found at the base of the tongue that remains patent = cystic structure Ectopic thyroid tissue vs. thyroglossal duct cyst

  6. Base of tongue mass

  7. Thyroid Scan

  8. Thyroglossal Duct Cyst B-mode Ultrasound Thyroid Scan in patients that do not demonstrate a normal thyroid by US.

  9. Thyroglossal Duct Cyst • Simple Excision leads to high recurrence rate • Sistrunk Procedure • Patients at high risk for recurrence- Modified Sistrunk Procedure

  10. Dermoids and Teratomas • Developmental anomalies composed of different germ cell layers. • Isolation of pluripotent stem cells or closure of germ cell layers within points of failed embryonic fusion lines. • Classified according to composition.

  11. Dermoid Cysts • Mesoderm and Ectoderm • Midline, paramedian, painless masses that usually do not elevate with tongue protrusion. • Commonly misdiagnosed as Thyroglossal Duct Cysts. • Treatment is simple surgical excision

  12. Teratoid Cysts and Teratomas • All three germ cell layers- Endoderm, mesoderm and ectoderm. • Larger midline masses, present earlier in life. • Epignathi :most differantiated Teratoma • Surgical excision.

  13. Branchial System Six pairs of mesodermal arches separated externally by ectodermally-lined clefts and internally endodermally-lined pouches Each arch consists of a nerve, artery, muscle rudiment and cartilaginous skeleton This region develop between 3 to 7 week in fetus.

  14. Ectoderm Pharyngeal Pouches and Aortic Arch

  15. Cranial region of developing embryo 1.Arch components and floor of primordial pharynx

  16. Branchial System First Branchial arch Maxillary and mandibular (Meckel’s) process regress to leave the malleus and incus. Ossification around Meckel’s cartilage gives rise to the mandible, sphenomandibular ligament, and anterior mallear ligaments. Muscles- temporalis, masseter, pterygoids, mylohyoid, ant belly of digastric, tensor tympani, tensor veli palatini

  17. Branchial System First Branchial Cleft persists as the external auditory canal, and tympanic membrane First Branchial Arch Nerve- 5th cranial nerve Artery- maxillary artery First Branchial Pouch persists as the Eustachian tube, middle ear, portions of the mastoid bone.

  18. Pharyngeal Arches. Second arch growing over the third and fourth arch

  19. Branchial System Second Branchial Cleft: Cervical sinus of His Second Branchial Arch Reichert’s cartilage contributes to the superstructure of the stapes, the upper body and lesser cornu of the hyoid, the styloid process and stylohyoid ligament. Muscles- platysma, muscles of facial expression, posterior belly of digastric, stylohyoid, and stapedius Nerve- 7th cranial nerve Artery- stapedial artery

  20. Branchial System Third Branchial Cleft: Cervical sinus of His Third Branchial Arch Lower body of the hyoid and greater cornu. Muscles- stylopharyngeus, superior and middle pharyngeal constrictors. Nerve- 9th cranial nerve Artery- common carotid and proximal portions of the internal and external carotid. Third Branchial Pouch Inferior parathyroids Thymus gland and thymic duct

  21. Branchial System Fourth Cleft: Cervical sinus of His Fourth Arch Muscles- cricothyroid, inferior pharyngeal constrictors Nerve- Superior Laryngeal Nerve Artery- Right Subclavian, Aortic arch Fourth Pouch- superior parathyroid glands and parafollicular thyroid cells Fourth and Sixth Branchial arches fuse to form the laryngeal cartilages.

  22. Branchial System Sixth Branchial Arch Muscles- remaining laryngeal musculature Nerve- Recurrent Laryngeal Nerve Artery- Pulmonary Artery and ductus arteriosus

  23. First Branchial Cleft Cysts • Type I • Ectodermal duplication anomaly of the EAC with squamous epithelium only • Fistulous tracts near the lower portion of the parotid gland • Parallel to the EAC • Pretragal/ postauricular sulcus • Surgical Excision

  24. First Branchial Cleft Cysts Type II Represents anomalous EAC and rudimentary pinna (epithelium, mesoderm) Cyst/ tract below angle of mandible and through the parotid in variable position to CN VII Tract runs from the neck to the EAC or middle ear Surgical excision- superficial parotidectomy

  25. Second Branchial Cleft Cysts Most Common (90%) branchial anomaly – failure of obliteration of cervical sinus of His Painless, fluctuant mass in anterior triangle Can occur at carotid bifurcation or parapharyngeal space Inferior-middle 2/3 junction of SCM, deep to platysma, lateral to IX, X, XII, between the internal and external carotid and terminate in the tonsillar fossa Surgical treatment may include tonsillectomy

  26. Second Branchial Cleft Cysts and Fistula

  27. Third Branchial Cleft Cysts • Patients present with recurrent infections of the lower lateral neck • Masses low in the anterior neck, more often on the left side • Sinus tract starting at the piriform fossa, through the thyrohyoid membrane, tracking under CN XII and carotid, but anterior to CN X • Often track through the upper pole of the thyroid

  28. Lymphangioma • Microcystic and macrocystic • Large, soft, compressible masses • 60% presenting in 1st year, 90% by three years of age • Type I and Type II • Anterior/OC/FOM vs. Posterior triangle • 40% presenting with airway compromise • Centrifugal vs. Centripetal theory • MRI • Spontaneous regression is rare (8-15%) and surgical excision is the treatment of choice. • Recurrence is 10-52%

  29. Lymphangioma

  30. Vascular Lesions - Classification • Mulliken and Glowacki: simple biologic classification • Hemangiomas and vascular malformations • Hemangioma: not evident at birth, rapid endothelial proliferation followed by slow involution. • Vascular malformation: present at birth, normal rate of endothelial turnover, lesion grows with the child, progressive dilation of vessels

  31. Most common pediatric tumor. Rapid proliferation of endothelium, slow progressive involution. Less than 33% present at birth 90% of lesion involute CT w/ contrast or MRI w/ Gadolinium. If associated w/ stridor, must rule out subglottic hemangioma. Kasabach-Merritt syndrome relation? Hemangiomas

  32. Vascular malformations • Nevus flammeus vs. port wine stain • Sturge-Weber Syndrome • Venous Malformations • Lips and cheeks • Expand with jugular venous congestion • Intraosseous “soap bubble” appearance • AVM • High flow – CHF • Thrill/bruit • Pain, ulceration, bleeding and pulsatile tinnitus

  33. Fibromatosis colli • Torticollis with firm mass on the SCM • Noted at birth or within 1st few weeks • Inflammatory lesion of unknown etiology with muscle replacement by fibrosis • Range of motion exercises • Myoplasty of the SCM only if refractory to PT

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