Lateral Neck Swellings: Diagnostic and Therapeutic Challenges

Preface
Acknowledgment
Contents
1: Surgical Anatomy of the Neck
1.1 Muscles of the Neck
1.2 The Anterior Triangle of the Neck
1.2.1 Boundaries
1.2.2 Subdivisions
1.2.3 Contents
1.2.4 Tissue Planes and Fasciae of the Anterior Triangle [4]
1.2.4.1 The Skin and Superficial Fascia
1.2.4.2 The Investing Layer of the Deep Cervical Fascia
1.2.4.3 The Prevertebral Fascia
1.3 The Submental Triangle
1.3.1 Boundaries
1.3.2 Contents
1.3.3 Clinical Significance
1.4 The Carotid Triangle
1.4.1 Boundaries
1.4.2 Contents
1.4.2.1 Arteries
1.4.2.2 Veins
1.4.2.3 Nerves
1.4.3 Clinical Significance
1.4.4 A Triangle Within the Carotid Triangle: Farabeuf’s Triangle
1.5 The Muscular Triangle
1.5.1 Boundaries
1.5.2 Contents
1.5.3 Clinical Significance
1.6 The Submandibular Triangle
1.6.1 Introduction
1.6.2 Boundaries
1.6.3 Contents
1.6.4 Basic Anatomy
1.6.4.1 Superficial Plane of the Submandibular Triangle
1.6.4.2 The Submandibular Space [1]
1.6.4.3 The Floor of the Submandibular Triangle
1.6.4.4 Lymphatic Drainage
1.6.5 Clinical Significance
1.6.5.1 Submandibular Gland Excision (Sialadenectomy)
1.6.5.2 Soft Tissue Space Infection
1.6.5.3 Submandibular Masses
1.6.6 Triangles Within the Submandibular Triangle
1.6.6.1 Lesser’s Triangle (The Lingual Triangle)
1.6.6.2 Pirogov’s Triangle
1.6.6.3 Béclard’s Triangle
1.7 The Posterior Triangle of the Neck
1.7.1 Boundaries
1.7.2 Subdivisions
1.7.3 Contents
1.7.4 Important Features of Some of the Contents
1.7.4.1 Nerves [25]
The Spinal Accessory Nerve (SAN)
Four Cutaneous Branches of the Cervical Plexus [28]
Muscular Branches Attached to the Levator Scapulae and Trapezius Muscles (C3 and C4)
The Nerve to the Rhomboids
The Phrenic Nerve
The Cervical Part of the Brachial Plexus
1.7.4.2 Blood Vessels
The Transverse Cervical Artery
The Suprascapular Artery
The Dorsal Scapular Artery
The Occipital Artery
The Subclavian Artery and Vein
The Terminal Part of the External Jugular Vein (EJV)
1.7.4.3 Lymph Nodes (LNs)
1.7.5 The Roof of the Posterior Triangle
1.7.5.1 The Skin, Platysma, and Fascia
1.7.6 The Floor of the Posterior Triangle
1.7.6.1 Muscles Forming the Floor of the Posterior Triangle
1.7.6.2 Fascial Carpeting of the Posterior Triangle
1.7.7 Clinical Significance
1.7.8 The First Rib
1.8 The Occipital Triangle
1.8.1 Borders
1.8.2 The Main Contents
1.9 The Subclavian (Supraclavicular) Triangle
1.9.1 Borders
1.9.2 The Main Contents
1.10 Other Triangles of the Neck
1.10.1 The Suboccipital Triangle
1.10.1.1 Boundaries
1.10.1.2 Contents
1.10.1.3 Clinical Significance
1.10.2 The Triangle of the Vertebral Artery
1.10.2.1 Boundaries
1.10.2.2 Contents
1.10.2.3 Clinical Significance
1.10.3 The Scalene Triangle
1.10.3.1 Boundaries
1.10.3.2 Contents
1.10.3.3 Clinical Significance
1.11 Surgical Levels of the Neck
1.11.1 Surgical Anatomy of the Suprahyoid Area (Level I)
1.11.2 Surgical Anatomy of the Upper Neck (Levels II and III)
1.11.3 Surgical Anatomy of the Inferior Neck (Level IV)
1.11.4 Surgical Anatomy of the Lateral Neck (The Posterior Triangle) (Level V)
1.11.4.1 Exposure of the Posterior Triangle [52]
1.11.4.2 Exposure of the Vagus Nerve
1.11.5 Surgical Anatomy of the Central Neck (Level VI)
1.12 Important Triangles in Thyroid Surgery
1.12.1 Beahrs’ Triangle (Riddle’s Triangle)
1.12.2 Simon’s Triangle
1.12.3 Lore’s Triangle
1.12.4 The Recurrent Laryngeal Nerve (RLN) Triangle
1.12.5 Joll’s Triangle
1.12.6 The Cricothyroid Space of Reeve’s
1.12.7 The Triangle of Concern
References
2: Neck Swellings: Classification and Clinical Approach
2.1 Introduction
2.2 Classification of Lateral Neck Swellings
2.3 History-Taking
2.4 Clinical Examination
2.4.1 General/Targeted Examination
2.4.2 Local Examination of the Swelling
2.4.2.1 Stand-Alone Suspicious Physical Examination (Table 2.5)
2.4.2.2 Additional Suspicious Signs and Symptoms (Table 2.6)
History-Taking
Physical Examination
2.5 Investigations
2.5.1 Computed Tomography (CT) Scan of the Neck with Contrast
2.5.2 Magnetic Resonance Imaging (MRI) of the Neck with Contrast
2.5.3 Ultrasonography (US)
2.5.4 Computed Tomography Angiography or Magnetic Resonance Angiography
2.5.5 Chest X-Rays
2.5.6 Positron Emission Tomography with Computed Tomography (PET/CT)
2.5.7 Panendoscopy
2.5.8 Fine Needle Aspiration (FNA)
2.5.9 Core Biopsies
2.5.10 Open Biopsies
2.5.10.1 Examination Under Anesthesia (EUA) of the Upper Aerodigestive Tract Before an Open Biopsy
2.5.10.2 The Open Biopsy Procedure
2.5.11 Ancillary Investigations
2.6 Differential Diagnosis
References
3: Solid Swellings of the Anterior Triangle: Cervical Lymphadenopathy
3.1 Introduction
3.2 Anatomical Considerations
3.2.1 Lymphatic Drainage of the Superficial Tissues of the Head and Neck
3.2.2 Lymphatic Drainage of the Deep Tissues of the Head and Neck (DCLNs)
3.2.3 Delineation of Cervical Lymph Node Levels (Fig. 3.2)
3.2.3.1 Level IA (The Submental Region)
3.2.3.2 Level IB (The Submandibular Region)
3.2.3.3 Levels IIA and IIB (The Upper Jugular Group)
3.2.3.4 Level III (The Middle Jugular Group)
3.2.3.5 Level IV (The Lower Jugular Group)
3.2.3.6 Levels VA and VB (The Posterior Triangle Group)
3.2.3.7 Level VI (The Central Compartment Group)
3.3 Classification/Etiology
3.4 Infections
3.5 Acute Bacterial Infections
3.6 Acute Viral Adenitis
3.6.1 Infectious Mononucleosis (IMN)
3.7 Chronic Nonspecific Infectious Lymphadenitis
3.8 Chronic Specific Infectious Lymphadenitis
3.8.1 Tuberculous (Mycobacterial) Lymphadenitis
3.8.1.1 Epidemiology
3.8.1.2 Pathophysiology
3.8.1.3 Etiology
3.8.1.4 Mode of Infection/Pathogenesis
3.8.1.5 Pathological Types of Tuberculous Lymphadenitis
3.8.1.6 Clinical Manifestations
3.8.1.7 Primary Diagnostic Studies
Culture/Polymerase Chain Reaction (PCR)
Excisional Biopsies
Fine Needle Aspiration (FNA)
Nucleic Acid Amplification Tests (NAATs)
The GeneXpert Test
3.8.1.8 Ancillary Diagnostic Tests
The Tuberculin Skin Test (TST)
Interferon-Gamma Release Assays (IGRAs)
Chest Radiography
Ultrasonography (US)
Computed Tomography (CT) Scan and Magnetic Resonance Imaging (MRI)
Laboratory Studies
3.8.1.9 Differential Diagnosis
3.8.1.10 Treatment of Tuberculous Lymphadenitis
Medical Treatment
Antibiotic Therapy
Steroid Therapy
Adjuvant Immunotherapy
Surgical Treatment
Further Outpatient Care
3.8.1.11 Complications
3.8.1.12 Prognosis
3.9 Syphilis (Syphilitic Lymphadenitis)
3.9.1 Epidemiology
3.9.2 Clinical Course
3.9.2.1 Primary Syphilis
3.9.2.2 Secondary Syphilis
3.9.2.3 The Latent Phase
3.9.2.4 Tertiary Syphilis
3.9.3 Diagnosis
3.9.3.1 Definite Diagnosis by Direct Detection
3.9.3.2 Diagnosis Using Serology
3.9.3.3 Diagnosis Using Histopathology
3.9.4 Management
3.9.4.1 Penicillin
3.9.4.2 Second-Line Treatments
3.10 Cat Scratch Disease (CSD)
3.10.1 Synonyms
3.10.2 An Overview
3.10.3 A Historical Review
3.10.4 Epidemiology
3.10.5 Cause/Transmission
3.10.6 Clinical Picture
3.10.7 Diagnosis
3.10.8 Differential Diagnosis
3.10.9 Prevention
3.10.10 Treatment
3.11 Toxoplasmosis (Parasitic)
3.11.1 History
3.11.2 Epidemiology
3.11.3 Transmission
3.11.4 Clinical Picture
3.11.4.1 The Acute Stage
3.11.4.2 The Latent Stage
3.11.4.3 The Skin Stage
3.11.5 Diagnosis
3.11.6 Prevention
3.11.7 Treatment
3.11.7.1 Acute Toxoplasmosis
3.11.7.2 Latent Toxoplasmosis
3.12 Malignancy
3.12.1 Regional Lymph Nodes: TNM (Tumor, Node, and Metastasis) Staging
3.13 Metastatic Lymphadenopathy
3.13.1 Lymph Node Metastases from Cervical Draining Areas (Overt Primary)
3.13.1.1 Pathophysiological Lymphatic Spread of Tumor Cells
3.13.1.2 Primary Sites: Patterns of Drainage and Treatment
3.13.2 Cervical Lymph Node Metastases from Remote Primary
3.13.2.1 Pathogenesis/Lymphatic Drainage
3.13.2.2 Remote Primary Sites
3.13.2.3 Investigations and Identification
3.13.2.4 Management
3.13.3 Cervical Lymph Node Metastases of an Unknown Primary
3.13.3.1 Epidemiology
3.13.3.2 Patient History and Examination
3.13.3.3 Investigations
Fine Needle Aspiration Biopsies (FNABs)
Immunohistochemistry (IHC)
Imaging
Panendoscopy with Biopsies
Molecular Studies
3.13.3.4 Treatment
3.13.3.5 Prognosis
3.14 Lymphoma
3.14.1 History
3.14.2 Epidemiology
3.14.3 Clinical Presentation
3.14.4 Diagnosis
3.14.5 Risk Factors
3.14.6 Classification
3.14.6.1 Hodgkin’s Lymphoma (HL)
3.14.6.2 Non-Hodgkin’s Lymphoma (NHL)
3.14.6.3 Epstein–Barr Virus-Associated Lymphoproliferative Diseases
3.14.6.4 The WHO Classification
3.14.7 Diagnosis/Staging
3.14.8 Treatment
3.14.9 Prognosis
3.15 Leukemia (Chronic Lymphocytic Leukemia (CLL))
3.15.1 Risk Factors
3.15.2 Epidemiology
3.15.3 Clinical Presentation
3.15.4 Diagnosis/Investigations
3.15.4.1 Hematological Tests
3.15.4.2 Flow Cytometry and Cytochemistry
3.15.4.3 Genomic and Molecular Testing [352, 353]
3.15.4.4 Imaging Studies
3.15.4.5 Bone Marrow Aspiration and Biopsy
3.15.5 Staging
3.15.5.1 The Rai Staging System
3.15.5.2 Binet Classification
3.15.6 Treatment
3.15.7 Prognosis
3.15.7.1 Adverse Prognostic Factors
3.15.7.2 Favorable Prognostic Factors
3.16 Autoimmune Diseases
3.16.1 Rheumatoid Arthritis (RA)
3.16.2 Systemic Lupus Erythematosus (SLE)
3.16.3 Kikuchi–Fujimoto Disease (KFD)
3.17 Endocrine Diseases
3.18 Lipid Storage Disorders
3.18.1 Gaucher’s Disease (GD)
3.18.2 Niemann–Pick Disease (NPD)
3.19 Drug-Induced Lymphadenopathy
3.20 Miscellaneous Causes of Cervical Lymphadenopathy
3.20.1 Kawasaki Disease (KD)
3.20.2 Sarcoidosis (Boeck’s Sarcoid, Besnier–Boeck–Schaumann Disease)
3.20.3 Histiocytosis X (Langerhans Cell Histiocytosis (LCH))
3.20.4 Nomenclature
3.20.5 Prevalence
3.20.6 Classification
3.20.6.1 The Unifocal Form
3.20.6.2 The Multifocal Uni-System Form
3.20.6.3 The Multifocal Multisystem Form
3.20.6.4 Pulmonary Langerhans Cell Histiocytosis (PLCH)
3.20.7 Pathophysiology
3.20.8 Clinical Presentation
3.20.9 Diagnosis
3.20.10 Treatment
3.20.11 Prognosis
3.21 Castleman Disease
3.21.1 Classification/Treatment
3.21.1.1 Unicentric Castleman Disease (UCD)
3.21.1.2 Idiopathic Multicentric Castleman Disease (iMCD)
3.21.1.3 Human Herpesvirus 8-Associated Multicentric Castleman Disease
3.21.1.4 TAFRO (Thrombocytopenia, Ascites, Myelofibrosis, Renal Dysfunction, and Organomegaly) Syndrome
3.21.2 Pathological Variants
3.22 Kimura’s Disease
3.22.1 A Historical Review
3.22.2 Etiology/Pathophysiology
3.22.3 Clinical Presentation
3.22.4 Diagnosis
3.22.5 Treatment
3.22.5.1 Medical Therapy
3.22.5.2 Radiotherapy
3.22.5.3 Surgery
3.23 Rosai–Dorfman Disease (RDD)
3.23.1 A Review
3.23.2 Pathophysiology
3.23.3 Clinical Presentation
3.23.4 Investigations
3.23.4.1 Laboratory Findings
3.23.4.2 Fine Needle Aspiration (FNA)
3.23.4.3 Excision Biopsies
Gross Appearance
The Microscopic Picture
3.23.4.4 Ancillary Studies
3.23.5 Differential Diagnosis
3.23.5.1 Nodal Disease
3.23.5.2 Extra-Nodal Disease
3.23.6 Treatment
3.24 Cervical Lymphadenopathy: A Diagnostic Approach
3.24.1 History-Taking
3.24.2 Physical Examination
3.24.3 Investigations
3.24.3.1 Imaging Modalities
Ultrasonography (US)
Computed Tomography (CT) Scan and Magnetic Resonance Imaging (MRI)
Other Imaging Modalities
3.24.3.2 Biopsies
Fine Needle Aspiration (FNA)
Core Needle Biopsies
Excisional Biopsies
Certain Pathogens Cause Typical Findings
3.24.3.3 Endoscopy
3.24.4 Differential Diagnosis
References
4: Solid Swellings of the Anterior Triangle: Solitary Thyroid Nodules
4.1 Definition
4.2 Epidemiology
4.3 Etiology
4.4 Pathological Classification
4.4.1 Benign Thyroid Nodules
4.4.1.1 Thyroid Adenomas
Follicular Adenomas
Papillary Adenomas
4.4.1.2 Hyperplastic Nodules
4.4.1.3 Solitary Toxic Nodules
4.4.1.4 Congenital Thyroid Nodules
4.4.1.5 Thyroiditis
Hashimoto’s Thyroiditis
Other Forms of Thyroiditis
4.4.2 Malignant Thyroid Nodules
4.4.2.1 Papillary Thyroid Carcinomas (PTCs)
4.4.2.2 Follicular Thyroid Carcinomas (FTCs)
4.4.2.3 Hurthle Cell Carcinomas (HCCs)
4.4.2.4 Medullary Thyroid Carcinomas (MTCs)
4.4.2.5 Anaplastic Thyroid Carcinomas (ATCs)
4.4.2.6 Poorly Differentiated Thyroid Carcinomas (PDTCs) (Insular Carcinomas)
4.4.2.7 Thyroid Lymphomas
4.4.2.8 Metastatic Thyroid Lesions
4.5 Clinical Features
4.5.1 Benign Versus Malignant Nodules
4.5.2 Endocrinal Dysfunction
4.5.3 Nerve Involvement
4.6 Diagnosis/Clinical Approach
4.7 History-Taking: Risk Factors
4.7.1 Age
4.7.2 Gender
4.7.3 Radiation Exposure
4.7.4 Time Course
4.7.5 Symptoms of Local Infiltration or Spread
4.7.6 Thyroid Dysfunction
4.7.7 Medical History
4.7.8 Family History
4.7.9 Alkylating Agents, Alcohol, and Tobacco
4.8 Physical Examination: Risk Factors
4.8.1 Physical Characteristics of Thyroid Nodules
4.8.2 Cervical Lymph Nodes (LNs) (Regional Lymphadenopathy)
4.8.3 General Examination
4.9 Investigations
4.9.1 Laboratory Studies
4.9.1.1 Thyroid Function Tests (TFTs)
4.9.1.2 Serum Thyroglobulin (Tg)
4.9.1.3 Serum Calcitonin
4.9.1.4 Carcinoembryonic Antigen (CEA)
4.9.1.5 DNA Testing
4.9.1.6 Complete Blood Count and Serum Calcium Levels
4.9.1.7 Follow-Up Tests
4.9.2 Imaging Studies
4.9.2.1 Ultrasonography (US)
4.9.2.2 Doppler Scanning
4.9.2.3 Ultrasound Elastography (Elasto-Sonography)
4.9.2.4 Radionuclide Imaging (Thyroid Scintigraphy)
4.9.2.5 Computed Tomography (CT) Scan and Magnetic Resonance Imaging (MRI)
4.9.2.6 Plain Chest Radiography
4.9.2.7 Positron Emission Tomography (PET)
4.9.3 Biopsy (Cytology/Histology)
4.9.3.1 Fine Needle Aspiration (FNA): Free-Hand or US-Guided
4.9.3.2 Large Needle Biopsies (LNBs) and Core Needle Biopsies (CNBs)
4.9.3.3 Intraoperative Frozen Section Biopsy
4.10 Staging of a Malignant Thyroid Nodule
4.10.1 Well-Differentiated Thyroid Carcinomas (WDTCs)
4.10.2 Anaplastic Thyroid Carcinomas (ATCs)
4.10.3 Medullary Thyroid Cancer (MTC)
4.11 Management
4.11.1 Clinically Non-Palpable Incidental Nodule <1 cm (Incidentaloma)
4.11.2 Benign Simple Nodules
4.11.2.1 Surgery (Hemithyroidectomy)
4.11.2.2 Observation
4.11.2.3 Levothyroxine (L-T4)
4.11.2.4 Ultrasound-Guided Minimally Invasive Procedures
Percutaneous Ethanol Injection (PEI)
Thermal Ablation
Radio-Frequency Ablation (RFA)
US-Guided Thermal Ablation with Laser
4.11.3 Benign Toxic Nodules
4.11.3.1 Observation
4.11.3.2 Surgical Treatment
4.11.3.3 Radioactive Iodine (RAI)
4.11.3.4 Other Therapeutic Options
Antithyroid Drugs (ATDs)
Percutaneous Ethanol Injection (PEI)
4.11.4 Indeterminate Nodules (Follicular or Hurthle Cell Neoplasms)
4.11.4.1 Definite Diagnosis
4.11.4.2 Surgical Treatment
4.11.5 Suspicious Nodules
4.11.6 Malignant Nodules
4.11.6.1 Treatment of Well-Differentiated Thyroid Cancers (WDTCs)
Treatment of Papillary Thyroid Cancer (PTC)
Total Thyroidectomy (TT)
Hemithyroidectomy
Lymph Node Dissection
Treatment of Follicular Thyroid Cancer (FTC)
Role of Radioactive Iodine (RAI) in DTC
4.11.6.2 Treatment of Oncocytic (Hurthle Cell) Thyroid Cancer
4.11.6.3 Treatment of Medullary Thyroid Carcinomas (MTCs)
4.11.6.4 Treatment of Anaplastic Thyroid Carcinomas (ATCs)
4.11.6.5 Treatment of Metastatic Thyroid Cancer
Treatment of Pulmonary Metastases
Radioactive Iodine (RAI) Treatment of Bone Metastases
Treatment of Brain Metastases
4.11.6.6 Follow-Up and Further Care of Patients with a Malignant STN
4.11.6.7 Management Algorithm of STNs
4.12 Prognosis
4.12.1 Age
4.12.2 Gender
4.12.3 Histological Findings
4.12.4 Genetic Markers
4.12.5 Other Risk Factors
4.12.6 Operative Morbidity
4.12.7 Consequences of Hypothyroidism in Children
References
5: Solid Swellings of the Anterior Triangle: Parotid Tail Swelling
5.1 Evaluation of Parotid Swelling
5.1.1 Clinical Evaluation
5.1.1.1 History-Taking
5.1.1.2 Physical Examination
Inspection
Palpation
Auscultation
5.1.2 Imaging Studies
5.1.2.1 Sialography
5.1.2.2 Ultrasonography (US)
5.1.2.3 Computed Tomography (CT) Scanning
5.1.2.4 Magnetic Resonance Imaging (MRI)
5.1.2.5 An Algorithm for Imaging
5.1.3 Biopsies (Cytology/Histology)
5.1.3.1 Fine Needle Aspiration Cytology (FNAC)
5.1.3.2 Ultrasound Core Biopsies (USCBs)
5.1.3.3 Intraoperative Frozen Sections (IOFSs)
5.2 Tumors of the Parotid Gland
5.2.1 Benign Tumors (BTs)
5.2.1.1 Pleomorphic Adenomas (PAs) (Mixed Salivary Tumors)
5.2.1.2 Warthin’s Tumors (Adenolymphomas)
5.2.1.3 Other Benign Tumors of the Parotid Gland
Basal Cell Adenomas (BCAs)
5.2.1.4 Canalicular Adenomas
Myoepitheliomas
Cystadenomas
5.2.2 Malignant Tumors (MTs)
5.2.2.1 Mucoepidermoid Carcinomas (MECs)
5.2.2.2 Adenoid Cystic Carcinomas (ACCs) (Previously Known as Cylindromas)
5.2.2.3 Carcinoma Ex Pleomorphic Adenomas (CEPAs)
5.2.2.4 True Malignant Mixed Tumors
5.2.2.5 Acinic Cell Carcinomas
5.2.2.6 Basal Cell Adenocarcinomas
5.2.2.7 Myoepithelial Carcinomas (Malignant Myoepitheliomas)
5.2.2.8 Cystadenocarcinomas
5.3 Parotidectomy
5.3.1 Superficial Parotidectomy
5.3.1.1 Steps of the Procedure
5.3.1.2 Complications
5.3.2 Total Parotidectomy
5.3.3 Extended Total Parotidectomy
References
6: Solid Swellings of the Anterior Triangle: A Submandibular Gland Swelling
6.1 Clinical Evaluation
6.1.1 History-Taking
6.1.2 Physical Examination
6.1.2.1 Extraoral Examination
Extraoral Inspection
Extraoral Palpation
6.1.2.2 Intraoral Examination
Intraoral Inspection
Intraoral Palpation
6.1.2.3 Bimanual Examination
6.1.3 Imaging Studies
6.1.3.1 Plain-Film Radiographs
6.1.3.2 Sialography
6.1.3.3 Computed Tomography (CT) Scanning
6.1.3.4 Magnetic Resonance Imaging (MRI)
6.1.4 Endoscopic Examination (Sialendoscopy)
6.1.5 Biopsies
6.2 Submandibular Sialadenitis/Sialadenosis
6.2.1 Acute Submandibular Sialadenitis
6.2.1.1 Etiology
6.2.1.2 Clinical Picture
6.2.1.3 Workup of the Patient
6.2.1.4 Treatment
Medical Management
Surgical Management
6.2.1.5 Prognosis
6.2.2 Chronic Submandibular Sialadenitis/Sialolithiasis
6.2.2.1 Chronic Sialadenitis
Papillary Stenosis
Sialolithiasis
6.2.2.2 Clinical Picture
6.2.2.3 Investigations
6.2.2.4 Treatment
6.2.3 Autoimmune Sialadenitis
6.2.3.1 Sjögren’s Syndrome
6.2.3.2 Mikulicz’s Disease/Syndrome
6.2.4 Sialadenosis
6.3 Tumors of the Submandibular Gland
6.3.1 Pathological Classification
6.3.1.1 Benign Tumors (BTs)
6.3.1.2 Malignant Tumors (MTs)
Adenoid Cystic Carcinomas (ACCs)
Mucoepidermoid Carcinomas (MECs)
Squamous Cell Carcinomas (SCCs)
Adenocarcinomas
6.3.2 Clinical Presentation
6.3.3 Differential Diagnosis
6.3.4 Diagnostic Imaging
6.3.4.1 Plain Radiographs, Sialography, and Nuclear Scans
6.3.4.2 Ultrasonography (US)
6.3.4.3 Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
6.3.5 Cytopathology
6.3.5.1 Fine Needle Aspiration Cytology (FNAC)
6.3.6 Patterns of Spread
6.3.7 Management
6.3.7.1 Benign Tumors
6.3.7.2 Malignant Tumors
Resectable Tumors
Advanced Non-Resectable Tumors
Management of the Neck
6.3.7.3 Chemotherapy
6.3.8 Prognosis
6.4 Submandibular Sialoadenectomy
6.4.1 Steps of the Procedure
6.4.2 Postoperative Complications
References
7: Solid Swellings of the Anterior Triangle: Carotid Body Tumors
7.1 An Overview
7.1.1 Definition
7.1.2 Synonyms
7.1.3 The Site of Origin
7.1.3.1 Head and Neck Paragangliomas (HNPGLs)
7.1.3.2 The Organ of Zuckerkandl
7.1.3.3 Pulmonary Paragangliomas
7.1.3.4 Other Sites
7.1.4 Classification
7.2 Natural History
7.3 Epidemiology
7.4 Pathology
7.5 Etiology/Genetics
7.6 Clinical Picture
7.6.1 Malignant Carotid Body Tumors
7.7 Investigations/Workup
7.7.1 Duplex US Scanning
7.7.2 Magnetic Resonance Imaging (MRI)
7.7.3 Computed Tomography (CT) Scanning
7.7.4 Carotid Arteriography
7.7.5 Meta-Iodobenzyl Guanidine Scintigraphy
7.8 Differential Diagnosis
7.9 Treatment
7.9.1 Surgical Treatment
7.9.1.1 Preoperative Embolization
7.9.1.2 Intraoperative Details
7.9.1.3 Postoperative Care
7.9.1.4 Follow-Up
7.9.1.5 Complications
Vascular Complications
Nerve Complications
7.9.2 Radiotherapy
References
8: Solid Swellings of the Anterior Triangle: Schwannomas
8.1 Origin and Epidemiology
8.2 Genetic Syndromes
8.2.1 Neurofibromatosis Type 2 (NF2)
8.2.2 Schwannomatosis
8.2.3 Carney’s Complex
8.3 Pathological Features
8.3.1 Gross Appearance
8.3.2 Histopathological Appearance
8.3.2.1 Cellular Schwannomas
8.3.2.2 Plexiform Schwannomas
8.3.2.3 Melanotic Schwannomas
8.4 Clinical Presentation
8.5 Diagnosis
8.5.1 Imaging Studies
8.5.1.1 Computed Tomography (CT) Scanning
8.5.1.2 Magnetic Resonance Imaging (MRI)
8.5.2 Cytology/Histology
8.5.2.1 Fine Needle Aspiration Cytology (FNAC)
8.5.2.2 Tissue Biopsies
8.5.3 Differential Diagnosis
8.6 Treatment
8.6.1 Surgery/Management of Resectable Schwannomas
8.6.2 Management of Unresectable Schwannomas
8.6.2.1 Radiotherapy (RT)
8.6.2.2 Pharmacotherapy
8.6.2.3 Watchful Waiting (Wait and Scan)
8.7 Prognosis
References
9: Solid Swellings of the Anterior Triangle: Sternocleidomastoid (SCM) Tumors
9.1 Synonyms/Definition
9.1.1 Synonyms
9.1.2 Definition
9.2 Etiology/Pathogenesis
9.2.1 Ischemic Theory
9.2.2 Traumatic Theory
9.2.3 Compartment Syndrome
9.2.4 Developmental Anomaly
9.3 Pathology
9.4 Clinical Picture
9.5 Diagnosis/Differential Diagnosis
9.5.1 Diagnosis
9.5.1.1 Imaging Studies
9.5.1.2 Cytology/Histology
9.5.2 Differential Diagnosis
9.6 Treatment
9.6.1 Conservative Treatment
9.6.1.1 Active Home Stimulation Program
9.6.1.2 Targeted Physiotherapy
9.6.1.3 Other Physical Treatments
9.6.1.4 Botulinum Toxin (BTX) Type A
9.6.2 Surgical Treatment
9.6.2.1 Unipolar Tenotomy
9.6.2.2 Bipolar Tenotomy
9.7 Prognosis
9.7.1 Recurrence
9.7.2 Secondary Effects of Untreated Torticollis
9.7.2.1 Plagiocephaly
9.7.2.2 Facial Hypoplasia
9.7.2.3 Musculoskeletal Effects
9.7.2.4 Neurodevelopmental Conditions
9.8 Bilateral Sternocleidomastoid Tumors
References
10: Cystic Swellings of the Anterior Triangle: Cervical Abscesses
10.1 Pyogenic Abscesses
10.1.1 Definition
10.1.2 Etiology
10.1.3 Clinical Presentation
10.1.4 Diagnosis
10.1.5 Treatment
10.2 Cold Abscesses (Tuberculous Abscesses)
10.2.1 Etiology
10.2.2 Clinical Picture
10.2.3 Diagnosis/Differential Diagnosis
10.2.4 Treatment
10.3 Ludwig’s Angina Suppuration
10.3.1 Introduction
10.3.2 Etymology
10.3.3 Definition
10.3.4 Etiology
10.3.5 Clinical Presentation
10.3.6 Diagnosis
10.3.6.1 Imaging
10.3.6.2 Microbiology
10.3.6.3 Differential Diagnosis
10.3.7 Treatment
10.3.7.1 Airway Management
10.3.7.2 Antibiotics
10.3.7.3 Corticosteroids
10.3.7.4 Incision and Drainage
10.3.7.5 Nutritional Support
10.3.7.6 Postoperative Care
References
11: Cystic Swellings of the Anterior Triangle: Branchial Cysts
11.1 Introduction
11.2 Embryology and Pathogenesis
11.3 Epidemiology
11.4 Types/Subtypes
11.4.1 Types
11.4.2 Subtypes of Second Arch Branchial Cysts
11.5 Clinical Picture (Second Arch Branchial Cysts)
11.5.1 History-Taking
11.5.2 Physical Examination
11.6 Workup (Investigations)
11.6.1 Imaging Studies
11.6.1.1 Ultrasonography (US)
11.6.1.2 Computed Tomography (CT) Scanning
11.6.1.3 Magnetic Resonance Imaging (MRI)
11.6.1.4 Cytology/Histopathology
11.7 Differential Diagnosis
11.8 Complications
11.9 Treatment
11.9.1 The Conventional (Open) Technique
11.9.2 The Endoscope-Assisted Technique
11.9.3 Robot-Assisted Surgery
11.10 Prognosis
11.11 Branchial Fistulas
11.11.1 The Congenital Type
11.11.2 The Acquired Type
References
12: Cystic Swellings of the Anterior Triangle: Extracranial Carotid Artery Aneurysm
12.1 Definition/Classification
12.1.1 Definition
12.1.2 Classification
12.2 Epidemiology
12.3 Etiology and Pathogenesis
12.4 Clinical Presentation
12.5 Diagnostic Workup (Imaging)
12.6 Management
12.6.1 Medical Therapy
12.6.2 Surgical (Invasive)Treatment
12.6.2.1 Open Surgical Approaches
12.6.2.2 The Endovascular Approach
12.6.3 Technical Aspects
12.6.3.1 Open Surgical Treatment
12.6.3.2 Endovascular Treatment Options
12.6.4 Summary
References
13: Cystic Swellings of the Anterior Triangle: Laryngoceles
13.1 Definitions and Synonyms
13.2 A Historical Review
13.3 Classification
13.4 Etiology/Pathophysiology
13.5 Epidemiology
13.6 Clinical Picture
13.7 Diagnosis/Workup
13.7.1 Plain X-Rays
13.7.2 Computed Tomography (CT) Scanning
13.7.3 Magnetic Resonance Imaging (MRI)
13.7.4 Ultrasonography (US)
13.7.5 Laryngoscopy
13.8 Treatment
13.8.1 External (Open) Approaches
13.8.1.1 Advantages and Disadvantages
13.8.1.2 Indications
13.8.1.3 Types of External (Open) Procedures
13.8.1.4 Technical Aspects
13.8.1.5 Complications
13.8.2 Internal (Endoscopic) Approaches
13.8.2.1 The Endo-Laryngeal (Micro-Laryngeal) Approach
13.8.2.2 Robotic Surgery
13.8.3 The Combined Approach
13.8.4 Airway Management/Tracheostomy
References
14: Cystic Swellings of the Anterior Triangle: Plunging Ranulas
14.1 Definitions and Classification
14.1.1 Definitions
14.1.2 Classification
14.2 Etiology
14.3 Epidemiology
14.4 Clinical Picture
14.5 Investigations and Differential Diagnosis
14.5.1 Imaging Studies
14.5.1.1 Ultrasonography
14.5.1.2 Computed Tomography (CT) Scanning
14.5.1.3 Magnetic Resonance Imaging (MRI)
14.5.2 Histopathology
14.5.3 Differential Diagnosis
14.6 Treatment
14.6.1 Marsupialization
14.6.2 Sublingual Gland Excision and Cyst Drainage
14.6.3 Carbon Dioxide Laser
14.6.4 Radiotherapy
14.6.5 Sclerosing Therapy
14.7 Complications/Prognosis
References
15: Solid Swellings of the Posterior Triangle: Cervical Ribs
15.1 Definition
15.2 Developmental and Morphological Aspects
15.2.1 Developmental Aspects
15.2.2 Morphological Aspects
15.3 Epidemiology
15.4 Pathological Features
15.5 Etiology (Cervical Rib Syndrome)
15.6 Clinical Picture (Cervical Rib Syndrome)
15.6.1 Symptoms
15.6.2 Physical Examination
15.7 Imaging for Detection of a Cervical Rib
15.7.1 Plain X-Rays
15.7.2 Computed Tomography (CT) Scanning
15.7.3 Magnetic Resonance Imaging (MRI)
15.7.4 Ultrasonography
15.8 Differential Diagnosis
15.9 Treatment
15.10 Classification of Thoracic Outlet Syndrome
15.10.1 The Neurogenic Type
15.10.1.1 Clinical Picture
15.10.1.2 Investigations
15.10.1.3 Differential Diagnosis [24]
15.10.1.4 Treatment
15.10.2 The Arterial Type
15.10.2.1 Pathogenesis
15.10.2.2 Clinical Picture
15.10.2.3 Investigations
15.10.2.4 Treatment
15.10.3 The Venous Type
15.10.3.1 Clinical Picture
15.10.3.2 Investigations
15.10.3.3 Treatment
References
16: Solid Swellings of the Posterior Triangle: Lipomas/Liposarcomas
16.1 An Overview
16.2 Epidemiology
16.3 Etiology
16.4 Location
16.5 Types/Subtypes
16.5.1 Simple (Typical) Lipomas
16.5.1.1 Simple (Superficial) Subcutaneous (SC) Lipomas
16.5.1.2 Simple Lipomas in Other Locations
16.5.2 Infiltrating (Atypical) Lipomas
16.5.2.1 Subfascial Lipomas
16.5.2.2 Intra- and Intermuscular Lipomas
16.5.3 Mixed Lipomas
16.5.3.1 Angiolipomas
16.5.3.2 Angiolipoleiomyomas
16.5.3.3 Adenolipomas
16.5.3.4 Fibrolipomas
16.5.3.5 Neural Fibrolipomas
16.5.3.6 Fibroblastic Lipomas (Spindle Cell Lipomas: SCLs)
16.5.3.7 Intradermal Spindle Cell Lipomas
16.5.3.8 Pleomorphic Lipomas
16.5.4 Hibernomas
16.5.5 Diffuse (Hereditary) Lipomatosis
16.5.5.1 Bannayan–Zonana Syndrome
16.5.5.2 Cowden Syndrome
16.5.5.3 Froelich Syndrome (Adiposogenital Dystrophy)
16.5.5.4 Proteus Syndrome
16.5.5.5 Dercum’s Disease (Adiposis Dolorosa)
16.5.5.6 Madelung’s Disease (Benign Symmetric Lipomatosis)
16.5.5.7 Familial Multiple Lipomatosis (FML)
16.6 Diagnosis
16.6.1 Clinical Evaluation
16.6.1.1 Symptoms
16.6.1.2 Clinical Examination
16.6.2 Imaging
16.6.2.1 Plain Radiographs
16.6.2.2 Ultrasound (US)
16.6.2.3 Computed Tomography (CT) Scanning
16.6.2.4 Magnetic Resonance Imaging (MRI)
16.6.3 Biopsy/Histopathology
16.7 Treatment
16.7.1 Simple Excision
16.7.2 Liposuction (Suction-Assisted Lipectomy)
16.7.3 Newer Methods
16.8 Prognosis
16.9 Special Types in the Posterior Triangle
16.9.1 Intermuscular Lipomas
16.9.2 Spindle Cell Lipomas (SCLs)
16.9.2.1 Locations
16.9.2.2 Pathology
16.9.2.3 Differential Diagnosis
16.9.2.4 Management
References
17: Solid Swellings of the Posterior Triangle: Fibromas/Fibromatosis
17.1 Types of Fibromas
17.1.1 Hard Fibromas
17.1.2 Soft Fibromas
17.1.3 Other Types of Fibromas
17.2 Collagenous Fibromas
17.2.1 Introduction
17.2.2 Epidemiology
17.2.3 Clinical Picture
17.2.4 Investigations/Diagnosis
17.2.4.1 Ultrasonography (US)
17.2.4.2 Computed Tomography (CT) Scanning
17.2.4.3 Magnetic Resonance Imaging (MRI)
17.2.4.4 Biopsies
Gross Appearance
Histopathology
Immunohistochemistry (IHC)
Molecular/Cytogenetic Analysis
17.2.5 Differential Diagnosis
17.2.6 Treatment
17.3 Fibromatosis (Desmoid Tumors)
17.3.1 Introduction
17.3.2 Epidemiology/Sites
17.3.3 Etiology/Pathophysiology
17.3.4 Clinical Picture
17.3.5 Imaging Studies
17.3.5.1 Ultrasonography (US)
17.3.5.2 Computed Tomography (CT) Scanning
17.3.5.3 Magnetic Resonance Imaging (MRI)
17.3.6 Pathology
17.3.6.1 Gross Appearance
17.3.6.2 Cytology
17.3.6.3 Microscopic (Histological) Picture
17.3.6.4 Immunohistochemistry (IHC)
17.3.6.5 Molecular/Cytogenetic Analysis
17.3.7 Differential Diagnosis
17.3.8 Treatment
17.3.8.1 Surgical Treatment
17.3.8.2 Radiation Therapy (RT)
17.3.8.3 Chemotherapy/Systemic Therapy
17.3.9 Prognosis
References
18: Solid Swellings of the Posterior Triangle: Virchow’s Lymph Nodes
18.1 A Historical Review
18.2 Surgical Anatomy
18.3 Pathophysiology
18.4 Clinical Significance
18.5 Imaging Studies
18.5.1 Ultrasonography (US)
18.5.2 Computed Tomography (CT) Scanning
18.5.3 Magnetic Resonance Imaging (MRI)
18.5.4 Positron Emission Tomography (PET) Scanning
18.6 Biopsy: Cytology/Histology
18.6.1 Fine Needle Aspiration (FNA)/Core Needle Biopsy (CNB)
18.6.2 Technical Aspects
18.6.3 Excisional Biopsies
18.7 Differential Diagnosis
18.8 Prognosis
18.9 Summary
References
19: Cystic Swellings of the Posterior Triangle: Cystic Hygromas
19.1 Definition and Terminology
19.2 Embryology
19.3 Epidemiology
19.4 Clinical Picture
19.4.1 History-Taking
19.4.2 Physical Examination
19.5 Complications
19.6 Evaluation/Diagnosis
19.6.1 Antenatal Evaluation
19.6.2 Postnatal Evaluation
19.6.2.1 Imaging Studies
Ultrasonography (US)
Computed Tomography (CT) Scanning
Magnetic Resonance Imaging (MRI)
Plain Radiography
Lymphoscintigraphy
19.6.2.2 Pathology/Histological Findings
19.7 Classification/Staging
19.8 Differential Diagnosis
19.9 Treatment
19.9.1 Prenatal Management
19.9.2 Surgical Treatment
19.9.3 Sclerosing Therapy
19.9.3.1 Bleomycin
19.9.3.2 Picibanil (OK-432)
19.9.3.3 Absolute Alcohol
19.9.3.4 Doxycycline
19.9.3.5 Fibrin Sealants (Tissucol)
19.9.3.6 Hydrocolloid Dental Impression Material
19.9.4 Other Less Popular Methods
19.9.4.1 Aspiration
19.9.4.2 Radiotherapy (Deep X-Rays)
19.9.5 Medical Treatment
19.9.5.1 Sildenafil (Viagra): Oral
19.9.5.2 Sirolimus (Rapamycin): Oral
19.9.5.3 Alfa-2a-Interferon: Subcutaneous
19.9.6 More Recent Techniques
19.9.6.1 Laser Therapy
19.9.6.2 Radio-Frequency Ablation (RFA)
19.10 Prognosis
References
20: Cystic Swellings of the Posterior Triangle: Pharyngeal Pouch (Zenker’s Diverticulum)
20.1 Definition and Synonyms
20.2 A Historical Review
20.3 Epidemiology
20.4 Etiology/Pathophysiology
20.5 Histopathology
20.6 Clinical Presentation
20.6.1 Symptoms
20.6.2 Physical Examination of the Cervical Swelling
20.7 Complications
20.8 Evaluation/Investigations
20.9 Staging
20.10 Differential Diagnosis
20.11 Treatment
20.12 Open (Transcervical) Surgery
20.12.1 CP Myotomy: Necessity and Extent
20.12.2 Dealing with the Diverticulum: Resection, Suspension, or Inversion
20.13 Endoscopic (Trans-Oral) Procedures
20.13.1 Rigid Endoscopic Diverticulectomy
20.13.1.1 Endoscopic Electrocautery (Dohlman’s Technique)
20.13.1.2 The Endoscopic CO2 Laser Technique
20.13.1.3 The Endoscopic Stapling Technique
20.13.1.4 Endoscopic Harmonic Scalpels
20.13.1.5 Conversion of Rigid Endoscopic Diverticulectomy to Open Surgery
20.13.2 Flexible Endoscopic Diverticulectomy (FED)
20.13.3 Comparison Between Endoscopic and Open Surgery
20.14 Summary of Treatment Options
References
21: Cystic Swellings of the Posterior Triangle: Pneumatoceles
21.1 Definition
21.2 Epidemiology
21.3 Etiology
21.3.1 Infectious Causes
21.3.2 Noninfectious Causes
21.3.3 Hyperimmunoglobulin E (IgE) Syndrome
21.4 Pathophysiology
21.5 Clinical Picture
21.5.1 History-Taking/Symptoms
21.5.2 Physical Examination
21.6 Complications
21.7 Investigations
21.7.1 Laboratory Studies
21.7.2 Imaging Studies
21.7.3 Procedures
21.7.4 Histological Features
21.8 Differential Diagnosis
21.8.1 Pediatric Bronchogenic Cysts
21.8.2 Congenital Cystic Adenomatoid Malformation (CCAM)
21.8.3 Hyperimmunoglobulin-E Syndrome (HIES) (Job Syndrome)
21.8.4 Pediatric Pneumococcal Infections
21.8.5 Pediatric Pneumonia
21.8.6 Pediatric Tuberculosis (TB)
21.8.7 Pulmonary Sequestration
21.9 Treatment
21.9.1 Observation
21.9.2 Antibiotic Therapy
21.9.3 Conservative Measures
21.9.4 Invasive Intervention/Drainage
21.9.4.1 Percutaneous Needle Decompression
21.9.4.2 Injection of an Intrapleural Fibrin Sealant
21.9.4.3 Percutaneous Catheter Drainage
21.9.4.4 Chest Tube Drainage
21.9.4.5 Surgical Intervention
Video-Assisted Thoracoscopic Surgery (VATS)
Lobectomy
Pneumonectomy
21.10 Prognosis
References
22: Follow-Up and Patient Education
22.1 Follow-Up of Patients Who are Not at an Increased Risk
22.2 Education of Patients Who are at an Increased Risk
22.2.1 Patient Education and Counseling
22.2.2 Diagnostic Procedures
References