Head, neck and otorhinolaryngology

CHAPTER 8 Head, neck and otorhinolaryngology



The majority of head and neck problems seen in a surgical clinic are usually lumps. Often it is difficult for the family doctor to decide whether the lump lies in the field of the general surgeon, ENT surgeon, dental surgeon or dermatologist. The conditions described in this chapter are those that one may expect to see in a general surgery clinic or in an ENT clinic. The speciality of otorhinolaryngology (ear, nose and throat – ENT) is diverse. A multidisciplinary approach is mandatory and involves allied professionals such as audiologists, speech and language therapists, dentists, specialist nurses and prosthetists. ENT surgeons possess a detailed knowledge of the anatomy of the head and neck and its related benign and malignant pathological conditions, and have developed a variety of surgical techniques to manage these. Head and neck cancers are discussed at diagnosis in the context of a multidisciplinary team.





Swellings in the neck


A convenient classification of these is: superficial, lymph nodes and deep swellings (→ Table 8.1).


TABLE 8.1 Swellings in the neck





























Superficial Sebaceous cyst
Lipoma
Dermoid cyst
Abscess
Lymph nodes
Deep  
Anterior triangle

Posterior triangle Cervical rib
Subclavian artery aneurysm
Pharyngeal pouch
Cystic hygroma

The key to assessment and diagnosis of soft tissue neck swellings is careful history-taking, examination of the site, size and nature of the swelling (soft or firm, mobile or fixed, transilluminates, presence of a bruit). Fine needle biopsy is indicated for non-pulsatile masses. If the cytology is not definitive, then ultrasound core biopsy may be indicated if the imaging suggests it. The definitive investigation for soft tissue swellings is MRI.


In general, in patients over 45 years of age, assume a neck lump is metastatic malignant disease until proven otherwise.




Lymph nodes


The majority of swellings in the neck, especially in children, are likely to be lymph nodes. The lymph nodes of the head and neck are basically arranged in two circles; an outer superficial one including submental, submandibular, preauricular, and occipital nodes; and an inner one surrounding the trachea and oesophagus and including the paratracheal and retropharyngeal nodes. Both the superficial and deep groups drain into a chain of deep cervical lymph nodes that surround the internal jugular vein. Lymph from there drains into the thoracic duct on the left and into the right lymphatic duct. The causes of cervical lymphadenopathy are shown in Table 8.2.


TABLE 8.2 Causes of cervical lymphadenopathy


























Infection Local lesions on head and neck
Upper respiratory tract infection
Tonsillitis
Glandular fever
Toxoplasmosis
Tuberculosis
HIV
Cat-scratch disease
Malignancy

Sarcoidosis  



Deep swellings of the anterior triangle




Swellings that do not move on swallowing



Salivary glands: inflammatory


The parotid gland is included here, although only a part of the gland extends into the neck under normal conditions. In pathological conditions it may present with the swelling largely in the neck. The causes of swellings of the salivary glands are shown in Table 8.3.


TABLE 8.3 Swellings of the salivary glands
















Inflammatory and infective Acute sialadenitis, e.g. mumps parotitis
Chronic sialadenitis, e.g. calculus, duct stenosis
Neoplastic

Autoimmune Mikulicz’s syndrome
Sjögren’s syndrome




Salivary glands: tumours


Salivary gland tumours are rare; 85% arise in the parotid gland, 8–15% in the submandibular gland, and 5–8% in the sublingual gland. Of these, the majority are benign and in the parotid, are usually pleomorphic adenomas. The minor salivary glands are submucosal around the oral cavity. In general, the smaller the gland, the more likely a neoplasm will be malignant.



Benign: Pleomorphic adenoma

Some 90% occur in the parotid. The old name of ‘mixed parotid’ tumour arose from the histological appearances of mixed element, i.e. epithelial, fibrous, myxomatous and ‘pseudocartilaginous’. The latter was, in fact, mucus. They are slow growing and may enlarge over many years. The tumour sends processes into the surrounding parotid tissue, thus explaining why shelling out (enucleation) of these lesions may leave tumour behind with a high recurrence rate. After many years (10–30 years of slow growth), some pleomorphic adenomas develop into invasive malignant tumours.













Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on Head, neck and otorhinolaryngology

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