MEZINÁRODNÍ CENTRUM
KLINICKÉHO VÝZKUMU
„TVOŘÍME BUDOUCNOST MEDICÍNY“
Neck
ENT Clinic of Masaryk university, Brno
Faculty St. Ann Hospital
Head: Ass.prof. Gál Břetislav, MD, Ph.D.
Pekařská 53, Brno , 656 91
Neck - anatomy
Superior boundary – inferior edge of
mandibula, mastoid process and
protuberantia occipitalis ext.
Inferior boundary – plain formed by the
suprasternal notch, clavicle and the
spinous process of the seventh cervical
vertebra.
Osteomuscular system is adapted to the
upright human posture.
Visceral part of the neck contains upper
aerodigestive tract, the carotic sheath
and its contents on each side and
cervical lymphatic systém
There is on the neck cca 200 lymph nodes
Lymph nodes of the neck
Nodi cervicales superficiales
Along v. jug. ext. tributary zone: parotid gland, retroauricular region, intraparotic and occipital lymph nodes.
Nodi lymphatici cervicales profundi
They are in the carotid sheath.
Superior group (subdigastric)
Lymph channels lead to this regional lymph nodes (group) from the tributary tissue area: soft palate, tonsils, radix
linguae, supraglottis, sinus piriformis.
Nodus jugulodigastricus = Woodova uzlina= Küttnerova uzlina= Chassegnacova uzlina je v
Middle group
Tributary tissue area: supraglottis, glandula thyreoidea, sinus piriformis. Boundary to the crossing of m. omohyoideus
and carotid sheath.
Inferior group
Tributary tissue area: subglottis, trachea, cervical oesophagus, glandula thyreoidea. „Great venous angle“ = the left
jugulosubclavian angle. In this area is Troisier-Wirchow lymph node. Ductus thoracicus (thoracic duct) receive afferents
from the lower half of the body, the cranial area.
Lymphatic chain at n. accessorius
Tributary tissue area: nasopharynx, oropharynx, paranasal sinuses..
Lymphatic chain along vasa transversa colli
nodi supraclaviculares – closely above clavicula.
Special groups of lymphnodes
Nodi submentales, retropharyngei (the greatest Rouvier lymph node), paratracheales, nodus praelaryngicus (Poirier
lymph node).
Classification of cervical lymph
nodes
I submental and
submandibular group
II upper jugular group
III middle jugular group
IV lower jugular group
V posterior triangle group
VI anterior compartment
group
The Memorial Sloan Kettering
Cancer Center classification
Investigation
• inspection
• palpation
• diagnostic imaging:
• ultrasound, Doppler technique - provide information
about vascular lesions, distinguish between cyst and solid
tumor
• computed tomography - allows greater differentiation :
vascular lesion, tumors, cysts - including their position and
extent
• biopsy
• cervical lymphography - is of little clinical value when
compared with other methods of investigation.
• MRI
• Scintigraphy
Summary of findings
of palpation
• form and size in cm,
• site (localisation), topographic
description
• consistency - soft, elastic,
fluctuant, firm or hard
• mobility - vertically or
horizontally, fixed or adherent
• pulsation, skin - appearance of
the skin, comparison to the
surrounding tissues
„Sentinel lymph node“
• First lymph node to which the lymph is coming from primary
tumor. If there is no metastasis, the probability of metastatic
spread is low.
• Identification –
• Before surgery – lymphoscintigraphy 1 day before surg.
• During surgery - peritumoral application of lymphotropic agent
(colloid solutions marked with radioactive technetium, stain).
• Palpation- up to 1/3 of cases false negative or false positive.
• UZ - sensitivity 94 % a specifity 91 % (depends on experience of
interpreter)
• FNAB fine needle aspiration cytology and biopsy guided by
ultrasound - až 76 % sensitivity a 100 % specifity
• Reliability of CT scan for metastasis into neck lymph nodes is
given about 72 % - 93 %
• PET reveals higher sensitivity, but lower specifity than CT scan.
• Combination of evaluation methods shows presence of neck
metastasis approx. in 70 % of cases. About 30 % of ill without
clinical symptoms of metastasis is threaten with locoregional
relapses from micrometastastatic disease from micro
metastasis in regional lymph nodes.
Utilization rate
Cancer metastases
into neck lymph node
Cancer of thyroid gland
Differential diagnosis of lumps of
the neck
Lymphnodes X Extra lymphnodes
• Inflammatory Cervical
Lymphadenopathy
• Tumors
• Congenital Anomalies
Inflammatory Cervical
Lymphadenopathy
acute - lymph nodes are painful
Chronic non specific lymphadenitis
shows on repeated infections in the region of pharynx in past. Persistent or recurrent lymph node swellings are not
compatible with a diagnosis of nonspecific lymphadenitis.
Chronic specific lymphadenitis tuberculosis,
sarcoidosis.
Lymphadenitis reticullaris abscedens
Cat Scretch Fever the pustulous primary focus, which tends to ulcerate, occurs in the skin, . This is followed 1 to
5 weeks later by a regional lymphadenopathy. In one third of cases a fistula forms. Is caused by the cat scratch
virus.
Tularemia
Lymphadenitis with changes in blood account
mononucleosis infectiosa, rubeola, adenovirosis, hepatitis epidemica, viral pneumonia, listeriosis, toxoplasmosis,
lymphadenitis after hydantoin
Rare lymphadenitis
collagenases, syphilis, mycosis.
Tumors
Benign
hemangiomas, lymphangioma (Cystic Hygroma), paraganglioma, lipomas (Morbus Madelung-benign symetric
lipomatosis of the neck)
Malignant lymph node tumors
Malignant lymphomas Hodgkin´s disease, Non - Hodgkin´s lymphoma. Treatment according to oncologist.- actinoand
chemotherapy.
Primary neck cancer
Thyroid gland , tzv. „branchiocarcinoma“ from lateral Branchial Fistulae and Cysts.
Lymph Node Metastases
treatment - surgery.
TNM classification (p16 negative):
N1 single homolateral less than < 3 cm;
N2 single homolateral > 3 cm < 6 cm
more homolateral lymph nodes< 6 cm
bilateral or contralateral < 6 cm
N3 > 6 cm
Malignant tumors of the
external neck
Primary neck cancer
Tumors of lymph nodes malignant
lymphomas
▪ M. Hodgkin
– 30 % lymphomas in neck, 75 % male
▪ Nonhodgkin lymphomas
– number of lymphoreticular malignant
tumors, arising from cells of immune
system
– Lymphomas with low and high grade
of malignity, chronic lymphatic
leukemia
▪ Diagnosis: histology
▪ treatment: conservative oncologic (CHT,
RT, combination)
Zdroj obr.: Fotoarchiv KOCHHK FN u sv. Anny a LF MU
Paraganglioma
Paraganglioma
▪ rare neuroendocrine tumor arising from neuroectodermal tissue,
– more than 80 % of this tumors arising from the adrenal
medulla
– 2 bis 4 % arising in the neck
glomus caroticum, (carotid body
tumor, glomus tympanicum, glomus
jugulare)
▪ 50 to 60 year, 4x frequently in women
▪ Malignant course in 2 to 10 % cases
▪ Clinic features: „fungal structure“ mass, non painful, pulsating,
glomus caroticum – possible movement into side not craniocaudal
direction
▪ Diagnosis: CT/MR angio (CAVE punction) – „ lyra symptom“
▪ Therapy: surgery x radiotherapy x see and wait)
Zdroj obr.: Fotoarchiv KOCHHK FN u sv. Anny a LF MU
Paraganglioma
glomi carotici
on the left side
Secondary malignant tumors on the
neck
Metastases (primary tumor in tributary region)
Metastatic tumor of unknown primary (primum ignotum)
• histologically verified disease without known primary tumor in the time of
diagnosis
• In Secondary malignant tumors on the neck is primary tumor approx. in
75–90 % found in head and neck
• more frequent localization: palatine tonsils, base of the tongue, epipharynx and
hypopharynx
Diagnosis:
• ENT evaluation – follow up once a year
• Imaging methods: ultrasound (+ puncture) CT, MRI, PET-CT
• Pan endoscopy, biopsy, TE
Therapy: surgery – neck dissection +- adj. RT/CHT/CHRT
The methods of surgical treatment
of lymph node metastases
Surgery from external approach – in case of primary
surgical treatment, combined with
Radiotherapy/radio chemotherapy
Non surgical treatment – in case of „organ saving
protocols“ - Radiotherapy/radio chemotherapy
The methods of treatment
Prescalene node biopsy (Daniels operation)
The radical curative neck dissection (Resectio venae jugularis
internae en bloc sec. Crile 1906) - the upper boundary of the
operation is the base of the skull and the lower boundary
lies at the level of the clavicle. The sternocledomastoid
muscle, the internal jugular vein are removed.
The goal of neck dissection is complete removal of lymph
nodes and vessels between the superficial and deep
cervical fascia.
Functional deck dissection- the sternocleidomastoid muscle,
the internal jugular vein, the accessory nerve are
preserved.
An elective neck dissection is a neck dissection carried out in
the absence of palpable lymph nodes for a primary tumor
which experience has shown to have a high metastatic
rate - oropharynx, hypopharynx, supraglottic larynx, the
base of the tongue. The purpose of this operation is to
deal with micro metastases.
Types of neck dissections
(classification according to Ferlito)
ND (neck dissection)
L (left,) or R (right,) – side of neck dissection
removed region lymph nodes, described with Roman numeral to VII, in increasing order
removed non lymphatic structures
Examples:
ND (R, I-V, SCM, IJV, CN XI) – Radical neck dissection
ND (L, I-V, SCM, IJV, CN XI, CN XII) - extended Radical neck dissection with removal of n. hypoglossus
ND (I-V, SCM, IJV) – Modified radical dissection with saving n. accessorius (n. XI)
Abbreviations: ND – neck dissection , SCM – m. sternocleidomastoideus, IJV – v. jugularis interna,
CN XII – n. hypoglossus, CN XI, SAN – n. accesorius (spinal accesory nerve), ECA – a. carotis externa, ICA – a.carotis
interna, CCA – a. carotis communis, CN VII – n. facialis,
CN X – n. vagus, SN – neck sympaticus, PN – n. phrenicus, SKN –skin,
PG – glandula parotis, SG – glandula submandinbularis, DCM – deep cervical muscles
Radical neck dissection
ND (R, I-V, SCM, IJV, CN XI) sec. Crile
Modified radical dissection with saving n.
accessorius(I-V, n.XI saved)
Congenital Anomalies
• Lateral Branchial Fistulae and
Cysts
• Medial - thyroglossal Duct
cysts and fistulae
Typical sites for cervical cysts and ducts
1.Foramen caecum
2.Thyroglossal duct
3. Submental and prelaryngeal dystrs
4. Hyoid bone
a) Thyroglossal duct cysts
b) Fistulas
c) Branchial cleft cysts and fistulas
9. Lateral cervical cysts
Cystis colli lateralis l.sin.
Inflammatory cervical lympadenopathy -
actinomycosis
Morbus
Madelung
benign symmetrical neck
lipomatosis
Morbus Madelung
Metastasis of
oropharyngeal
cancer
Oropharyngeal cancer with metastasis
on the left neck side
Carotic sheath between
deep and superficial
cervical fascia
Neck fascial spaces
1.abscess in retropharyngeal space, 2. in „dangerous space, 3. in prevertebral space.
A superficial
fascia
B carotic
sheath
C middle leaf of
deep neck fascia
D alar fascia
E prevertebral
fascia
Phlegmona colli (Inflammation of the
Cervical soft tissues), Mediastinitis
• Source –infection of para tonsillar a retromolar region, injury
of oral cavity base, pharynx or cervical esophagus. Visceral
spaces of the neck have no distal boundary with mediastinum.
• Clinical picture – fever, usually septic, dysphagia, pain in the
back (intrascapular), retrosternal pain
• Inflammatory infiltration of the neck without boundary,
fluctuation, special palpation feeling; by spread into the
mediastinum – dysphagia and even dyspnea
• Treatment – surgical opening of space surrounding great neck
vessels, collateral mediastinotomy, treatment of primary
source, general treatment aimed against sepsis, thrombosis,
kidney failure etc.
• Bad prognosis, high mortality
Esophagus
▪ Esophageal wall: tloušťka 2- 5mm
– Mucosa membrane
▪ Stratified non keratinizing squamous epithelium
– Submucosal layer
– Muscle layer
▪ circular
▪ longitudinal
▪ Kilian´s triangle -hypopharyngeal diverticulum
(Zenkeri)
– Adventitia
▪ The full length of the esophagus is 20-26 cm
in adult person
M. constrictor
pharyngis inf.
(m.
thyrofaryngeus)
Trachea
Oeso
phag
us
Zenker
diverticl
M. constrictor
pharyngis inf
(m.
cricofaryngeus)
The esophagus
▪ Esophagus topography
– Cervical part - C6-Th1
– Thoracic part - the longist, Th1-Th7-8
– Abdominal - the shortest, Th 9-11.
▪ Esophagus constrictions:
– The upper constriction - Killian´s
sphincter – opening lies 15 cm from
the upper incisor
– The middle (thoracic) constriction aortic
arch and left main bronchus – 27
cm from the upper incisor
– The lower (diaphgramatic)
constriction - 40 cm from the upper
incisor
Zdroj obr.: [online cit. 2.4.2020]. Doi.
http://www.travici-potize.cz
Esophagus
▪ Innervation
– n.X and cervical and thoracical sympathicus
▪ Physiology
– Food income
▪ The act of swallowing – pharyngeal and esophageal
phases – under autonomic control – swallowing reflex
▪ Active mobility of the esophagus – food transport
Investigation methods
▪ Diagnostic imaging
– Simple X-ray- diagnosis of RTG contrast foreign
bodies
– Contrast administration
▪ Barium
▪ Iodium contrast medium
(gastrografin) in suspicion on injury
of esophagus, perforation
▪ CT, MRI – suspicion on malignancy
▪ Esophagoscopy
– rigid – treatment, foreign body extraction
– Flexible - mainly diagnosis
▪ Esophagus manometry
▪ Multichannel intraluminal impedance, two
channel manometry (pH metry)
Zdroj obr.: Fotoarchiv KOCHHK FN u sv. Anny a LF MU
Esophagus - congenital stenosis
and aplasia
▪ Disorder of recanalization during
development
▪ Aplasia- newborn cannot swallow,
coughing, vomiting
▪ Strictures - dysphagia
▪ Diagnosis: diagnostic imaging, CT,
MR, esophagoscopy, bronchoscopy
▪ Therapy:
– Stenosis- dilatation
– Atresia- surgery Zdroj obr.: [online cit. 2.4.2020]. Doi https://www.wikiwand.com/en/Esophageal_a
Tracheoesophageal fistulas
▪ Symptoms – recognized immediately
after birth, with choking attacks,
dyspnea, cyanosis
▪ Diagnosis – radiography and
endoscopy
▪ Therapy - surgery
Zdroj obr.: [online cit. 2.4.2020]. Doi
https://www.wikiskripta.eu/w/Atr%C3%A9zie_j%C3%ADcn
u
Achalasia (cardiospam)
▪ Syndrome of nonorganic obstruction of
lower esophageal sphincter connected with
esophagus hypertrophy and dilatation
▪ pathogenesis: neuromuscular disorder,
possibly degeneration of the myenteric
plexus (Auerbach).
▪ Symptoms – feeling of retention of food in
the esophagus, vomiting
▪ Diagnosis – radiography and endoscopy
▪ Therapy - dilatation, surgery –
kardiomyotomy sec. Heller
Zdroj obr.: [online cit. 2.4.2020]. Doi
https://www.wikiskripta.eu/w/Achal%C3%A1zi
e
Caustic ingestion of
esophagus
Typical history, very severe pain in the mouth,
pharynx, behind the sternum.
The coagulation necrosis due to acids and
colliquative necrosis due to lye's penetrates to
varying depths
primary local necrosis
generalized intoxication
acute, subacute and chronic corrosive esophagitis
healing of the esophagitis with scarring or stricture
late complications (restenosis, possibly malignant
degeneration).
The scar tissue stenosis begins about the 3rd week.
Caustic ingestion of
esophagus - diagnosis
• History
• Diagnostic imaging - Contrast administration
Iodium contrast medium (gastrografin) in suspicion on
injury of esophagus, perforation
• Esophagoscopy
Esophagus – caustic
ingestion
▪ course:
– acute phases: damage of superficial epithelium with possibly deeper spread
with bacterial infiltration until 48 hours. Mucosa membrane is reddened or
cyanotic.
– Reparative phases: approximately in 5 days – creation of granulations, deposits
of fibrin, collagen.
– Scar phases: 2.-3. week, in circular injury threated esophageal strictures.
▪ diagnosis:
– flexible nasopharyngolaryngoscopy, KO, electrolytes, astrup, chest X-ray.
– Esophagoscopy in time window 12-24 hours after injury.
– Do not correspondent status of mucosa membrane in mouth and in esophagus.
– Consultation in toxicologic center
Esophagus – caustic ingestion
Esophagoscopy
– Flexible until first pathological
changes
– Time window: from 12 to 24
hours
– First – diagnostic imaging
– Follow up not earlier than in 6
weeks
Zargar, S.A: Gastrointerst Endosc 1991, 37: 165
Cheng, H.T.: BMC Gasttroenerology, 2008, 8:31
Endoscopic classification in time 12-24/48 hours after
injury
Degree Endoscopic view Consequences
0 normal
1 Hyperemia, oedema
2A Exudation, bleeding, superficial
ulcers
2B Deep ulcers Strictures
3A Focal necrosis
3B Advanced necrosis Perforations
Esophagus – caustic ingestion
Treatment
– Acute care:
▪ Transportation to workplace treating this injury
– First aid in caustic ingestion of esophagus
▪ Anti shock treatment
▪ Analgesics gargle of oral cavity with local anesthetic
▪ No irrigation of stomach, dilute or neutralization of lye or acids!
Esophagus – caustic ingestion
Intermediary care: broad-spectrum antibiotics, parenteral nutrition, management of
shock, fluid administration, if necessary – tracheotomy, gastrotomy. Nasogastric probe in
circular injury 2. stage or in perforation 6 weeks.
▪ 1st degree: small risk of stenosis, special treatment not necessary, follow up
▪ 2nd degree – antibiotic treatment 2 weeks, H2 blockers 2-4 weeks, follow up after 3
weeks imaging
▪ 3rd degree (perforation): surgery - laparotomy, gastrectomy, esophagectomy.
Esophagoscopy and extraction of battery in esophagus.
Late care: stenosis dilatation under general anesthesia
Complication
– early: perforation and mediastinitis
– late: scar esophageal stenosis, malignant tumors as a consequence of ingestion
Foreign bodies in swalloving ways
- causes
• Bad habit to give objects into mouth
• Bad habits at eating – quick, inattentive, greedy…
• Alcohol abuse, unconscious
• penologic medicine – intention at prisoners
• Old people with teeth prosthesis and with week
swalloving reflex
Foreign body (metal toy) in cervical
oesophagus –2y old children
Foreign body (pencil sharper) in cervical
oesophagus 19-year-old patient
Foreign bodies in swalloving ways -
localisation
• hypopharynx, piriform sinus – bigger size
• esophagus – in regions of physiological
constriction, usually in Kilian´s sphincter, scars,
tumors etc.
Foreign body - chicken bone in
hypopharynx
Foreign body - chicken bone in cervical
oesophagus
Foreing body- coin in
cervical oesophagus
Foreign bodies in swalloving ways -
symptoms
• painful dysphagia
• increased salivation
• dyspnea
Foreign bodies in swalloving ways -
diagnosis
• history of disease
• indirect laryngoscopy
• X-ray examination native, at non contrast foreign
body roll of cotton wool with contrast medium
• Hypo-pharyngoscopy, esophagoscopy
Negative X-ray finding is not cause for avoiding
endoscopy! – especially in sharp hard foreign
body.
Foreign bodies in swalloving ways therapy
+ complications
Endoskopic extraction
Complication
• Injury or perforation of oesophagus
• Picture of shock, subcutaneous emphysema, mediastinal
emphysema. Miningerod´s sign = presence of air in posterior
superior mediastinum. The greatest mistake – physician has
suspicion, but he hushed it up.
• Scar stenosis
• Bleeding
• Esophago-tracheal fistulas
• Recurrent palsy
Adapted safety pin
in oesophagus –
wanted swallowing
– by prisoners
Wanted swallowing – handle of spoon –
by prisoners
Wanted swallowing – handle of
spoon – by prisoners
Stone from nectarine
mental retardated boy, 20 yr
localisation – 2nd physiologic
stenosis
Esophageal diverticulum
Diverticulum – congenital or acquired protrusion of
hollow organ.
– Pulsatory diverticula
– Traction diverticula – tbc, peri-esophageal
lymphadenopathy due to scar contracture
The most common type - cricopharyngeal (false)
pulsatory Zenker diverticulum.
– pathogenesis – protrusion of mucosa
membrane between thyropharyngeal and
cricopharyngeal part of inferior pharyngeal
constrictor.
Esophageal diverticulum
Zenker diverticulum
– Prevalence - create 70% of all esophageal diverticula. Disease of higher age, age
average 60-65 let, 2:1 male to female
– Symptoms
▪ Dysphagia, feeling of pressure in jugular region, attacs of coughing
▪ Disorder of swallowing especially tough food
▪ Return of not digested food, loss of weight
▪ In pressure externally on the neck - special sound (Boyce sign).
▪ Big diverticula's: recurrent nerve palsy, aspiration of food, risk of malignant tumor.
Esophageal diverticulum
Zenker diverticulum
– Diagnosis – diagnostic imaging
– Therapy – surgery
▪ External approach – resection of pouch and myotomy m.
cricopharyngeus
▪ Endoscopic approach – incision of threshold
a pathogenesis of diverticulum
b Principle of endoscopic incision
1 esophagus
2 threshold with place of incision
3 diverticulum
Hematemesis – bleeding from
swallowing ways - cause
• esophageal varices (portal
hypertension, portal bloc etc. )
• peptic ulcer of esophagus (Barett)
• corrosive ulcer, esophagitis
• tumors
• diverticulosis
• hernia hiatica
Hematemesis - symptoms
• sometime without symptoms
• spitting out fresh or coagulated blood
(=hematemesis)
• melaena
Hematemesis - diagnosis
It is necessary to distinguish between vomiting and
only presence of the blood in saliva.
Evaluation :
• ENT examination
• direct hypopharyngoscopy
• flexible esophagoscopy
• X-ray evaluation in negative endoscopy
Hematemesis - therapy
• preserve a calm atmosphere
• swallowing small pieces of ice, hem styptic agent
(Bismuthum subnitricum in powder)
• small dosage of anti-anxiety drugs
• three-way balloon probe Sengstaken-Blakemore
• sclerotization of varices
• surgery