Head, neck and otorhinolaryngology

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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.

Facial swellings

These include boils, sebaceous cysts, dermoid cysts, squamous cell carcinoma, basal cell carcinoma, malignant melanoma (→ Ch. 19).

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	Move on swallowing: • thyroid • thyroglossal cyst • lymph node Do not move on swallowing: • salivary glands • branchial cyst • carotid body tumour • carotid aneurysm • sternomastoid ‘tumour’

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.

Superficial

Superficial lumps include sebaceous cysts, lipomas, dermoids and infective lesions, e.g. boils and abscesses. A common site for lipomas is in the midline posteriorly at the level of the collar line (→ Ch. 19).

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	Primary: • lymphoma • lymphosarcoma • leukaemia Secondary: • almost anywhere in the body, e.g. breast, lung, testis

Sarcoidosis

Investigation of cervical lymphadenopathy

Clinical examination. Look for local lesions, e.g. scalp, face, neck, mouth, tonsil. A full general examination of chest, breast, abdomen, testes and lower limb is required. Check for axillary and inguinal lymphadenopathy. Check for hepatosplenomegaly.

• Hb, FBC, ESR, Paul–Bunnell, Toxoplasma screen, viral antibodies, HIV

• CXR for hilar nodes or primary lung tumour

• Laryngoscopy and examination of postnasal space

• Ultrasound guided core biopsy of node

• Excisional biopsy of node – if lymphoma suspected

• MRI or CT of the head and neck to examine nodes and look for possible primary

• Examination under anaesthetic by panendoscopy of nasopharynx, oropharynx, hypopharynx, larynx, trachea and upper bronchi, oesophagus and stomach and biopsy of suspicious areas and likely primary sites, i.e. nasopharynx, tongue base and the pyriform and tonsillar fossae.

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
Inflammatory and infective	Chronic sialadenitis, e.g. calculus, duct stenosis
Neoplastic	Benign: • adenolymphoma • pleomorphic adenoma Malignant: • adenocarcinoma

Autoimmune Mikulicz’s syndrome Sjögren’s syndrome

Acute sialadenitis

This is most common in the parotid gland and is due to epidemic viral parotitis of mumps. It is bilateral. Occasionally sialadenitis of both parotids and submandibular glands can be caused by poor oral hygiene, dehydration or duct obstruction by stone or stenosis. Acute bacterial sialadenitis is often unilateral.

Symptoms and signs

Sudden onset of pain and swelling over salivary glands. Made worse by eating. General malaise. Examination reveals redness, tenderness and swelling in the region of the gland.

Treatment

Viral parotitis – treat symptomatically with analgesics. Acute bacterial sialadenitis is treated by antibiotics, e.g. flucloxacillin. If an abscess forms, drainage is required. Recurrent parotitis should be investigated by sialography to exclude sialectasis and areas of duct stenosis.

Chronic sialadenitis

This is usually due to calculus in the duct or duct stenosis. Salivary calculi are composed of calcium or magnesium phosphate and are usually radio-opaque.

Symptoms and signs

Pain and swelling of the affected gland occur on eating and drinking. The swelling can be reproduced in clinic by putting lemon juice on the tongue. If the stone becomes impacted, the gland remains swollen. Infection and abscess formation may ensue. Inspect the duct orifice. In the case of submandibular calculi, the swelling may be seen in the duct in the floor of the mouth. Feel along the duct with a gloved finger in the floor of the mouth, palpating bimanually from the outside with the other hand. The calculus may be felt.

Investigations

• Plain radiograph

• ‘Floor of mouth’ view for submandibular calculi

• If no stone is seen, arrange sialogram.

Treatment

• Stone in the submandibular duct may be removed by incising directly over the stone into the duct in the floor of the mouth. The stone is extracted leaving the duct marsupialized.

• With duct stenosis, a ductoplasty (widening of the duct orifice) is carried out.

• For the stones in the gland itself, total (submandibular) or partial (parotid) removal of the gland is indicated.

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.

Symptoms and signs

Early and middle adult life. Painless swelling on side of face. Slow growing. Examination reveals a non-tender, diffuse swelling in the angle between the mandible and mastoid process. It may extend down into the neck and forward on to the cheek overlying masseter. Test the integrity of the facial nerve. Diagnosis is made on clinical history and examination.

Differential diagnosis

Parotitis, sebaceous cyst, lipoma, preauricular lymph node, tumour of ramus of mandible.

Treatment

Superficial parotidectomy, i.e. removal of the gland superficial to the facial nerve. Enucleation is associated with a high incidence of recurrence.

Complications

Facial nerve palsy either temporary or permanent. Salivary fistula – usually dries up spontaneously. Frey’s syndrome, i.e. facial flushing and sweating on eating, occurs in areas supplied by the auriculotemporal nerve.

The patient should be warned of these complications, especially the facial nerve palsy, prior to informed consent being obtained.

Benign: Adenolymphoma (Warthin’s tumour)

This is a cystic tumour that contains epithelial and lymphoid elements. It is benign.

Symptoms and signs

Middle and old age. More common in males. Slow-growing, painless swelling over angle of jaw. It is soft and well defined.

Treatment

Surgical excision. If patient is elderly and diagnosis is certain, these can be left alone. Recurrence is rare.

Malignant

Usually affects parotid and may arise in a longstanding pleomorphic adenoma. Mucoepidermoid tumours are primary squamous cell tumors of the parotid gland and are of variable grade.

Adenoid cystic carcinoma is associated with early perineural spread and skip lesions which normally requires adjuvant radiotherapy following removal of the gland and nerve branch. Patients may have a long latency period before haematogenous lung, liver or bone metastasis become clinically evident.

Symptoms and signs

The gland becomes hard, irregular and painful. Facial nerve palsy may develop.

Treatment

Radical parotidectomy with sacrifice of the facial nerve. Neck dissection may be required. Radiotherapy is of limited value. The prognosis is poor.

Secondary squamous cell carcinoma or melanomas of the head and upper aerodigestive tract may present with a lump in the parotid gland. These are treated with total parotidectomy and ipsilateral neck dissection.

Lymphomas may arise in the parotid gland. Surgery is confined to incisional biopsy prior to definitive oncological therapy.

Salivary glands: autoimmune

This is a slow painless enlargement of salivary glands. The glandular tissue is invaded by lymphocytes.

Mikulicz’s syndrome

This causes symmetrical enlargement of the salivary glands, both parotid and submandibular. There is involvement of lacrimal glands and a dry mouth (xerostomia).

Sjögren’s syndrome

This has the same symptoms as Mikulicz’s disease but in addition has keratoconjunctivitis sicca (dry eyes) and seronegative arthritis.

Treatment

No treatment may be required but steroids may help. Dry eyes may be treated with hypromellose drops (artificial tears).

Branchial cyst

This is a remnant of the second branchial cleft. It may be associated with a sinus or fistula.

Symptoms and signs

It appears in early adult life, usually with soft swelling but consistency varies with tension in the cyst and some may be firm. It occurs at the level of the junction of the upper third and lower two-thirds of sternomastoid, appearing from under the anterior border of that muscle. It may be associated with the branchial sinus that opens over the anterior border of sternomastoid at the junction of the middle and lower thirds of that muscle. The sinus may extend up between the internal and external carotid arteries and open as a fistula into the side-wall of the pharynx.

Differential diagnosis of a branchial cyst

This is a lymph node. Diagnosis can be confirmed by aspirating the cyst and examining the fluid under the microscope, when cholesterol crystals will be seen.

Treatment

Surgical excision of cyst, sinus or fistula tract.

Carotid aneurysm

A true aneurysm is extremely rare. A false aneurysm may arise following penetrating trauma of the neck. A tortuous carotid artery appearing from under the anterior border of sternomastoid may give the impression of an aneurysm. Careful examination will reveal the tortuosity and lack of an expansile area.

Sternomastoid ‘tumour’

This is a swelling of the middle third of sternomastoid in neonates. It consists of oedematous and infarcted muscle.

Symptoms and signs

Neonates. Difficult birth, e.g. breech or forceps. Lump or torticollis. Pain on attempting to straighten neck. Head becomes turned to opposite side and tilted towards shoulder on side of lesion.

Treatment

Sternomastoid tenotomy.

Related

Churchills Pocketbook of Surgery