Lateral Neck Swellings: Diagnostic and Therapeutic Challenges

Description

The book provides a comprehensive overview of the challenges and debates on the diagnosis and treatment of lateral neck swellings to clarify some uncertainties, make suggestions for resolving others, and establish strategies for achieving therapeutic success. In addition to information on the surgical anatomy of the neck, and the classification and clinical approach for diagnosis and management of neck swellings, the chapters explore solid swellings and cystic swellings of the anterior and posterior triangles. The last chapter emphasizes the importance of scheduling regular follow-ups as well as patient counselling and education. The volume, enriched with colour images and flowcharts, will be an indispensable resource for head and neck surgeons, maxillofacial surgeons, endocrinologists, oncologists, pediatricians, and clinicians in other specialties as they face the most challenging lateral neck swellings and work towards providing each patient with the best possible outcome. 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