Chapter 16. Anterior and lateral triangles.

Anterior triangle - Midline, SCM, mandible.

Sub-divided into - Submental - Midline, Hyoid, Ant. belly of digastric
Submandibular - Mandible, Ant. and Post. belly of digastric.
Carotid - SCM, Stylohyoid (Post. belly of digastric), Omohyoid.
Muscular - SCM, Omohyoid, Midline.
Posterior triangle - Trapezius, SCM, Clavicle

Covered by platysma - Cx branch of VII

Superficial veins - EJV - from retromandibular v. and posterior auricular v. Passes over SCM to
pierce fascia over post. triangle and drain into subclavian v.
- AJV - from submand. and submental region
Veins are firmly attached to Cx fascia

Superficial nerves. - sensory, from Cx plexus, appear under post. belly of SCM 1/2 way down.
Greater auricular. - ascends to ear over SCM
Lesser occipital - ascends up the post. border of SCM.
Transverse cervical- C2 and 3. Passes forward.
Supraclavicular - C3 and 4.

.
DDx
Congenital Inflammatory Neoplasms Miscellaneous
Bacterial or viral Granulomatous Benign Malignant
Thyroglossal cyst Cx adenitis TB Haemangioma Primary SM fibrosis
Branchial cleft cyst Abscesses MAIS lymphangioma Secondary Normal structure
Foregut cyst Cat-scratch fever Sarcoidosis teratoma -neuroblastoma ranula
Dermoid cyst IM Actinomycosis Sal gland - rhabdo laryngocoele
Bronchogenic cyst Toxoplasmosis thyroid Lymphoma
brucellosis Paraganglioma
Schwannoma
Neurofibroma

CONGENITAL

PHARYNGEAL ARCHES (INCLUDING ORIGINS OF CYSTS AND FISTULAE)

Embryology:
During 4th to 8th week, 5 pairs (and 1 rudimentary pair) of well developed arches connect paired dorsal
and ventral aortas in lateral cervical area. Each consist of a mesodermal cartilagenous centre, an intervening
ectodermal lined cleft, an endodermal lined pouch internally, artery, nerve.

1st arch derivatives:

1st arch splits into maxillary and mandibular processes
Most of malleous and incus of the middle ear. Part of pinna
Maxillary process.
Muscles of mastication, mylohyoid, ant belly of digastric, tensor paliti and tympani.
Maxillary artery (possibly only a small part)..
Mandibular and maxillary branches of the V nerve.
anterior 2/3 of the tongue (mucous membrane from 1st arch ectoderm, but muscles are from cervical
myotomes which bring XII with them).
1st Groove: External auditory meatus
1st Pouch: Eustachian tube, middle ear and mastoid antrum.
The tympanic membrane is formed from the area where groove meets pouch at closing membrane only
remnant of this

2nd Arch derivatives:

External surface of 2nd arch grows caudally to overlap 3rd and 4th, and join with epicardial ridge forming
the side of the neck. 2nd, 3rd, and 4th clefts form a cervical sinus which disappears. Therefore the skin of
the face and neck is supplied by V and C2,3,4. The ectoderm supplied by VII, IX, X and C1 lines the
cervical sinus
Lesser cornu and upper part of body of hyoid.
Stylo-hyoid ligament.
Styloid process.
Stapes (and some of malleus and incus).
Stapedeus, stylohyoid muscle, posterior belly of digastric, muscles of facial expression and platysma.
Artery to stapedius
Facial nerve.
Part of the pinna also forms externally in the region of the 2nd arch.
2nd pouch: Palatine tonsillar crypts and supratonsillar fossa,
From the floor - foramen caecum and the thyroid gland (may explain why thyroglossal fistula goes through
body of hyoid bone).

3rd Arch Derivatives:

Greater cornu of hyoid and lower part of body of hyoid bone.
Stylopharyngeus
IX
Internal carotid artery, including the carotid sinus.
3rd Pouch: Inferior parathyroid glands , Thymus (greater part) - descent drags parathyroids below the
superior ones, Pyriform fossa
mucous membranes of the posterior 1/3 of the tongue, the valleculae and the anterior surface of the
epiglottis is derived from the 3rd arch.

4th Arch Derivatives:

Thyroid cartilage
Crycothyroid muscle
Superior laryngeal nerve
Arch of aorta on the L, and on the R the subclavian artery.
4th pouch: Superior parathyroid glands, Some of thymus

5th Arch: Ultimobranchial body - C cells of thyroid

6th Arch derivatives:

Arytenoid cartilage.
Intrinsic muscles of larynx.
Recurrent laryngeal N
Part of the pulmonary artery and the ductus arteriosus.
6th Pouch: Possibly oesophagus and trachea develop.

Incidence:
= all neck masses in kids. ~ 1/3 branchial, 1/3 thyroglossal, 20% dermoids
90% 2nd cleft, 74% cysts, 25% fistulas, 1% skin tags / cartilage
8% 1st, 2% 3rd.

First Pharyngeal Fistula:

A true sinus or fistula rare, opening just below the angle of the jaw along the uppermost border of the SCM.
communication with the external meatus, rarely ME
The tract may enter the parotid gland, VII smaller + more sup.and harder to ID..
Find VII 1st, at SM foramen, dissect out. Sup parotidectomy
Elliptical excision of opening, extend incision behind mandible and then in front of ear.
dissect tract out, may pass b/w VII branches.
Excise portion of cartilage and skin lining ear canal.

2nd Pharyngeal remnants:

sinus presents in 1st decade, cyst in 2-3rd.
external opening - anterior border of sternomastoid at junction of middle and lower 1/3. may be bilateral
and extend to the supratonsillar fossa.
Tract will run between the carotids and runs cranial to IX and XII. A thin, mucoid fluid can be secreted
from a sinus, although secondary infection is often the reason for referral. Aspirate / Abs if infected vs I+D
:- palpate tract
transverse elliptical excision of opening. Blunt probe, Me blue too messy.
Dissect up, keeping close to the tract until tract goes through platysma.
Step ladder incision at carotid bifurcation if nec- sub-platysmal flaps, ID tract - passes lateral to
carotid sheath, superficial to IX and XII, b/w ICA & ECA, to pharynx. Do not dissect beyond the
constrictors transfix, Close in layers, drain if infected.

Third pharyngeal fistula:

Usually on L (same applies to IV fistulae). Can present with thyroiditis or acute RD in infant.
The external ostium should lie along the anterior border of sternomastoid. The tract then proceeds
cephaloid posterior and medial (Ashcraft says lateral) to the internal carotid artery to open into the pyriform
fossa. It is usually associated with the superior pole of the thyroid, which means a partial thyroidectomy
necessary. The tract pierces thyrohyoid membrane above X (superior laryng. nerve).

4th Pharyngeal tracts:

(very rare)
Enters larynx below X (sup. laryng n.) passes rostral to XII and around subclavian artery or aorta, deep to
clavicle. Close association with recurrent laryngeal nerve.

Branchial cysts:
palpable anterior to the middle third of sternomastoid, upper 1/3 - lower 2/3 junction.
and may become more prominant after a respiratory tract infection. Probably arise from remnants of the
cervical sinus. They are not usually apparent during childhood.
Contain cholesterol crystals, lined by epithelium with much lymphoid tissue.
DDx :- LN
- CB tumour, Haemangioma, Neurofibroma, Cystic hygroma
Treatment is elective excision, b/c of infection risk. If infected, first control with antis if possible.
When excising, keep close to the cyst as X, XI and XII are often in the proximity. may be very close to IJV
or Carotid artery
Some authors (including those in Melbourne) have used this and the obvious lymphoid tissue in the wall as
evidence against these being branchial remnants at all and have suggested that they are derived from the
cystic degeneration in lymph nodes.

Malignant degeneration has been described in branchial remnants persisting to adulthood.

Thyroglossal duct cysts.

Tract is from Foramen caecum to Isthmus of the thyroid.
Soft non-tender mobile mass, not attached to skin. Can lead to sinus if incised or spontaneously
drains after infection. Rx infection with Abs and aspiration
Ascends with swallowing or tongue protrusion diff to assess in kids (DDx dermoid cyst :- no movement
with tongue).
ectopic thyroid (0.5-1%, esp in females, ?need for thyroid scan only if H+E suggests hypothyroidism)
Cysts are :- mainly in region of hyoid (just below)
midline (never more than 2cm from midline)
no external opening (unless incised or infected with spont. discharge)
filled with viscous fluid, lined by st sq or ciliated
may have ectopic thyroid tissue in the wall - columnar epithelium
mainly present in 1st decade, often after URTI.
If located above the hyoid, more likely to contain thyroid tissue, so consider thyroid scanning

Sistrunk procedure.
Excision of cyst, central hyoid and duct up to the foramen caecum.
Extended neck, tv incision over cyst (excise sinus if present), platysma reflected, cyst dissected out.
Dissect track up to hyoid, excise central 1cm, continue dissection of a core of tissue up to f caecum
Assistant pushes f caecum downward to facilitate dissection.
Ligate duct at base of tongue by excising a conical area of tongue muscle. Close defect 3/0 vicryl
Leave hyoid unapproximated, close in layers over drain.

Recurrence rate 5-7%, even with hyoid excision. Risk - younger, skin involvement, cyst lobulation, rupture
of cyst at op, failure of hyoid removal and core above.
< 1% develop carcinoma, 80% papillary

CRANIOFACIAL DERMOIDS
= epidermis + appendages in cyst wall.
The soft tissues of the face are formed by the convergence of three facial processes (frontal, maxillary and
mandibular). lines of fusion where islands of ectodermal tissue may become submerged, later to secrete
sebaceous material and present as obvious cystic swellings known as dermoids.
commonest site is upper lateral part of the forehead (an external angular dermoid), other sites include
-upper medial part of the eye, or along the midline of the face and neck - nasal bridge, submental,
superficial to sternum. 23% occur in the floor of the mouth..
Rarely, communication through the calvarium with two dermoid elements occuring on either side of the
bone to resemble a dumb-bell tumour. Any suspicion that a dermoid may be fixed to the bone should
prompt an x-ray examination or even CT.
Malignant degeneration of dermoid cysts is possible but extremely rare.

difference between a dermoid cyst and a epidermoid cyst - epidermoid cyst is lined by epithelium without
any other of the skin adnexae (glandular structures etc).

PREAURICULAR PITS, SINUSES and ACCESSORY AURICLES

congenital sinus on the anterior aspect of the helix, passes anteriorly and inferiorly through the skin to end
in a group of preauricular cysts. arise from imperfect fusion of the six fetal tubercles which form the pinna.
Symptoms are rare in infants. Infection commonly occurs in older children and is difficult to treat. If
untreated, recurrent infection results in a preauricular ulcer. The lesion may be unilateral or bilateral and
may be familial. Not associated with a syndromic hearing loss except in branchio-otorenal syndrome.
Most common in Chinese and least in Scots, it is an autosomal dominant condition.
only treat symptomatic ones.

Complete excision is necessary to effect a cure. Operative: raise a flap as an inverted L, tract and cysts
should come up with flap. After abscess drainage some of them scar up so much that they do not require
excision (Vipul). Martin operates using methylene blue and an elliptical incision.

Accessory auricles:
Situated on the line of fusion of the maxillary and mandibular processes of the first branchial arch and are
managed by surgical excision.
INFLAMMATORY

Acute infection.
Mostly viral. Bact = Staph, esp in infants, Group A Strep or both > Group B Strep, haemophilus. If cellulitis
/ toxic / infant. Failure to respond in 24h US / FNA. Either aspiration or formal drainage.
If neglected, can extend into lateral pharyngeal space
"Ludwig angina" - extension of a dental infection into floor of mouth. Pain with tongue movement.
Can cause airway obstruction.
Chronic infection.
MAIS :- not contagious, portal of entry = oropharynx, 1-5yrs, generally unilateral submental or
submandibular. Nodes firm and rubbery, non-tender. May have fistula after spontaneous discharge of collar
stud abscess. Mantoux ve or intermediate. AFBs in pus. Not gen responsive to Abs. Trial with
roxithromycin suggest may be as good as Sx. Sx excise affected skin as ellipse and affected nodes.
Consider nerve stimulator.
Cat Scratch disease: - Bartonella henselae = gram neg bacillus. Entry via skin, papule at site in 3-5d,
draining nodes up in 1-2w. Early systemic symptoms common. Most in limbs, but neck 25%. Org can be
Ided with Warthin-Starry stain of nodes. Most resolve in 6-8w. Suppuration unusual, but systemic
manifestations such as encephalitis, ocular in 12%. Excisional Bx may be needed if sinus develops or Dx
uncertain.
TB :- painless nodes with malaise, LoW, cough, fever. Esp in posterior triangle. Mantoux +ve.
Actinomycosis. :- involves soft tissues, not nodes. Woody mass, Sinuses often present.

LYMPHATIC MALFORMATION, CYSTIC HYGROMA

Definition:
(Greek, hygros-moist)
A cystic lesion caused by a mass of dilated lymphatics which is usually found in the neck.
Mulliken says should not be called lymphangiomas because this signifies a tumour. He feels it should be
called a lymphatic malformation.

Incidence:
1/12,000 births , M=F
usually at birth or within the first year of life
may be identified in utero by ultrasound

Pathology:
Cystic hygromas begin to develop at about 40 days gestation and are due to the failure of the embryonic
lymphatics to connect with the venous system -> the lymphatics become dilated and continue to grow
forming cystic structures
the left-sided predominance may be due to a failure of the thoracic duct junction to connect with the left
subclavian vein
There are six primative lymph sacs: 2 jugular, 2 posterior in the sacral region, the cysterna chyli and the
thoracic duct, all of which eventually join up.

These are hamartomatous, lymphatic malformations that result in a multicystic mass which infiltrates tissue
planes and has no tendency to spontaneous regression (except occasionally antenatally, see later).
If diagnosed before 30/40 tend to be associated with a poor prognosis. They tend to be located in the
posterior cervical region and are associated with the presence of fetal hydrops and difuse
lymphangiomatosis. 1/2 will have abnormal karyotypes (Turner syn, trisomy 13, 21, 22) also Noonan
(Turner-like syndrome, webbing of neck, pectus excavatum, cryptorchidism, pulmonary stenosis), fetal
alcohol. Some with Turner and Noonan Syn will spontaneously regress in the second trimester and some
authors believe that it may be the aetiology behind the webbed neck seen in children with these syndromes.

After 30/40 it does not seem to be associated with hydrops or genetic anomalies.

Location:
75% in the neck, L:R 2:1
20% in the axilla
5% in the mediastinum, retroperitoneum, or pelvis

Lymphangioma is the most common cause of macroglossia in infancy. can also involve the buccal mucosa.
floor of mouth, salivary glands, including the parotid

Clinical Features:
diffuse, non-tender mass usually found in the neck at birth soft, well-demarcated, and irregular on
palpation
usually found in the posterior triangle of the neck
mass may be small -> large
easy to transilluminate
small and medium size hygromas are usually asymptomatic
larger hygromas may extend into the face, mouth, tongue, parotid, larynx, or chest (15% extend into the
mediastinum) and can be associated with complications

Complications:
upper airway obstruction (stridor, apneas, cyanosis) dysphagia
mandibular maldevelopment, and malocclusion.
nerve palsies
hemorrhage
infection
sinus formation

Investigations:
1. Ultrasound - unilocular or multilocular cyst with a thin or thick wall
2. Needle Aspiration - usually a clear or straw-colored fluid, may also be bloody, blood tinged, brown,
and/or purulent if complicated by hemorrhage or infection

Management:
Antenatal diagnosis by U/S is possible for larger masses; affected infants should be delivered in a centre
capable of expert ET intubation rare cause of obstructed labour, and elective C/S may be necessary in a
proportion.

Surgery:
surgical removal if large and/or symptomatic, may require multiple surgeries
In neck masses, the accessory nerve seems to be at most danger because it tends to get tented up by the
mass or become invested by it. The facial nerve usually lies deep to the masses and is less commonly
damaged (Pitkin).

Injection therapy:
OK-432 (an incubation of streptococcus and penicillin G) -has been very effective. Cannot give with
penicillin allergy, as made with penicillin G. Need pre and post op photographs, and preoperative CT scans.
Latest paper on how it works (Ogita et al 1996 31 477-480).

Bleomycin in a microsphere-in-oil fat emulsion (9mg/ml) given at a dose of 0.3-0.6 mg/kg has been used
with success in Japan (Tanaka et al 1990 PSI 5 270). Dr Shun uses 0.5mg/Kg.
Jill Orford (JPS 1995 30 1282). They treated 16 cases with an excellent response in 44%, good in 44% and
poor or none in 12%. 11 single treatments were used and 5 patients required multiple treatments.
no major side effects, and minor side effect occurred after 27% of injections (fever, vomiting, cellulitis,
skin discoloration. Recommends injection always under U/S control to miss the vessels.
Pulmonary toxicity resulting in pulmonary fibrosis is the main side effect of this drug- but has not been
reported after injection therapy and would not be expected with the low doses used.

Laser: - Has a use in airway lesions and is done in Sydney by the ENT Surgeons.
Radiotherapy: - Has been used in past but has side effects such as growth problems and thyroid
insufficiency.

Prognosis:
depends on size of cyst and if complications
unpredictable cystic growth and growth into surrounding tissues
some cysts may resolve spontaneously
recurrence is possible
normal life span and intelligence

Papers:
Langer et al looked at 29 fetuses diagnosed with cystic hygroma antenatally and found the majority
developed hydrops fetalis or diffuse lymphangiomatosis which led to fetal demise. There was usually either
an associated chromosomal abnormality (usually Turner syndrome, but many others have been reported)
spontaneous regression has occasionally been seen with Turner or Noonan syndrome. of the 27 fetuses
diagnosed before 30 weeks gestation only one survived. Twenty five of the 27 were aborted (21
therapeutic); severe hydrops was present in 21 of these 25. Two of the 27, both with stigmata of Noonan
syndrome, underwent spontaneous regression during the second trimester. Karyotype analysis appeared to
be important for genetic counselling, in that fetuses with abnormal chromosomes tended to be sporadic
cases, with a low risk of recurrence in future pregnancies. Normal chromosomes were correlated with a
history of consanguinity, multiple structural anomalies, polyhydramnios, and familial syndromes, with a
higher recurrence risk. The two fetuses diagnosed after 30 weeks gestation had a much different outcome.
Neither had hydrops, polyhydramnios, associated anomalies, or an abnormal karyotype. One had a
completely normal sonogram at 17/40, which suggests that the cystic hygroma had developed later in
gestation. Both survived after an operation at 4 days of life. They continue to say that there may be two
separate aetiologies for this condition with vastly different outcomes, ie those presenting before 30/40 and
those after which include the majority of cystic hygromas.

RANULA AND PLUNGING RANULA

A ranula is a cystic swelling in the floor of the mouth containing mucoid salivary secretions, which most
commonly originate from a sublingual salivary gland. The extravasated mucous may track below the
myolohyoid (plunging ranula). A plunging ranula is not epithelially lined and are therefore pseudocysts.
This may occur without a ranula being present in the floor of the mouth, in which case its origin may not be
appreciated.
Diff diag: branchial cyst, thyroglossal cyst, epidermoid cyst, tetatoid cyst, cystic hygroma, cervical thymic
cyst, laryngocoele, AV-malformation, lymphadenopathy, abscess, or soft tissue tumour.
U/S or CT should give diagnosis.
Excision of the ipsilateral sublingual gland seems to be essential in order to cure the condition. The
recurrence rate for plunging ranula after excision of the cyst through a submandibular incision is 85%, 53%
after marsupialisation, and 2% after excisionn of the sublingual gland with transoral drainage of the cyst.
TORTICOLLIS

Causes inc:
SM tumour common, > 3/52
Abn in utero posture improves with age
Cx hemivertebrae structural plain x-ray
RPh abscess toxic
Ocular imbalance 2o to squint
Post fossa tumour rare, other neurol signs
Spasmodic with GOR Sandifers syndrome
Postural familial

0.4% all births.

Bilat in 2-8%, Complete resolution in 50-70% by 6/12. 10% persist > 1yr
? d/t idiopathic embryopathy, positional disorder with SCM compartment syndrome
Assoc obstetric diffs in 60% ? cause or result. Breech 20-30%
Path is endomysial fibrosis around m fibres which then atrophy maturity of this in neonates suggests
prenatal onset
Discrete hard swelling 1-3cm in 2/3, rest have diffuse process affecting whole muscle. Head rotated to side
opposite, rotation restricted.

Secondary effects plagiocephaly within 1st few months, tends to resolve when sitting. Sig facial
hemihypoplasia > 8/12, more often noticed at 3-4yrs. Elevate ipsilat shoulder, scoliosis to keep eyes level.
All improve with SMT resolved.

Treatment:
Value of manipulation not proven, ? value of something being done ? place toys etc on opp side
Indications for Sx: - persistent tightness with LOR >12-15/12
- progressive facial hemihypoplasia
- presentation > 1yr
Technique GA, supine, shoulder roll, head to opp side
3-4cm incision 1cm > clavicle, 2 heads dissected and div with diathermy. Investing fascia divided
ant and post to muscle, continue across post triangle to ant border of trapezius can feel tightness,
under vision!. Close platysma, skin
recurrence rare - <3%. Comps haematoma, nerve damage
follow patients until T resolved completely, full ROM, SM feels normal.