5. Tumors of the neck. Tracheostomia. Indications and types

Question 1

Tumors of The Neck

Most common carcinoma

Answer 1

Squamous cell carcinoma (SCC) comprises >90% of all of the malignant pathology of the
mucosal lining of the upper aerodigestive tract

Question 2

Tumors of The Neck

Upper aerodigestive tract divisions

4 Points

Answer 2

Oral cavity

Pharynx

Larynx

Nasal cavity/
paranasal sinuses

Question 3

Tumors of The Neck

Etiology

Answer 3

Tobacco products

Alcohol

; cause most head and neck cancers

Question 4

Tumors of Neck

Tumor 1/2

Answer 4

Carotid Body Tumor
aka

Potato Tumour

Chemodectoma

Nonchromaffin
Paraganglioma

Question 5

Carotid Body Tumor

Arises from:

Answer 5

The carotid body, which is located at the bifurcation of the common carotid artery.

Question 6

Carotid Body Tumor

Types (3)

Answer 6

Sporadic (75%)

Familial (20%)

Hyperplastic (5%) - is associated with the chronic hypoxia
seen in high altitude (5,000 feet from sea level), COPD, cyanotic heart disease.

Question 7

Carotid Body Tumor Location

Answer 7

The tumour is situated in the adventitia of the artery

Question 8

Carotid Body Tumor -

Main Points

4

Answer 8

They are benign or locally malignant tumours (10%), but in 20% cases spread can occur to the regional lymph nodes and lungs.

Blood supply to the tumour is from ascending pharyngeal artery and external carotid artery. Tumour does not secrete epinephrine or any endocrine substances.
Blood supply comes through Meyer’s ligament on the posteromedial wall of the carotid at bifurcation.

Pathologically, it is well-encapsulated, hard creamy yellowish tumour with dense fibrous tissue. Carotid body tumour cells are not hormonally active.

Histologically cells are arranged in a classical pseudoalveolar pattern known as cell ball – Zellballen. It contains type I chief cells with catecholamine granules and type II sustentacular cells without granules.

Question 9

Carotid Body Tumor -

Clinical Features

10 points

Answer 9

Usually unilateral; 5% bilateral.

More common in middle age. Common in females.

Swelling (75%) in the carotid region of the neck which is smooth, firm, pulsatile (transmitted pulsation—due to pulsatile carotid vessel overlying its surface) and
moves only side to side but not in vertical direction (Fontaine sign).

It can often compress over oesophagus and larynx.

Headache, neck pain (35%), dysphagia, and syncope are other presentations.

10% may present with cranial nerve palsy (hypoglossal, glossopharyngeal,
recurrent laryngeal or spinal accessory) or sympathetic chain; so present as pain,
tongue deviation towards same side while protruding, dysphagia, unilateral vocal
cord palsy, hoarseness of voice, drooping shoulder and Horner’s syndrome.

Features of transient ischaemic attacks due to compression over the carotids, “carotid body syncope.”

Thrill may be felt and bruit may be heard.

It is located at the level of hyoid bone deep to anterior edge of the sternomastoid
muscle in anterior triangle, vertically placed, round, firm ‘potato’ like swelling.

Often tumour may extend into the cranial cavity along the internal carotid artery as dumbbell tumour.

Question 10

Sites where dumbbell tumours are seen

3 points

Answer 10

Parotid tumour

Spinal cord tumour

Carotid body tumour

Question 11

Classification of Carotid body tumor:

Name

3 Points

Answer 11

Shamblin classification:

1. Type I: Localised, easily resectable (26%)
2. Type II: Adherent, partially surrounding the carotids (46%)
3. Type III: Adherent, encased carotids completely (27%)

Question 12

Carotid body tumor

Investigations

6 Points

Answer 12

Doppler Angiogram to see the ‘tumour blush’—DSA. Widening/ splaying of the
carotid artery with tumour blush in an angiogram is called as Lyre sign.

CT scan

MR

MR angiography

MIBG scan

Question 13

MIBG scan - Function

Answer 13

Useful in multiple familial and functioning tumours
(they are smaller in size); in nonfunctioning tumours pentetreotide scan using
radiolabeled somatostatin analogue is used.

• No FNAC, No trucut biopsy, No partial excision.*

Question 14

Carotid body tumor

Differential Diagnosis

Answer 14

Carotid artery aneurysm

Soft tissue tumour (Sarcoma)

Lymph node enlargement.

Neurofibroma of the vagus nerve

Question 15

Neurofibroma of the vagus nerve

Presentation

3 Points

Answer 15

Presents as swelling in the carotid triangle in the region of thyroid as vertically placed, oval, hard swelling.

On palpation of the swelling, patient often develops bradycardia and dry cough. It does not move with deglutition and
has only transverse mobility.

As the tumour lies behind the carotid it can stretch the
carotid in front causing transmitted pulsation.

Question 16

Carotid body tumor

Treatment

4 Points

Answer 16

If it is small, then it can be excised easily as the tumour is situated in the adventitia.

When it is large, as commonly observed, complete excision has to be done followed by
placing a vascular graft.

During resection a temporary shunt (diversion of blood) is placed between common carotid below and internal carotid above to safeguard cerebral perfusion; external carotid artery is ligated. Venous or prosthetic graft is placed between common
carotid and internal carotid arteries.

Carotid body tumour is not radiosensitive (controversial).

Question 17

Carotid body tumor

Surgical Complications

3 points

Answer 17

Bleeding.

Blockage of common carotid artery, leading to contralateral side hemiplegia (3%).
This can be prevented by stenting the common carotid artery towards internal
carotid artery and is done during surgical excision of the tumour.

Cranial nerve injury X and XI (40%). Injury to vagus causes hoarseness of voice;
injury to superior laryngeal nerve alters the pitch of voice.

Question 18

Tumors of Neck

Tumor 2/2

Answer 18

Sternomastoid Tumor

Question 19

Sternomastoid Tumor

Etiology

Answer 19

It is due to birth injury to the sternomastoid muscle.

It is a misnomer. It is not a tumour

Question 20

Sternomastoid Tumor

Pathogenesis

2 points

Answer 20

During child birth, injury to the sternomastoid muscle causes haematoma in the
muscle which gets organised to form sternomastoid tumour.

Common in breech delivery

Question 21

Sternomastoid Tumor

Features

5 Points

Answer 21

It is seen in infants of 3–4 weeks age.

Swelling of about 2 cm size, in the sternomastoid muscle which is smooth, hard,
nontender and adherent to the muscle—in the middle part.

Chin pointing towards opposite side. Head towards same side (Scoliosis capitis).

In later age groups it causes hemifacial atrophy due to less blood supply as a result
of compression of the external carotid artery by sternomastoid tumour and due to
kinking by position of neck. Distance between the outer canthus of eye to angle of mouth is reduced, with less arched eyebrow, flat or less filled cheek and flat nose compared to opposite side.

Compensatory cervical scoliosis, and squint

Question 22

Sternomastoid Tumor

Differential Diagnosis

Answer 22

Other causes for torticollis

Question 23

Sternomastoid Tumor

Treatment

2 points

Answer 23

Division of the lower end of the sternomastoid muscle or excision of the muscle.
Both sternal and clavicular heads of sternocleidomastoid muscle should be divided
under general anaesthesia using horizontal incision. One should not injure IJV,
carotid, vagus, spinal accessory nerve. Additional all fibrous bands are also cut.
Usually over correction is done. Physiotherapy exercise and toricollis harness is used for 6–12 months.

Exercise and active stimulation of muscles in early cases

Question 24

Tracheotomy

Indiations and Timing

3 points

Answer 24

The most common cause for tracheotomy is prolonged intubation typically in critically ill intensive care unit patients. Prolonged intubation increases the risk of laryngeal and subglottic injury, which may lead to stenosis.

In the critically ill patient, it has been hypothesized that early tracheotomy may
improve inpatient survival and decreased intensive care unit length of stay while
increasing patient comfort.

Beyond prolonged intubation, tracheotomy is also indicated in patients who require
frequent pulmonary toilet, in patients with neurologic deficits that impair protective airway reflexes, and in head and neck upper aerodigestive tract surgery as a temporary airway in the perioperative period to bypass airway obstruction.

Question 25

Tracheotomy

Technique and Complications

4 points

Answer 25

The procedure can be performed using an open or a percutaneous technique.
Complications of tracheostomy include pneumothorax, tracheal stenosis, wound
infection/stomatitis with large-vessel erosion, and failure to close after
decannulation. No difference between the open and percutaneous techniques,
although there was a trend toward fewer complications in the percutaneous
approach.

The percutaneous approach was also found to be cheaper and had the added benefit
of being performed at the bedside outside of the operating room.

The use of cricothyroidotomy, typically in the emergency setting, is inferior to a
tracheotomy due to higher incidence of vocal cord dysfunction and subglottic
stenosis. Therefore, soon after a cricothyroidotomy is performed, a formal
tracheotomy should be used with decannulation of the cricothyroidotomy site.

Most tracheostomies are not permanent and can be reversed simply by removing
the tube and applying a pressure dressing. The stoma usually spontaneously heals
within 2 to 3 weeks.

Question 26

Tracheotomy

Speech with Tracheotomy and Decannulation

3 points

Answer 26

When a large cuffed tracheostomy is initially placed, speech is not possible, particularly
when the cuff is up.

However, when the tube is downsized to a cuffless tracheostomy
tube, intermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper airway obstruction in inspiration.

Prior to decannulation, the patient has to tolerate capping for 24 to 48 hours, but this period can be extended in patients with concerns for pulmonary toilet and an inability to clear secretions.