In The Name of God
Congenital Neck Masses
Dr. Babak Saedi
otolaryngologist
imam Khomeini hospital
Neck Masses - Considerations
Age
 Location

Lateral – branchial cleft cysts and laryngoceles
 Midline – thyroglossal duct cyst, dermoid cyst,
thymic cyst, and teratoma
 Exceptions – hemangiomas and vascular
malformation lesions
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Thyroglossal Cyst
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Painless, cystic midline swelling in the region of the
hyoid bone
Most common congenital midline mass
Can occur any age most common up to 12 years
F/M: 1
Commonly at the level of the hyoid
Become symptomatic through inflammation – Pain
and swelling
Moves up on swallowing and protrusion of the
tongue
Thyroglossal Duct Cyst
Cyst is a portion of the
thyroglossal duct, found at
the base of the tongue that
remains patent = cystic
structure
Ectopic thyroid tissue vs.
thyroglossal duct cyst
Base of tongue mass
Thyroid Scan
Thyroglossal Duct Cyst
B-mode Ultrasound
Thyroid Scan in patients
that do not demonstrate
a normal thyroid by US.
Thyroglossal Duct Cyst
Simple Excision leads to high recurrence rate
 Sistrunk Procedure
 Patients at high risk for recurrence- Modified
Sistrunk Procedure

Dermoids and Teratomas
Developmental anomalies composed of
different germ cell layers.
 Isolation of pluripotent stem cells or closure
of germ cell layers within points of failed
embryonic fusion lines.
 Classified according to composition.

Dermoid Cysts
Mesoderm and Ectoderm
 Midline, paramedian, painless masses that
usually do not elevate with tongue protrusion.
 Commonly misdiagnosed as Thyroglossal
Duct Cysts.
 Treatment is simple surgical excision

Teratoid Cysts and Teratomas
All three germ cell layers- Endoderm,
mesoderm and ectoderm.
 Larger midline masses, present earlier in life.
 Epignathi :most differantiated Teratoma
 Surgical excision.

Branchial System
Six pairs of mesodermal arches separated
externally by ectodermally-lined clefts and
internally endodermally-lined pouches
 Each arch consists of a nerve, artery, muscle
rudiment and cartilaginous skeleton
 This region develop between 3 to 7 week in
fetus.

Ectoderm
Pharyngeal Pouches and Aortic Arch
Cranial region of
developing
embryo
1.Arch
components
and floor of
primordial
pharynx
Branchial System

First Branchial arch
Maxillary and mandibular (Meckel’s) process
regress to leave the malleus and incus.
Ossification around Meckel’s cartilage gives rise to
the mandible, sphenomandibular ligament, and
anterior mallear ligaments.
Muscles- temporalis, masseter, pterygoids,
mylohyoid, ant belly of digastric, tensor tympani,
tensor veli palatini
Branchial System

First Branchial Cleft
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persists as the external auditory canal, and
tympanic membrane
First Branchial Arch
Nerve- 5th cranial nerve
 Artery- maxillary artery
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First Branchial Pouch
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persists as the Eustachian tube, middle ear,
portions of the mastoid bone.
Pharyngeal Arches. Second arch growing over
the third and fourth arch
Branchial System
Second Branchial Cleft: Cervical sinus of His
 Second Branchial Arch

Reichert’s cartilage contributes to the
superstructure of the stapes, the upper body and
lesser cornu of the hyoid, the styloid process and
stylohyoid ligament.
 Muscles- platysma, muscles of facial expression,
posterior belly of digastric, stylohyoid, and
stapedius
 Nerve- 7th cranial nerve
 Artery- stapedial artery
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Branchial System
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Third Branchial Cleft: Cervical sinus of His
Third Branchial Arch
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Lower body of the hyoid and greater cornu.
Muscles- stylopharyngeus, superior and middle
pharyngeal constrictors.
Nerve- 9th cranial nerve
Artery- common carotid and proximal portions of the
internal and external carotid.
Third Branchial Pouch
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Inferior parathyroids
Thymus gland and thymic duct
Branchial System
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Fourth Cleft: Cervical sinus of His
Fourth Arch
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Muscles- cricothyroid, inferior pharyngeal constrictors
Nerve- Superior Laryngeal Nerve
Artery- Right Subclavian, Aortic arch
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Fourth Pouch- superior parathyroid glands and
parafollicular thyroid cells
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Fourth and Sixth Branchial arches fuse to form the
laryngeal cartilages.
Branchial System
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Sixth Branchial Arch
Muscles- remaining laryngeal musculature
 Nerve- Recurrent Laryngeal Nerve
 Artery- Pulmonary Artery and ductus arteriosus
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Arch
Nerve
Muscles
Trigemina Muscles of
mastication
(mandibula l (CN V)
Mylohyoid and
r)
First
Skeletal
structures
ligaments
Malleus
Incus
Anterior
ligament of
malleus
Sphenomandibular
ligament
Stapes
Styloid
process
Lesser cornu
of hyoid
Upper part of
body of hyoid
bone
Stylohyoid
ligament
anterior belly of
digastric
Tensor tympani
Tensor veli
palatini
Second
(hyoid)
Facial
(CN VII)
Muscles of
facial
expression
Stapedius
Stylohyoid
Posterior belly
of digastric
Arch
Nerve
Muscles
Third
Glossopharyngea Stylopharyngeus Greater cornu of
l
hyoid
(CN IX)
Cranial laryngeal
Fourth
and Sixth branch of vagus
(CN X)
Recurrent
laryngeal branch
of vagus
(CN X)
Skeletal
Structures
Lower part of
body of hyoid
bone
Cricothyroid
Levator veli
palatini
Constrictors of
pharynx
Intrinsic muscles
of larynx
Striated muscles
of esophagus
Thyroid cartilage
Cricoid cartilage
Arytenoid
cartilage
Corniculate
cartilage
Cuneiform
cartilage
First Branchial Cleft Cysts
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Type I
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Ectodermal duplication
anomaly of the EAC with
squamous epithelium
only
Fistulous tracts near the
lower portion of the
parotid gland
Parallel to the EAC
Pretragal/ postauricular
sulcus
Surgical Excision
First Branchial Cleft Cysts
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Type II
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Represents anomalous EAC and
rudimentary pinna (epithelium,
mesoderm)
Cyst/ tract below angle of
mandible and through the parotid
in variable position to CN VII
Tract runs from the neck to the
EAC or middle ear
Surgical excision- superficial
parotidectomy
Second Branchial Cleft Cysts
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Most Common (90%) branchial
anomaly – failure of obliteration of
cervical sinus of His
Painless, fluctuant mass in anterior
triangle
Can occur at carotid bifurcation or
parapharyngeal space
Inferior-middle 2/3 junction of SCM,
deep to platysma, lateral to IX, X,
XII, between the internal and
external carotid and terminate in
the tonsillar fossa
Surgical treatment may include
tonsillectomy
Second Branchial Cleft Cysts and
Fistula
Third Branchial Cleft Cysts
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Patients present with recurrent
infections of the lower lateral
neck
Masses low in the anterior neck,
more often on the left side
Sinus tract starting at the piriform
fossa, through the thyrohyoid
membrane, tracking under CN
XII and carotid, but anterior to
CN X
Often track through the upper
pole of the thyroid
Lymphangioma
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Microcystic and macrocystic
Large, soft, compressible masses
60% presenting in 1st year, 90% by three years of
age
Type I and Type II
Anterior/OC/FOM vs. Posterior triangle
40% presenting with airway compromise
Centrifugal vs. Centripetal theory
MRI
Spontaneous regression is rare (8-15%) and
surgical excision is the treatment of choice.
Recurrence is 10-52%
Lymphangioma
Vascular Lesions - Classification
Mulliken and Glowacki: simple biologic
classification
 Hemangiomas and vascular malformations

Hemangioma: not evident at birth, rapid
endothelial proliferation followed by slow
involution.
 Vascular malformation: present at birth, normal
rate of endothelial turnover, lesion grows with the
child, progressive dilation of vessels
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Hemangiomas
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Most common pediatric
tumor.
Rapid proliferation of
endothelium, slow
progressive involution.
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Less than 33% present at
birth
90% of lesion involute
CT w/ contrast or MRI w/
Gadolinium.
If associated w/ stridor,
must rule out subglottic
hemangioma.
Vascular malformations

Nevus flammeus vs. port wine stain
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Sturge-Weber Syndrome
Venous Malformations
Lips and cheeks
 Expand with jugular venous congestion
 Intraosseous “soap bubble” appearance
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AVM
High flow – CHF
 Thrill/bruit
 Pain, ulceration, bleeding and pulsatile tinnitus
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Fibromatosis colli
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Torticollis with firm mass on the
SCM
Noted at birth or within 1st few
weeks
Inflammatory lesion of unknown
etiology with muscle
replacement by fibrosis
Range of motion exercises
Myoplasty of the SCM only if
refractory to PT