29. Neck tumours and tracheostomy

1. Neck tumours: approach to a neck lump

By age

• Children → mostly inflammatory or congenital
• Young adults → inflammatory, congenital, lymphoma, thyroid
• Over 40 years → malignancy until proven otherwise (most often metastatic SCC)

By site

• Midline → thyroglossal cyst, thyroid isthmus, dermoid, lymph node
• Anterior triangle → lymph nodes, branchial cyst, carotid body tumour, salivary gland, thyroid lobe
• Posterior triangle → lymph nodes (lymphoma, metastasis, tuberculosis), lymphatic malformation, lipoma

Rule of 80 (adults)

• 80% of non-thyroid neck masses are neoplastic
• 80% of neoplastic masses are malignant
• 80% of malignant masses are metastatic
• 80% of metastases come from a primary above the clavicles

2. Benign neck tumours

• Lipoma
• Carotid body tumour (paraganglioma) → carotid bifurcation; pulsatile, moves side to side but not up and down (Fontaine's sign); splays internal and external carotid arteries (lyre sign) on imaging
• Schwannoma → vagus nerve, sympathetic chain
• Neurofibroma
• Benign salivary tumours → pleomorphic adenoma
• Thyroid adenoma, goitre

3. Malignant neck tumours

Primary

• Thyroid carcinoma
• Lymphoma → rubbery, painless nodes; B symptoms (fever, night sweats, weight loss)
• Salivary carcinoma
• Sarcoma

Secondary (metastatic)

• SCC of the upper aerodigestive tract → oral cavity, pharynx, larynx
• Thyroid carcinoma (papillary)
• From below the clavicles → Virchow's node (left supraclavicular, Troisier's sign) from stomach, lung, breast
• Unknown primary → panendoscopy, positron emission tomography-CT (PET-CT), tonsillectomy, tongue-base biopsy

Neck node levels

1. Level I → submental and submandibular
2. Level II → upper jugular
3. Level III → middle jugular
4. Level IV → lower jugular
5. Level V → posterior triangle
6. Level VI → central (pretracheal, paratracheal)

4. Diagnosis of neck masses

• History → duration, pain, smoking, alcohol, dysphagia, hoarseness, otalgia, B symptoms
• Examination → full ear, nose and throat (ENT) exam including nasoendoscopy
• Ultrasound with FNA → first-line
• Core biopsy → lymphoma
• CT or MRI of the neck, PET-CT
• Avoid open biopsy of a suspected SCC node → seeds the neck and worsens prognosis
• Excision biopsy → lymphoma when FNA and core are not diagnostic

5. Treatment principles of neck tumours

• Benign → excision
• Carotid body tumour → excision (Shamblin classification), preoperative embolisation in large tumours
• Metastatic SCC → treat the primary; neck dissection and/or radiotherapy
  • Radical neck dissection → levels I–V + sternocleidomastoid, internal jugular vein, accessory nerve
  • Modified radical → preserves one or more of these structures
  • Selective → only some levels
• Lymphoma → chemotherapy, radiotherapy

6. Tracheostomy

Definitions

• Tracheotomy → incision of the trachea
• Tracheostomy → creation of an opening in the anterior wall of the trachea, with a tube inserted
• Cricothyroidotomy → emergency airway through the cricothyroid membrane

Types

• By timing → emergency or elective
• By technique → open surgical, percutaneous dilatational (intensive care), cricothyroidotomy
• By level (relation to the thyroid isthmus) → upper (above), middle (through), lower (below the isthmus)
• By duration → temporary, permanent (laryngectomy stoma)

Indications

1. Upper airway obstruction → tumour, trauma, bilateral vocal cord palsy, angioedema, foreign body, infection (epiglottitis, Ludwig's angina)
2. Prolonged mechanical ventilation → > 7–14 days
3. Bronchial toilet → inability to clear secretions (neuromuscular disease, coma)
4. Protection from aspiration
5. Part of major head and neck surgery
6. Obstructive sleep apnoea (rare)

Steps (open elective tracheostomy)

1. Supine, shoulder roll, neck extended
2. Horizontal skin incision 2 cm above the sternal notch (midway between cricoid and sternal notch)
3. Divide platysma; separate strap muscles in the midline
4. Retract or divide and ligate the thyroid isthmus
5. Identify tracheal rings 2–4
6. Make the tracheal window (Björk flap, vertical slit, or excised window)
7. Withdraw the endotracheal tube to just above the opening
8. Insert the tracheostomy tube; inflate the cuff; confirm with capnography
9. Secure with ties and sutures

Postoperative care

• Humidified oxygen, suction
• Inner tube cleaning
• Spare tube and tracheal dilator at the bedside
• First tube change after 5–7 days, when the tract has formed

Complications

• Immediate → bleeding, pneumothorax, air embolism, injury to the recurrent laryngeal nerve or oesophagus, false passage
• Early → tube displacement, blockage (crusting), surgical emphysema, infection
• Late → tracheal stenosis, tracheomalacia, tracheo-innominate fistula (massive bleeding), tracheo-oesophageal fistula, persistent stoma, scar