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9.1 Introduction

The neck connects the organs of the head with those of the thorax. It contains important anatomic structures, including blood and lymphatic vessels, nerves and para-ganglia, muscles and vertebrae, and numerous lymph nodes, in addition to parenchymatous glands, salivary, thyroid, and parathyroid. The neck also contains organs of the upper aerodigestive tract: larynx, hypopharynx and segments of the oesophagus and trachea.

The fact that a neck mass can originate in any of the cervical structures means that a host of disorders challenges the diagnostic ability of the surgical pathologist. The differential diagnosis of a neck mass includes developmental, inflammatory, benign and malignant neoplastic lesions. The purpose of this chapter is to review the pathology and diagnosis of cervical cysts. Occult primary tumours of the neck and neck dissection also are discussed.

9.2 Anatomy

9.2.1 Triangles of the Neck

It is customary to divide the neck into two large triangles, the anterior cervical triangle and the posterior cervical triangle. The anterior triangle is bounded by the midline of the neck, the anterior border of the ster-nocleidomastoid muscle, and the inferior border of the mandible. The posterior triangle is bounded by the anterior margin of the trapezius muscle, the posterior border of the sternocleidomastoid muscle and the clavicle.

The anterior cervical triangle can be further subdivided into four lesser triangles (submental, submandibular, superior carotid and inferior carotid) and the posterior triangle into two (occipital and supraclavicular) the boundaries of which are described in greater detail in other sources [12].

Fig. 9.1. Cervical nodes by levels and sublevels: IA submental, IB submandibular, II upper jugular, IIA jugulogastric, IIB supraspinal accessory, III middle jugular, IV lower jugular, V Posterior cervical, VA spinal accessory nerve nodes, VB transverse cervical nodes, SC supraclavicular, VI anterior group

9.2.2 Lymph Node Regions of the Neck

Fig. 9.1. Cervical nodes by levels and sublevels: IA submental, IB submandibular, II upper jugular, IIA jugulogastric, IIB supraspinal accessory, III middle jugular, IV lower jugular, V Posterior cervical, VA spinal accessory nerve nodes, VB transverse cervical nodes, SC supraclavicular, VI anterior group

The deep medial cervical group consists of the prelaryn-geal, prethyroidal, pretracheal and paratracheal lymph nodes. The superficial medial lymph nodes are distributed around the anterior jugular vein. The superficial lateral cervical nodes are located along the external jugular vein.

Figure 9. 1 shows the system for describing the location of lymph nodes in the neck, and used the levels recommended by the Committee for Head and Neck Surgery and Oncology of the American Academy for Oto-laryngology-Head and Neck Surgery [99].

9.3 Cysts of the Neck

The cervical lymph nodes can be divided into superficial and deep nodes, and each of these groups into lateral and medial. The deep lateral nodes are distributed among several large groups:

1. The submental and submandibular group;

2. The internal jugular chain (superior, middle, and inferior);

3. The spinal accessory nerves chain;

4. The supraclavicular node chain.

Cysts of the neck are pathological cavities lined with epithelium. The type of epithelium varies, and the cavity may contain fluid, keratin, mucus or other products. Cervical cysts can be divided into two large groups: developmental and non-developmental. Establishing the precise nature of these cysts is important because there are considerable differences in their biological and clini-

Table 9.1. Order of frequency of cervical cystic tumours according to age (extracted from [52, 68, 70, 115]). CA carcinoma

Infants and children


Thyroglossal duct cyst Branchial cleft cyst Lymphangioma Haemangioma Teratoma and dermoid Bronchogenic cyst Thymic cyst Laryngocele Metastatic thyroid ca

Thyroglossal duct cyst Branchial cleft cyst Bronchogenic cyst Thymic cyst Teratoma and dermoid Metastatic thyroid ca

Metastatic cystic ca Thyroglossal duct cyst Cervical ranula Branchial cleft cyst Laryngocele Parathyroid cyst Thymic cyst cal behaviour [26]. Because of the frequent similarities in the morphological aspects of various cysts, a definitive diagnosis is dependent on clinical data. These include the exact location of the lesion and the age of the patient. The clinical manifestations of cysts depend largely on their size. Most cysts in the early stages are asymptomatic and are found on routine physical or radiographic examination. Rupture and drainage leads to infection, abscess, and sinus formation, which are frequently accompanied by pain and swelling. In certain instances, computed tomography scan can be of benefit in establishing the diagnosis and/or extension into adjacent structures [59]. Aspiration needle biopsy can also be useful in distinguishing between cysts and other pathoses that present a similar roentgenographic appearance [41].

In adults, an asymptomatic neck mass should be considered malignancy until proven otherwise. With the exception of thyroid nodules and salivary gland tumours, neck masses in adults have the following characteristics: 80% of the masses are neoplastic, 80% of neoplastic masses are malignant, 80% of malignancies are metastatic, and in 80%, the primary tumour is located above the level of clavicle [70]. In contrast, 90% of neck masses in children represent benign conditions. In a review of 445 children with neck masses, 55% of the masses were congenital cysts, 27% were inflammatory lesions, 11% were malignant and 7% were miscellaneous conditions [117]. Table 9.1 lists the causes of neck masses in order of the frequency with which they occur, according to the age of the patient.

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