Head and Neck PPT 2024

HEAD AND NECK
CONGENITAL
ANOMALIES
DR.MANOJKUMAR K B
General surgery
Etiology of Congenital Anomalies
• Unknown cause (60%):
• The causes of malformations are not identifiable in the
majority of cases.
• Multifactorial factors (20%):

• Due to an interaction between genetic predisposition
and non-genetic intrauterine factors.
• Examples include neural tube defects, hydrocephaly,

facial clefts, cardiac anomalies, and imperforate anus.
2
DEVELOPMENT OF FACE
• Face is formed by 5 process which surround the stomodium
• 1]frontonasal -1
• 2]maxillary-1+1
• 3]mandibular-1+1
• Olfactory pits appear at 5th week
• FNP divided into –central median nasal process and two lateral nasal
processes
• MNP-forms septum,philtrum &premaxilla
• LNP-side of the nose
• Maxillary process -> cheek,whole upper lip,upperjaw and part of
palate.
• Mandibular process->lower jaw
• CLEFT LIP- FAILURE OF FUSION OF MAXILLARY AND MEDIAL NASAL
PROCESSES.
• Types of CL- unilateral cl
• -complete/ incomplete
• -bilateral cl.
DEVELOPMENT AND FUSION OF PALATE
THEORIES PROPOSED
CLEFT PALATE:
Cleft palate can be
Bifid uvula. A cleft on midline uvula.

Cleft soft palate.
Cleft bony palate.
Gap in the alveolar arch.
 Feeding problems leading to aspiration and infection.
 Corrective surgery: best results if performed around one year of age.
 Postoperative complications: are not rare.

 Recurrent otitis media.
 Speech and hearing problems
Classification of cleft palate
Etiology
• Genetic and environmental influences

• PR syndrome-mainly due mechanical obstruction by tongue
position due to retrognathia,
• Rubella
• Drugs-valium,anti convulsant,salicylates,steroids
• Monozygotic twins-40-50%
• Dizygotic-5%
ENVIRONMENTAL FACTORS
Clinical feautures
1]Feeding difficulties- due to difficulty in creation of negative pressure.
2]malnutrition,anaemia
3]recurrent resp infection-chronic rhinorrhea-middle ear effusion and
conductive hearing loss.
4]recurrent regurgitation –pneumonia,fever
5]Defective dentition-fused,missimg teeth.
-hypoplastic enamel,difficult oral hygiene- tooth decay
6] learning difficulty –due to compromised hearing
7]Hypernasal speech-inability to sound plosives[p/k/d/t]and fricatives[s/f]
8]Physical app-psychological depression to parents and toddlers.
THYRO-GLOSSAL CYST
• Embryological remanant due to failure of closure of thyroglossal duct
extending from foramen cecum in tongue to location of thyroid gland
in neck
• Midline cyst . Usually, asymptomatic till gets infected presents in
childhood or early adulthood
• Investifation- USG
• Excision of the middle third of the hyoid bone in continuity with the
cyst (Sistrunk's operation) should be performed to reduce the
possibility of recurrence
• A radioisotope thyroid scan before excision to ensure that a normal
thyroid gland is present.
BRANCHIAL CYST AND FISTULA
• Congenital epithelial cysts, on the lateral part of the neck due to

failure of obliteration of the second branchial cleft in embryonic
development.
• Commonest cysts to arise in the neck.
• Branchial cleft cyst = Lymphoepithelial cyst “Lymphatic origin, Modern
Theory”.
• Classical location Anterior to the sternocleidomastoid muscle.
CLINICAL PRESENTATION
• Solitary, painless mass in the neck .
• History of intermittent swelling and tenderness of the lesion during
upper respiratory tract infection may exist.
• Discharge if associated with a sinus tract.
• May present with locally compressive symptoms.
• Positive family history.
• On examination- smooth, nontender, fluctuant masses, along the
lower one third of the anteromedial border of the
sternocleidomastoid muscle between the muscle and the overlying
skin.
• Tenderness if secondarily inflamed or infected.
• When associated with a sinus tract, mucoid or purulent discharge
onto the skin or into the pharynx may be present
Differential Diagnosis
• Branchiogenic carcinoma , Tuberculous adenitis , Lipoma
• Metastatic malignant neoplasms (SCCA from a primary site in the
aerodigestive tract)
• Cystic hygroma (lymphangioma) , Carotid body tumors
• Lymphomas , Hemangiomas , Thyroid cysts , Ectopic thyroid
• Cervical thymic cysts , Thyroglossal duct cyst
• Parotid cystic tumors
• INVESTIGATIONS
Ultrasound - Well defined, echogenic mass usually anterior to the
carotid artery, draped anterior to the sternocleidomastoid muscle
CT NECK- Well defined, low density unilocular mass with a thin

uniformly enhancing rim
TREATMENT - surgical excision

Cervical lymphadenopathy
Characteristic features of lymphadenopathy found along jugular vein.
Mostly benign related to respiratory and throat infections .
Histological appearance - reactive hyperplasia

Lymphadenitis
• If the history of the condition is longer (over a period of weeks), less
acutely tender,— and responds only partially or not at all to an
appropriate antibiotic then lymphadenitis due to mycobacterial
organisms should be considered.
• In Western countries the causative organism is usually an atypical
mycobacterium (such as Mycobacterium avium-intracellulare).
Characteristic features of lymphadenitis
• Acute tenderness
• Pain
• Swelling
• Erythema of overlying skin
• If pus formed, it requires surgical drainage
Oral Candidiasis
Candida albicans is an oral commensal in 20-40% of population.
Infection occurs in: Infants Patients on broad spectrum antibiotics,

steriod or cytotoxic therapy Diabetes Neutropenia Immunodeficiency
(AIDS).
Presents as superficial gray-white inflammatory membranes comprising

fungus in a fibrinosuppurative exudate.
Treatment
- Mild, chronic – topical Nystatin + Clotrimazole troches
(troche=lozenge)
- Refractory or immunocomprimised WITHOUT systemic involvement –

add oral Fluconazole Severe forms (systemic) – IV Amphotericin B with
or without Fluconazole.
Apthous Ulcers (Canker Sores)
• Apthous ulcers are extremely common lesions (up to 20% of
population)
• They are painful, multiple, small, shallow, recurrent ulcerations
• Presented clinically as white lesions (1<,1> CM) Etiology is unknown

• Aphtha = Whitish spot
• Most common cause of non-traumatic ulcerations of the oral cavity.
• Diagnosis of exclusion.
• Classification
- Minor aphthous ulcer < 1cm in diameter.
Located on freely mobile oral mucosa.
Resolve in 7-10 days without scars
- Major aphthous ulcer > 1cm in diameter.
Involves freely mobile mucosa, tongue, and palate.
Last much longer – 6 weeks or more .Heals with ulcer
HERPETIFORM ULCERS
• Small, 1-3mm in diameter ulcerations .
• Typically located on mobile oral mucosa, tongue, and palate .
• Last 1-2 weeks .
• Called herpetiform because ulcerations resemble those of HSV, but

there is no vesicular phase .
• Treatment Topical tetracycline solution for 5-7 days

Oral Cancer Aetiology:
• Tobacco and alcohol are the most common associations: Smokers can
have 15-fold greater risk ( than nonsmokers ) of malignancy.
• Leukoplakia and Erythroplakia
• Human papilloma virus (HPV) (type16)
• Genetic factors may also play a role (deletions in chromosomes 18q,
lap, 8p, and 3p are implicated).
• Exposure to ultra-violet light (cancer of the lip).
Squamous cell carcinoma of lip
• Gross: Ulcerated nodule with raised everted edges often on lower lip
• Histologically: Well differentiated squamous carcinomas .Growth is

relatively slow .
• Metastasis to submandibular nodes and deeper cervical lymph nodes

SQUAMOUS CELL CARCINOMA OF
TONGUE & FLOOR OF THE MOUTH
• More aggressive than tumors of the lips .
• Spread:
-Local Local infiltration to floor of the mouth, facuces and pharynx
leads to fixation the tongue, interfering with speech and swallowing.
Local spread also into the medullary cavity of the mandible.
-lymphatic spread (occurs early) → deep cervical lymph nodes.

• Precancerous Lesions- Leukoplakia and Erythroplakia
• Causes include:
- Chronic tobacco use (pipe - smoking).
- Chronic irritation (e.g.; dentures).
- Alcohol abuse.
LEUKOPLAKIA
• Whitish plaque that cannot be scrapped off .5-20% malignant
potential .
• Microscopic examination reveals hyperkeratosis and atypia.
• Lesions on lateral tongue, lower lip, and floor of mouth more likely to
progress to malignancy
ERYTHROPLAKIA
• Red patch or macule with soft, velvety texture.
• Much higher chance of harboring malignancy – 60-90% of untreated

cases .
• Treatment is surgical excision or laser ablation

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HEAD AND NECK

• Multifactorial factors (20%):

• Examples include neural tube defects, hydrocephaly,

Bifid uvula. A cleft on midline uvula.

 Postoperative complications: are not rare.

• Genetic and environmental influences

• Congenital epithelial cysts, on the lateral part of the neck due to

CT NECK- Well defined, low density unilocular mass with a thin

TREATMENT - surgical excision

Characteristic features of lymphadenopathy found along jugular vein.

Mostly benign related to respiratory and throat infections .

Histological appearance - reactive hyperplasia

Candida albicans is an oral commensal in 20-40% of population.

Infection occurs in: Infants Patients on broad spectrum antibiotics,

Presents as superficial gray-white inflammatory membranes comprising

- Refractory or immunocomprimised WITHOUT systemic involvement –

• They are painful, multiple, small, shallow, recurrent ulcerations

• Presented clinically as white lesions (1<,1> CM) Etiology is unknown

• Typically located on mobile oral mucosa, tongue, and palate .

• Last 1-2 weeks .

• Called herpetiform because ulcerations resemble those of HSV, but

• Treatment Topical tetracycline solution for 5-7 days

• Histologically: Well differentiated squamous carcinomas .Growth is

• Metastasis to submandibular nodes and deeper cervical lymph nodes

-lymphatic spread (occurs early) → deep cervical lymph nodes.

• Microscopic examination reveals hyperkeratosis and atypia.

• Much higher chance of harboring malignancy – 60-90% of untreated

• Treatment is surgical excision or laser ablation

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