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Benign Tumors of
Head and Neck
Dr. Billones

Erik
14

References: Source: Cor Christi batch 2009 and 2011, past powerpoint, recording, past-e
Guys, this is based on batch 2012 ppt. Ayaw kasi bigay ni doc ung new ppt nya.
Items that came out in the past-es are Emphasized.
I encourage everyone to read other references na rin, remember mahirap maging pula ulit ung Evals
results nating lahat. Thats all I ask of you. God bless!
BENIGN TUMORS OF HEAD AND NECK
I. SURGICAL ANATOMY OF THE NECK
Anterior
Submandibular
Carotid
Muscular
Submental
Lateral
Occipital
Supraclavicular
The neck is divided into specific
triangles: anterior triangle and
postero-lateral triangles.
The sternocleidomastoid will divide
. the neck into anterior and posterior
triangle.

A. TRIANGLES OF THE NECK


Knowing the anatomy is important so that you will know what structures to look for when
presented with masses in these particular areas. And based on what is under those triangles,
more or less it will give us an idea of what structures are involved:
Location
Anterior

Posterolateral

Triangle

Boundaries

Components

submandibular
triangle

digastric muscles

floor of the mouth,


submandibular gland
and LN, facial
vessels, carotids,
IJV, vagus nerve

carotid

digastric and
omohyoid

carotid artery, IJV,


hypoglossal
and
laryngeal nerve

muscular

omohyoid and hyoid

midline
structures;
thyroid,
strap
muscles,
larynx,
traches, esophagus

submental

digastric and hyoid

submental
nodes

Occipital

SCM, traps, inferior


belly of omohyoid

nerves
spinal
nerve

Supraclavicular

SCM, inferior belly


of
omohyoid,
clavicle

low and middle


trunk of brachial
plexus,EJV,
subclavian artery,
nerve
to
subclavius

lymph

such
as
accessory

contains the cervical


parts of the
aerodigestive tract:
larynx and trachea,
hypopharynx and
esophagus, thyroid
and parathyroid
glands, carotid
sheath and the large
neurovascular
structures contained
therein, and
suprahyoid and
infrahyoid strap
muscles, and
associated
neurovascular and
lymphatic structures.
bounded by the
borders of the
sternocleidomastoid
and trapezius and
the middle third of
the clavicle.
Contains fibrofatty
lymphatics,, CN XI,
cervical nerve
plexus, and small
vascular bundles,
hence known as
bloody gulch

B. CERVICAL LYMPHATICS
Cervical lymphatics are important in localization of the sites because this will give an idea on what
primary sites to look for.
Superficial
lie near the surface of the neck along the external jugular vein
Superficial anterior and Superficial lateral
perforate the first layer of cervical fascia to empty into the deep cervical lymphatic chain
Although frequently involved by metastasis, especially during the late stages, the superficial
lymph nodes are nevertheless of little significance from a practical standpoint of surgical
treatment.
The reason is that if superficial lymphatics are involved with cancer they cannot be removed
without resection of large areas of skin.
Deep more important
since they receive lymph from the mucous membranes lining the mouth, pharynx larynx, and
major salivary and thyroid glands, as well as the skin of the head and neck.
Accompany the internal jugular vein and their branches or lie within the major salivary glands
Anterior
Submandibular (I)
preglandular
interglandular
prevascular and retrovascular
submental (IB)
Anterior Compartment Group (VI)
Pre-tracheal
Para-tracheal
Pre-laryngeal
Jugular chain (II, III, IV) -> related to IJV
superior jugular (Subdigastric) (II)
o junctional nodes of Finch
middle (III)
inferior (IV)
o prescalene nodal masses
Lateral (Spinal accessory group) (V)
Upper
Middle
Inferior
o supraclavicular group
Left
Thoracic duct
climbs upward and left lateral arch behind the carotid sheath, receives tributaries from the neck,
enters the venous junction between the internal jugular and subclavian veins
Virchows nodes-enlarged, hard, left supraclavicular nodes that may indicate abdominal
malignancy
Multiple lymphatic ducts drain the right side which also drains to the venous system in the right.
Right
Multiple lymph vessels (right lymphatic duct)

II. BENIGN TUMORS OF HEAD AND NECK

0-15

Frequency distribution by age, causative group and location


16-40
>40

CONGENITAL
Vascular lesions (AT)
Branchial cyst (AT)
Thyroglossal cyst (M)
Dermoid (M)

CONGENITAL
Branchial cyst (AT)
Thyroglossal cyst (M)
Dermoid (M)

NEOPLASTIC
Metastatic
Carcinoma
Thyroid

INFLAMMATORY ADENITIS
Bacterial (AT/PT)
Viral (AT/PT)
Granulomatous (PT/AT)

INFLAMMATORY ADENITIS
Viral (AT/PT)
Bacterial (AT/PT)
Granulomatous (PT/AT)

INFLAMMATORY ADENITIS
Viral (AT/PT)
Bacterial (AT/PT)
Granulomatous (PT/AT)

NEOPLASTIC
Lymphoma (AT/PT)
Thyroid Ca (M)
Sarcoma (AT/PT)

NEOPLASTIC
Lymphoma (AT/PT)
Thyroid Ca (M)
Salivary (AT)
Metastatic (AT/PT)
Vascular (AT/PT)
Neurogenic (AT)

CONGENITAL
Branchial cyst (AT)
Thyroglossal cyst (M)

AT anterior triangle
PT posterior triangle
M midline
younger group (0-15) -> Congenital (more common in this group) > inflammatory adenitis >
neoplastic(least to think of)
***middle age group (16-40) -> most present with congenital
***older age group (>40) -> (think of) neoplastic > inflammatory adenitis > congenital (least to
think of)
A. BENIGN VASCULAR LESIONS
1. HEMANGIOMAS
a. Classification of Vascular Anomalies
Tumors (proliferative)- grow by cellular or endothelial hyperplasia, regress or persists

Juvenile hemangioma
Rapidly involuting congenital hemangioma
Noninvoluting congenital hemangioma
Kaposiform hemangioendothelioma
Tufted angioma

Vascular malformations (structural anomalies)- quiescent


morphogenesis, never regress
High-flow
o Arteriovenous malformation
Low-flow Venous malformation
o Lymphatic malformation
o Lymphatic-venous malformation
o Capillary (or venular) malformation

endothelium,

local

defects

b. Description
overproliferation of vascular entities due to abnormal changes in angiogenesis
characterized histologically by high endothelial cell turnover
compared with vascular malformation which have normal endothelial cell turnover and
abnormal gross vascular anatomy
clinical "life cycle includes proliferative, plateau, and involution
30% are visible at birth, 70% become visible within one to four weeks after birth; majority are
visible a month after birth

of

occur 5 times more often in females than in males, predominantly in Caucasians


low birth weight infants (less than 2.2 pounds) have a 26% chance of developing a lesion
usually involute in time (30% will resolve by 3 years of age, 50% by 5 years of age, and 80%-90%
by 9 years of age) -> so do watchful waiting and manage conservatively
composed of proliferating, plump endothelial cells with limited basement membranes which
eventually form vascular spaces and channels
tissue inhibitors of metalloproteinases(TIMPs), along with interferon and transforming growth
factor produced by the mast cells, terminate the endothelial cell proliferation and passively
induce involution by senescence of endothelial cells
cause nor the cell of origin of infantile hemangiomas has not been definitively elucidated
Theories on the cell of origin:

- placental tissue- cell markers (GLUT- 1, merosin, Lewis Y)


- endothelial progenitor cells (EPCs)
- mesenchymal stem cells

visible lesion on the face or neck may signify presence of another internal hemangioma
or may be part of a syndromic complex
o
o
o
o
o

PHACES
Posterior fossa structural brain abnormalities
Hemangioma
Arterial Lesions
Cardiac abnormalities/Coarcatation
Eye abnormalities

over one-half of hemangiomas heal with an excellent cosmetic result without treatment
hemangiomas are proliferative lesions as compared to arteriovenous malformations which are
vessel malformations
Superficial

flat lesions which appear reddish in color

deep beneath the skin and bluish in color

both deep and superficial

Deep
Compound

c. Clinical Presentations:

Cavernous

compressible globular, bright red or deep purple involving deep structures

plaque-like lesions, slightly elevated, more superficial

flat, capillary type, mostly in dermis

Capillary
Port-wine stain

Strawberry marks

capillary type with cavernous component

Spider telangiectasia
Senile hemangiomas/ruby spots
d. Indications for treatment: (PAST E)
***usually just do watchful waiting and inform the parents/px that it will involute in time because chances
are, it will.

Involvement of a vital organ, like the eye or ear, or windpipe


Bleeding (recurrent)
Ulceration
Crusting or infection
Rapid growth and deformity (that will compromise function; e.g airway)of the surrounding tissues

e. Diagnosis and Treatment:


CT scan, MRI for deep and large lesions
Ultrasonography with color flow is cost effective but is operator dependent and does
notaccurately depict the relation of the lesion to other anatomic structures
for fairly small areas and not on the face, intralesional injection with steroids with or without
liquid nitrogen cryosurgery
Pulsed dye laser can be used to reduce the superficial component along with the steroid
injection
Larger hemangiomas require oral steroids usually given during the proliferative phase,
inhibits vascular endothelial growth factor (VEGF)
Alpha-interferon is recommended for lesions not responding to steroids and if the lesion is
problematic or life threatening (Spastic dysplegia has been associated in 10-12% of the children
taking this drug)
Surgical excision -> could be very bloody (since it is a vascular lesion) so plan the surgery well
to prevent blood loss
Embolization
2. LYMPHANGIOMAS
a. Description
represents tumors, malformations or hamartomas of the lymphatic system
collections of lymph vessels filled with serous fluid
soft lesions with ill-defined borders
50% apparent at birth, 90% appear before age 2 years
reflects a failure of lymph ducts to connect with the venous system during
embryogenesis, abnormal sequestration of lymphatic structures, or both
found in patients with syndromic conditions (Turner, Klinefelter and Noonans syndromes)
b. Types

Lymphangioma circumscriptum
confined to superficial skin, forming small, vesicle-like lesions
Cavernous
tongue, cheek, floor of mouth, lips, nose
Cystic Hygroma
most common in the neck (posterior triangle behind the SCM) but may extend to
the head, face, axilla or mediastinum
Multicystic
tend to spread along vital structures and high incidence of recurrence

c. Diagnosis and Treatment


CT Scan, MRI for large and deep lesions
Wide surgical excision, staged excisions
in localized disease, a conservative period of watchful waiting is appropriate if the
lesion causes no immediate compromise to life functions
fewer than 15% of lesions spontaneously regress
some surgeons believe that if the lesion has not spontaneously regressed by age 5
years, surgical intervention is warranted
excision should be performed sooner to avoid complications (e.g. infection)
multistage operation for diffuse disease

B. BENIGN SALIVARY GLAND TUMORS


most (70%) salivary gland tumors originate in the parotid gland (PAST E)
remaining tumors arise in the submandibular gland (8%) and minor salivary glands (22%)
75% of parotid gland tumors are benign, slightly more than 50% of tumors of the submandibular
gland and 60-80% of minor SGTs are found to be malignant
classic presentation of a benign SGT is a painless, slow-growing mass on the face(parotid), angle
of the jaw (parotid tail, submandibular), or neck (submandibular) or a swelling at the floor of the
mouth (sublingual).
freely mobile, no facial nerve involvement- PAST E
sudden increase in size may be indicative of infection, cystic degeneration, hemorrhage
inside the mass, or malignant degeneration
1. BENIGN EPITHELIAL TUMORS
Pleomorphic Adenoma (Benign Mixed Tumor)
most common tumor of the salivary gland
originate from intercalated duct cells and myoepithelial cells
most often located in the tail of the parotid gland
when in the minor salivary glands, the hard palate is the site most frequently involved, followed
by the upper lip
contains epithelial and connective tissue components
Case Example: A 45 yr old female, right pre-auricular mass, firm, well-circumscribed, movable,
nontender w/ no facial nerve deficit.
Warthins Tumor (Cystadenolymphoma)
smooth, soft, parotid mass, well encapsulated and contains multiple cysts
has a heavy lymphoid stroma
tends to be bilateral (10% of cases)
Intraductal papilloma
small, tan, fairly smooth lesion, usually found in the submucosal layer
rare
Oxyphil adenoma (oncocytoma)
manifest as small (<5 cm in diameter), firm, slow-growing, encapsulated, spherical masses
bilateral oncocytomas of the parotid glands have been described
originate from striated duct cells

2. BENIGN NON-EPITHELIAL TUMORS


Hemangiomas
most common SGTs in children and usually involve the parotid gland (PAST E)
may be distinguished from vascular malformations by their presence early in life, rapid growth phase
in children aged approximately 1-6 months, and gradual involution over 1-12 years
an asymptomatic, unilateral, compressible mass
treatment should initially consist of steroids (response may be immediate in 40-60% of cases)
despite the tendency toward spontaneous involution, specific conditions may warrant surgical
excision.
Lymphangioma (Cystic Hygroma)

manifest as painless masses that may involve parotid glands, submandibular glands, or both
diagnosis is made based on clinical findings -> soft with straw-colored fluid upon aspiration
surgical excision with preservation of the vital structures is the treatment of choice
rarely cause symptoms of airway obstruction and excision is usually for cosmetic reasons

Lipoma
relatively uncommon in a major salivary gland
derived from fat cells
appear grossly as smooth, well-demarcated, bright-yellow masses
consists of mature adipose cells with uniform nuclei.

3. SALIVARY GLAND TUMORS DIAGNOSTIC PROCEDURES


the utility of FNAB has been well established with a reported accuracy rates of 74-90%
procedure is somewhat operator dependent
it is generally regarded as safe, simple to perform, and relatively inexpensive and results in
low morbidity
controversy exists about whether FNAB is warranted for masses in the superficial lobe of the
parotid gland, as it is not likely to change the management because you end up still removing
the superficial lobe
CT scan or MRI for deeper lesions
Management of benign SGTs includes complete removal with an adequate margin of tissue To avoid
recurrences
Surgical Complications
- recurrence from inadequate excision or innoculation
bleeding
seroma formation
nerve injury (facial, lingual, hypoglossal nerves)
salivary fistula
Frey Syndrome gustatory sweating caused by aberrant connection of parasympathetic fibers of
the salivary gland to sweat glands of the skin. (PAST E)
C. BENIGN ODONTOGENIC TUMORS
ODONTOGENIC CYSTS AND TUMORS
derived from tissues of developing teeth

1. ODONTOGENIC CYSTS (Inflammatory)


Radicular Cyst

Did you know?


For the taga-taas dati, DLSU-D is
now PAASCU Level 4, meaning it
now has the same quality of
education as DLSU-M and ADMU

most common odontogenic cyst (65%)


thought to arise in response to inflammation
originate in preexisting periapical granulomas
painless when sterile but painful when infected
xray shows pulpless, nonvital tooth with small well-defined periapical
radiolucency at its apex

Tx: extraction of the affected tooth and its periapical soft tissue

Paradental Cyst
Due to inflammation of the gingiva overlying a partly erupted third molar.

2. ODONTOGENIC CYSTS (Developmental)


Dentigerous Cyst
nd

developmental cyst, 2 most common (24%)


originate via the accumulation of fluid between reduced enamel epithelium and a completed tooth
crown
usually found in the mandibular third molars, maxillary canines, maxillary third molars
most are asymptomatic, but large lesions can cause displacement or resorption of adjacent teeth and
pain
xray shows a unilocular radiolucency with well defined sclerotic margins encircling the crown
of an unerupted tooth -> may clinically present the same as a radicular cyst but is different
radiographically (PAST-E)
enucleation or decompression followed by enucleation if large.

Break Bati:

Odontogenic Keratocyst
rd

3 most common
scalloping on x-rays
great mimic (e.g. ameloblastoma, dentigerous cyst)
diagnosis is a histologic one
aggressive and can be difficult to remove
can grow quite rapidly, with frequent
recurrences
- 40% of OKCs appear in a dentigerous
relationship, 9% of dentigerous cysts are OKCs when the histology is examined

Hi to my buchi mates! And


my SC cam whore mates,
seatmates and all other
mates. Hehe.
Rusty, pag nasa Thailand ka
na pakikamuzta kay PJune
ha. Check mo na lng sa Fb
ko. Hehe.

Lateral Periodontal cyst


-

well-circumscribed unilocular radiolucency along the lateral periodontal are


arises from cystic degeneration of clear cells of the dental lamina
most frequent location is at the level of the mandibular premolars but it has been reported
occurring in other areas
clinically silent and is usually discovered during routine radiologic examination

Residual Cyst
-

an odontogenic cyst that remains within the jaw after the removal of the tooth with which it was
associated
Gingival Cyst of the Newborn- Bohn's nodules

few or many, white to yellowish, round to oval, nodes in the maxillary and/or mandibular gingiva
and alveolar ridge of newborns (PAST-E)
cystic degeneration of epithelial rests of the dental lamina (rests of Serres).
majority of these cysts break by themselves, a few days after birth exuding the keratin.
In some babies they may remain for a period of several months, in such cases surgical opening
is indicated.

3. ODONTOGENIC TUMORS
Ameloblastoma
most common odontogenic tumor (PAST-E)
benign but locally invasive neoplasm
(acts like a malignant lesion) derived from
odontogenic epithelium
multicystic (86%), unicystic (13%) and peripheral (extraosseus 1%)
may arise from the lining of a dentigerous cyst but more often
arises independently of impacted teeth
progressive growth rate and may reach enormous proportions
symptoms may include a painless swelling, loose teeth, malocclusion, or nasal obstruction.
maxillary tumors frequently perforate into the antrum and may grow freely, with extension into the
nasal cavity, ethmoid sinuses, and skull base
they can exhibit cytologic features of malignancy with squamous differentiation (< 1%) -> malignant
degeneration
unilocular often confused with odontogenic cysts
radiograph shows multilocular radiolucency with a predilection for the posterior mandible, wellcircumscribed, soap-bubble appearance (PAST E)
Dx: biopsy
Tx: complete excision, including adequate zone of normal-appearing bone around the main tumor
mass; mandibular reconstruction
Calcifying Epithelial Odontogenic Tumor
Adenomatoid Odontogenic Tumor
Squamous Odontogenic Tumor
Calcifying Odontogenic Cyst

4. RELATED JAW LESIONS


FIBROOSSEUS LESIONS
Fibrous dysplasia
replacement of medullary bone with fibrous tissues, leading to expansion and weakness of
the involved bone
likely due to gene mutation
found in the proximal femur, tibia, humerus, ribs, and craniofacial bones (aside from the head
& neck)
monostotic, polyostotic (different bone involvement), McCune-Albright syndrome (polyostotic
fibrous dysplasia occurs with pigmented skin lesions or "cafe au lait" spots and hormonal
abnormalities
radiography shows a ground glass appearance- PAST E
bone scan (particularly for polyostotic lesions) to evaluate entire skeleton
CT scan
conservative management, tend to mature -> when they mature, they harden
contouring or resection with reconstruction -> for cosmetic purposes
D. SOFT TISSUE TUMORS
1. FIBROMATOSES
non metastasizing, locally invasive fibroblastic or myofibroblastic lesions
Desmoid fibromatosis
deep-seated, benign, slowly growing
Greek word "desmos - band or tendon-like
intraabdominal or extraabdominal
usually at the supraclavicular fossa at head and neck
may develop along surgical scars
locally aggressive, but do metastasize
tumor-related destruction of vital structures and/or organs can be fatal, particularly when they
arise in patients with familial adenomatous polyposis (FAP, Gardner's syndrome)
CT Scan, MRI, biopsy
high rate of recurrence with surgery alone
Systemic therapy include antiinflammatory agents, hormonal agents (eg, tamoxifen), and
cytotoxic chemotherapy
Radiotherapy
Fibromatosis Colli (Sternocleidomastoid Tumor)
produces torticollis (wry neck)
usually develops several weeks after birth, slowly increase in size over 2-3 months, then
regresses and disappears in 4-6 months
olive-shaped or oval tumor mass in the lower third of the SCM
high incidence of difficult labor and breech presentation
CT Scan, MRI, biopsy
conservative managament, stretching exercises
surgery for progressive torticollis at an older age

2. NEUROGENIC TUMORS
Neurilemoma (Schwannoma)
encapsulated neoplasms from Schwann cells
slow-growing tumor, present for several years
pain and neurologic symptoms are uncommon unless the tumor is
large or, by virtue of a deep-seated location, is impinging on neighboring structures.

waxing and waning of the tumor size may be noted due to fluctuations in the amount of cystic
change and high vascularity
common along lateral neck region
exact nerve of origin may be impossible to determine
CT Scan, MRI, biopsy
Surgical excision

Neurofibroma
affects all neural crest cells (schwann cells, melanocytes, endoneural fibroblasts genetically
inherited, autosomal dominant
usually arise from subcutaneous tissues(ill-defined and unencapsulated) but
may also occur deeper in head areas (circumscribed and encapsulated)

tend to be multiple (associated with caf-au-lait spots, von Recklinghausens


disease)

significant risk of developing malignant neurogenic tumors if with multiple


neurofibromatosis frequently found in the head rather than neck

CT Scan, MRI, biopsy


Surgical excision

3. PARAGANGLIOMAS
arise from the glomus cells (chemoreceptors located along blood vessels that have a role in
regulating blood pressure and blood flow)
found in the abdomen (85%), thorax (12%), and head and neck (3%)
unlike paragangliomas of the abdomen,
head andneck paragangliomas
rarely secrete
catecholamines
most occur as single tumor
when occuring at multiple sites they are usually found as a part of a heritable syndrome such as
multiple endocrine neoplasia types II-A and II-B
MEN Type IIA
Medullary Ca
Pheochromocytoma
Parathyroid

MEN Type IIB


Pheochromocytoma
Medullary Ca
Mucosal Neuromas
Marfanoid habitus

Typical locations for paragangliomas of the head and neck


1) Carotid body tumor - from the carotid body, a baroreceptor and chemoreceptor, at the
bifurcation of the common carotid,(PAST-E) may extend to the skull base, pharynx, or along
cranial nerves
2) Glomus vagale - from the paraganglia of the vagus nerve, may compress the internal jugular,
displace the carotid vessels anteromedially, or pushe the pharyngeal wall medially

3) Glomus tympanicum - from paraganglia along the tympanic branch of the glossopharyngeal
nerve, also known as Jacobsen's nerve, or the auricular branch of the vagus nerve, also known
as Arnold's nerve. It is often seen at the dome of the jugular bulb or submucosally at the cochlear
promontory. By definition it remains confined to the middle ear and mastoid air cells.

4) Glomus jugulare - within the jugular foramen from the jugular bulb, Jacobsen's nerve, or
Arnold's nerve. It may extend through bone into the mastoid air cells and middle ear with an
aggressive pattern of bone destruction.
Carotid Body Tumor/ Paraganglioma
most common head and neck paraganglioma
slow-growing, painless neck mass along the anterior edge of the SCM lateral to the tip of the
hyoid bone
may expand and cause bulging of the pharynx
may compress adjacent nerves to cause hoarseness, dysphagia, cord paralysis
Angiography, CT Scan
Surgical excision

4. LIPOMAS

most common soft tissue tumor


composed of mature adipose cells
tend to occur in obese patients or those with recent weight gain
smooth, soft, encapsulated, freely movable masses that almost always arise in the subcutaneous
tissue
presence of capsule differentiates the tumor from simple aggregation of fat
deeper lipomas may occur between muscle groups or within muscles that become obvious with
muscular contraction
Surgical excision with biopsy
From the net: Benign Symmetric Lipomatosis or Madelung's
Disease and Lanois-Bensaude Syndrome is a metabolic condition
characterized by the growth of fatty masses around the face,
back of the head, neck, upper arms, abdomen, back and upper
leg in a very specific pattern or distribution. Unlike the usual
lipoma, these benign, fatty masses are not enclosed within a
membranous capsule with very distinct boundaries. (PAST-E)

5. RHABDOMYOMA
rare, benign tumor of striated muscles
important to differentiate from malignant rhabdomyosarcoma
Adult Rhabdomyoma
most common subtype, occuring at a mean age of approximately 50 years
predilection for head and neck region (larynx, pharynx, and the floor of the mouth)
circumscribed mass (usually less than 10 cm), coarse, with a brick-red colour
may be multinodular
Fetal Rhabdomyoma
slow growing mass, usually less than 5cm in size.
occurs primarily in the subcutaneous tissues of the head and neck region (common behind ear)
usually among infants usually less than 3 years of age
CT scan, MRI, section biopsy
Surgical excision
E. DEVELOPMENTAL NECK MASSES
1. DERMOID CYSTS (PAST E)
solitary, or occasionally multiple, hamartomatous tumor
containing structures derived
from ectoderm
covered by a thick dermis-like wall that contains multiple
sebaceous glands and almost
all skin adnexa
may contain substances such as nails and dental, cartilagelike, and bonelike structures
occur mostly on the face, neck, or scalp but can be intracranial, intraspinal, perispinal or within the
ovary or omentum
2. CERVICAL TERATOMAS
midline mass in an infant with airway obstruction
Ex. A dyspneic newborn w/ large midline neck mass (PAST E)
tumors containing tissue elements derived from all three germinal layers
usually discovered at birth, rarely presents after age of 1 year
encapsulated, partially cystic
sometimes referred to as thyroid teratoma since it is in the midline
symptoms develops over time due to progressive pressure, resulting in upper
airway obstruction
maternal hydramnios has been incriminated as a predisposing factor
Ultrasonography, CT scan
Surgical excision

3. BRANCHIAL CLEFT REMNANTS


lateral cervical lesions arising from congenital developmental defects
of the primitive branchial arches,clefts and pouches
may take the form of cysts, fistulas, sinuses
rarely diagnosed at birth, becomes apparent in childhood or adulthood
may become infected, develop abscess, form draining sinuses
fistulas and sinuses usually present as a small opening along
anterior border of SCM
orifice may discharge milky, serous, mucoid or purulent material

First Branchial Cleft Remnants

duplications of membranous EAC ending at a


cul-de-sac
extend near angle of mandible through parotid
Type II
substance to the vicinity of EAC
Type I

Second Branchial Cleft Remnants


most common (PAST E)
external opening along anterior border of SCM at the junction of its
middle and lower thirds
tract follows the carotid sheath crossing over the hypoglossal nerve
and coursing between the internal and external carotid arteries,
ending at the tonsillar fossa (where it rarely opens into the posterior
tonsillar pillar)

Third Branchial Cleft Anomalies


rare
opening may also be located in the same place
as the second branchial cleft
tract extend along the carotid sheath behind
the internal carotid artery over
the hypoglossal nerve and follows
the superior laryngeal nerve
internal opening would be at the region of the pyriform sinus

Fourth Branchial Cleft Anomalies

more of a theoretical possibility than reality


opening would have to be along the anterior border of SCM in
the lower third
tract would extend along the carotid sheath into the chest,
passing under either the arch of the aorta on the left or the
subclavian on the right
internal opening would be along the esophagus

Diagnostics: cystogram with contrast


Treatment: management of infection with antibiotics and drainage; complete surgical excision

4. THYROGLOSSAL DUCT CYST


results from the persistence of the thyroglossal tract
midline- NALABAS LAGI SA PAST-E! or paramedian masses
tract is intimately related to the hyoid bone and the mass is usually seen below the hyoid
may retract on swallowing or tongue protrusion -> just like thyroid gland
fistulas may occur spontaneously or secondary to trauma or infection

Diagnosis and Treatment:


Ultrasonography
Thyroid scintiscans
Complete surgical excision with removal of the central portion of the hyoid (Sistrunk)

F. BENIGN SKIN TUMORS


1. EPIDERMAL TUMORS
Seborrheic keratosis
sharply demarcated, keratotic, usually pigmented lesions, elevated
above the level of the adjacent epidermis
may be confused with malignant melanoma

Keratoacanthoma
develops over several months, assuming an elevated dome-shape
configuration with a central keratin plug
diagnosis is clinicopathologic

2. ADNEXAL TUMORS
Hair Follicle Tumors -> excise and send for histopathology

Pilar Cyst (Trichilemmal Cyst)

Trichoepithelioma

Trichofolliculoma

Pilomatrixom

Sebaceous Gland Tumors

Senile Sebaceous Hyperplasia


Apocrine Gland Tumors
Eccrine Sweat Gland Tumors

Nevus Sebaceus

Sebaceous Adenoma

3. MELANOCYTIC TUMORS
Ephelis common freckle due to localized increase in melanin pigment
Lentigo nonspecific term for flat, macular hyperpigmented skin lesion, related to sun exposure
Melanocytic Nevus circumscribed new growth of skin of congenital origin
junctional at epidermal-dermal junction
intradermal confined at dermis
compound both junctional and intradermal are present
Premalignant Melanocytic Lesions irregular
Lentigo maligna flat, slow-growing, pigmented lesion
Atypical intraepidermal melanocytic proliferation more rapid growth

4. SEBACEOUS CYST
(EPIDERMAL CYST; KERATIN CYST; EPIDERMOID CYST)

closed sac found just under the skin, most often arising from swollen hair follicles
contains cheesy-looking skin secretions.
skin trauma can also induce a cyst to form
a sac of cells is created into which a protein called keratin is secreted
usually slow- growing, painless, freely movable lumps beneath the skin
occur in almost any part of head and neck
asymptomatic unless infected
management of infection with local heat, antibiotics and drainage
surgical excision with meticulous removal of all cyst remnants to prevent recurrence

III. THE SANDS OF TIME (PAST-E


Which does not belong to the group?
TIP: Marami pa yan. Most of the questions are based on under what heading they are. Some memorize!
1. muscular, carotid, occipital, submandibular, submental triangle
2. MRI, Plain X-ray, UTZ, CT, biopsy
3. digastric, lateral triangle, supraclavicular triangle, trapezius, omohyoid
4. carotid body tumor, glomus vagale, neurofibroma, glomus tympanicum, paraganglioma
5. E. Inclusion cyst, radicular cyst, dentigerous cyst, paradental, residual
For the Past-e, Doc seems to recycle his questions. Different Questions but same points of emphasis.
Know the must knows and ESPECIALLY the group of diseases they are under.
------------------------------------------END OF TRANSCRIPTION------------------------------------------------Hello Christine

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