REMEMBERING PROF. R.P. SAHI BY HIS LECTURE ON MIDLINE SWELLINGS OF THE HEAD AND NECK

 

Prof. R.P. Sahi was our teacher in the Department of Surgery in King George’s Medical College, Lucknow. He was easily the best teacher in the campus. His baritone voice was renowned for its richness, strength and unmistakable quality, making it a defining feature of his aristocratic persona and a major factor in his enduring and universal popularity. This also made him instantly recognizable and command attention every time.

 

As an undergraduate teacher he was matchless because he could sub-divide the most complex subject into easily understandable bits, and once he taught a topic it somehow got imprinted in our brain for life. There was a method in his teaching which invariably simplified problems for even the back-benchers.

 

As a resident in his unit, I found him to be an inspiring leader and an outstanding post-graduate teacher with priceless qualities of a communicator, a disciplinarian, a conveyor of information, an evaluator, a Unit manager, a counselor, a member of many teams and groups, a decision-maker, a role-model, and a surrogate parent all rolled in one. His umbrella of benevolence was so reassuring that trainees got the best opportunity to express themselves. He understood the strengths and weaknesses of his trainees and steered them towards what would be best for them. Looking back, I can understand today how important this individualized approach was in his unit.

 

Prof. Sahi was a very sought after speaker, whether in surgical conferences or on social occasions. He was invariably our first choice for C.M.E and Conference inaugurations as well as after post dinner speeches. He somehow could palpate the mood of the gathering and say exactly what the occasion demanded. When Prof. P.C. Dubey was the Head of the Department of Surgery, Prof. Sahi was entrusted with the responsibility of resident posting and academic scheduling and the Department of Surgery was the best Department of the Medical College by miles. When I was applying for my Microsurgery training fellowship in St. Vincent’s Hospital, Melbourne, he and Prof. N.C. Misra gave me some glowing recommendations.

 

After his retirement he practiced in Krishna Medical Centre and mostly spent his time in academic pursuits. He stays in Hazratganj in his old bunglow wnd enjoys his retired life to the fullest.

 

I came across a lecture he delivered to our batch in 1978 on ‘Swellings of the Head & Neck’. He taught this vast topic in two lectures ‘Midline Swellings of the Head & Neck’ and ‘Lateral Swellings f the Head & Neck’ and this is the first lecture of this series.

  

Introduction

The deep fascia of the neck splits to envelope the Sternomastoid muscles. All swellings situated superficial to it are superficial swellings and all lying deep to it are the deep swellings.

 

Thus superficial swellings at this site are like any other site:

Skin             Epidermoid or Pilar cyst          

Fat               Lipoma

Nerve          Neurofibroma                          

Vessels        Haemangioma

 

The deep swellings of the neck for the purpose of description are sub divided into midline swellings and swellings in the lateral aspect of the neck.

 

Classification by Duration of lesion

1.      Acute: Cellulites, Ludwig’s Angina, Abscess, Carbuncle, Ac. Lymphadenitis

2.      Chronic:

A.    Cystic: Branchial cyst, Thyroglossal cyst, Cystic Hygroma, Cystic adenoma of Thyroid gland, Cold Abscess, Pharyngeal pouch

B.    Solid: Lymph nodes, Submandibular salivary gland, Thyroid tumours, Cervical Rib, Carotid body tumour, Branchogenic carcinoma, Sternomastoid Tumour

C.    Pulsatile: Aneurysm of Carotid artery / Subclavian artery, Aorta, Exophthalmic goiter.

 

Classification of Midline swellings

1.      On the face:

·        Median Angular Dermoid

·        Syncipital Meningocele

·        Fronto-nasal Meningo-encephalocele

·        Lachrymal sac swellings

·        Rhinophyma

·        Symphyseal odontomes

·        Gummata

2.      Submental region

·        Sub mental lymphadenitis

3.      Between menton and Hyoid

·        Ludwig’s Angina

·        Sublingual / Midline Neck Dermoid

·        Ranula / Plunging Ranula

·        Thyroglossal cyst

4.      Between Hyoid and Thyroid Cartilage

·        Sub Hyoid bursitis

·        Osteoma of Hyoid bone

·        Chondritis / Perichondritis

·        Chondroma of Thyroid cartilage

·        Laryngocele

·        Thyroglossal cyst

5.      Between Thyroid and Cricoid

·        Lymph node on crico-thyroid membrane

6.       Between Cricoid and Supra sternal notch

·        Thyroid gland – Goitres

7.      At Supra sternal space of Burns

·        Cold Abscess

·         Lymph nodes

·        Ectopic Thyroid

·        Supra sternal bursitis

·        Neurofibroma

·        Aneurysm of Arch of Aorta

 

Median Dermoids: Can be present at the midline either on the vault or on the floor of mouth or neck. They usually contain skin elements – sebum, hairs etc. They may scallop the skull bones and rarely have intra cranial extension through a gap in the skull. Treatment is excision and repair.

 

Fronto nasal Meningocele / Meningo-encephalocele: Meningoceles are brilliantly trans illuminent, cystic swellings, getting tense on coughing, crying or jugular pressure. Meningomyloceles have ectopic brain tissue in them and so are not trans illuminent. The inter orbital distance is widened – hypertelorism and there are cross fluctuations between it and the fontannele. CT scan demonstrates the gap in the skull and the treatment is excision, replacement of herniated contents, and repair of the bony gap by bone grafts and surgical correction of hypertelorism.

 

Lachrymal sac swellings: These are in the medial canthus of eye, usually inflammatory, and cause by blockage of naso-lachrymal duct with resultant epiphora. Treatment is initially conservative and if unsuccessful a DCR is done.

 

Rhinophyma: Sebaceous cyst adenomatosis affecting the skin of nose. There are multiple sessile nodular elevations over the nasal tip. Treatment is aesthetic rhinoplasty.

 

Gummata: These are seen in the midline in the tertiary stage of Syphilis causing erosion of skin, mucous membrane and bone. Midline structures like palate, hyoid, nasal bone, forehead etc. can be involved. VDRL test clinches the diagnosis. It is getting more and more uncommon in this antibiotic age.

 

Sub mental Lymphadenitis: May be inflammatory or neoplastic and so the entire drainage area – the tip of tongue, floor of mouth, incisors, symphyseal alveolus should be examined for focus of infection or primary tumour. Other lymph nodes should also be examined to rule out a primary Lymphoma.

 

Ranula: Myxomatous or mucoid degeneration of sublingual salivary gland. It appears as a blue-grey domed cyst in the floor of mouth, which is brilliantly trans illuminant. It has a tendency to split the mylohyoid and project in the submental region- plunging ranula. Treatment is excision by oral approach or marsupilization.

 

Sublingual dermoid: Sizable swelling filling and distorting the sublingual space, this dermoid is located within the mylohyoid muscle or the intrinsic muscles of tongue. Treatment is excision by sub mental approach.

 

Ludwig’s Angina: This is a form of cellullitis, which starts in the submandibular region and spreads to the floor of mouth. It produces a diffuse swelling beneath the jaw as well as the floor of mouth, often fixing the tongue. The unyielding deep fascia of the neck pushes the oedema up towards the glottis and down towards the mediastinum. Fatal septicemia, airway obstruction and death may result. Treatment is emergency drainage and broad spectrum anti bacterial coverage for Gram +ve, Gram –ve and anaerobes.

 

Thyroglossal cyst: These are cystic swellings mostly infrahyoid but may be suprahyoid as well and they move both with deglutition and tongue protrusion. The Thyroid develops from the foramen caecum and invaginates down as a tract called Thyroglossal tract to become the Thyroid isthmus. The cyst can occur anywhere along this tract. The cyst can become infected and form an abscess, which can be drained like any other abscess and result in the formation of a fistula. Thyroglossal fistula thus formed is never congenital, always acquired. These cysts are lined by squamous, cuboidal or columnar epithelium and may have lymphoid and thyroid tissue. They can turn malignant. Treatment of cyst and fistula is excision in toto along with the entire tract right up to the foramen caecum, taking the middle 1/3 of hyoid along with.

 

Subhyoid bursitis: Soft fluctuant swelling below the hyoid, it moves with deglutition and cannot be distinguished from Thyroglossal cyst easily.

 

Lymph node on crico thyroid membrane: A secondary deposit from a primary in the larynx, if present an endoscopic laryngeal examination and biopsy is a must. It also moves with deglutition.

 

Laryngocele: A soft, variable, unilateral or bilateral swelling, arising from the upper part of Thyroid cartilage, this is a herniation of the laryngeal mucosa through a gap in the thyrohyoid membrane. The swelling moves with deglutition and is usually seen in musicians playing wind instruments like flute and bagpipes Treatment is excision and repair.

 

Thyroid: This butterfly like endocrine gland straddles the trachea and its isthmus is situated over the 3^rd.and 4^th. tracheal rings. It moves up with deglutition and may have variable shape, size, consistency and tenderness. Lesions in Thyroid can be inflammatory, neoplastic, autoimmune and idiopathic. Lymph nodes on either sides of the neck and features of hypo and hyperthyroidism should always be examined.

 

Thus ended Prof. Sahi’s lecture on Midline Swellings of the Head & Neck. The diagram that he made on the board, every time pops up in my mind, whenever I see patients with midline head and neck swellings. This was once in a lifetime teaching, which has stayed life-long!