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Usually, infection arises from the teeth, lymph nodes, mastoiditis,
tonsils, after tonsillectomy and from the submandibular space.
Polymicrobial infection is common—anaerobes, Fusobacterium,
Peptostreptococcus, Staphylococcus. It is common in diabetics
and immunosuppressed.
Features
It causes diffuse swelling in the upper lateral neck with
obliteration of the inferior margin of the mandible, trismus,
dysphagia, respiratory distress with airway obstruction, rapid
onset of fever, toxicity.
SRB's Manual of Surgery
Fig. 5.19: Typical Ludwing’s angina.
Swelling lies behind the posterior pillar with oedema of soft
palate with bulging of the pharyngeal wall. There will be
oropharyngeal asymmetry, medial deviation of the tonsils,
cervical lymphadenopathy.
Complications: Thrombosis of internal jugular vein (septic
thrombophlebitis which may spread into sigmoid sinus intracranially), erosion of the carotid artery and torrential bleeding,
Horner’s syndrome, cranial nerve palsy (9–12); mediastinitis.
Investigations: Blood count, blood culture, X-ray neck, US
neck (to identify abscess),
check extension into other spaces and mediastinum), MRI
head and neck (to check IJV thrombosis and extension).
Treatment: Airway maintenance (may require nasotracheal
intubation, tracheostomy); Antibiotics (Intravenous penicillins,
clindamycin or higher generations); Incision and drainage
through neck incision (along the angle of the mandible
extending downwards and medially) with wound debridement,
irrigation; intraoral approach if abscess is medially towards
pharyngeal wall mainly in children and in nondiabetics.
CT scan head, neck and chest (to
Fig. 5.20: Incisions to decompress the Ludwig’s angina. 1. Multiple
deep submandibular incisions. 2. Two parallel deep submandibular
incisions with a vertical midline submental incision. 3. Single horizontal
curved bilateral deep submandibular incision.
PARAPHARYNGEAL ABSCESS
It is infection of parapharyngeal (pharyngomaxillary/pterygomaxillary/lateral pharyngeal) space.
Surgical anatomy: This is a cone/inverted pyramid-shaped
potential space; base is formed by the base of skull; apex is
formed by the greater cornu of hyoid bone; medial wall by the
superior constrictor (naso and oropharynx [pharyngobasilar
fascia and pharyngeal wall]); lateral wall is formed by the lateral
pterygoid, mandible and deep lobe of the parotid, posteromedial
by retropharyngeal space. It is divided into anterior prestyloid
compartment (contains fat, connective tissue, retromandibular
deep portion of the parotid, ascending pharyngeal vessels) and
posterior poststyloid compartment (contains carotid sheath
[artery, IJV, vagus] and contents, 9th and 12th cranial nerves,
cervical sympathetic chain and lymph nodes).
RETROPHARYNGEAL ABSCESS
Surgical Anatomy: The wall of the pharynx has got 5 layers.
Mucosa, submucosa, pharyngobasilar fascia, muscular layer
(contains 3 constrictors and stylo, salpingo, palatopharyngeus
muscles) and buccopharyngeal fascia covers outer part of
constrictors and extends over buccinator. Buccopharyngeal
fascia is adherent to prevertebral fascia posteriorly in the midline.
The retropharyngeal space is bounded by the buccopharyngeal
fascia anteriorly, the prevertebral fascia posteriorly, and the
carotid sheaths laterally. It extends superiorly to the base of the
skull and inferiorly to the mediastinum. Retropharyngeal lymph
nodes are located between buccopharyngeal fascia and prevertebral fascia in paramedian (eccentric) position (not midline).
Types: (1) Acute. (2)
Chronic.
Acute Retropharyngeal Abscess
It is infection and suppuration of retropharyngeal lymph nodes
due to beta-hemolytic streptococci and Staphylococcus, anaer-
obes, Gram negative organisms.
It is commonly from tonsils or pharynx; common in infants
and children. It is often seen in diabetics and immunosuppressed. Foreign body, endoscopic procedure injury, nasogastric
tube are other causes.
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CHAPTER 5 Neck
Fig. 5.21: Note acute and chronic retropharyngeal abscess. Normal
anatomy is also shown. Acute is eccentric and is due to suppuration
of retropharyngeal lymph nodes.
to tuberculosis of the cervical vertebra.
Chronic is central, midline and is due
Features
In infants and children—fever, difficulty in oral intake,
cough, dysphagia, odynophagia, sore throat, neck stiffness,
dyspnoea.
It presents as lateral (paramedian, eccentric) smooth, tender
swelling in the pharynx with stridor, toxic features, trismus
and neck rigidity.
Differential diagnosis: Pneumonia, meningitis, acute tonsil-
litis, pharyngitis.
Complications: Airway obstruction; rupture of abscess and
aspiration pneumonia; mediastinitis; septicaemia; erosion
into neck vessels and bleeding.
Investigations: X-ray lateral view of neck shows widened
retropharyngeal space >7 mm at C2 and >22 mm at C6; CECT
is very useful which shows retropharyngeal mass, hypodense
lesion with ring enhancement, obliteration of fat planes. CT
is useful for follow up also. Chest x-ray to confirm aspiration
pneumonia if develops. Total count and C reactive protein
will be raised.
Treatment: Antibiotics intravenously is essential (penicillins,
clindamycin, piperacillin and tazobactam). Managing airway
obstruction by emergency cricothyrotomy or tracheostomy
may be needed if endotracheal intubation fails. Drainage is
done usually through per oral incision under careful general
anaesthesia. Only occasionally drainage may be done through
a neck incision. Pus should be sent for culture.
Chronic Retropharyngeal Abscess
It is invariably due to tuberculosis of cervical spine (common
in C6).
Fig. 5.22: X-ray neck showing retropharyngeal abscess with
tuberculosis lesion involving the
Chandra Shetty, MD, Radiologist, Mangaluru).
Abscess is in the midline behind the prevertebral fascia. There
C2 cervical spine (Courtesy: Dr Navin
is destruction of the body of the vertebra due to tuberculosis.
It presents as midline swelling in the posterior pharyngeal
wall, which is smooth and nontender.
Features of tuberculosis of cervical spine will be observed.
Often abscess may point in the neck in relation to sternomas-
toid. Neurological manifestations may occur in severe disease.
Investigations: X-ray spine, chest X-ray, ESR, MRI of cervical
spine are essential investigations.
Treatment: Antitubercular drugs; Drainage of the abscess
should be done through neck approach (never intraoral
approach). Decompression of the vertebra and stabilization
is also often required.
SUBHYOID BURSITIS
(Retrohyoid Bursa/Boyer’s Bursa)
Subhyoid bursa is space between posterior surface of the
body of hyoid bone and thyrohyoid membrane. It lessens
friction between these two structures during swallowing.
Due to constant friction inflammatory fluid collects in the
bursa leading to bursitis, which presents like a horizontally
placed midline swelling between lower part of the hyoid bone
and thyrohyoid membrane. \
Smooth, soft, cystic, fluctuant, nontransilluminating swelling
which moves upwards with deglutition but not while
protruding the tongue out.
It should be differentiated from thyroglossal cyst and prel-
aryngeal lymph nodes.
It contains turbid fluid often may get infected to make the
swelling tender or to form an abscess.
Treatment: Excision under general anaesthesia.
Happiness is a direction not a destination.
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SRB's Manual of Surgery
Fig. 5.23: Sagittal and front view showing location and
relation of subhyoid bursa.
CAROTID BODY TUMOUR (Potato Tumour, Chemodectoma, Nonchromafn Paraganglioma)
It arises from the carotid body, which is located at the bifurca-
tion of the common carotid artery.
Carotid body is derived from neural crest which is essential
for adaptation in fluctuation in the O2, CO2 and pH.
Carotid body tumour can be sporadic (75%); familial (20%,
common in young, can be multiple); or hyperplastic (5%)
which is associated with the chronic hypoxia seen in high altitude (5,000 feet from sea level), COPD, cyanotic heart disease.
The tumour is situated in the adventitia of the artery.
They are benign or locally malignant tumours (10%), but in
20% cases spread can occur to the regional lymph nodes
and lungs.
Blood supply to the tumour is from ascending pharyngeal
artery and external carotid artery. Tumour does not secrete
epinephrine or any endocrine substances. Blood supply
comes through Meyer’s ligament on the posteromedial wall
of the carotid at bifurcation.
Fig. 5.24: Carotid body tumour—note the site and location. Splaying
of the carotid is common.
Histologically cells are arranged in a classical pseudoalveolar
pattern known as cell ball – Zellballen. It contains type I chief
cells with catecholamine granules and type II sustentacular
cells without granules.
CAROTID BODY
B
x Normal carotid body is 3–5 mm sized, 15 mg weight, flat brownish
nodule in the adventitious of common carotid artery
x It consists of chief cells (contains catecholamine granules) and
supportive cells
x Its nerve supply is from Hering nerve, a branch of Glossopharyn-
geal nerve
x These chemoreceptors are sensitive to changes in pH and
temperature in the body especially in hypoxia, help in autoregulation of respiration and circulation
x Carotid body hyperplasia can occur in people residing in high
altitudes who are exposed to chronic hypoxia
x Other chemoreceptors in the body are—aortic bodies in the arch
of aorta; glomus jugular in the bulb of the internal jugular vein;
glomus intravagale in relation to ganglion nodosum of the vagus
nerve and others like pulmonary (near pulmonary artery) and
myocardial (near coronary artery origin) receptors
Features
0.5%—Incidence.
Usually unilateral; 5% bilateral.
More common in middle age. Common in females.
Swelling (75%) in the carotid region of the neck which
is smooth, firm, pulsatile (transmitted pulsation—due to
pulsatile carotid vessel overlying its surface) and moves
only side to side but not in vertical direction (Fontaine
sign).
It can often compress over oesophagus and larynx.
Headache, neck pain (35%), dysphagia, and syncope are
other presentations.
10% may present with cranial nerve palsy (hypoglossal,
glossopharyngeal, recurrent laryngeal or spinal accessory)
or sympathetic chain; so present as pain, tongue deviation
towards same side while protruding, dysphagia, unilateral
vocal cord palsy, hoarseness of voice, drooping shoulder
and Horner’s syndrome.
Features of transient ischaemic attacks due to com pression
over the carotids, “carotid body syncope.”
Thrill may be felt and bruit may be heard.
It is located at the level of hyoid bone deep to anterior edge
of the sternomastoid muscle in anterior triangle, vertically
placed, round, firm ‘potato’ like swelling.
Often tumour may extend into the cranial cavity along the
internal carotid artery as dumbbell tumour.
Pathologically, it is well-encapsulated, hard creamy yellowish
tumour with dense fibrous tissue. Carotid body tumour cells
are not hormonally active.
SITES WHERE DUMBBELL TUMOURS ARE SEEN
B
Parotid; Spinal cord; Carotid body
SHAMBLIN CLASSIFICATION OF CAROTID BODY TUMOR
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B
x Type I: Localised, easily resectable (26%)
x Type II: Adherent, partially surrounding the carotids (46%)
x Type III: Adherent, encased carotids completely (27%)
Investigations
Arterial Doppler.
Angiogram to see the ‘tumour blush’—DSA. Widening/
splaying of the carotid artery with tumour blush in an angiogram is called as Lyre sign.
CT scan, MRI, MR angiography.
MIBG scan in useful in multiple familial and functioning
tumours (they are smaller in size); in nonfunctioning tumours
pentetreotide scan using radiolabeled somatostatin analogue
is used.
No FNAC, No trucut biopsy, No partial excision.
Differential Diagnosis
Carotid artery aneurysm.
Soft tissue tumour (Sarcoma).
Lymph node enlargement.
Neurofibroma of the vagus nerve presents as swelling in the
carotid triangle in the region of thyroid as vertically placed,
oval, hard swelling. On palpation of the swelling, patient often
develops bradycardia and dry cough. It does not move with
deglutition and has only transverse mobility. As the tumour
lies behind the carotid it can stretch the carotid in front
causing transmitted pulsation (Figs. 5.25A to C).
Treatment
If it is small, then it can be excised easily as the tumour is
situated in the adventitia.
When it is large, as commonly observed, complete excision
has to be done followed by placing a vascular graft.
During resection a temporary shunt (diversion of blood) is
placed between common carotid below and internal carotid
above to safeguard cerebral perfusion; external carotid artery
is ligated. Venous or prosthetic graft is placed between
common carotid and internal carotid arteries.
Carotid body tumour is not radiosensitive (contro versial).
Complications of the Surgery
Bleeding.
Blockage of common carotid artery, leading to contralateral
side hemiplegia (3%). This can be prevented by stenting the
common carotid artery towards internal carotid artery and is
done during surgical excision of the tumour.
Cranial nerve injury X and XI (40%). Injury to vagus causes
hoarseness of voice; injury to superior laryngeal nerve alters
the pitch of voice.
CYSTIC SWELLINGS IN THE NECK
B
x Cold abscess
x Cystic hygroma
x Branchial cyst
x Thyroglossal cyst
x Laryngocoele
x Pharyngeal pouch
x Subhyoid bursa
TORTICOLLIS (WRY NECK)
It is turning of the neck to one side with chin pointing towards
opposite side.
Causes
Sternomastoid tumour.
Trauma—spinal injury, disc prolapse, spondy losis.
Inflammatory: Lymphadenitis either tuberculous or suppura-
tive; tuberculosis of cervical spine.
Spasmodic—due to spasm of sternomastoid muscle of same
side or spasm of posterior cervical muscles of opposite side.
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CHAPTER 5 Neck
A B C
Figs. 5.25A to C: Vagal Neurofibroma: (A) Large neurofibroma of vagus—clinical look; (B) CT image showing tumour; (C) On table look of
tumour with anteriouly displaced carotid artery.
Direction is a matter of fact; ideas are matter of opinion.
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Reflex.
Rheumatic—after exposure to cold/draught.
Burns—causing contracture.
Ocular causes.
Compensatory due to scoliosis.
STERNOMASTOID TUMOUR
It is due to birth injury to the sternomastoid muscle. It is a
misnomer. It is not a tumour.
SRB's Manual of Surgery
A
Figs. 5.26A and B: Boy having right-sided torticollis.
Fig. 5.27: Torticollis (right-sided) with chin towards opposite side.
B
Features
Restricted neck movements.
Chin pointing towards opposite side.
Squint.
Features relevant of the causes.
Treatment: The cause is treated. Benik Contralateral Torticollis
Bracing System; TOT collar used only child is awake; Kinesio
taping technique—are used.
Note
One-third of congenital torticollis is due to sternomastoid tumour and twothirds due to abnormal position in utero which recovers spontaneously in
a few weeks. — Kenneth F Hulbert.
Fig. 5.28: Sternomastoid tumour—typical location.
During child birth, injury to the sternomastoid muscle causes
haematoma in the muscle which gets organised to form
sternomastoid tumour.
Common in breech delivery.
It is seen in infants of 3–4 weeks age.
Swelling of about 2 cm size, in the sternomastoid muscle
which is smooth, hard, nontender and adherent to the
muscle—in the middle part.
Chin pointing towards opposite side. Head to wards same
side (Scoliosis capitis).
In later age groups it causes hemifacial atrophy due to
less blood supply as a result of compression of the external
carotid artery by sternomastoid tumour and due to kinking by
position of neck. Distance between the outer canthus of eye
to angle of mouth is reduced, with less arched eyebrow, flat
or less filled cheek and flat nose compared to opposite side.
Compensatory cervical scoliosis.
Compensatory squint.
Differential diagnosis: Other causes for torticollis.
Treatment
Division of the lower end of the sternomastoid muscle or
excision of the muscle. Both sternal and clavicular heads of
sternocleidomastoid muscle should be divided under general
anaesthesia using horizontal incision. One should not injure
IJV, carotid, vagus, spinal accessory nerve. Additional all
fibrous bands are also cut. Usually over correction is done.
Physiotherapy exercise and toricollis harness is used for
6–12 months.
Exercise and active stimulation of muscles in early cases.
T
Differential diagnosis for neck lymph node enlargement
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• Tuberculous lymphadenitis • Secondaries in lymph nodes
• HIV infection • Lymphomas
Chronic lymphatic leukaemia • Nonspecific lymphadenitis
•
• Infectious mononucleosis • Sarcoidosis
• Actinomycosis • Brucellosis
• Toxoplasmosis
Disease can also occur in other lymph nodes like—axillary,
para-aortic, mesenteric, inguinal, mediastinal, intercostal.
Disease may be associated with HIV infection, lymphomas.
A
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CHAPTER 5 Neck
Fig. 5.29: Lymphoma neck involving both sides. Lymphomas are
smooth, nontender, firm/India rubber consistency.
Fig. 5.30: Swelling in the neck well-localised. Note the scar of previous
biopsy/excision. It could be lymph node enlargement due to lymphoma
or tuberculosis.
TUBERCULOUS LYMPHADENITIS
(Earlier called as Scrofula). It is the commonest form of extrapulmonary tuberculosis.
Causative organism: Mycobacterium tuberculosis.
B
Sites
Common in neck lymph nodes—80%
Common in upper deep cervical (jugulodigastric—54%).
lymph nodes 20% bilateral.
Next common is posterior triangle lymph nodes (22%).
C
Figs. 5.31A to C: Cold abscess due to caseating tuberculous lymphadenitis in neck. Collar stud abscess in the neck. Tuberculous sinus
formation after drainage.
It takes 5 years to learn when to operate, and 20 years to learn when not to.
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Features
Mode of Infection: Usually through the tonsils, occa-
sionally through blood from lungs. Tonsillar infection
shows multiple tubercles on its surface; from here
infection spreads into jugulodigastric nodes (anterior
triangle nodes) then to other nodes. Infection reach
lymph node first into subcapsular space/sinus then
to lymph node cortex which contains plenty of lymph follicles.
Matting is due to periadenitis involving subcapsular sinus/
space of lymph node. In children infection to neck
come from either tonsils or adenoids or both. When it occurs
SRB's Manual of Surgery
from adenoids, lymph nodes in posterior triangle are involved
through retropharyngeal lymphatics.
It may be associated with pulmonary tuberculosis or renal
tuberculosis. Through blood infection reaches medullary
cords of lymph node and so medulla of lymph node.
Rarely spread can occur from tuberculous lesion of the apex
of lung through suprapleural Sibson’s fascia/membrane to
supraclavicular nodes.
Often fibrosis and calcification can occur with or without
treatment.
Gross Pathology: Firm, matted, lymph node, with cut section
showing yellowish caseating material.
Microscopic Features: Epithelioid cells with caseating mate-
rial are seen along with Langhans type of giant cells.
node can
Fig. 5.33: Stages of tuberculous lymphadenitis (Hogarth’s Rake).
Fig. 5.32: Tuberculous lymphadenitis—cut section of the specimen.
Note the yellowish caseating material with periadenitis (matting).
Caseating type is more common than hyperplastic type.
STAGES OF TUBERCULOUS LYMPHADENITIS
B
1. Stage of infection, and lymphadenitis
2. Stage of periadenitis with matting
3. Stage of caseating necrosis and cold abscess formation
4. Stage of formation of collar stud abscess
5. Stage of formation of sinus which discharges yellowish caseating
material
CLINICAL TYPES
B
x Acute type: Seen in infants and early childhood below 5 years
x Hyperplastic type: Lymphoid hyperplasia is typical; it is seen in
patients with good resistance; hard discrete mobile lymph nodes;
15–20% common
x Caseating type: 75–80% common; matted nodes often with cold
abscess; poor body resistance; seen in young adults
x Atrophic type: Rare type; seen in elderly; small lymph nodes but
caseating type with atrophied nodes
Presentations
Swelling in the neck which is firm, matted.
Cold abscess is soft, smooth, nontender, fluctuant, without
involvement of the skin. It is not warm.
As a result of increased pressure, cold abscess ruptures
out of the deep fascia to form collar stud abscess which is
adherent to the overlying skin.
Once collar stud abscess bursts open, discharging sinus is
formed. It can be multiple, wide open mouth, often undermined, nonmobile with bluish color around the edge. It is
usually not indurated.
Tonsils may be studded with tubercles and so clinically should
always be examined.
Associated pulmonary tuberculosis should also be looked
for. In 20% cases of tuberculous lymphadenitis, there may
be associated pulmonary tuberculosis or it may be a primary
focus.
Cervical spine is examined for tuber culosis.
Types
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T
1. Hyperplastic 2. Caseating
a. 20% common —— a. 80% common
b. Discrete, firm or hard —— b. Matted due to periadenitis
c. Occurs in the cortex of lymph node —— c. Involves medulla with periadenitis
d. Host immunity is good —— d. Body resistance is not adequate
e. Drugs act better —— e. Drugs do not reach in proper concentration and may not be effective
f. Drug resistance is uncommon —— f. Drug resistance is common
g. No cold abscess or sinus formation —— g.
h. Blood spread —— h. Spread from tonsils
Cold abscess or sinus are common
433
CHAPTER 5 Neck
Axillary nodes, when involved, is due to retrograde lymphatic
spread from neck nodes or blood spread.
Inguinal lymph nodes are involved occasionally through
blood.
Bluish hyperpigmented involved overlying skin is called as
scrofuloderma.
Tuberculous pus with caseating cheesy creamy material is
infective as it contains multiplying organisms.
Atypical mycobacterial tuberculosis can occur occasionally.
Such disease may be resistant to drug therapy.
Sinus may persist due to—fibrosis, calcification, secondary
infection, inadequate reach of drug to maintain optimum
concentration in caseation.
Differential diagnosis:
¾
Nonspecific lymphadenitis.
¾
Lymphomas, and chronic lymphatic leukaemia.
¾
Secondaries in the neck.
¾
Branchial cyst mimics cold abscess.
¾
Lymph cyst mimics cold abscess.
COLD ABSCESS
B
x Deep-to-deep fascia
x No evidence of signs of inflammation
x Not warm, nontender, smooth, soft and fluctuant, non-transil-
luminating
x Not adherent to skin (skin is free); no redness
x Contains cheesy caseating material
x It is seen in caseating tuberculous lymphadenitis due to casea-
tion necrosis
x It may form collar stud abscess and later sinus
x FNAC, AFB, culture are useful investigations
x Differential diagnosis are branchial cyst, lymph cyst
x Treated by
– Antituberculous drugs
– ‘Zig-zag’ aspiration by wide bore needle in nondependent area
to prevent sinus formation
– Drainage using nondependent incision; later closure of the
wound without placing a drain
HIV with lymph node involvement.
When there is discharging sinus—actinomycosis.
Investigations
Haematocrit, ESR, peripheral smear.
Ultrasound neck: It shows node size, matting, cold abscess,
track, number of nodes; Doppler USG helps in demonstrating
the vascularity (hilar vascularity in tuberculous node; peripheral capsular vascularity in metastatic node).
FNAC of lymph node and smear for AFB and culture. FNAC
is very useful but not as superior as open node biopsy. False
negative, false positive results and altering the node architecture, and so eventual need of open biopsy are the problems.
Epithelioid cells (modified histiocytes/macrophages) are
diagnostic. Langhans giant cells, lymphocytes, plasma cells
are other features.
Open biopsy when FNAC is inconclusive. Open biopsy is more
reliable for tuberculosis (and also in lymphoma; but it is contraindicated in node secondaries); entire node (ideally two nodes if
possible) has to be taken intact; one in formalin for pathology,
other in normal saline for microbiology (AFB) and culture.
HIV test (ELISA and Western blot), CD
Löwenstein–Jensen media is used for culture which takes 6
count
4
weeks to give result; so selenite media is often used which
shows growth in 5 days.
Mantoux test may be useful; but not very reliable.
Chest X-ray to look for pulmonary tuberculosis.
Polymerase chain reaction (PCR) is very useful method.
CT neck and chest to study nodal status.
Treatment
Drugs
Antitubercular drugs has to be started:
Rifampicin 450 mg OD on empty stomach. It is bactericidal.
It discolours urine red. It is also hepatotoxic.
INH: 300 mg OD. It is bactericidal. It causes into lerance of
GIT, Neuritis, Hepatitis (INH).
Ethambutol 800 mg OD. It is bacteriostatic. It causes GIT
intolerance, retrobulbar neuritis (green colour blindness).
Pyrazinamide 1500 mg OD (or 750 mg BD). It is bactericidal.
It is hepatotoxic, also causes hyper uricaemia and increases
psychosis.
Duration of treatment is usually 6–9 months.
Happiness is when what you think, what you say, and what you do are in harmony. —Mahatma Gandhi
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Aspiration
When there is cold abscess, initially it is aspirated. [Wide bore
needle is introduced into the cold abscess in a nondependent
site along a “Z” track (in zig-zag pathway) so as to prevent sinus
formation].
SRB's Manual of Surgery
A B
C
Figs. 5.34A to C: Typical cold abscess in the neck in which pus is
aspirated. Pus should be sent for cytology (for epithelioid cells), staining
(Ziehl-Neelsen—AFB) and culture.
Incision and drainage
If it recurs, then it should be drained. Drainage is done through
a nondependent incision. After draining the caseating material,
wound is closed without placing a drain.
Surgical removal
Surgical removal of tubercular lymph nodes are indicated, when
1. There is no local response to drugs or
2. When sinus persists.
It is done by raising skin flaps and removing all caseating
material and lymph nodes. Care is taken not to injure major
structures.
Excision of the sinus track
It is often essential when sinus develops.
Note:
“Paradoxical upgrade reactions” (PUR) is worsening of the symptoms
during treatment period with development new nodes, nodes become
larger, more sinus formation in patients who have received at least 10
days of therapy. It is due to rapid killing of mycobacteria which releases
mycobacterial products like cytokines, TNF-alpha, interleukins etc causing
extensive local inflammation and necrosis. It shows negative stains for AFB.
Baseline peripheral monocytosis is a significant predictor.
Non-tuberculous Mycobacterial Lymphadenitis (NTML): It is seen in developed countries like Australia, Canada, and USA; commonly due Mycobacte-
rium avium, M. scrofulaceum, M. kansasii. Level 1 neck nodes are involved;
Fig. 5.35: Tuberculous sinus excision with excision of
diseased lymph nodes.
truly localized; unilateral; biopsy, NTM antigen specific ¥ interferon and skin
tests. Surgical excision is the main treatment.
BCG lymphadenitis: It occurs as a complication of the BCG vaccination. It
can be simple nonsuppurative which regresses spontaneously or suppurative which forms often an abscess which is nontender, not warm without
fever. Needle aspiration or often incision and drainage help. There is no
role of antitubercular drugs.
Mycobacterium bovis also can cause tuberculous lymphadenitis but is
rare now. Infection occurs through dairy products and droplets. It is more
aggressive with high mortality in HIV patients. Pyrazinamide is not useful
for M. bovis lymphadenitis. BCG vaccine is derived from M. bovis (1919).
COLD ABSCESS
Cold abscess is common in neck. It can also occur in groin,
intercostal space, loin or any site where tuberculous caseating
material with cheesy content can get collected and localised.
Cold abscess may originate from tuberculosis of spine
(thoracic or cervical spines), lymph node, internal organs,
bone, etc.
In the neck
Tuberculous lymphadenitis is common cause. Here cold
abscess is commonly seen in anterior triangle.
Tuberculosis of cervical spine is also an important cause.
Commonly here cold abscess occurs in posterior triangle.
Caseating material from the cervical spine collects in front of
the vertebra behind the prevertebral fascia which eventually
ruptures either anteriorly or posteriorly.
¾
Anterior rupture allows passage of caseating material
below and behind the prevertebral fascia reaching supe-
rior mediastinum; laterally behind the prevertebral fascia
and carotid sheath to form cold abscess in posterior
triangle; in midline upper part, protruding forwards from
behind the prevertebral fascia in midline presenting as
chronic retropharyngeal abscess; in midline lower part
protrudes into oesophagus; caseation runs along the axil-
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lary sheath and neurovascular plane to reach axilla and
arm to cause cold abscess in axilla and arm/cubital fossa.
¾
Posterior rupture occurs towards spinal canal facilitating the passage of caseation along the cervical nerves
towards posterior triangle and brachial plexus and so
axilla and arm.
SEQUELAE OF COLD ABSCESS
B
x Secondary infection of the cold abscess making it tender.
x Formation of collar stud abscess, once pressure increases inside
the cold abscess which will give way through the deep fascia to
reach the subcutaneous plane to get adherent to skin.
x Sinus formation.
x Spread of disease to multiple lymph nodes and other organs.
Differential
x Branchial cyst and other cystic swellings in neck.
x Secondaries in neck lymph nodes.
x Secondaries in cervical spine.
Diagnosis
Treatment
Antituberculous drugs.
Nondependent aspiration or drainage of the cold abscess.
Excision of the diseased neck nodes.
Immobilization of cervical spine by plaster jacket/collar for
4 months. Cervical spine fusion by open surgical method, if
diseased spine is unstable.
SECONDARIES IN NECK LYMPH NODES
435
CHAPTER 5 Neck
Fig. 5.36: Tuberculous cold abscess and sinus in the neck.
Features
It is common in young but can occur in any age group. Equal
incidence in both sexes.
Swelling in the neck, which is smooth, nontender, soft,
fluctuant, nontransilluminating, with restricted mobility but
is not adherent to skin.
Neck pain, neck rigidity, restricted movements of cervical
spine in case of cervical spine tuberculosis. With every
change of position and often when patient is seated he
supports his head with his hands and forearm—Rust’s sign
(Jan N Rust, surgeon, Poland).
Evening fever, loss of weight and appetite, anaemia.
Features of systemic disease, if present like of pulmonary
tuberculosis—cough, haemoptysis.
Matted lymph nodes adjacent to cold abscess may be
palpable.
Oral cavity, tonsils, chest should be examined.
Raised ESR, positive Mantoux test, anaemia, lymphocytosis,
chest x-ray may show pulmonary tuberculosis, aspiration of
cold abscess (FNAC) to see microscopically epithelioid cells.
Acid-fast bacilli may be identified from the aspirated fluid
using Ziehl-Neelsen stain.
X-ray neck in case of cervical spine tuberculosis to iden-
tify reduced joint space, vertebral destruction, soft tissue
shadow.
MRI of cervical spine, US/CT scan neck are needed to confirm
the anatomical location, number of lesions.
Levels in Neck Nodes (Memorial Sloan—
Kettering Cancer centre levelling of neck nodes)
Level I: Submental (Ia) and submandibular (Ib) lymph nodes.
Level II: Lymph nodes in upper deep cervical region.
(It extends from base of skull to hyoid bone and from lateral
margin of sternohyoid to posterior margin of sternomastoid
muscle). Level IIa is below and in front of the line of the
spinal accessory nerve in the upper part; IIb is above and
posterior.
Level III: Lymph nodes in middle cervical region (from hyoid
bone to omohyoid muscle or cricothyroid membrane).
Level IV: Lymph nodes in lower cervical region (from omohyoid
muscle/cricothyroid membrane to clavicle).
Level V: Lymph nodes in posterior triangle including supraclavicular region from posterior border of sternocleidomastoid
muscle to anterior border of trapezius muscle. Level Va is
above the line of spinal accessory nerve in the lower part;
Vb is below.
Level VI: Lymph nodes in the midline neck—pretracheal and
prelaryngeal from hyoid bone above to suprasternal notch below,
medial border of carotid sheath on either side.
Level VII: Lymph nodes in the mediastinum. inferior to
suprasternal notch to innominate artery below.
Note:
• Level I nodefromoralcavity,lip,salivarygland, skin; level IInode
fromoralcavity,oropharynx,nasopharynx,salivary gland;level III
nodefrom oralcavity,oropharynx, hypopharynx,larynx,thyroid;
level IVnode from oropharynx, hypopharynx, larynx, thyroid,
cervicaloesophagus;level V nodefromnasopharynx,scalp, GIT,
breast,lungs.
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