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Examination of Neck
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the developmental period in utero. It presents during
birth and so may cause obstructed labour. Occasionally
it presents in early infancy.
Sites
Posterior triangle of the neck – commonest site (75%).
Eventually may extend upwards in the neck; cheek;
axilla; tongue—lymphangiogenetic macroglossia;
groin; mediastinum; Often may occur in multiple sites.
Pathology
It contains aggregation of cysts looking like soap
bubbles. Cysts have mosaic appearance with larger
cysts near the surface and smaller cysts in the deeper
planes. Each cyst contains clear lymph with endothelial
lining. Fluid does not coagulate.
Clinical Features
Swelling is present since birth in the posterior triangle
of neck causing obstructed labour; Swelling is smooth,
soft, fluctuant (cystic), compressible, brilliantly trans-
illuminant; Swelling may rapidly increase in size
causing respiratory obstruction—dangerous sign; It
may get infected forming an abscess which forms
tender, warm, soft swelling. It may cause life threatening septicaemia (Figs 13.26A to C).
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A
Complications
Respiratory distress; infection; abscess; septicaemia;
surgery itself may cause torrential haemorrhage.
Carotid Body Tumour (Potato Tumour,
Chemodectoma, Nonchromaffin
Paraganglioma)
It arises from the carotid body, which is located at
the bifurcation of the carotid artery.
Cells of the carotid body are sensitive to the changes
in pH and temperature of the blood. They are often
locally malignant tumours, but in 20% cases spread
can occur to the regional lymph nodes. Blood supply
to the tumour is from external carotid artery. Tumour
does not secrete epinephrine or any endocrine
substances. They can be familial. 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.
B
C
Figs 13.26A to C: Cystic hygroma in a newborn. Note the
extensive involvement (Courtesy by Dr Manjunath Shetty
MS MCh Urology Mangalore).
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Clinical Features
SRB’s Clinical Surgery
Usually unilateral, more common in middle age.
Swelling is situated in the carotid region of the neck
which is smooth, firm, and pulsatile (due to pulsatile
vessel overlying its surface) and moves only side-toside but not in vertical direction. May present with
features of transient ischaemic attacks due to compression over the carotids. Thrill may be felt and bruit
may be heard. Often tumour may extend into the cranial
cavity along the internal carotid artery as dumb-bell
tumour (Fig. 13.27). Shamblin classification of carotid
body tumour: Type I—Localised easily resectable
(26%); T ype II—Adherent, partially surrounding the
carotids (46%); T ype III—Adherent, carotids encased
completely (27%).
Carotid body –
Normal carotid body is 3-5 mm sized flat brownish nodule
in the adventitia of common carotid artery.
It consists of chief cells (contains catecholamine granules)
and supportive cells.
It gets its nerve supply from glossopharyngeal nerve
These chemoreceptors are sensitive to changes in pH
and temperature in the body especially in hypoxia helping
in autoregulation of respiration and circulation.
Carotid body hyperplasia can occur in people residing
in high altitudes who are exposed to chronic hypoxia.
Other chemoreceptors in the body are – aortic bodies
in the arch of aorta; glomus jugulare 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.
Note: Dumb-bell tumours are seen in parotid tumour;
spinal cord tumour; carotid body tumour.
Sternomastoid Tumour
It is due to birth injury to the sternomastoid muscle.
It is a misnomer. It is not a tumour.
Fig. 13.27 Carotid body tumour.
Investigations
Doppler; Angiogram to see the ‘tumour blush’;
Widening/splaying of the car otid artery with tumour
blush in an angiogram is called as Lyre sign. CT
scan; No FNAC; No partial excision.
Carotid aneurysm; soft tissue tumour (Sarcoma); lymph
node enlargement; neurofibroma of vagus.
Pathogenesis
During child birth injury to sternomastoid muscle
causes haematoma in the muscle which gets organised
to form sternomastoid tumour. It causes congenital
torticollis. In congenital torticollis, 1/3rd is due to
injury to sternomastoid resulting in sternomastoid
tumour; 2/3rd is due to abnormal foetal position in
utero causing sternomastoid spasm which recovers
spontaneously.
Clinical Features
It is seen in infants of 3-4weeks age. Swelling occurs
in the sternomastoid muscle which is smooth, hard,
nontender and adherent to the muscle. Chin points
towards opposite side and head towards same side
(Scoliosis capitis). In later age groups it causes hemi-
facial atrophy due to reduced blood supply because
of the compression of external carotid artery by sternomastoid tumour (Fig. 13.28). Compensatory cervical
scoliosis and compensatory squint can also occur.
Other causes for torticollis.
Examination of Neck
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Fig. 13.28: Location of sternomastoid tumour.
Torticollis (Wryneck)
Head is bent to one side with chin pointing towards
opposite side. Affected side of face shows mild facial
atrophy due to reduced vasculature by restricted
movements. Features are - Less arched eyebrow;
reduced distance from outer canthus of eye to angle
of mouth; flat nose; flat withdrawn cheek.
Causes
Congenital–sternomastoid tumour; Traumatic fracture
dislocation of cervical spine; inflammatory pathology
of neck nodes; spasmodic due to spasm of same side
sternomastoid and posterior neck muscles of opposite
side (Fig. 13.29); compensatory to scoliosis or ocular
causes; rheumatic due to exposure to cold; after burns
contracture.
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Differential Diagnosis for Neck Lymph Node
Enlargement
Tuberculous lymphadenitis.
Secondaries in lymph nodes.
HIV infection.
Lymphomas.
Chronic lymphatic leukaemia.
Nonspecific lymphadenitis.
Infectious mononucleosis.
Sarcoidosis.
Tuberculous Lymphadenitis
It is due to Mycobacterium tuberculosis infection.
Infection is often from tonsils; occasionally from lungs.
Tuberculosis may be present in cervical spine. It is
common in neck nodes; more often in jugulodigastric
nodes (54%); posterior triangle nodes (22%). It can
occur in nodes in axilla, para-aortic region, mediastinum, mesentery, iliac region and groin. It may be
associated with lymphoma or HIV . It is more common
in HIV patients. In tuberculous lymphadenitis – there
are five stages of formation – stage of lymphadenitis;
stage of matting; stage of cold abscess formation; stage
of collar stud abscess formation and stage of sinus
formation (Fig. 13.30). Often fibrosis and calcification
can occur. It contains caseating material with
epithelioid and Langerhans’ giant cells.
Types
Caseating: It is commonest type (80%). It shows
periadenitis with matting, forms cold abscess, collar
stud abscess and sinus. It is often resistant to drug
therapy. Body resistance is not adequate here.
Hyperplastic type—is 20% common; discrete, firm
nodes are common; shows good response to drugs
with better host immunity. Complications are less.
Fig. 13.29: Torticollis.
Features
Firm, matted, nontender, mobile or fixed swellings
in neck often bilateral are the presentations. Tonsils
may show tubercles on examination; chronic midline
retropharyngeal tuberculous abscess may be evident.
Lymphoma, secondaries in nodes, nonspecific
lymphadenitis, and chronic lymphatic leukaemia are
the differential diagnosis.
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SRB’s Clinical Surgery
Fig. 13.31: Tuberculous lymphadenitis—
neck forming cold abscess.
Fig. 13.30: Staging of tuberculous lymphadenitis.
Cold Abscess
It is a complication of tubercular disease. It is commonly observed in neck in relation to caseating
tuberculous cervical lymphadenitis. It can occur in
relation to spine, like psoas abscess, paraspinal region
or any other area. Cold abscess does not show any
signs of acute inflammation. It will be soft, smooth,
nontender well localised swelling. Relevant lymph
nodes, oral cavity/tonsils, cervical/thoracic spines,
lungs should be examined. It is well localised, smooth,
soft, fluctuant, nontransilluminating swelling with free
skin in front (Figs 13.31 to 13.34). Branchial cyst,
Fig. 13.32: Sinus in the neck due to tuberculosis.
Fig. 13.33: Tuberculous ulcer in the neck which is undermined
(Courtesy by Dr Balasaraswathy MD DNB, Dermatologist,
Mangalore).
Examination of Neck
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Fig. 13.34: Cold abscess forming collar
stud abscess in a young boy.
lymph cyst, suppurated lymph node are the differential
diagnosis.
Investigations are—ESR, chest X-ray , FNAC shows
epithelioid cells and Langerhans giant cells, X-ray
spine.
Complications are—Sinus formation, systemic
spread, secondary infection, resistance tuberculosis.
Cold Abscess
Deep to deep fascia
No evidence of signs of inflammation
Not warm, nontender, smooth, soft and fluctuant, nontransilluminating
Not adherent to skin (skin is free); no redness
Contains cheesy caseating material
It is seen in caseating tuberculous lymphadenitis due to
caseation necrosis
It may form collar stud abscess and later sinus
FNAC, AFB, culture are useful investigations
Differential diagnosis are branchial cyst, lymph cyst
Treated by - Antituberculous drugs; ‘Zigzag’ aspiration
by wide bore needle on nondependent area to prevent
sinus formation; Drainage using nondependent incision;
later closure of the wound without placing a drain.
Secondaries in Neck Lymph Nodes
Levels in Neck Nodes (Memorial Sloan—
Kettering Cancer Center Leveling of Neck Nodes)
Level I-Submandibular lymph nodes and submental
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 sternothyroid to
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posterior margin of sternomastoid muscle). Level IIILymph 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 to clavicle). Level V - Lymph
nodes in posterior triangle including supraclavicular
region. Level VI-L ymph nodes in the midline neck—
pretracheal and prelaryngeal. Level VII - L ymph nodes
in the mediastinum. Note: Level II and V are now
subdivided into Level IIa/Level IIb and Level V a/Level
Vb; depending whether these nodes are above the level
(Level IIb/Level Va) of the spinal accessory nerve
or below (Level IIa/Level Vb). Note: Retropharyngeal
nodes, facial nodes, post-auricular nodes are not
included in these levels.
Common Sites of Primary
Oral cavity , tongue, tonsils; salivary glands; pharynx
–nasopharynx; larynx; oesophagus; lungs; GIT;
thyroid.
It is commonly from squamous cell carcinoma, but
can be from adenocarcinoma, or melanoma. Squamous
cell carcinoma is mainly from oral cavity, pharynx.
Adenocarcinoma is usually from GIT, commonly
involving left supraclavicular lymphnodes (Figs
13.35A and B).
Features of Secondaries in Neck
Presents as swellings with nodular surface, hard, often
fixed when it is advanced. Secondaries from papillary
carcinoma of thyroid can be soft, cystic and contains
brownish black fluid. Secondaries can infiltrate into
carotids, sternomastoid, posterior vertebral muscles,
spinal accessory nerve (shrugging of shoulder is
affected), hypoglossal nerve (tongue deviates towards
the same side), cervical sympathetic chain (Horner’s
syndrome). Secondaries spread into adjacent soft
tissues and also to the skin causing fungation and
ulceration. Often because of tumour necrosis, softer
area develops in the hard node. In advanced cases
tumour may infiltrate into the major vessels like
carotids, or branches of external carotid artery causing
torrential haemorrhage. Dysphagia, dyspnoea,
haemoptysis, hoarseness of voice, ear pain, and
deafness are other features seen depending on the
primary site location.
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SRB’s Clinical Surgery
secondaries have to be confirmed. Then search for
the primary has to be done by various investigations.
They are Nasopharyngoscopy; Laryngoscopy; Oesophagoscopy; Bronchoscopy; Blind biopsies are taken
from the fossa of Rosenmuller, lateral wall of pharynx,
pyriform fossa, larynx; FNAC of thyroid and suspected
areas are done; CT scan.
3. Secondaries in the neck with an occult primary
(70% in jugulodigastric nodes): Here secondaries in
the neck lymph nodes are confirmed by FNAC, but
primary has not been revealed by any available
investigations. When all the investigations mentioned
above do not show any evidence of primary, then only
it is called as occult primary. Primary tumour is not
identified at the time when definitive therapy is started.
Initially the secondaries in the neck are treated by
radical neck dissection, then regular follow up is done
(at three monthly intervals) until the primary reveals.
A
Once primary is revealed it is confirmed by biopsy
and treated accordingly, either by curative radio-
therapy or by wide excision depending on location
of revealed primary. This type is usually less aggressive
and has got better prognosis
B
Figs 13.35A and B: Different types of secondaries in neck
– hard nodular; fungating advanced. Involvement of platysma
can be made out as a band.
Types of Secondaries in the Neck
1. Secondaries in the neck with known primary: Here
secondaries are present in the neck and primary has
been identified clinically in the oral cavity , pharynx,
larynx, thyroid, or other areas. Biopsy from the primary
and FNAC from the secondaries has to be taken.
2. Secondaries in the neck with clinically unidenti-
fied primary: Hard, neck lymph nodes are the
secondaries, but primary has not been identified
clinically. FNAC of the neck node has to be done and
(1) Lymphomas. (2) Tuberculous lymphadenitis. (3)
Non-specific lymphadenitis. (4) Primary branchio-
genic carcinoma. Reasons for primary lesion being
occult: Primary being too small to be detected;
possibility of immunological spontaneous regression
of primary and inability of the present diagnostic tools
to detect the primary. FNAC is the tool to confirm
the occult primary. If FNAC is inconclusive, only then
open biopsy (incision/excision) is done to confirm.
Open biopsy helps in high suspects of lymphomas
or poorly differentiated carcinomas. It facilitates tissue
study, immunohistochemistry , and special stains. Many
studies prove that risk of seedling, survival and
prognosis will not alter by open biopsy. But at present
it is proposed only when FNAC fails or special methods
are mandatory to type the disease. Immunoperoxidase
staining can be done in FNAC specimen or formalin
fixed paraffin tissue using monoclonal or polyclonal
antibodies. Immunoperoxidase is the most commonly
used tool. It is mainly useful in lymphomas/neuroendocrine tumours. Electron microscopy is superior to
immunohistochemistry as ultrastructure details can be
Examination of Neck
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assessed. But it is costly. Chromosomal analysis for
tumour specific genes is used in B, T and germ cell
lymphomas.
Occult primary sites which can cause secondaries
in neck
Fossa of Rosenmuller
Lateral wall of pharynx
Posterior third of the tongue
Thyroid
Paranasal sinuses
Bronchus
Oesophagus
Nodal staging in secondaries
N0—nodes not detected
N1—single node same side < 3 cm
N2a—single node same side 3-6 cm
N2b—multiple nodes same side < 6 cm
N2c—bilateral/contralateral nodes < 6 cm
N3—node > 6 cm
Hoarseness—carcinoma larynx, thyroid
Dysphagia—carcinoma posterior 1/3rd of the tongue,
pharynx, oesophagus
Haemoptysis, cough, dyspnoea—carcinoma lung
Ear pain, deafness—nasopharyngeal carcinoma
Spinal accessory nerve—Shrugging of shoulder is difficult
Hypoglossal nerve—Tongue deviates to same side with
wasting
Sympathetic chain—Horner’s syndrome with miosis,
anhidrosis, upper eyelid droop (pseudoptosis), enophthalmos, loss of spinociliary reflex.
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Primary Branchiogenic Carcinoma
It is rare but important. It is arising from remnants
of branchial cleft. It is diagnosed by method of
exclusion. It is probably a final histological diagnosis.
Ludwig’s Angina
It is an inflammatory oedema of submandibular region
and floor of the mouth, commonly due to streptococcal
infection. It causes diffuse swelling and brawny oedema
of the submandibular region. .It is common in severely
ill and in advanced malignancy, causing trismus,
laryngeal oedema. Extension of infection into parapharyngeal space may lead to dreaded internal jugular
vein thrombosis.As the infection is deep to the deep
fascia in a closed fascial plane, it spreads very fast
causing dangerous complications (Fig. 13.36).
Rule of 7 in the neck
• 7 days—inflammation
• 7 months—neoplasm
• 7 years—congenital defect
Note: The Rule of 7 provides a probable diagnosis of
the neck mass based on the average duration of the
patient’s symptoms.
Retrosphenoid syndrome/Jacob syndr ome is involvement of 6th cranial nerve mainly; 2nd to 6th cranial
nerves by neoplastic secondaries causing unilateral
ophthalmoplegia, pain, ptosis, trigeminal neuralgia,
unilateral weakness of muscles.
Rule of 80 in the neck
80% of nonthyroid neck masses are neoplastic
80% of neoplastic neck masses are seen in males
80% of neoplastic neck masses are malignant
80% malignant neck masses are metastatic
80% of metastatic neck masses are having primary above
the clavicle
Fig. 13.36: Abscess in submandibular region.
Clinical Features
Fever, toxicity , diffuse swelling, dysphagia, dyspnoea,
trismus, intraoral oedema, brawny submandibular
swelling, and putrid halitosis.
Complications
Laryngeal oedema and respiratory distress may require
tracheostomy; septicaemia; extension of infection into
parapharyngeal space.
Parapharyngeal Abscess
It is infection of pharyngomaxillary space. This is
a cone shaped space with base formed by base of the
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SRB’s Clinical Surgery
skull and apex by the greater cornu of hyoid bone;
medial wall by the superior constrictor; lateral wall
by the internal pterygoid, angle of mandible and
submandibular salivary gland. Usually infection arises
from the tonsils after tonsillectomy and from the
submandibular space.
Clinical Features
It causes diffuse swelling in the upper neck, trismus,
fever, toxicity.
Complications
Thrombosis of internal jugular vein; Erosion into the
internal carotid artery causing torrential bleeding;
Septicaemia.
Retroparapharyngeal 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. Retropharyngeal lymph nodes are located between buccopharyngeal fascia and prevertebral fascia in paramedian (eccentric) position (Not midline) (Fig.
13.37A).
A
Types—Acute; Chronic
Acute retropharyngeal abscess: It is infection and
suppuration of retropharyngeal lymph nodes due to
staphylococci or streptococci organisms; commonly
from tonsils or pharynx; common in infants and
children.
Clinical features: It presents as lateral (paramedian,
eccentric) smooth, tender swelling in the pharynx with
dysphagia, dyspnoea, cough, toxic features and neck
rigidity. Diagnosis is obvious on proper clinical
examination. It is drained inraorally under general
anaesthesia.
Chronic retropharyngeal abscess: It is invariably
due to tuberculosis of cervical spine. Abscess is located
B
Figs 13.37A and B: Note acute and chronic retropharyngeal
abscess. Normal anatomy is also shown. Acute is eccentric
and is due to suppuration of retropharyngeal lymph nodes.
Chronic is central, midline and is due to tuberculosis of the
cervical vertebra. X-ray picture showing retropharyngeal
abscess due to tuberculosis.
Examination of Neck
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in the midline behind the prevertebral fascia. There
is destruction of the body of the vertebra due to
tuberculosis.
Clinical features: It is 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 sternomastoid. Neurological manifestations
may occur in severe disease.
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Signs
Scalene muscle tenderness; pulsatile swelling in
supraclavicular region with thrill and bruit (25%); bony
mass above clavicle; Adson’s test positive; Roos test
positive; Elevated arm stress test (EAST) positive;
costoclavicular compression maneuver and hyperabduction maneuver positive; poor capillary refilling;
absence or feeble pulse (Please refer Chapter 5:
Examination of Arterial Diseases for details of tests).
Investigations: X-ray spine, chest X-ray, ESR, MRI
of cervical spine are essential investigations. Drainage
of the abscess should be done through neck approach
(never intraoral approach) (Fig. 13.37B).
Thoracic Outlet Syndrome (TOS)
It is syndrome complex due to compression of
neurovascular bundle in the thoracic outlet. Thoracic
outlet has got two main spaces—Scalene triangle
which is bound by scalenus anterior, scalenus medius
and first rib and contains subclavian artery and brachial
plexus; Costoclavicular space which is bound by
clavicle, first rib, costoclavicular ligament and scalenus
medius and contains subclavian artery, vein and
brachial plexus.
Causes
Cervical rib; long C7 transverse process; anomalous
insertion of scalene muscles; scalene muscle hypertrophy; scalene minimus; abnormal bands and ligaments; fracture clavicle or first rib; exostosis; tumours
in the region; brachial plexus trauma and diseases.
Differential Diagnosis of TOS
Carpal tunnel syndrome; cervical spondylosis; spinal
canal tumours; shoulder myositis; angina; Raynaud’s
disease; spinal stenosis; ulnar nerve compression;
Epicondylitis.
Clinical Features
Neurological—Paresthesia; pain in shoulder, arm,
forearm and fingers; occipital headache as referred
pain from tight scalene muscles; weakness in forearm,
hand.
Vascular—Claudication, ischaemic ulcers, gangrene.
Cervical Rib
Definition
It is an extension of transverse process of C7 vertebra
more than 2.5 cm (normal). Syndrome caused by it
is called as cervical rib syndrome, thoracic inlet syn-
drome, thoracic outlet syndr ome; scalene syndrome.
It is 0.46% common, common in females, more frequently on right side. It can be unilateral or bilateral;
can be asymptomatic or symptomatic.
Types
(1) Complete bony: Cervical rib is radio-opaque,
anteriorly ends over the first rib or manubrium.
(2) Fibrous: Cannot be demonstrated radiologically.
(3) Combined: Partly bony partly fibrous. (4) Partial
bony: With free end expanding as bony mass.
Pathology
Cervical rib narrows the scalene triangle (bounded
by scalenus anterior, scalenus medius and first thoracic
rib below) → compression of subclavian artery; C
and T1 nerve roots due to cervical rib → angulation
of subclavian artery → causes constriction of artery
at the site where artery crosses the cervical rib →
‘Eddie’s current’ created in the blood flow causes
sudden release of pressure distal to the narrowing →
Post-stenotic dilatation due to spasm of vasa vasorum
of localised segment of the artery → Venturi pheno-
menon → stasis of blood → Thrombosis → Embolus
→ Features of ischaemia in the hand and forearm.
Later digital gangrene develops (Fig. 13.38A). Compression of C
and T1 causes tingling and numbness
8
along its distribution, i.e. in the little finger, medial
side of hand and forearm. Rarely thrombus may extend
proximally into the subclavian artery causing vertebrobasilar insufficiency . Paget-Schrotter syndrome is
subclavian vein compression by cervical rib. It is rare.
8
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Clinical Features
SRB’s Clinical Surgery
Majority of patients are asymptomatic.
Neurological features (Most common presentation):
Is due to compression of T1 and C8 causing sensory
(tingling and numbness in the little finger, medial side
of hand and forearm); motor (wasting of thenar and
hypothenar eminence with often claw hand and loss
of power of the hand); vasomotor with excessive
sweating of the hand.
Vascular manifestations (More problematic presentation): Pain is due to ischaemia in the muscle. It is
more during work, exercise and is relieved by rest.
Roos test is positive (i.e. raising the arm above the
shoulder. The side where cervical rib is present, patient
cannot continue and so drops the hand down). EAST-
Elevated Arm Stress Test (Modified Roos test): Arm
is elevated above the shoulder, with elbow stretched
fully . Rapid movements of fingers will cause fatigue
on the side where cervical rib is present. Adson’ s test:
The hand is raised above after feeling the radial pulse.
The patient is asked to take a deep inspiration and
turn the head to the same side. Any change in pulse,
i.e. either becoming feeble or absent is noted. Modified
Adson’s test is same as Adson’s, but neck is turned
towards the opposite side. Wasting of thenar,
hypothenar and forearm muscles are evident. Often
digital gangrene may be observed. Limb is colder
and pallor than the opposite side.
conduction studies to confirm neurological compression and also to rule out carpal tunnel syndrome or
cervical spondylosis. Arterial Doppler of subclavian
artery and of the upper limb. Subclavian angiogram
is done to look for vascular involvement (Fig. 13.38B).
A
Features in the neck: (a) Hard, fixed, bony mass in
the supraclavicular region. (b) Palpable thrill above
the clavicle in the subclavian artery. (c) Bruit on
auscultation.
(1) Cervical spondylosis-X-ray neck—lateral view
should be taken to differentiate. (2) Carpal tunnel
syndrome. (3) Tumours or swellings compressing over
the vessel or nerves in the neck. (4) Other causes of
digital gangrene like Raynaud’s, atherosclerosis,
diabetes, collagen diseases, embolism. (5) Syringomyelia, motor neuron disease. (6) Pancoast tumour.
Investigations
Chest X-ray P A-view and lateral view including neckonly bony rib (radiopaque) can be identified. Nerve
B
Figs 13.38A and B: Cervical rib causing gangrene of
digits. X-ray showing cervical rib.
Subhyoid Bursitis
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.
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