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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
118
CHAP TER4 The back oftheneck
Figure4.6 Spinal cord sagittal T
resonance i mages from a patient with A rnold– Chia ri ty pe Imalform ation and
syringomyelia.
Reproduced with permission from Filippi M., Oxford Textbook of Neuroimaging, Figure2 6.4,
p.328, Co pyrig ht © 2015 with pe rmis sion fr om Ox ford Un iversit yPres s.
eAcute spinal cord compression
This is a neurosurgical/ spinal emergenc y. Urgent referral and management
- weighted (a)and T1- weig hted (b)magnetic
2
are essential to minimize permanent loss of function.
Causes ofspinal cord compression
• Trau m a
• Tumours (benign or malignant):bone tumours, primary or metastatic
tumours, lymphomas, multiple myeloma and neurobromata
• Prolapsed interver tebraldisc
• Extradur al or subdur al haematoma (following recent epidur al, lumbar
puncture, spinal surgery, or anticoagulant therapy)
• Inammatory disease, especially rheumatoid arthritis
• Spinal infections (bacterial, TB, fungal, vertebral osteomyelitis,
discitis or epidural abscess)
• Spinal manipulation.
DIFFE RENT IAL DIAGNOS IS OF NE CKPAIN
Symptoms that suggest spinal compression include:
• Insidious progression
• Neurological symptoms:gait disturbance, clumsy or weak hands, or
loss of sexual, bladder, or bowel function
• Neurologicalsigns:
•
Lher mitte’s sign — exion of the neck causes an elec tric shock- type
sensation that radiates down the spine into thelimbs
•
UMN signs in the lowerlimbs
•
LMN signs in the upperlimbs
•
Sensory changes are variable.
Cervical spine compression can result in quadriplegia if untreated.
Compression above the level of C3, C4, C5 (level of the phrenic nerve)
causes paralysis of the diaphr agm and articial ventilation is required.
Sphincter disturbances are late features of cer vical cord compression.
There may also be loss of autonomic ac tivity with lack of sweating below
the level, loss of thermoregulation, and hypotension. Always check and
document bladder/ bowel function, sphincter tone, and check for saddle
anaesthesia (cauda equina).
Management
Initial measures are suppor tive and the prevention of fur ther injury. The
neck should be immobilized and ur gent imaging (CT or MRI) undertaken.
Urgent referral to a spinal unit/ neurosurgeon is required. Occasionally
clinical oncology may be involved if surgery is not an option and the cause
is a radiosensitive tumour. Steroids may help, depending on the underlying
cause and should be discussed with the specialist. Depending on the extent
of neurological decit patients may require IV uids and catheterization.
Spinal cord compression due tometastases
This can occur in around 5% of patients with cancer. Spinal pain is often
present for several months before paraplegia. The thoracic spine is most
commonly aected in metastatic cancers.
119
Dierential diagnosis ofneckpain
Neck pain is a common problem. Like a headache, in most cases the
cause is not ser ious. However, the patient still needs careful assessment.
The dierential diagnoses include:
• Simple neck pain:acute neck strain, postural neck ache, or whiplash
• Headache
• Referred pain, e.g. from the shoulder
• Degenerative disc disease/ cervical spondylosis
• Traumatic prolapsed intervertebraldisc
• Malignancy:primary tumours, secondary deposits, or myeloma
• Infections:discitis, osteomyelitis,orTB
• Fibromyalgia
• Vascular insuciency
• Psychogenic neckpain
• Inammatory disease:rheumatoid arthritis
• Metabolic diseases:Paget’s disease of bone, osteoporosis.
120
CHAP TER4 The back oftheneck
cAcute tor ticollis (wryneck)
This refers to a dystonic condition resulting in an abnormal positioning of
the head. It ha s many causes , the most common bei ng muscular irritation,
often the sternocleidomastoid (SCM) and trapezius. These will usually
settle spontaneously within a couple of days. Treatment includes simple
analgesia and NSAIDs. Diazepam can also be used to improve symptoms
by helping muscle relaxation. Physiotherapy can be very helpful.
Other rarer causes include infections involving ear s or throat (e.g.
otitis media and retrophar yngeal abscess), tardive dystonia, secondary
to medications such as antiemetics and antipsychotics, and posterior
fossa tumour s compressing the nerve supply to theneck.
cVertebrobasilar insuciency
(beauty parlour syndrome)
This condition refers to the temporary onset of vertigo- like symptoms as
a result of decreased blood ow in the posterior circulation of the br ain.
This supplies blood to the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex. Symptoms vary accordingly, but commonly
include ver tigo. Patients may suddenly become weak at the k nee and
crumple (a ‘drop attack’). The dierential diagnosis is large and includes
labyrinthitis, vestibular neuronitis, and benign paroxysmal positional vertigo as well as cardiac causes and strokes/ TIAs. Eagle syndrome is a rare
condition which also presents with neurological symptoms occurr ing on
head rotation (see E Chapter 5, p. 173).
In ver tebrobasilar insucienc y, osteophyte formation in the cer vical
spine occurs with increasing age and gr adually compresses the vertebr al
vessels. This is made worse by any associated atherosclerosis, so this
condition is commonly associated with diabetes, smoking, and hypertension. Occlusion of the vessels can result in positional- dependent vertigo
or blackouts in which specic movement of the neck results in the symptoms. This is a useful clinical sign but be careful when eliciting it! Magnetic
resonance angiography (MRA) may be used to identif y ver tebrobasilar
stenoses or occlusions, but is not often required.
Management
Treatable coexisting problems should be managed (e.g. diabetes, hypertension). An appropriate exercise regimen can also be designed in order
to avoid excessive pooling of blood in the legs. To prevent drop att acks,
patients are advised to ‘go to the ground’ shortly af ter feeling dizzy or
if they experience changes in vision. Patients may be started on an antiplatelet agent or anticoagulants once haemorrhage has been excluded
with imaging.
LUMP(S) IN THE BACK OF THENECK
bLump(s) inthe back oftheneck
Lumps are also discussed elsewhere (see E Chapter 5). An isolated
palpable lymph node in the back of the neck is usually non- neopla stic
in nature.
An overview ofthe posterior triangle anatomy
Boundaries
• Front:poster ior border of the SCMmuscle
• Back:anterior border of the trapeziusmuscle
• Below:the lateral part of the clavicle.
The posterior triangle is a spiral that passes from its apex at the back of
the skull down to its base in the front at the root of the neck. Its roof is
formed by the investing layer of deep cervical fascia, and its oor by the
prevertebral fascia.
Contents ofimportance
• Third part of the subclavian artery:runs ver y low in the posterior
triangle at the level of the clavicle; just above the clavicle the
suprascapular and transverse cervical vesselspass.
• External jugular vein:r uns through the anterior/ inferior part of the
triangle to drain into the subclavian vein which lies more inferiorly
and is not included in the posterior triangle.
• Occipital, transverse cervical, suprascapular, and subclavian arteries.
• Accessor y nerve emerges from the posterior border of the SCM at
the junction of its upper and middle thirds. It runs vertically down
(over levator scapulae) to enter the anterior border of the trapezius
usually 5– 6cm above the clavicle.
• Cervical plexus branches:
•
Muscular branches
•
Aloop from C1 to hypoglossal
•
C2/ 3 branches to SCM and C3/ 4 to trapezius
•
Inferior root of ansa cervicalis
•
Phrenic nerve (C3, C4, C5)— r uns from lateral to medial over
scalenus anterior
•
Cutaneous branches
•
Lesser occipital nerve (C2)— posterior par t of the neck to the
superior nuchal line, and behind the auricle
•
Great auricular nerve (C2& 3)— skin over the angle of the
mandible and parotid gland, and the aur icle
•
Transverse cervical (C2& 3)— skin in the midline of theneck
•
Supraclavicular nerve (C3& 4)— root of neck/ upperchest.
• Brachial plexus trunk s:the three trunks of the brachial plexus along
with the cer vical plexus are held down to the prevertebral muscles
by the covering of prevertebral fascia that forms the oor of the
posterior triangle. Strictly speak ing they are not contents of this
triangle, but are mentioned, however, because of their anatomical
importance in penetrating injuries.
121
122
CHAP TER4 The back oftheneck
• Omohyoid muscle:posterior belly. From its or igin at the hyoid bone
it passes deep to the SCM, coming to lie over the carotid sheath. As
it overlies the internal jugular vein the bres form a at tendon (the
‘intermediate tendon’) that is a useful marker during neck dissections
to the vein’s position. The muscle is held down to the clavicle at the
intermediate tendon by a fascialsling.
• Cervical lymph nodes:levelV.
Common lumps inthe back oftheneck
• Skin lumps (sebaceous cyst, skin tags,etc.)
• Lymph node (usually benign if solitary)
• Lipoma.
Disea ses of the mastoid process and parotid tumour s (in the parotid tail)
may cause confusion in diagnosis. These are strictly not part of the posterior triangle, but if large enough may appear to be involvingit.
Chapter5
123
The front oftheneck
Common presentations 124
Common problems and their causes 124
Useful questions and what to look for 128
Examination of the front of the neck 132
Useful investigations 134
Injuries to the front of the neck 13 6
Assessing injuries to the front of the neck 13 8
Diculty breathing, noisy breathing, and upper airway
obstruction 140
Initial management of stridor 142
Subglottic stenosis 143
The acutely swollen neck 14 4
Infec tions deep in the neck 145
Some specic types of neck infection 148
Lump(s) in the neck 149
Over view of the anterior triangle 150
Over view of the posterior tr iangle 151
Miscellaneous anatomical structures and an overview
of causes of lumps 152
Assessing a neck lump 153
Lymphadenopathy 156
Thyroid/ thyroglossal cyst/ thymus 158
Carotid body tumour 160
Branchial cysts/ sinuses/ stulae 161
Plunging ranula 162
Dermoid cysts and ter atomas 163
The salivary glands 164
Hoarse voice (dysphonia)/ loss of voice 167
Vocal cord palsy and other conditions 168
Carotid arter y disease 170
Coughing up blood (haemoptysis) 171
Foreign body ingestion 172
Miscellaneous conditions 173
124
CHAP TER5 The front oftheneck
Common presentations
• Cough (chronic/ severe)
• Diculty breathing (stridor) (see also E Chapter 8)
• Diculty swallowing (dysphagia) (see also E Chapter 8)
• Foreign body ingestion and aspiration
• Haemoptysis (coughing upblood)
• Hoarse voice/ loss ofvoice
• Injuries
• Lumps and swellings
• Pain on swallowing (odynophagia) (see also E Chapter 8).
Common problems and theircauses
Cough (chronic/ severe)
Common
• Infections (especially upper respiratory tract infections (URTIs))
• Gastroesophagealreux
• Air pollution/ reactive airway disease
• Foreignbody
• Lung diseases (bronchiectasis, cystic brosis, interstitial lung
diseases, and sarcoidosis)
• Lung tumours
• Diseases/ stimulation of the external auditory canal (vagal
stimulation)
• Cardiorespiratory diseases (heart failure, infection, infarction,
asthma)
• Post- nasaldr ip.
Uncommon
• Angiotensin- converting enzyme (ACE) inhibitor
• Psychogenic/ habit
• Occupational (factory workers).
Diculty breathing (stridor)
Common
• Foreignbody
• Spreading infection (e.g. tonsillitis, quinsy, epiglottitis,
retropharyngeal abscess,croup)
• Airway oedema (e.g. trauma, anaphylaxis)
• Obstructive sleep apnoea (stertor due to upper airway collapse)
• Laryngitis
• Tumour/ polyps
• Reinke’soedema
• Gastroesophageal reux.
COMMON PROBLEMS AND THEIRCAUSES
Uncommon
• Epiglottitis (children)
• Mediastinalmass
• Subglottic stenosis
• Thyroiditis
• Vocal cordpalsy
• Tracheo/ laryngomalacia
• Congenital anomalies in infants and children
• Vascular anomalies.
Diculty swallowing (dysphagia)
(See also E Chapter 8.)
Common
• Cerebrovascular accident
• Tumour
• Neurological diseases, e.g. Parkinson’s disease, multiple sclerosis
(MS), amyotrophic lateral sclerosis
• Globus.
Uncommon
• Oesophageal atresia
• Paterson– Kelly syndrome
• Benign strictures
• Oesophageal diverticula (pharyngealpouch)
• Scleroderma
• Diuse oesophagealspasm
• Webs andrings.
Foreign body ingestion and aspiration
Common
• Fishbones
• Peanuts
• Coins (most common object in children)
• Meat (food bolus commonest in adults).
Uncommon
• Dentures
• Many miscellaneousitems.
Haemoptysis (coughing upblood)
Common
• Chest pathology (bronchitis, pneumonia, TB, bronchiectasis,
pulmonary embolism, cystic brosis)
• Sinusitis
• Tumours (lung/ upper aerodigestivetract)
• Cardiac (congestive cardiac failure and mitral stenosis)
• Trau m a .
125
126
CHAP TER5 The front oftheneck
Uncommon
• Hereditary haemorrhagic telangiectasia
• Goodpasture’s syndrome
• Wegener’s granulomatosis
• Foreign body in the respiratorytract
• Sarcoidosis
• Bleeding diathesis (warfarin, antiplatelet drugs).
Hoarse voice/ loss ofvoice
Common
• Prolonged excessive shouting/ singing
• Laryngitis (viral, bacterial, fungal)
• Vocal fold paralysis
• Reinke’s oedema (secondary to smoking)
• Hypothyroidism (laryngeal myxoedema)
• Gastroesophageal reux disease(GOR D)
• Injury.
Uncommon
• Psychological
• Lar yngealcancer
• Benign neoplasms (cysts, nodules, polyps, and ulcers,
papillomatosis, haemangioma)
• Congenital disorders
• Adductor spasmodic dysphonia and muscle- tension disorders
• Vocal fold granulomas and caustic inhalation injuries
• Endocrine:adrenal, pituitary, and gonadic disorders
• Neuromuscular:MS, Parkinson’s, stroke, Guillain– Barré syndrome,
myastheniagravis
• Connective tissue disorders (rheumatoid arthritis, systemic lupus
erythematosus (SLE)).
Injuries
Common
• Blunt trauma— bruising andoedema
• Smoke inhalation
• Super cial lacerations.
Uncommon
• Fracturedlarynx
• Trachea avulsion
• Surgical emphysema
• Penetrating injuries
• Blast injuries.
COMMON PROBLEMS AND THEIRCAUSES
Lumps and swellings (lateral side ofneck)
Common
• Lymphadenopathy (inammatory, infectious, reactive, tumour)
• Abscess (Ludwig’s)/ deep neck space infections
• Submandibular gland enlargement (tumour, infection,stone)
• Thyroid enlargement
• Parotid gland (tail).
Uncommon
• Plungingranula
• Branchial cleftcyst
• Pharyngealpouch
• Laryngocoele
• Teratoma and dermoidcyst
• Carotid bodytumour
• Carotid artery aneurysm
• Cystic hygroma
• Cervicalrib
• Torticollis.
Lumps and swellings (midline ofneck)
Common
• Submental lymphnode
• Thyroid enlargement
• Thyroglossal cyst (children and adolescents).
Uncommon
• Dermoid cyst (sublingual)
• Plungingranula
• Lar yngeal swellings (bursitis, chondroma,etc.)
• Thymiccysts
• Super cial swellings (sebaceous cyst, dermoid cyst, lipoma,
abscess,etc.).
127
Pain onswallowing (odynophagia)
(See E Chapter 8.)
Common
• Ingestion of very hot or cold food ordrink
• URTIs/ epiglottitis
• Drugs
• Ulcers.
Uncommon
• Immune disorders
• Neurological disorders
• Tumour.