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148
CHAP TER5 The front oftheneck
CT of the neck and chest is usually required to determine the extent of
infection. Aggressive surgical drainage and removal of dead tissue is usually required, even if there is only cellulitis. By opening tissue planes not
only is pus released but tissue perfusion is improved by reducing tension.
The surgical approach depends on the location of the abscess. Some can
be drained intraorally, eliminating a scar. However, drainage via a neck
incision is more common, with placement of large drains.
There is some evidence that hyper baric oxygen may be benecial, but
this is a controversial issue. Only in ver y mild cases can patient s be managed conser vatively, if so they must be watched very closely. In selected
cases ultrasound guided aspiration may avoid aggressive surgery.
Choice ofantibiotics
Since many infections originate as dental, pharyngeal, or tonsillar infections, coverage should include organisms k nown to aect these areas.
Most infections will be mixed and will include Gram- positive cocci and
anaerobes. If necessary, discuss with maxillofacial/ ENT or microbiology.
Some specific types ofneck infection
eNecrotizing fasciitis
This is a rare but potentially life- threatening mixed infection, characterized by necrosis of the fascia and subcutaneous tissues.
Untreated, the conditi on can spread rapidly with a mor tality approaching 40%. Although it is more commonly seen in the groin, it can occur in
the neck where it is nearly always due to an underlying dental infection.
Patients of ten have an underlying predisposition such as diabetes, alcoholism. or chronic malnutrition.
Clinically the overlying skin is often pale and mottled or may appear
dusk y due to thrombosis of underlying vessels. Blisters and ulceration
may develop. Complications include:
• Systemic toxicity
• Lung abscess
• Carotid artery erosion, with haemorrhage or septicemboli
• Jugular vein thrombosis and mediastinitis.
Treatment involves IV antibiotics, wide sur gical debr idement. and in
some ca ses hyperbaric oxygen. Any underlying predisposition must be
managed aswell.
cAcute bacterial submandibular sialadenitis
The majority of these infections are secondary to a calculus (stone) in the
duct . Other causes include surgical scarring or strictures secondary to
radiation or other causes of chronic brosis. The whole gland swells up
and there is malaise, pyrexia, and pain. Submandibular calculi are opaque
in 80% of cases, so a radiogr aph may aid in the diagnosis. Antibiotics are
required. If the stone is easily felt in the mouth it can be removed intraorally. If the infection leads to a collection, then incision and dr ainage of
the submandibular space must be carried out, and the gland removed on
an elective basis later. Mumps virus infection involving the submandibular
gland is rare but has been repor ted.
LUMP(S) IN THENECK
bChronic submandibular sialadenitis
(Kuttner’s tumour)
This results from repeated episodes of acute sialadenitis. The structure,
parenchyma, and funct ion of the gland are gradually destroyed. The gland
ends up feeling ver y hard to palpation. Treatment is by sur gical excision.
bLump(s) intheneck
An important consideration
One of the most important considerations in an adult presenting with a lump
in the neck is that it may be a metastatic lymph node. In such cases the
primary cancer is often in the upper respiratory or alimentary tract. The
risk is high in smokers and heavy drinkers. The primar y tumour must
then be found quickly (by imaging, examination under anaesthesia, and
panendoscopy). Around half of malignancies can be found by careful clinical examination alone. Endoscopy of the upper aerodigestive tract will
nd it in another 10– 20%. FNA cytology of a lump may be useful.
There are many dierent causes for a lump in the neck, but by far the com-
monest is an enlarged lymph node (benign or malignant).
Some keypoints
• In patients over 40, 75% of lateral neck masses are caused by
malignant tumours.
• In the absence of obvious infection, a lateral neck mass is malignant
until proven other wise (metastatic squamous cell carcinoma or
lymphoma).
• Open biopsy of a node should be avoided (risk of tumour seeding).
Applied anatomy
The neck is the link between head and trunk. It therefore contains vital
neurovascular structures within a relatively conned space. The surrounding musculoskeletal system not only protects these structures, but
also allows mobility of the head while helping in breathing, swallowing,
and speech. The neck has an extensive lymphatic supply with around 30 0
lymph nodes distributed on bothsides.
Triangles oftheneck
The neck is divided into anterior and posterior triangles by the obliquely
running SCM muscle (Figure 5.4). These are further subdivided into sub mental, submandibular, carotid, muscular, occipital, and subclavian triangles … but these subdivisions are often regarded as unnecessary from
a clinical perspective.
149
150
)
Sternocleidomastoi
CHAP TER5 The front oftheneck
Figure5.4 Triangles of theneck .
Repro duced from E llis H. a nd Mahadev an V., Clinical Anatomy, Thirt eenth Edit ion, Fi gure187,
copyr ight (2 013) with p ermi ssion from Jo hn Wiley andS ons.
Overview ofthe anterior triangle
The anterior triangle is bounded superiorly by the inferior border of the
mandible; posteriorly by anterior border of the SCM muscle; and anteriorly by the midline. This may be further subdivided into submental,
digastric, carotid, and muscular triangles by the digastric muscle and the
hyoid bone. Clinically this subdivision is not necessary.
Contents ofimportance
• Suprahyoid muscles:digastric, stylohyoid, geniohyoid, mylohyoid
• Infrahyoid muscles (the ‘strap muscles’):sternohyoid, omohyoid,
• Carotid sheath:runs from the level of the sternoclavicular joint to the
• Common carotid artery dividing into internal carotid (no extra-
• Internal jugular vein (IJV):surface markings run from the ear lobe to
• Anterior jugular veins:commencing beneath the chin, running
• Vagus ner ve, runs in the groove between the common carotid ar ter y
Digastric
(posterior belly)
Trapezius
Posterior triangle
d
Digastric (anterior belly
Digastric
triangle
Anterior
Carotid
triangle
triangle
Muscular
triangle
Omohyoid
(forming the diaphragm of the oor of the mouth).
thyrohyoid, sternohyoid.
bifurcation of the common carotid artery (at the level of the upper
border of the thyroid car tilage at C3 vertebra).
cranial branches) and external carotid artery.
the sternal end of the clavicle. The deep cervical lymph nodes are
adjacent to the vein throughout its course. On the left- hand side the
thoracic duct crosses behind the vein at the level of C7 vertebra .
infer iorly to the suprasternal region.
and theIJV.
OVERVIEW OF THE POSTERIOR TRIANGLE
• Phrenic ner ve ‘C3, C4, and C5 keep the diaphr agm alive’.
• Hypoglossal nerve:emerges between the internal carotid artery and
the IJV in the upper part of the neck. It lays on the carotid sheath
deep to the posterior digastric and passes forwards beneath the
tendon of digastric to provide motor inner vation to the tongue.
• Cervical lymph nodes:levels ItoIV.
• Submandibular salivar y gland:this comprises a large supercial par t
and smaller deep part that wraps around the posterior border of
mylohyoid. Its duct r uns forwards in the oor of the mouth, crossing
the lingual nerve, to open in the anterior oor ofmouth.
• Parotid:the lower pole, or tail, can pass into the neck, just below
the earlobe. The lower branches of the facial nerve pass through and
both can be injured by penetrating injuries in this region.
• Thyroid:a bi- lobed endocrine gland united in the midline by its
isthmus, overlying the second to four th tracheal rings. Pathological
enlargement of the gland may displace other structures in theneck.
• Parathyroids:small glandular tissue lying on the posterior aspects of
the lateral thyroid lobes— normally four (90% of population).
• Trachea:continues from larynx at the level of C6. Avital site for
urgent and elective surgical airways.
• Oesophagus:behind the tr achea, a continuity of the pharynx at the
level of C6. The recurrent laryngeal ner ves run on each side in the
groove between the oesophagus and trachea.
Overview ofthe posterior triangle
The posterior triangle is a spiral that passes from its apex at the back
of the skull to its base in the front at the root of the neck. It is bounded
anteriorly by the posterior border of SCM, posterior ly by the anterior
border of the trapezius muscle, and below by the lateral part of the clavicle. 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 — runs through the anterior/ inferior par t 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 SCM at the
junction of its upper and middle thirds. It runs vertically down (over
the levator scapulae) to enter the anterior border of 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
151
152
CHAP TER5 The front oftheneck
•
Phrenic nerve (C3, C4, and C5) — runs from later al 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 and C3)— skin over the angle of the
mandible and parotid gland, and the aur icle
•
Transverse cer vical (C2 and C3)— skin in the midline of theneck
•
Supraclavicular nerve (C3 and C4) — 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.
• 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 IJV the bres form a at tendon (the ‘intermediate
tendon’) that is a useful maker 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.
Miscellaneous anatomical structures
and anoverview ofcauses oflumps
Sternomastoidmuscle
This muscle arises from the manubrium sterni and the medial clavicle. It
passes superoposteriorly as a eshy belly, which inser ts into the mastoid
process and the superior nuchal line of the occipital bone. The tr iangular
gap between the two heads of origin of the SCM overlays the IJV— this
site may be used for central venous access.
The strip of anatomy deep to the SCM should not be for gotten.
Essentially the lower half covers the carotid sheath containing the common carotid artery, the IJV, and the vagus nerve, and the upper half lies
over the emerging cervical plexus.
Omohyoid
The omohyoid muscle consists of two bellies, an inferior belly from the
scapula, which ends in a middle tendon, and a superior belly, which continues from the tendon to the hyoid bone. The middle tendon, situated
deep to the SCM, is attached by fascia to the manubrium, rst costal
cartilage, and clavicle.
Platysma
The platysma is a subcutaneous, quadrilateral muscular sheet which
arises from the skin over the deltoid muscle and the pectoralis major and
is inserted into the lower border of the mandible and the sk in around the
ASSESSING A NECKLUMP
mouth. It is supplied by the cervical branch of the facial nerve. It raises
the skin, thereby probably relieving pressure on the underlyingveins.
Causes oflumps intheneck
Not all lumps in the neck are lymph nodes. Although lymphadenopathy
is the commonest cause of a neck lump, it is important to be mindful of
other causes:
• Developmental:branchial cyst, haemangioma, laryngocoele,
teratoma, thyroglossal duct cyst, cer vicalrib
• Skin and subcutaneous tissues:sebaceous cyst,lipoma
• Infected lymphnodes:
•
Viral:Epstein – Barr virus,HIV
•
Bacterial:Staphylococcus, TB, cat scratch, Brucella
•
Protozoa:toxoplasma, leishmaniasis
•
fungal:histoplasmosis, blastomycosis, coccidioidomycosis
• Neoplastic lymph nodes:lymphoma, metastasis
• Granulomatous lymph nodes:sarcoid, foreign body reaction,etc.
• Paraganglioma, vascular tumours,etc.
• Carotid sheath:aneurysm, carotid body tumour, vagal or sympathetic
neuroma
• Salivary gland (parotid or submandibular):
•
Infective:sialadenitis, sialolithiasis
•
Autoimmune:Sjögren’s syndrome, neoplastic
• Miscellaneous:AIDS- related disease, Kawasaki disease, plunging
ranula, thyroid, parathyroid, thymus, subclavian aneurysm.
Assessing a necklump
History
Even with an obvious lump, take a full medical histor y. This will ensure
that coexisting diseases and other possible causes of the lump are not
overlooked. TB, for example, is still a common cause of cervical lymphadenopathy and can aect the administration of general anaesthesia.
Smoking and alcohol are impor tant in head and neck malignancy. Some
animals (cats) can pass on infections (toxoplasmosis). Travel abroad may
result in unusual infections.
Useful information whendiagnosing necklumps
Age
This may be a usefulguide:
• <16years:cer vical lymphadenopathy secondary to infection is the
commonest cause of neck lumps in this age group, followed by
congenital and developmental lesions. Neoplastic disease can still
occur (leukaemia/ lymphoma) but is less common.
• 16– 40years:inammator y lesions are still the most common
followed by developmental lesions. Neoplasia is next most common
with benign disease seen slightly more than malignant disease.
• >40years:neoplasia is the most common cause of neck swellings
with malignant disease predominating.
153
154
CHAP TER5 The front oftheneck
How long has thelump been present?
Was it acute in onset or a gradual increase over many months or years?
Developmental lesions tend to gradually increase in size becoming
increasingly troublesome. Inammatory causes tend to develop rapidly
and are often associated withpain.
Is it painful?
Cervical lymphadenopathy secondary to infection and inammatory salivary gland disea se often present with painful swellings. Metastatic lesions
in the neck are rarely painful unless a ssociated with secondary infection
or malignant invasion of local nerves.
Does it vary insize?
Has the lump gradually increased in size, or does it increase and then
decrease in size at dierent times of the day? Ask particularly about
mealtimes as obstructive sialadenitis secondar y to sialolithiasis (salivar y
stones) is quite common and of ten presents as submandibular swelling
worse at mealtimes.
Does thepatient have foul breath (halitosis) or a foul taste intheirmouth?
Submandibular gland infection may discharge pus in the mouth, resulting in a foul tasting discharge. Similarly, a pharyngeal pouch can become
secondarily infected as a result of food stagnation; the patient (usually
elderly) will present with halitosis, dysphagia, and a painful neck swelling
just anterior toSCM.
Ask about sore throat, unilateral hearing loss, earache, and hoarseness
These may indicate underlying malignancy.
Other symptoms ofsystemicupset
Are there other infective symptoms present: malaise, fever, and lethargy? Cervical lymphadenopathy may represent a generalized viral infection, e.g. glandular fever (late teens).
Has thepatient travelled overseas recently?
Are there other features ofmalignant disease?
Weight loss/ cachexia, lethargy, malaise. Gener alized lymphadenopathy,
sweating, skin itching associated with lymphoma.
Are there features ofthyroid disease?
Thyrotoxic (tremor, tachycardia/ atrial brillation, perspiration, lid lag,
thyroid eye disease, bruit), hypothyroid (dr y hair/ skin, xanthelasma ,
puy face, croaky voice).
Examination
Examine the entire head and neck including the throat, mouth, and teeth
(infec tions and malignancy). This is discussed in det ail in the relevant
chapters. You may also need to examine other body sites and systems
(lymphadenopathy, abdominal masses, liver, spleen, etc.). Fibreoptic nasendoscopy may also be required to assess the nasophar ynx for occult
primary tumours. This requires specialist training.
ASSESSING A NECKLUMP
Neck nodelevels
Clinically, the deep cervical lymph nodes are divided into ve levels. This
classication is impor tant in the management of some cancer s of the
head andneck .
Investigations
These are tailored according to the suspectedcause.
Plainlms
OPT and CXR are usually required to assess the dentition and look for
lung pathology (tumours/ infections).
CT scanning
CT scanning is exceptionally useful in assessing the extent of neck
swellings particularly invasion into deeper tissues. However, artefact
produced by metal in dental restorations often cause problems when
investigating lesions in the oor of the mouth and upperneck.
MRI
MRI is useful in the head and neck as it produces images with excellent soft tissue denition. It is par ticularly useful in the assessment of
salivary glands and other neck masses. Remember that its use is contraindicated in patients with met al implants such as aneurysm clips or cardiac pacemakers.
Fine- needle aspiration
A ne- bore needle (‘green’ gauge) attached to a 20 mL syringe is passed
into the mass while it is immobilized between the ngers of the other
hand. Negative pressure is applied by withdrawing the plunger of the
syringe, thus collecting cells from the lesion into the needle/ syringe. The
sample is placed on a microscope slide and viewed by a histopathologist. Comment can then be made as to whether the cells show malignant
features or not. This is quite an ‘operator- sensitive’ technique and on
occasion a non - diagnostic sample istaken.
Ultrasound
Ultr asound is useful for distinguishing between solid and c ystic lesions
and may be used to guide biopsy needles to sample masses or aspirate
collections. It is particularly useful in the investigation of salivar y gland
lesions as it can often distinguish between suspected inammation and
tumours. Ultrasound may also be able to distinguish whether a suspected tumour is benign or malignant.
Sialography
Sialography involves the injection of a radiopaque medium into salivary
duct s which are then visualized with image intensication or plain lms.
It is a useful process in the investigation of neck swellings when stones,
strictures, or intrinsic salivary gland pathology are suspected. Acute
infection and iodine sensitivity are contraindications to sialography.
Examination underanaesthesia
This may be required to look for tumours of the upper aerodigestive
trac t, not visible by other means. It also allows for biopsy at dicult to
reach sites (tongue ba se/ supraglottic,etc.)
155
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CHAP TER5 The front oftheneck
bLymphadenopathy
Lymphadenopathy in the neck (especially supraclavicular) can arise from
disease both above and below the collarbones.
Enlarged cervical lymph nodes (cervical lymphadenopathy), is the most common cause of a lump(s) in the neck. Lymphadenopathy in the neck (especially
supraclavicular) can arise from disease both above and below the collar bones
(e.g. bronchial/ gastric malignancy). The two common causes of lymphadenopathy are infections and tumours.
Causes ofenlarged lymphnodes
Localcauses
• Local infection— dental, tonsillitis, skinsepsis
• TB necknodes
• Neoplastic — lymphoma or metastatic (any where in head andneck)
• Intraparotid nodes (may occur with facial skin cancers)
• Supraclavicular lymph node (Virchow’s node) can arise from disease
both above and below the collar bones (e.g. bronchial/ gastric
malignancy).
Generalizedcauses
• URTI
• Infective mononucleosis
• Toxoplasma
• Cat scratch
• HIV
• Sarcoidosis
• Lymphomas (Hodgkin’s disease, non- Hodgkin’s lymphoma)
• Lymphatic leukaemia.
bInfections causing lymphadenopathy
Acute infections are the commonest cause of lymph node enlargement in
patients under 40. They are generally vir al (colds, glandular fever, etc.) or
bacterial (dental infections, tonsillitis, and scalp infections such as impetigo). TB is a chronic inammatory cause that has seen an increase in
incidence in recent years. TB lymph nodes tend to be rm and indurated
and often give rise to sinuses. Clinically they may appear malignant.
Bacterial cervical adenitis
• Pathogens:most commonly group Astreptococci and Staphylococcus
aureus.
• Symptoms:tender, mobile lump, associated with constitutional
symptoms (malaise, fever). Diagnosis is usually clinically but aspiration
for culture and sensitivity may be required.
• Complications:untreated can rapidly progress to spreading infection,
such as Ludwig’s angina or generalized sepsis.
• Treatment:may require incision and drainage. All require antibiotics
and treatment of the underlying cause (most commonly tooth/
tonsil).
LYMPHADENOPATHY
Atypical mycobacteria
• Pathogens:Mycobacterium avium, M.scrofulaceum, M.intracellulare.
These are less virulent than M.tuberculosis. However they are also
less responsive to antituberculosis medications.
• Common in children, immunocompromised, or those who travel
abroad.
• Symptoms:unilateral cer vical adenopathy (adherent to overlying
skin with purplish discolour ation). Induration and adherence are also
features of malignancy and can cause diagnostic confusion.
• Diagnosis:clinical, culture requires 2– 4 weeks, tuberculin testing is
often negative.
• Treatment:these should be discussed with your local microbiologist.
Often complete excision (avoid incision and drainage) is required
in addition to antibiotics (may consider rifampin or macrolides for
3– 6months)
Non- specic lymphadenitis
This is a reactive adenitis, typically secondary to a nasopharyngeal or
oropharyngeal infection, although it may also occur from any infection
of the head and neck. The primar y infection may have resolved leaving
persistent, enlarged cer vical lymph nodes. These may be confused with
malignant lymph nodes (and vice versa) and therefore require a detailed
clinical histor y and careful examination of the entire head and neck for
primary infection or a tumour. FNA cytology may be required. Large
nodes may be removed to enable a more precise diagnosis.
Cervical adenopathy inthe patient withHIV
This carries a risk for lymphoma, at ypical mycobacterium, carcinoma,
and TB. Excision biopsy should be reser ved for highly suspicious lesions.
Persistent generalized lymphadenopathy(PGL)
• Cervical adenopathy is the third most common lymphatic site
(axillary and inguinal more common).
• Symptoms:typically asymptomatic adenopathy.
• Diagnosis:based on clinical history and exam. Neoplastic and
infectious causes must be ruled out . Must have adenopathy of two or
more sites for greater than 3months
• Treatment:observation.
Cat- scratch disease
This is a self- limiting condition caused by the cat- scratch bacillus (bacillus angiomatosis). Symptoms include cutaneous lesions at primar y site,
tender cer vical adenopathy, mild fever, and malaise. Diagnosis includes
culture and cat- scr atch antigen testing, together with a history of cat
exposure. Treatment is generally supportive. Avoid incision and drainage
to prevent sinus formation. If a specimen is required, consider aspiration.
bTumours causing lymphadenopathy
Primar y:Hodgkin’s disease and non- Hodgkin’s lymphomas
• Lymphomas are malignant neoplasms of lymphoid tissue.
• Broadly divided into Hodgkin’s and non- Hodgkin’s type with fur ther
subdivisions on immunohistological criteria.
157