Inflammatory
conditions of the neck
Parapharyngeal and retropharyngeal abscess
formation has been covered earlier in this chapter.
Ludwig
angina
Ludwig described a clinical entity
characterised by a brawny swelling of the submandibular region combined with
inflammatory oedema of the mouth. It is these combined cervical and intraoral
signs that constitute the characteristic feature of the lesion, as well as the
putrid halitosis that is always present. The infection is often caused by a
virulent streptococcal infection associated with anaerobic organisms and
sometimes with other lesions of the floor of the mouth such as carcinoma. The
infection encompasses both sides of the mylohyoid muscle causing oedema and
inflammation such that the tongue may be displaced upwards and backwards giving
rise initially to dysphagia and subsequently to potential obstruction of the
airway.
Clinical
cause
Unless the infection is controlled cellulitis
may extend down the neck beneath the deep fascial layers to involve the larynx
causing glottic oedema.
Treatment
Antibiotic therapy should be instituted as soon
as possible using intravenous broad-spectrum antibiotics such as amoxycillin
or cefuroxime combined with metronidazole to combat the anaerobes. In advanced
cases where the swelling does not subside rapidly with such treatment, a curved
submental incision may be used to drain both submandibular triangles. The
mylohyoid muscle may be incised to decompress the floor of the mouth. Simple but
generous corrugated drains may be placed in the wound which is then lightly
sutured. This operation may be conducted under local anaesthesia and on rare
occasions an additional tracheostomy may be necessary.
Cervical
lymphadenitis (Table 43.14)
There are approximately 800 lymph nodes in the
body; no fewer than 300 of them lie in the neck. Inflammation of the lymph nodes
of the neck is exceedingly common. Infection occurs from the oral and nasal
cavities, the pharynx, larynx, ear, scalp and face. The source of the infection
must be sought systematically.
Acute
lymphadenitis
The affected lymph nodes are enlarged and
tender, and there may be varying degrees of general constitutional disturbance
of the patient with pyrexia, anorexia and general malaise. The treatment in the
first instance is directed to the primary focus of infection, for example
tonsillitis or a dental abscess. If, despite antibiotic therapy, the pain
continues or abscess formation occurs in the lymph nodes, parapharyngeal or
retropharyngeal space then surgical drainage may be required.
Chronic
lymphadenitis
Chronic painless lymphadenopathy may be either
tuberculus, in children or young adults, or due to secondary malignant
metastases most commonly from a squamous carcinoma in older people. Lymphoma
also commonly presents in cervical nodes in young adults.
Tuberculous
adenitis
Tuberculosis (TB) remains a problem throughout
the world and is still a common cause of cervical lymphadenopathy. The condition
most commonly affects children or young
In
most instances the tubercular bacilli gain entrance through the tonsil of the
corresponding side of the lymphadenopathy. Both bovine and human TB may be
responsible. In approximately 80 per cent of cases the tuberculous process is
limited to the clinically affected group of lymph nodes but a primary focus in
the lungs must always be suspected and investigated. As renal and pulmonary TB
occasionally
coexist, the
urine should be examined carefully. Rarely, the patient may develop
a natural resistance
to the infection and
the nodes
may be
detected at a later date as evidenced by calcification on an X-ray. This can also
be seen after appropriate general treatment
of tuberculous adenitis. If treatment is not instituted, the caseated node may
liquefy and break down with the formation of a cold abscess in the neck (Fig.
43.60). The pus is first confined by the deep cervical fascia but after weeks or
months this may become eroded at one point and the pus flows through the small
opening into the space beneath the superficial fascia. The process has now
reached the well-known stage of a ‘collar stud’ abscess. The superficial
abscess enlarges steadily and, unless suitable treatment is adopted, the skin
will soon become reddened over the centre of the fluctuating swelling and before
long a discharging sinus occurs in the neck.
Treatment.
The patient should be treated by appropriate chemotherapy, as confirmed by
assessment of abscess contents for sensitivities to the antituberculous drugs.
If an abscess fails to resolve despite appropriate chemotherapy and general measures,
occasionally excision of the abscess and its surrounding fibrous capsule is
necessary together with the relevant lymph nodes. If there is active TB of
another system, for example pulmonary, then removal of tuberculosis lymph nodes
in the neck is inappropriate. The nodes are commonly related to the internal
jugular vein, common carotid and vagus nerve, and they may be associated with a
great deal of surrounding fibrosis. Surgery can be difficult and a portion of
the internal jugular vein may require excision with considerable care to avoid
damage to the vagus or the cervical sympathetic trunk. A good view and access
should be obtained at all times during this surgery and the sternocleidomastoid
muscle divided to facilitate access, particularly if the disease is adjacent to
the spinal accessory nerve or the hypoglossal nerve. The resected nodes should
be sent for both pathological and microbiological analysis.
Primary
tumours of the neck
Neurogenous
tumours
Chemodectoma (carotid body tumour). This is a
rare tumour
Clinical features.
The
patients often present with a long history of several years of a slowly
enlarging painless lump at the carotid bifurcation. About one-third of patients
present with a
pharyngeal mass pushing the tonsil medially and anteriorly. The mass is firm,
rubbery, pulsatile and is mobile from side to side but not up and down, and can
sometimes be emptied by firm pressure, after which it will slowly refill in a pulsatile manner. A bruit may also be present.
Investigations.
When a chemodectoma
is suspected a duplex
study and, if
indicated, a carotid angiogram
should be carried out to demonstrate the carotid bifurcation which is usually
splayed and a blush which outlines the normal tumour vessels. This tumour must
not be biopsied and fine needle aspiration is also contraindicated.
Treatment.
Because these
tumours rarely metastasise and their overall rate of growth is slow, the need
for surgical removal must be considered carefully as complications of surgery
are potentially serious. The operation is best avoided in elderly patients.
Radiotherapy has no effect. In some cases it may be possible to dissect the tumour away from the
Vagal
body tumours. Vagal paragangliomas arise from nests of paraganglionic tissue of
the vagus nerve just below the base of the skull near the jugular foramen. They
may also be found at various sites along the nerve down to the level of the
carotid artery bifurcation.
Clinical features.
They
also present as slowly growing and painless masses in the anterolateral aspect
of the neck, and may also have a long history commonly of 2—3 years before
diagnosis. Diagnosis is confirmed by CT and MRI scanning and additional
arteriography if necessary.
Secondary
carcinoma of the neck
Secondary carcinomatous infiltration of the
cervical lymph nodes is a common occurrence from important primary sites in
the head and
neck. These are nasopharynx, tonsil, tongue, piriform fossa and supraglottic
larynx. All of these areas must be carefully assessed to search for the primary
growth before considering biopsy or any surgery on the neck. Investigation is
further assisted by fine needle aspirate of the neck node.
Management
The management of the involved cervical lymph
nodes depends on the overall treatment regime to be given to the patient.
•
If surgery is being used to treat the primary disease and the cervical
nodes are palpable, and in excess of 3 cm, they may
be excised en
bloc with the
primary lesion.
•
If radiotherapy is used initially, as is always the case in carcinoma of
the nasopharynx, then radiotherapy may also be given to the neck nodes whatever
their stage. In the case of tongue, pharynx or larynx, however, if the node
exceeds 3 cm in diameter then surgery may be necessary for the neck nodes even if
the primary is treated by radiotherapy.
•
If radiotherapy is used initially, as is always the case in carcinoma of
the nasopharynx, then radiography may also be given to the neck nodes, whatever
their stage. In the case of the tongues, pharynx or larynx however, if the node
exceeds 3 cm in diameter then surgery may be necessary for the neck nodes,
even if the primary is treated by radiotherapy. If radiotherapy is used
initially with resolution of the primary but there is subsequent residual or
recurrent nodal disease then this situation will require cervical lymph node
dissection.
Types
of neck dissection
•
Classical radical neck dissection (Crile) —
the classic
operation involves resection of the cervical lymphatics, the lymph nodes and
those structures closely associated such as the internal jugular vein, the
accessory nerve, the submandibular gland and the sternomastoid muscle. These
structures are all removed en bloc and in continuity
with the primary disease if possible. The main disability that follows the
operation is the drooping of the shoulder due to paralysis of the trapezius
muscle as a consequence of excision of the accessory nerve.
•
Modified radical neck dissection —
in selected cases
one or more of the three following structures are preserved, the accessory
nerve, the sternocleidomastoid muscle or the internal jugular vein, but
otherwise all major lymph node groups and lymphatics are excised. Whichever
structures are preserved at this dissection should be clearly noted.
•
Selective neck dissection —
in this type of
dissection one or more of the major lymph node groups is preserved along with
sternomastoid muscle, accessory nerve and internal jugular vein. Under these
circumstances the exact groups of nodes
excised must be documented.