Neck

بِسْمِ اللهِ الرَّحْمنِ الرَّحِيم

Surgery of the neck(3)


Superficial cellulitis is common & = cellulitis.2. Deep cellulitis=1. Retropharyngeal abscess2. Parapharyngeal abscess3. Submandibular space infection =Ludwig’s angina

INFECTIONS IN THE NECK

Is deep cellulitis of floor of mouth& submandibular with halitosis Caused by virulent strept. + anaerobes Secondary to odontogenic infections (tooth, tongue, mandible & salivary glands). S/S=General S/S of infection + cellulitis extends beneath deep fascia of submandibular as painful ,red, hot & tender brawny swelling Later, infection travels both sides of mylohyoid causing oedema of floor of mouth that elevates tongue &to larynx causing laryngeal edema . TREATMENT Early= massive AB(penicillin+ flagyl) Late= Curved submental release incision of skin &deep fascia with division of mylohyoid to drain both submandibular . Rarely, a tracheostomy needed

ANATOMY: 1-CIRCULAR HORIZONTAL CHAIN:
A-Inner chain in mouth (Waldeyers ring)
B-Outer chain Submental nodes Submandibular nodes Remaining nodes Facial (buccal/mandibular), pre-(parotid) &post-auricular (mastoid), occipital 2- VERTICAL CHAIN Superficial (along external jugular vein) Deep (along internal jugular vein) upper & lower gp. Retropharyngeal Prelarygenal Infrahyoid Pretracheal Paratracheal +/-Supra clavicular-Virchow LN draining breast, apex of lung, upper limbs, abdominal viscera & testes.

Half of LN of body are present in neck=300

Zones Landmarks and Nodal Group

Level 1 =midline = submental and submandibular nodes. Level 2 = medial to SCM, Upper internal jugular chain; Level 3 = Middle internal jugular chain Level 4. Lower internal jugular chain Level 5 contains posterior cervical triangle nodes. Level 6 includes anterior compartment nodes. Level 7 = paratracheal and pretracheal nodes. inferior to the suprasternal notch in the upper mediastinum


1-The oral cavity and lip: drain to nodes in levels I, II, and III.2- The oropharynx, hypopharynx, and larynx :drain to levels II, III, and IV.3- The nasopharynx and thyroid level drain to lV nodes. & to the jugular chain nodes.4- The hypopharynx, cervical esophagus, and thyroid drain to the paratracheal nodal compartment, and may extend to level VII gp
Drainage

Nodes that are abnormal in size, consistency or number • "generalized" (75%) if LN are enlarged in 2 or more noncontiguous areas• "localized" (25%) if only 1 area is involved. (search for an adjacent lesion)• Generalized LAD indicates systemic disease & need further clinical invx. Inflammatory(50%) Reactive hyperplasia Autoimmune RA, SLE & collagen diseasesInfective Viral (Infectious mononucleosis,HIV) Bacterial (Strept, Staph, actinomycosis,TB,Brucella) protozoan(Toxo)Neoplasms Primary- lymphoma (Hodgkin's , non Hodgkin's)., leukaemiasSecondary (Sq. cell ca)Metastasis- Known Or occult primary

Clinical Assessment

Historyo Age >40 = 70 % ca o Duration & growth rateo Distribution of lymphadenopathyo Drugs Allopurinol Atenolol Captopril tegretolo Risk factors Malignancy, TB exposure, Cat scratch, Autoimmune disorderso Associated S/S e.g. pain ,Symptoms of inflammation ,wt loss? Physical examination• Site• Size abnormal if cervical, axillary LN > 2 cm &inguinal > 2.5 cm • Overlying skin color if red indicate acute lymphadenitis• Pain/Tenderness in inflammation or suppuration& hemorrhage into the necrotic center of a malignant node.• Consistency. Stony-hard nodes: cancer, usually metastatic.Very firm, rubbery nodes: lymphoma.Soft nodes: infections or inflammatory conditions.Suppurant nodes may be fluctuant."shotty" =small LN feel like buckshot under skin in children with viral inf.• Matting. benign (TB, sarcoidosis) / malignant ( metastatic Ca).• Liver/spleen

Observation & re-examination in 2-4 wks with antibiotics trial…….. if no response…doBlood tests WBC count / differential count, ESR, blood film and serological tests (e.g. AIDS , TB,monospot ,toxoplasmosis etc)Ultrasonography if hard & solid LNCXRComputed TomographyPETMRIUpper aerodigestive tree endoscopy ( nasopharynx , larynx and hypopharynx)Fine needle aspiration cytology (FN AC)+/- flow cytometryBIOPSY if FNAC unhelpful



General Management of Cervical lymphadenopathy (LAD)


The most common cause of LAD between 1-5 years Infection carried to LN from skin sepsis in face, or from sepsis in nasoph, hypoph, tonsils ,ear or nose. Bacteria =staph aureus, strept. pyogens& anaerobe if dental cares. CLINICALLY : Picture of inflamed focus , Constitutional features Unilateral, large hot, red ,tender, soft & mobile LN. If pus, fluctuation +ve. There may be tender red streaks between primary focus & affected LN (Lymphangitis). COMPLICATIONS: Spread to more proximal LN. Spread to nearby tissue Suppuration (Abscess) MO remains dormant in LN & flare up later. TRAETMENT: Treat causative inflamed focus. Rest & antistaph AB with local heat. (fomentation) & review in 48 hours. Incision & drainage if no response or fluctuation ..

Reactive hyperplasia most common cause of cervical LAD (50%) ETIOLOGY Chronic infection of nearby focus like septic teeth, sinusitis, tonsillitis or adenoiditis. Chronic non specific LAD of post. triangle in children with head pediculosis or rubella. Chronic non specific LAD following incomplete resolution of acute LAD. CLINICALLY The LN are slightly enlarged, mobile, mildly tender & firm or elastic in consistency. TREATMENT: Treatment of original focus Nodes need no treatment. Chronic non specific LAD that persists for > 3-4 months ;TB or lymphomas must be excluded.


Affects children or young adults, . MO reach LN from adenoids& tonsils of same side filtered from infected cattle milk. PATHOLOGY : Organism may be bovine or human type In 80% The disease is unilateral In 80% limited to single group of LN The incidence of coexisting pulmonary or renal TB is< 20%

At any stage ? resolution or calcification or fibrosis

CLINICALLY:


General features :evening pyrexia, cough ,malaise, and failure to thrive . Locally .. stagesStage I: Chronic neck lump adherent to skin, non tender ,not warm ,firm or elastic due to unilateral enlarged 1 group LN without matting Any group of LN can be involved commonly (jugulodigastric, submandibular & supraclav)Stage II: LN enlarged and mattedStage III, a painless, fluctuant cystic mass, slightly warm & non tender due to underlying caseation called a ‘cold abscess’. Stage IV Left untreated, the cold abscess bursts through deep fascia into subcutaneous space producing a bilocular mass with cross fluctuation called a ‘collar-stud’ abscess. Eventually, this may rupture through skin forming a TB sinus or ulcer with thin blue margin, undermined edges & thin serous discharge. Healing of sinuses leaves scar

Diagnosis:

History &examination characteristics of LN Specific investigations: CXR, CBP (lymhocytosis) & E.S.R, CRP Tuberculin test LN excision biopsy Aspiration of cold abscess & culture Smears of sinus for AFB TREATMENT: In early stages Anti TB for 9-12 Mo Surgical excision of single or gp of LN if no response or complications In a child- remove & examine tonsils histologically before removing LN In late stages( cold abscess & sinuses): Anti TB Aspiration rather than drainage to avoid persistent discharging sinus and later ugly scar Excision of abscess with underlying LN only after exclusion of active TB .