NECK DISEASES
Dr. Amanj
Inflammatory conditions of the neck
Ludwig’s angina
It is 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 accompanying putrid halitosis.
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 to dysphagia and
subsequently to painful obstruction of the airway.
Unless treated, cellulitis may extend beneath the deep fascial layers of the neck to involve the
larynx, causing glottic oedema and airway compromise.
Treatment
1-Antibiotic ;- intravenous broad-spectrum antibiotics, such as amoxycillin or cefuroxime,
combined with metronidazole to combat the anaerobes.
2-In advanced cases when the swelling does not subside rapidly with such treatment, a curved
submental incision may be used to drain both submandibular triangles.
* This operation may be conducted under local anaesthetic.
* Rarely, a tracheostomy may be necessary.
Causes of cervical lymphadenopathy
Inflammatory
■ Reactive hyperplasia
Infective
■ Viral;-For example, infectious mononucleosis, HIV
■ Bacterial
Streptococcus, Staphylococcus, Actinomycosis,Tuberculosis
Brucellosis
■ Protozoan;-Toxoplasmosis
Neoplastic
■ Malignant
Primary, e.g. lymphoma
Secondary, e.g. squamous cell carcinoma
Known primary
Occult primary
Cervical lymphadenitis
Cervical lymphadenitis is common due to infection or inflammation in the oral and nasal cavities,
pharynx, larynx, ear, scalp and face.
Acute lymphadenitis
The affected lymph nodes are enlarged and tender, and there may be varying degrees of general
constitutional disturbance such as;-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.
Chronic lymphadenitis
Chronic, painless lymphadenopathy may be caused by tuberculosis in young children or adults, or
be secondary to malignant disease, most commonly from a squamous carcinoma in older
individuals.
Lymphoma and/or HIV infection may also present in the cervical nodes.
Tuberculous adenitis
The condition most commonly affects children or young adults, but can occur at any age.
The deep upper cervical nodes are most commonly affected, but there may be a widespread cervical
lymphadenitis with many matting together.
In most cases, the tubercular bacilli gain entrance through the tonsil of the corresponding side as the
lymphadenopathy.
Both bovine and human tuberculosis may be responsible. In approximately 80% of patients, the
tuberculous process is limited to the clinically affected group of lymph nodes, but a primary focus in
the lungs must always be suspected.
As renal and pulmonary tuberculosis occasionally coexist, the urine should be examined carefully.
If treatment is not instituted, the caseated node may liquefy and break down with the formation of a
cold abscess in the neck.
The pus is initially 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 suitably treated, a discharging sinus results.
Treatment
The patient should be treated by appropriate chemotherapy, dependent on the sensitivities derived
from the abscess contents.
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.
Branchial fistula
It may be unilateral or bilateral and is thought to represent a persistent second branchial cleft.
The external orifice is nearly always situated in the lower third of the neck near the
anterior border of the sternocleidomastoid, whilst the internal orifice is located on the anterior
aspect of the posterior faucial pillar just behind the tonsil.
However, the internal aspect of the tract may end blindly at or close to the lateral pharyngeal wall,
constituting a sinus rather than a fistula.
The tract is lined by ciliated columnar epithelium and, as such, there may be a small
amount of recurrent mucous or mucopurulent discharge onto the neck.
The tract follows the same path as a branchial cyst and requires complete excision, often by more
than one transverse incision in the neck.
Cystic hygroma
It is usually present in the neonate or in early infancy, and occasionally may present at birth and be
so large as to obstruct labour.
The cysts are filled with clear lymph and lined by a single layer of epithelium with a mosaic
appearance.
Swelling usually occurs in the neck and may involve the parotid, submandibular, tongue and floor of
mouth areas.
The swelling may be bilateral and is soft and partially compressible, visibly increasing in size when
the child coughs or cries.
The characteristic that distinguishes it from all other neck swellings is that it is brilliantly
translucent.
The cheek, axilla, groin and mediastinum are other less frequent sites for a cystic hygroma.
The behaviour of cystic hygromas during infancy is unpredictable.
Sometimes the cyst expands rapidly and occasionally respiratory difficulty ensues, requiring
immediate aspiration and even occasionally a tracheostomy.
The cyst may become infected.
Definitive treatment is complete excision of the cyst at an early stage. Injection of a sclerosing
agent, for example picibanil (OK-432), may reduce the size of the cyst; however, they are
commonly multicystic and if the injection is extracystic subsequent surgery may be more difficult.
Thyroglossal duct cysts
The thyroid gland descends early in fetal life from the base of the tongue towards its position in the
lower neck with the isthmus lying over the second and third tracheal rings. At the time of its
descent, the hyoid bone has not been formed and the track of the descent of the thyroid gland is
variable, passing in front, through or behind the eventual position of the hyoid body.
Thyroglossal duct cysts represent a persistence of this track and may therefore be found anywhere in
or adjacent to the midline from the tongue base to the thyroid isthmus.
Rarely, a thyroglossal cyst may contain the only functioning thyroid tissue in the
body.
Clinical features
1-The cysts almost always arise in the midline but, when they are adjacent to the thyroid cartilage,
they may lie slightly to one side of the midline.
2- Classically, the cyst moves upwards on swallowing and with tongue protrusion, but this can also
occur with other midline cysts such as dermoid cysts, as it merely indicates attachment to the hyoid
bone.
3-Thyroglossal cysts may become infected and rupture onto the skin of the neck presenting as a
discharging sinus. Although they often occur in children, they may also present in adults, even as
late as the sixth or seventh decade of life.
Treatment
Treatment must include excision of the whole thyroglossal tract, which involves removal of the
body of the hyoid bone and the suprahyoid tract through the tongue base to the vallecula at the site
of the primitive foramen caecum, together with a core of tissue on either side.
This operation is known as Sistrunk’s operation and prevents recurrence, most notably from small
side branches of the thyroglossal tract.