1. College of Medicine of Mosul
Surgery of the neck(3)
بِسْمِ اللهِ الرَّحْمنِ الرَّحِيم
Dr. Karam Kamal Sharif
Assist. prof. of surgery
College of Medicine of Mosul

2. Electro surgery in Gynaecology - Prof.S.N.Panda
INFECTIONS IN THE NECK
Superficial cellulitis is common & = cellulitis.
2. Deep cellulitis=
1. Retropharyngeal abscess
2. Parapharyngeal abscess
3. Submandibular space infection
=Ludwig’s angina
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
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

3. Electro surgery in Gynaecology - Prof.S.N.Panda
LYMPH NODES OF THE NECK
Half of LN of body are present in neck=300
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.
Level I: submental and submandibular
Level II - IV: jugular group=skull base superiorly down to level of the clavicle inferiorly along internal jugular vein
Level II: upper jugular group
Level III: middle jugular group
Level IV: lower jugular group
Level V: posterior cervical triangle
Level VI: anterior compartment group
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

4. 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
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

5. Electro surgery in Gynaecology - Prof.S.N.Panda
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
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

6. CERVICAL LYMPHADENOPATHY:
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 diseases
Infective
Viral (Infectious mononucleosis,HIV)
Bacterial (Strept, Staph, actinomycosis,TB,Brucella)
protozoan(Toxo)
Neoplasms
Primary- lymphoma (Hodgkin's , non Hodgkin's)., leukaemias
Secondary (Sq. cell ca)
Metastasis- Known Or occult primary
CAUSES OF CERVICAL LYMPHADENOPATHY:
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

7. Electro surgery in Gynaecology - Prof.S.N.Panda
Clinical Assessment
History
o Age >40 = 70 % ca
o Duration & growth rate
o Distribution of lymphadenopathy
o Drugs Allopurinol Atenolol Captopril tegretol
o Risk factors Malignancy, TB exposure, Cat scratch, Autoimmune disorders
o 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
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

8. General Management of Cervical lymphadenopathy (LAD)
Observation & re-examination in 2-4 wks with antibiotics trial…….. if no response…do
Blood tests WBC count / differential count, ESR, blood film and serological tests (e.g. AIDS , TB,monospot ,toxoplasmosis etc)
Ultrasonography if hard & solid LN
CXR
Computed Tomography
PET
MRI
Upper aerodigestive tree endoscopy ( nasopharynx , larynx and hypopharynx)
Fine needle aspiration cytology (FN AC)+/- flow cytometry
BIOPSY if FNAC unhelpful
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

9. ACUTE CERVICAL LAYMPHADENITIS:
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 ..
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

10. CHRONIC NON SPECIFIC LYMPHADENITIS
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.
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

11. Affects children or young adults, .
TUBERCULOUS LYMPHADENITIS (Scrofula or kings Evil)
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
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

12. Electro surgery in Gynaecology - Prof.S.N.Panda
CLINICALLY:
General features :evening pyrexia, cough ,malaise, and failure to thrive .
Locally .. stages
Stage 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 matted
Stage 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
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

13. Electro surgery in Gynaecology - Prof.S.N.Panda
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 .
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda

14. الْحَمْدُ للّهِ رَبِّ الْعَالَمِينَ
12 Oct. 02
Electro surgery in Gynaecology - Prof.S.N.Panda 14