CHAPTER XXXIII DIAGNOSIS OF DISEASES OF THE NECK The surgical aii'ectious of the neck may be grouped under the following heads : Swellings — Acute • Chronic • Solid [^Pulsating Fistula. J Conditions giving rise to rigidity. Enlargements of the thyroid gland. • The lymphatic glands of the neck are especially liable to disease. The diagnosis of^ diseases of glands has been discussed in Chap. XVIII.
I. Acute swellings oi the neck are, with the rare exception of that produced by emphysema (p. 130), inflammatory in their nature. The surgeon must endeavour to discover the seat of the mtlam- mation, and whether suppuration or sloughing has occurred.
<Callout type="important" title="Important">If the swelling is in the position and has the outline of a lymphatic gland, and is painful and tender, and there is not much surrounding a^di ma, it is an inflamed lymphatic gland; if fluctuation is obtained in such a swelling, it is an acute glandular abscess.</Callout>
II. If the swelling occupies one side of the neck, and the head is inclined to the same side, and at- 450 SWELLINfJS OF NECK , 457 tempts to rotate it cause pain, while the iuflamecl part is very paiufiil, ill defined, and tense, it is to be diagnosed as cellulitis beneath the sterno-mastoid muscle, and if the superficial parts are cedematous and glossy, and a fortiori if there is deep fluctuation, abscess beneath the muscle is to be diagnosed. It is important to detect suppuration at once, and in- creasing swelling, tension, marked superficial oedema, and fever warrant an incision, even in the absence of fluctuation.
Cellulitis in any other part of the neck will be recognized by the same characters.
III. If the swelling takes the form of a hard collar-like induration, extending between the jaw and the hyoid bone, pushing forwards the skin of this region, and raising and fixing the tongue, it is to be diagnosed as angina Ludovici ; this swelling may come on very rapidly, and quickly lead to ojdema glottidis, or to sloughing of the cellular tissue, and fatal blood-poisoning. When first seen there may be a sinus ia the floor of the mouth leading into the sphacelated tissue.
<Callout type="risk" title="Risk">Only when this form of celluHtis is idiopathic that it claims the above name.</Callout>
IV. If the swelling consists of an ill-defined area of the skin and superficial fascia which is livid-red in colour, brawny in consistence, very painful and tender, and on the surface are seen small vesicles or several small apertures in the skin exposing a soft grey slough, it is a carbuncle. This disease may be met with at any part, but is most common at the back of the neck.
<Callout type="tip" title="Tip">Carbuncles vary much in their rate of progress; they are usually single.</Callout>
- Chronic fluid swelUngs o£ tlie neck are either abscesses, cysts, or softened maUgnant growths.
Note particularly the position of the swelling, its depth, the parts to which it is adherent its tension, its outlone, the coexistence of any solid (growth or swelling or disease in neighbouring struc- tures The age of the patient, the duration of the swelling, and its mode of onset and progress are other facti of importance.
<Callout type="important" title="Important">If the swelling is in the position of a i^ymphatic gland, is of low tension, fixed to the surrounding parts, has followed upon a solid lump, or if a sohd part of the swelling can be felt deep to the fluid part, it is a chronic tuberculous glandular abscess.</Callout>
- Chronic solid swellings oi the ueek.— -i. A small swelling in the middle of the sterno-mastoid of an infant is hsematoma of the sterno-mastoid, caused by partial rupture of the muscle at birth.
<Callout type="beginner" title="Beginner">A cervical rib is very rarely discovered before puberty ; it is usually detected either in a routine examination of the neck or in searching for the cause of sensory or motor disturbances in the hand in the area of the eighth cervical nerve.</Callout>
- Pulsating tumouis of the neck form an important class. The surgeon must first of all decide whether the pulsation is inherent in the tumour or only transmitted to it, and, if the former, whether the tumour is an aneurysm or a vascular growth.
<Callout type="warning" title="Warning">Aneurysms can be life-threatening; always seek professional medical advice.</Callout>
- Fistluhc mid siiiusi-s. — By studying the his xxxiuj CERVICAL SINUSES 465 tory of the case aad noticing the jjositioii of tlie orifice, the direction of the sinus, and the nature of the discharge from it, a diagnosis of the various sinuses and fistulas may be arrived at.
<Callout type="important" title="Important">If the sinus opens in the middle line of the neck and runs up in front of the larynx towards or even up to the hyoid bone, it is a patent thyro-glossal duct.</Callout>
Key Takeaways
- Acute neck swellings are typically inflammatory and may indicate an abscess.
- Chronic fluid swellings can be abscesses, cysts, or malignant growths.
- Pulsating tumors in the neck could be aneurysms or vascular growths.
Practical Tips
- Be aware of the signs of cellulitis, such as pain, tension, and fever, which may require immediate surgical intervention.
- Recognize the difference between acute and chronic swellings to guide appropriate treatment.
- Always seek professional medical advice for pulsating tumors in the neck.
Warnings & Risks
- Aneurysms can be life-threatening; always seek professional medical advice.
- Do not attempt to treat serious infections or abscesses without proper medical training and equipment.
- Incorrect diagnosis of a condition like angina Ludovici could lead to severe complications if left untreated.
Modern Application
While the techniques described in this chapter are rooted in historical practices, the principles of diagnosing and treating neck swellings remain relevant. Modern medicine has improved diagnostic tools and treatment methods but still relies on accurate initial assessments. This knowledge is crucial for first responders or those in remote areas where immediate medical care may not be available.
Frequently Asked Questions
Q: What are the signs of an acute swelling that might indicate a glandular abscess?
An acute swelling in the neck, especially if it's painful and tender with a defined outline like a lymphatic gland, could suggest a glandular abscess. Fluctuation or pus formation would confirm this diagnosis.
Q: How can one differentiate between cellulitis and angina Ludovici?
Cellulitis typically presents as a red, painful area with fluctuation, while angina Ludovici is characterized by a hard collar-like induration that may lead to swelling of the larynx. A sinus in the floor of the mouth can be an early sign of angina Ludovici.
Q: What should one do if they suspect a patient has a carbuncle?
Immediate medical attention is crucial for treating carbuncles, as they can spread rapidly and cause systemic infection. The patient should be referred to a healthcare provider for proper treatment, which may include incision and drainage.