Case Presentation and Discussion on Posterior Neck Mass
Case Presentation and Discussion on Posterior Neck Mass
Case Presentation and Discussion on Posterior Neck Mass
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<str<strong>on</strong>g>Case</str<strong>on</strong>g> <str<strong>on</strong>g>Presentati<strong>on</strong></str<strong>on</strong>g><br />
<str<strong>on</strong>g>and</str<strong>on</strong>g><br />
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
<strong>on</strong><br />
<strong>Posterior</strong> <strong>Neck</strong> <strong>Mass</strong><br />
Martin Joseph S. Cabahug
General Data:<br />
C.A , 60 y/o male<br />
Sta. Ana, Mla
Chief Complaint:<br />
<strong>Posterior</strong> <strong>Neck</strong> <strong>Mass</strong>
History <str<strong>on</strong>g>and</str<strong>on</strong>g> Physical Exam<br />
2 wks PTA mass, 1 x 1 cm,<br />
soft, erythematous, tender<br />
no c<strong>on</strong>sult d<strong>on</strong>e<br />
no meds taken<br />
1 wk PTA mass 6 x 4 cms,<br />
no c<strong>on</strong>sult d<strong>on</strong>e<br />
self medicated with<br />
Amox 500mg tid<br />
ADMISSION
Physical History<br />
General Survey:<br />
c<strong>on</strong>scious, coherent, not in<br />
cardiorespiratory distress<br />
Vital Signs:<br />
BP= 120/80 CR= 85<br />
RR= 23 T = 37.5 c
6 x 4 cms mass, soft,<br />
erythematous, tender,<br />
fluctuant,
Chest & Lungs: symmetrical chest<br />
expansi<strong>on</strong>, no retracti<strong>on</strong>s, clear breath<br />
sounds<br />
Abdomen: flat, NABS, soft, n<strong>on</strong> tender<br />
Extremities: grossly normal
Salient Features<br />
- 60 y/o<br />
- male<br />
- mass posterior neck<br />
6 x 4 cms, erythematous, tender,<br />
fluctuant, warm to touch<br />
-DM
posterior neck mass<br />
skin soft tissue<br />
b<strong>on</strong>e
posterior neck mass<br />
soft tissue<br />
Inflammatory N<strong>on</strong> inflammatory
posterior neck mass<br />
soft tissue<br />
N<strong>on</strong> inflammatory<br />
benign malignant
posterior neck mass<br />
soft tissue<br />
Inflammatory<br />
TB Abscess
posterior neck mass<br />
skin, soft tissue<br />
Inflammatory<br />
Abscess
Primary diagnosis<br />
Abscess, posterior<br />
neck area<br />
Sec<strong>on</strong>dary diagnosis<br />
TB<br />
percent of certainty<br />
95%<br />
5%
• Do I need a Paraclinical Diagnostic<br />
procedure?<br />
-NO
Treatment<br />
Goal<br />
drainage of abscess<br />
resoluti<strong>on</strong> of infecti<strong>on</strong>
Incisi<strong>on</strong><br />
<str<strong>on</strong>g>and</str<strong>on</strong>g><br />
drainage +<br />
antibiotic<br />
Aspirati<strong>on</strong><br />
+<br />
antibiotic<br />
Treatment opti<strong>on</strong>s<br />
Benefit<br />
++++<br />
++<br />
Risk<br />
bleeding<br />
Incomplete<br />
resoluti<strong>on</strong><br />
recurrence<br />
Cost<br />
+++<br />
+<br />
Availability<br />
√<br />
√
PRE OPERATIVE EVALUATION<br />
• Optimize patient<br />
• Secure informed c<strong>on</strong>sent<br />
• Screen for medical problems<br />
• Prepare materials for operati<strong>on</strong>
OPERATIVE MANAGEMENT<br />
• Patient <strong>on</strong> R lateral positi<strong>on</strong> under GA<br />
• Asepsis <str<strong>on</strong>g>and</str<strong>on</strong>g> Antisepsis d<strong>on</strong>e<br />
• Sterile drapes placed<br />
• Cruciate Incisi<strong>on</strong> d<strong>on</strong>e over the fluctuant<br />
area<br />
• Intra-op findings noted
OPERATIVE MANAGEMENT<br />
• Intra-op findings:<br />
drained about 50 ml of purulent , n<strong>on</strong><br />
foul smell material
OPERATIVE MANAGEMENT<br />
• Copious washing with nss with H2O2<br />
• Hemostasis<br />
•DSD
POST OPERATIVE<br />
MANAGEMENT<br />
• Diabetic Diet<br />
• Adequate analgesia<br />
• Adequate antibiotic coverage<br />
• Daily wound flushing<br />
• C<strong>on</strong>trol of blood sugar
Final Daignosis<br />
Abscess, posterior neck area
<strong>Neck</strong><br />
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
There is a b<str<strong>on</strong>g>and</str<strong>on</strong>g> of tissue in the neck called<br />
the cervical fascia, which divides the neck into<br />
superficial (just under the skin) <str<strong>on</strong>g>and</str<strong>on</strong>g> deep layers.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
NECK ABSCESS<br />
1. Superficial neck abscesses<br />
The most comm<strong>on</strong> cause of these<br />
abscesses are Staphylococcus or Streptococcus<br />
bacteria.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
NECK ABSCESS<br />
2. Deep neck Abscess<br />
infecti<strong>on</strong> that is located in various spaces<br />
in the deep layer of the neck.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• RETROPHARYNGEAL SPACE<br />
This space is located directly behind the<br />
mouth.<br />
The lymph nodes that drain the ADENOIDS,<br />
SINUSES, nose, <str<strong>on</strong>g>and</str<strong>on</strong>g> pharynx are located in this<br />
space.<br />
Infecti<strong>on</strong>s in any of these areas can result in<br />
spread of infecti<strong>on</strong> to these lymph nodes,<br />
resulting in lymphadenitis <str<strong>on</strong>g>and</str<strong>on</strong>g> abscess<br />
formati<strong>on</strong>.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• PERITONSILLAR SPACE<br />
Located in the tissue around the t<strong>on</strong>sil in the<br />
back of the throat.<br />
Infecti<strong>on</strong> in this space usually results from an<br />
untreated infecti<strong>on</strong> of the t<strong>on</strong>sils<br />
This type of infecti<strong>on</strong> is known as a<br />
perit<strong>on</strong>sillar abscess or quinsy <str<strong>on</strong>g>and</str<strong>on</strong>g> is probably<br />
the most comm<strong>on</strong> type of deep neck infecti<strong>on</strong>.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• PARAPHARYNGEAL SPACE<br />
It is located just behind the carotid artery<br />
Infecti<strong>on</strong>s in this area are due to comm<strong>on</strong><br />
upper respiratory infecti<strong>on</strong>s that spread to the<br />
lymph nodes located in this space. If an infecti<strong>on</strong><br />
in this area remains untreated, the neck swells<br />
<str<strong>on</strong>g>and</str<strong>on</strong>g> the patient stops moving the neck, indicating<br />
pain.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• SUBMANDIBULAR SPACE<br />
This space is located under the jaw <strong>on</strong><br />
each side. Infecti<strong>on</strong> in this space is usually the<br />
result of a dental infecti<strong>on</strong> <str<strong>on</strong>g>and</str<strong>on</strong>g> is known as<br />
Ludwig's angina. It is more comm<strong>on</strong>ly seen in<br />
adolescents
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• In the pre-antibiotic era, 70% of neck infecti<strong>on</strong>s<br />
resulted from infecti<strong>on</strong>s of the pharynx <str<strong>on</strong>g>and</str<strong>on</strong>g><br />
t<strong>on</strong>sils, <str<strong>on</strong>g>and</str<strong>on</strong>g> approximately 20% were of dental<br />
origin.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• In the post-antibiotic era, an increasing<br />
percentage sec<strong>on</strong>dary to dental infecti<strong>on</strong>s<br />
(generally c<strong>on</strong>sidered #1 cause currently)<br />
<str<strong>on</strong>g>and</str<strong>on</strong>g> salivary gl<str<strong>on</strong>g>and</str<strong>on</strong>g> infecti<strong>on</strong>s.<br />
Overall incidence has decreased.
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• Other etiologies include upper respiratory tract<br />
infecti<strong>on</strong>s, trauma, foreign bodies,<br />
instrumentati<strong>on</strong>, spread of localized<br />
infecti<strong>on</strong>, <str<strong>on</strong>g>and</str<strong>on</strong>g> c<strong>on</strong>genital deformities (e.g.<br />
brachial cleft sinuses).
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• Source remains unknown in significant number<br />
of patients (22% unknown etiology, USC<br />
Study)<br />
• Pediatric Populati<strong>on</strong><br />
- Most comm<strong>on</strong> source is acute t<strong>on</strong>sillitis<br />
(perit<strong>on</strong>sillar space abscess)<br />
- Sec<strong>on</strong>d most comm<strong>on</strong> source is dental<br />
(subm<str<strong>on</strong>g>and</str<strong>on</strong>g>ibular - submental space<br />
abscess)
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
Bacteriology<br />
1. Most abscesses with mixed bacteria.<br />
Rare fungal etiology.<br />
2. Anaerobics most likely underrepresented<br />
by bacteriology studies, higher percent in<br />
abscesses of od<strong>on</strong>togenic origin
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
BACTERIA ISOLATED FROM NECK ABSCESSES<br />
• Aerobes Anaerobes<br />
• Streptococci 32<br />
• Alpha not group D 13<br />
• Beta group A 7<br />
• Bacteroides 11<br />
• Staphylococcus 9<br />
Aureus 6<br />
Epidermidis 3<br />
*Tom <str<strong>on</strong>g>and</str<strong>on</strong>g> Rice, 1988, Univ. of Southern California
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
• Surgical drainage<br />
- Gold st<str<strong>on</strong>g>and</str<strong>on</strong>g>ard<br />
- "Treatment is dependent up<strong>on</strong> the principle<br />
of proper drainage of abscess cavities...Both<br />
the primary space involved <str<strong>on</strong>g>and</str<strong>on</strong>g> any sec<strong>on</strong>dary<br />
compartments where infecti<strong>on</strong> have spread must<br />
be properly drained...Surgery of the neck is not<br />
primarily cosmetic. A large incisi<strong>on</strong> with well<br />
loosened <str<strong>on</strong>g>and</str<strong>on</strong>g> well retracted flaps is essential."<br />
(Levitt, 1970)
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
Needle aspirati<strong>on</strong><br />
• a. Therapeutic<br />
• - Herz<strong>on</strong> 1988 - 24 patients<br />
• - 83% resolved without surgery<br />
• - 58% needed multiple aspirati<strong>on</strong>s<br />
• - n<strong>on</strong>e required surgery)<br />
• - Better cosmetic result, eliminates major<br />
surgical procedure, decreased cost
<str<strong>on</strong>g>Discussi<strong>on</strong></str<strong>on</strong>g><br />
b. Used to c<strong>on</strong>firm diagnosis<br />
- Obtain material for culture<br />
c. CT - guided needle aspirati<strong>on</strong>