Case Presentation and Discussion on Posterior Neck Mass

<strong>Case</strong> <strong>Presentation</strong>
<strong>and</strong>
<strong>Discussion</strong>
on
Posterior Neck Mass
Martin Joseph S. Cabahug

General Data:
C.A , 60 y/o male
Sta. Ana, Mla

Chief Complaint:
Posterior Neck Mass

History <strong>and</strong> Physical Exam
2 wks PTA mass, 1 x 1 cm,
soft, erythematous, tender
no consult done
no meds taken
1 wk PTA mass 6 x 4 cms,
no consult done
self medicated with
Amox 500mg tid
ADMISSION

Physical History
General Survey:
conscious, coherent, not in
cardiorespiratory distress
Vital Signs:
BP= 120/80 CR= 85
RR= 23 T = 37.5 c

6 x 4 cms mass, soft,
erythematous, tender,
fluctuant,

Chest & Lungs: symmetrical chest
expansion, no retractions, clear breath
sounds
Abdomen: flat, NABS, soft, non tender
Extremities: grossly normal

Salient Features
- 60 y/o
- male
- mass posterior neck
6 x 4 cms, erythematous, tender,
fluctuant, warm to touch
-DM

posterior neck mass
skin soft tissue
bone

posterior neck mass
soft tissue
Inflammatory Non inflammatory

posterior neck mass
soft tissue
Non inflammatory
benign malignant

posterior neck mass
soft tissue
Inflammatory
TB Abscess

posterior neck mass
skin, soft tissue
Inflammatory
Abscess

Primary diagnosis
Abscess, posterior
neck area
Secondary diagnosis
TB
percent of certainty
95%
5%

• Do I need a Paraclinical Diagnostic
procedure?
-NO

Treatment
Goal
drainage of abscess
resolution of infection

Incision
<strong>and</strong>
drainage +
antibiotic
Aspiration
+
antibiotic
Treatment options
Benefit
++++
++
Risk
bleeding
Incomplete
resolution
recurrence
Cost
+++
+
Availability
√
√

PRE OPERATIVE EVALUATION
• Optimize patient
• Secure informed consent
• Screen for medical problems
• Prepare materials for operation

OPERATIVE MANAGEMENT
• Patient on R lateral position under GA
• Asepsis <strong>and</strong> Antisepsis done
• Sterile drapes placed
• Cruciate Incision done over the fluctuant
area
• Intra-op findings noted

OPERATIVE MANAGEMENT
• Intra-op findings:
drained about 50 ml of purulent , non
foul smell material

OPERATIVE MANAGEMENT
• Copious washing with nss with H2O2
• Hemostasis
•DSD

POST OPERATIVE
MANAGEMENT
• Diabetic Diet
• Adequate analgesia
• Adequate antibiotic coverage
• Daily wound flushing
• Control of blood sugar

Final Daignosis
Abscess, posterior neck area

Neck
<strong>Discussion</strong>
There is a b<strong>and</strong> of tissue in the neck called
the cervical fascia, which divides the neck into
superficial (just under the skin) <strong>and</strong> deep layers.

<strong>Discussion</strong>
NECK ABSCESS
1. Superficial neck abscesses
The most common cause of these
abscesses are Staphylococcus or Streptococcus
bacteria.

<strong>Discussion</strong>
NECK ABSCESS
2. Deep neck Abscess
infection that is located in various spaces
in the deep layer of the neck.

<strong>Discussion</strong>
• RETROPHARYNGEAL SPACE
This space is located directly behind the
mouth.
The lymph nodes that drain the ADENOIDS,
SINUSES, nose, <strong>and</strong> pharynx are located in this
space.
Infections in any of these areas can result in
spread of infection to these lymph nodes,
resulting in lymphadenitis <strong>and</strong> abscess
formation.

<strong>Discussion</strong>
• PERITONSILLAR SPACE
Located in the tissue around the tonsil in the
back of the throat.
Infection in this space usually results from an
untreated infection of the tonsils
This type of infection is known as a
peritonsillar abscess or quinsy <strong>and</strong> is probably
the most common type of deep neck infection.

<strong>Discussion</strong>
• PARAPHARYNGEAL SPACE
It is located just behind the carotid artery
Infections in this area are due to common
upper respiratory infections that spread to the
lymph nodes located in this space. If an infection
in this area remains untreated, the neck swells
<strong>and</strong> the patient stops moving the neck, indicating
pain.

<strong>Discussion</strong>
• SUBMANDIBULAR SPACE
This space is located under the jaw on
each side. Infection in this space is usually the
result of a dental infection <strong>and</strong> is known as
Ludwig's angina. It is more commonly seen in
adolescents

<strong>Discussion</strong>
• In the pre-antibiotic era, 70% of neck infections
resulted from infections of the pharynx <strong>and</strong>
tonsils, <strong>and</strong> approximately 20% were of dental
origin.

<strong>Discussion</strong>
• In the post-antibiotic era, an increasing
percentage secondary to dental infections
(generally considered #1 cause currently)
<strong>and</strong> salivary gl<strong>and</strong> infections.
Overall incidence has decreased.

<strong>Discussion</strong>
• Other etiologies include upper respiratory tract
infections, trauma, foreign bodies,
instrumentation, spread of localized
infection, <strong>and</strong> congenital deformities (e.g.
brachial cleft sinuses).

<strong>Discussion</strong>
• Source remains unknown in significant number
of patients (22% unknown etiology, USC
Study)
• Pediatric Population
- Most common source is acute tonsillitis
(peritonsillar space abscess)
- Second most common source is dental
(subm<strong>and</strong>ibular - submental space
abscess)

<strong>Discussion</strong>
Bacteriology
1. Most abscesses with mixed bacteria.
Rare fungal etiology.
2. Anaerobics most likely underrepresented
by bacteriology studies, higher percent in
abscesses of odontogenic origin

<strong>Discussion</strong>
BACTERIA ISOLATED FROM NECK ABSCESSES
• Aerobes Anaerobes
• Streptococci 32
• Alpha not group D 13
• Beta group A 7
• Bacteroides 11
• Staphylococcus 9
Aureus 6
Epidermidis 3
*Tom <strong>and</strong> Rice, 1988, Univ. of Southern California

<strong>Discussion</strong>
• Surgical drainage
- Gold st<strong>and</strong>ard
- "Treatment is dependent upon the principle
of proper drainage of abscess cavities...Both
the primary space involved <strong>and</strong> any secondary
compartments where infection have spread must
be properly drained...Surgery of the neck is not
primarily cosmetic. A large incision with well
loosened <strong>and</strong> well retracted flaps is essential."
(Levitt, 1970)

<strong>Discussion</strong>
Needle aspiration
• a. Therapeutic
• - Herzon 1988 - 24 patients
• - 83% resolved without surgery
• - 58% needed multiple aspirations
• - none required surgery)
• - Better cosmetic result, eliminates major
surgical procedure, decreased cost

<strong>Discussion</strong>
b. Used to confirm diagnosis
- Obtain material for culture
c. CT - guided needle aspiration