Case Presentation and

Discussion on

Posterior Neck Mass

Martin Joseph S. Cabahug

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

Chief Complaint:Posterior Neck Mass

History and Physical Exam

2 wks PTA mass, 1 x 1 cm, soft, erythematous, tenderno consult doneno meds taken

1 wk PTA mass 6 x 4 cms, no consult doneself medicated withAmox 500mg tid

ADMISSION

Physical History

General Survey:conscious, coherent, not in

cardiorespiratory distressVital Signs:

BP= 120/80 CR= 85RR= 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 tenderExtremities: 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 bonesoft tissue

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

5%Secondary diagnosis

TB

95%Primary diagnosis

Abscess, posterior neck area

percent of certainty

� Do I need a Paraclinical Diagnostic procedure?

-NO

Treatment

Goaldrainage of abscessresolution of infection

Treatment options

√+

Incomplete resolutionrecurrence

++Aspiration + antibiotic

√+++bleeding++++

Incision and drainage + antibiotic

AvailabilityCostRiskBenefit

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 and 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

DiscussionNeck

There is a band of tissue in the neck called the cervical fascia, which divides the neck into superficial (just under the skin) and deep layers.

DiscussionNECK ABSCESS

1. Superficial neck abscesses The most common cause of these

abscesses are Staphylococcus or Streptococcus bacteria.

Discussion

NECK ABSCESS 2. Deep neck Abscess

infection that is located in various spaces in the deep layer of the neck.

Discussion� RETROPHARYNGEAL SPACE

This space is located directly behind the mouth.

The lymph nodes that drain the ADENOIDS, SINUSES, nose, and 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 and abscess formation.

Discussion

� PERITONSILLAR SPACELocated 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 and is probably the most common type of deep neck infection.

Discussion

� PARAPHARYNGEAL SPACEIt 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 and the patient stops moving the neck, indicating pain.

Discussion

� SUBMANDIBULAR SPACEThis space is located under the jaw on

each side. Infection in this space is usually the result of a dental infection and is known as Ludwig's angina. It is more commonly seen in adolescents

Discussion

� In the pre-antibiotic era, 70% of neck infections resulted from infections of the pharynx and tonsils, and approximately 20% were of dental origin.

Discussion

� In the post-antibiotic era, an increasing percentage secondary to dental infections (generally considered #1 cause currently) and salivary gland infections. Overall incidence has decreased.

Discussion

� Other etiologies include upper respiratory tract infections, trauma, foreign bodies, instrumentation, spread of localized infection, and congenital deformities (e.g. brachial cleft sinuses).

Discussion� 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(submandibular - submental space

abscess)

Discussion

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

DiscussionBACTERIA ISOLATED FROM NECK ABSCESSES

� Aerobes Anaerobes � Streptococci 32 � Alpha not group D 13� Beta group A 7 � Bacteroides 11 � Staphylococcus 9

Aureus 6Epidermidis 3

*Tom and Rice, 1988, Univ. of Southern California

Discussion� Surgical drainage

- Gold standard - "Treatment is dependent upon the principle

of proper drainage of abscess cavities...Both the primary space involved and 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 and well retracted flaps is essential."

(Levitt, 1970)

DiscussionNeedle 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

Discussion

b. Used to confirm diagnosis - Obtain material for culture

c. CT - guided needle aspiration