THE NECK
Surgical Anatomy--Malformations: _Cervical auricles_; _Thyreo-glossal
cysts and fistulae_; _Lateral fistula_--Cervical ribs--Wry-neck:
_Varieties_; _Cicatricial contraction_--Injuries:
_Contusions_--_Fractures of hyoid, larynx, etc._:
_Cut-throat_--Infective conditions: _Diffuse cellulitis_;
_Actinomycosis_; _Boils and Carbuncles_--Tumours: _Cystic_:
_Branchial cysts_; _Cystic lymphangioma_; _Blood cysts_; _Bursal
cysts_--_Solid_: _Lipoma_; _Fibroma_; _Osteoma_; _Sarcoma_;
_Carcinoma_--The thymus gland--The carotid gland.
#Surgical Anatomy.#--In the middle line the following structures may
be recognised on palpation: (1) the _hyoid bone_, lying below and
behind the body of the lower jaw, on a level with the fourth cervical
vertebra; (2) the _hyo-thyreoid membrane_, behind which lies the base
of the epiglottis and the upper opening of the larynx; (3) the
_thyreoid cartilage_, to the angle of which the vocal cords are
attached about its middle; (4) the _crico-thyreoid_ membrane, across
which run transversely the crico-thyreoid branches of the superior
thyreoid arteries; (5) the _cricoid cartilage_, one of the most
important landmarks in the neck. It lies opposite the disc between the
fifth and sixth cervical vertebrae, and at this level the common
carotid artery may be compressed against the _carotid tubercle_ on the
transverse process of the sixth cervical vertebra. The cricoid also
marks the junction of the larynx with the trachea, and of the pharynx
with the oesophagus; at this point there is a constriction in the food
passage, and foreign bodies are frequently impacted here. At the level
of the cricoid cartilage the omo-hyoid crosses the carotid artery--a
point of importance in connection with ligation of that vessel. The
middle cervical ganglion of the sympathetic lies opposite the level of
the cricoid. (6) Seven or eight rings of the _trachea_ lie above the
level of the sternum, but they cannot be palpated individually. The
_isthmus_ of the thyreoid gland covers the second, third, and fourth
tracheal rings. As the trachea passes down the neck, it gradually
recedes from the surface, till at the level of the sternum it lies
about an inch and a half from the skin. The _thyreoidea ima_
artery--an inconstant branch of the anonyma (innominate) or of the
aorta--runs in front of the trachea as far up as the thyreoid isthmus.
The inferior thyreoid plexus of veins also lies in front of the
trachea. In the superficial fascia, cross branches between the
anterior jugular veins cross the middle line.
In children under two years of age the _thymus gland_ may extend for
some distance into the neck in front of the trachea and carotid
vessels, under cover of the depressors of the hyoid bone.
_Cervical Fascia._--This fascia completely envelops the neck, and from
its deep aspect two strong processes--the prevertebral and pretracheal
layers--pass transversely across the neck, dividing it into three main
compartments. The posterior or _vertebral compartment_ contains the
muscles of the back of the neck, the vertebral column and its
contents, and the prevertebral muscles. This compartment is limited
above by the base of the skull, and below is continued into the
posterior mediastinum. The middle or _visceral compartment_ contains
the pharynx and oesophagus, the larynx and trachea with the thyreoid
gland, and the carotid sheath and its contents. These different
structures derive their special fascial coverings from the processes
that bound this compartment. The middle compartment extends to the
base of the skull and passes into the anterior mediastinum as far as
the pericardium. The connective tissue space around the subclavian
vessels is continued into the axilla. The anterior or _muscular
compartment_ contains the sterno-mastoid muscle and the depressor
muscles of the hyoid bone. It extends upwards as far as the hyoid bone
and base of the mandible, and downwards as far as the sternum and
clavicle. The arrangement and limits of the different layers of the
cervical fascia explain the course taken by inflammatory products and
by new growths in the neck.
#Malformations of the Neck.#--Various congenital deformities result
from interference with the developmental processes which take place in
and around the fore-gut. These malformations are associated chiefly
with imperfect development of the visceral or branchial arches and
clefts, or of the hypoblastic diverticula from which the thyreoid and
thymus glands are formed.
The term _cervical auricles_ is applied to small outgrowths, composed
of skin, connective tissue, and yellow elastic cartilage, found
usually along the anterior border of the sterno-mastoid. These
appendages are usually unilateral, and are derived from the second
visceral arch. Sometimes they are situated near the orifice of a
lateral fistula. When, on account of their size, or their situation on
an exposed part of the neck, they give rise to disfigurement, they
should be removed.
_Thyreo-glossal Cysts and Fistulae._--The thyreo-glossal _cyst_ is
developed in relation to the thyreo-glossal tract of His, which in
early embryonic life extends from the foramen caecum at the base of the
tongue to the isthmus of the thyreoid. Those that form in the upper
part of the tract, in relation to the base of the tongue, have already
been described (p. 538). Those arising from the lower part form a
swelling in the middle line of the neck, usually above, but sometimes
below the hyoid bone. They have to be diagnosed from other forms of
cyst occurring in the middle line of the neck--sebaceous and dermoid
cysts--and when giving rise to disfigurement they should be excised.
Such a cyst may rupture on the surface, usually as a result of
superadded infection, and give rise to a _thyreo-glossal_ or _median
fistula of the neck_. As a rule the external opening of the fistula is
above the hyoid bone, only the upper part of the duct having remained
pervious. When the whole length of the duct has persisted, the fistula
extends from the skin to the foramen caecum, passing usually in front
of, but sometimes through the substance of, the hyoid bone.
Occasionally the fistula only extends as high as the hyoid.
[Illustration: FIG. 268.--Congenital Branchial Cyst in a woman aet. 33.
(Microscopically the cyst was lined with squamous epithelium and the
wall contained rudimentary salivary-gland tissue.)]
The part of the tract near the tongue is lined by squamous
epithelium; the lower part by columnar epithelium, which, below the
level of the hyoid, is usually ciliated. Lymphoid tissue and mucous
glands are found in its wall.
The _treatment_ consists in excising the duct and the connections, and
it is usually necessary to resect the central portion of the hyoid
bone to ensure complete removal.
The _lateral fistula of the neck_--formerly described as a branchial
fistula--according to Weglowski, usually takes origin from the remains
of the hypoblastic diverticulum, which arises from the pharyngeal part
of the third visceral cleft and extends downwards to form the thymus
gland. The internal opening is situated in the lateral wall of the
pharynx in the region of the posterior palatine arch close to the
tonsil, and the fistula passes out above the hypoglossal nerve, and
runs downwards and laterally between the carotids and along the medial
border of the sterno-mastoid muscle. When the fistula is complete, the
external opening is situated a short distance above the
sterno-clavicular joint. As the lower part of the thymus canal most
often persists, an incomplete external fistula is the form most
frequently met with. It is lined with ciliated columnar epithelium.
The fistula may be present at birth, or may result from the rupture of
a cystic swelling, which has become infected. Clear viscous fluid
exudes from it, and, when the fistula is complete and the lumen
sufficiently wide, particles of food may escape. As the track is
tortuous, it is seldom possible to pass a probe along it, but its
extent and course may be recognised by injecting an emulsion of
bismuth and taking an X-ray photograph.
The _treatment_ consists in excising the fistula in its whole length,
but, owing to its long and tortuous course, and its relations to
important structures, the operation is a tedious and difficult one.
Less radical measures, such as scraping with the sharp spoon,
cauterising, or packing, are seldom successful.
#Cervical Ribs.#--Supernumerary ribs are not infrequently met with in
connection with the seventh cervical vertebra, and in the majority of
cases the condition is bilateral. The extra rib may be thin and
pointed, and project straight out from the transverse process
terminating in a free end, in which case, as it passes above the
subclavian artery and the brachial plexus, it gives rise to no
trouble. In other cases it arches downwards and forwards, and is
attached by dense fibrous tissue to the first thoracic rib about the
level of the scalene tubercle, or to the sternum by cartilage like an
ordinary rib. When it encroaches upon the posterior triangle the
scalene muscles are attached to it, and the subclavian artery and the
lower trunk and medial cord of the brachial plexus pass over it in a
groove behind the scalenus anterior. The pleura may reach as high as
the medial border of the rib.
_Clinical Features._--The condition, which is more common in women
than in men, is seldom recognised before the age of twenty, and is
often discovered accidentally, for example after some emaciating
illness, or by a tight collar causing pain. The diagnosis is
established by the X-rays.
[Illustration: FIG. 269.--Bilateral Cervical Ribs; the left one is the
better developed.]
When symptoms arise, they may be referable either to pressure on the
artery or on the nerve roots. When the subclavian artery is displaced
upwards it may be recognisable as a prominent pulsatile swelling, and
as the part of the vessel distal to the rib is sometimes dilated and
yields a systolic bruit, it may simulate an aneurysm (Sir William
Turner). The pulse beyond is weakened while the arm hangs by the side,
but may be restored by raising the hand above the head. Gangrene of
the tips of the fingers has been observed in rare instances, but it is
probably nervous rather than vascular in origin.
Symptoms referable to pressure on the nerve roots usually affect the
right arm, and may be either neuralgic or paralytic in character (Wm.
Thorburn). In the neuralgic group there is tingling pain, a feeling of
numbness, and sensations of cold in the limb, most marked along the
ulnar border of the forearm; the arm is weak, and susceptible to cold.
This condition may be mistaken for brachial neuritis; it is relieved,
however, by holding the arm above the head, for example, during sleep.
In the paralytic group, the pressure symptoms are referred to the
first dorsal, or first dorsal and eighth cervical roots. The paralysis
is most marked in the muscles of the thumb, and becomes less towards
the ulnar side; the affected muscles atrophy, especially those forming
the thenar eminence, and the finer movements of the thumb and fingers
are impaired.
When pressure symptoms are present, the extra rib should be removed
through an incision which exposes the posterior triangle sufficiently
to admit of the bone and its periosteum being excised, without damage
being inflicted on the brachial plexus, the subclavian artery, or the
pleura.
Similar clinical features to those of cervical rib may be caused by a
prominent transverse process of the first thoracic vertebra and
similarly got rid of by its removal.
_Branchial cysts and branchial tumours_ are described with tumours of
the neck (p. 598).
WRY-NECK OR TORTICOLLIS.--The term wry-neck or torticollis is applied
to a condition in which the head assumes an abnormal attitude, which
is usually one of combined lateral flexion and rotation.
The most important form is due to faulty action of the cervical
muscles, and three varieties of muscular wry-neck are recognised--(1)
the acute or transient; (2) the chronic or permanent; and (3) the
spasmodic.
#Acute# or #transient wry-neck#--so-called "rheumatic
torticollis"--comes on suddenly, usually after the patient has been
exposed to a draught of cold air or to damp. The condition is
popularly known as "stiff neck," and is probably associated with
fibrositis of the affected muscles. The sterno-mastoid, and often the
trapezius, are contracted, and pull the head to one side, twisting
the face slightly towards the opposite side (Fig. 270). There is
tenderness on pressing over the affected muscles, and sometimes over
the vertebral spines, and in the lines of the cervical nerves, and
severe pain on attempting to move the head. Usually in the course of a
few days the condition passes off as suddenly as it came on, but in
some cases a certain amount of wasting of the affected muscles ensues.
[Illustration: FIG. 270.--Transient Wry-neck, which came on suddenly
after sitting in a draught, and passed off completely in a few days.]
In the _diagnosis_ of this form of wry-neck it is necessary to exclude
such conditions as cellulitis, inflammation of the cervical glands,
and disease of the cervical spine, in which the head may assume an
abnormal attitude, the position being that which gives the patient
greatest comfort.
The _treatment_ consists in ensuring free action of the bowels and
kidneys, in inducing hyperaemia by means of heat, and applying gentle
massage. Salicylates and similar drugs are useful in relieving the
pain.
#Permanent# or #true wry-neck# is due to an organic shortening of the
sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and
the levator scapulae muscle may also undergo shortening, along with
their investing sheaths derived from the cervical fascia.
The sternal head of the sterno-mastoid is always markedly shortened,
and stands out as a tight cord; sometimes the clavicular head is also
prominent.
There is evidence that in the majority of cases the deformity results
from some interference with the development of the muscles during
intra-uterine life. This is probably the effect of undue pressure on
the foetus diminishing the arterial supply to the central part of the
muscle, with the result that the muscle fibres undergo degeneration
with subsequent sclerosis and contraction. It may result also from
cicatricial contraction of the muscle following rupture of its fibres
during delivery. In such cases there is a history that the birth was a
difficult one, the presentation having been abnormal; and that a
swelling was observed in the sterno-mastoid shortly after birth. This
swelling--_a haematoma of the sterno-mastoid_--is at first soft, later
becomes smaller, and eventually disappears. In course of time,
sometimes months, sometimes years after the disappearance of the
swelling, shortening of the muscle takes place, and the deformity is
established.
_Clinical Features._--Although the condition is usually described as
"congenital," it is the common experience in practice that the child
has reached the age of from seven to ten years before advice is
sought. The appearance of the patient is characteristic (Fig. 271).
The shortening of the sterno-mastoid pulls the head towards the
affected side, usually the right, so that the ear is approximated to
the shoulder. At the same time the head is rotated towards the
opposite side and slightly tilted backwards, with the result that the
chin is directed towards the opposite side, and is somewhat raised.
The shortened sterno-mastoid stands out prominently, and, on any
attempt to straighten the head, can be felt as a firm, fibrous band.
The skin of the affected side of the neck may be thrown into
transverse folds. The patient is unable to correct the deformity, but
it is usually possible to diminish it by manipulation.
[Illustration: FIG. 271.--Congenital Wry-neck in a boy aet. 14.]
If the condition is not corrected, all the structures on the affected
side of the neck undergo organic shortening, with the result that the
deformity becomes accentuated. In advanced cases a lateral curvature,
with the convexity towards the normal side, occurs in the cervical
region, the vertebrae becoming wedge-shaped from side to side, and a
compensatory curve may develop in the thoracic region (Fig. 272).
[Illustration: FIG. 272.--Congenital Wry-neck seen from behind to show
scoliosis.]
There is also asymmetry of the head and face, the affected side being
the smaller. The eye on this side lies on a lower level, and is more
oblique than its neighbour, the cheek is flattened, and the mouth
asymmetrical. Instead of the eyebrows and the lips forming parallel
lines, their axes converge towards the side of the contracted muscles
and fasciae.
_Treatment._--While it may be possible when the condition is
recognised during infancy to counteract the tendency to contraction
and deformity by manipulations, massage, and exercises alone, it is
usually necessary to divide the shortened structures as a preliminary
to orthopaedic measures.
Subcutaneous tenotomy--at one time the favourite method of
treatment--has been entirely replaced by the _open operation_, which
admits of all the structures at fault, including the cervical fascia,
being thoroughly divided, without risk of injuring other structures in
the neck. The result of division of the shortened tissues is
seen at once in a marked increase in the interval between the
sterno-clavicular joint and the mastoid process. As in other
deformities, the operation is only a preliminary, although an
essential one, to the treatment by massage, movement, and exercises
which must be persevered with for months, and it may be for years.
When the torticollis attitude has been corrected in childhood, the
asymmetry of the skull disappears.
#Spasmodic wry-neck# is the term applied to a condition in which
clonic contractions of certain muscles produce jerkings of the head.
The muscles most frequently at fault are the sterno-mastoid and
trapezius of one side, and the posterior rotators of the opposite
side. By these muscles the head is pulled into the wry-neck position,
and is at the same time retracted, and there is more or less constant
nodding or jerking of the head.
The condition is usually met with in adults of a neurotic disposition
who are in a depressed state of health, and is due to some lesion, as
yet undiscovered, in the nerve mechanism of the affected muscles--most
probably in their cortical centres. It would appear that in some cases
the spasmodic jerkings are originated by certain movements habitually
made by the patient in the course of his work. In others, as a result
of astigmatism and other errors of refraction, the patient has
acquired the habit of repeatedly tilting his head to enable him to see
clearly, and these movements have become continuous and
uncontrollable.
The affection tends to become progressively worse until the patient is
incapacitated for work or enjoyment. Sleep even may be interfered
with.
_Treatment._--In well-marked cases the use of drugs, electricity, or
restraining apparatus is never curative, but these measures combined
with massage have been temporarily beneficial in milder cases.
Of the operative procedures, resection of portions of the accessory
nerve on one side, and of the posterior primary divisions of the first
five cervical nerves on the opposite side, seems to offer the best
prospect of recovery. Simple division of these nerves or resection of
the accessory alone has not proved permanently curative. Open division
of the offending muscles without interfering with the nerves has given
good results, and is a much simpler operation (Kocher).
Spasmodic wry-neck must be distinguished from the #hysterical#
variety, which after lasting for weeks, or even months, may pass off
completely, but, like other hysterical affections, is liable to recur.
Deviations of the neck simulating torticollis may occur in cervical
caries, and in unilateral dislocation of the spine.
The #cicatricial contraction# of the integument of the neck that
results from extensive burns, abscesses, or ulcers, may cause
unsightly deformity and fixation of the head in an abnormal attitude,
and call for surgical treatment. The contraction which follows the
disappearance of a gumma of the sterno-mastoid may also produce a
deformity resembling wry-neck.
INJURIES
#Contusion# of the neck may result from a blow or crush, as, for
example, the passage of a wheel over the neck, or from throttling,
strangling, or hanging. In medico-legal cases the distribution of the
discoloration should be carefully noted. When due to throttling, the
marks of the fingers may be recognisable, and nail-prints may be
present. In cases of strangling, the mark of the cord passes straight
round the neck, while in suicidal hanging it is more or less oblique
and is higher behind than in front. When due to a direct blow, for
example by a fist, the discoloration is limited, while it is usually
diffused over the neck when due to the passage of a wheel over the
part.
The clinical importance of these injuries depends on the complications
that may ensue; for example, extravasation of blood under the
cervical fascia may press upon the air-passage and oesophagus to such
an extent as to cause interference with breathing and swallowing; the
larynx or the trachea may be so grossly damaged that death results
immediately from suffocation, or later from gradually increasing
oedema causing obstruction of the glottis. If the mucous membrane of
the air-passage or the apex of the lung and its investing pleura is
torn, emphysema of the connective tissue may develop and spread widely
over the body. In contusions of the lower part of the neck the cords
of the brachial plexus may be injured.
#Fractures of the Hyoid, Larynx, and Trachea.#--The _hyoid bone_, on
account of its mobility and the protection it receives from the body
of the mandible, is seldom fractured, except in old people in whom the
great cornu has become ossified to the body of the bone. It is usually
broken either by a direct blow, or by transverse pressure as in
garrotting. The fracture is almost always at the junction of the great
cornu with the body, and there is marked displacement of the
fragments, which may injure the pharyngeal mucous membrane.
The _thyreoid and cricoid cartilages_ are also liable to be fractured
in run-over accidents, particularly in old people after calcification
or ossification has taken place.
The _trachea_ may be lacerated, or even completely torn from the
larynx, by the same forms of injury as produce fracture of the
laryngeal cartilages.
The _clinical features_ common to all these injuries are swelling and
discoloration; and if the mucous membrane is torn, air may escape into
the tissues and produce emphysema. There is always more or less
difficulty in breathing, which may amount to actual suffocation, and
this may come on immediately, or in the course of a few hours from
oedema of the glottis. Blood may pass into the lungs and be coughed
up. Swallowing is usually difficult and painful, especially in
fracture of the hyoid bone. There is also pain on speaking, the voice
is husky and indistinct, and spasmodic coughing is common. When blood
has entered the air-passages there is considerable risk of septic
pneumonia.
_Treatment._--As the immediate risk to life is from suffocation, it is
usually necessary to perform tracheotomy at once. In fracture of the
hyoid the fragments may be replaced by manipulation through the mouth,
after which the head and neck are immobilised by a poroplastic collar.
#Wounds--Cut-throat.#--The most important variety of wound of the neck
met with in civil practice is that known as "cut-throat"--an injury
usually inflicted with suicidal, less frequently with homicidal
intent.
Suicidal wounds are usually directed from left to right (if the
patient is right-handed), and they run more or less obliquely from
below upwards across the neck; the wound being deepest towards its
left end, that is where the weapon enters, and gradually tailing off
towards the right. In most cases the would-be suicide throws his head
so far back at the moment of inflicting the wound, that the main
vessels are carried backward under cover of the tense sterno-mastoid
muscles, and so escape injury. The knife may even reach the vertebral
column without damaging the contents of the carotid sheath.
Homicidal wounds are usually more directly transverse, and are of
equal depth throughout. The main vessels are generally divided, the
oesophagus and trachea opened into, and in some cases the vertebral
canal is opened and the cord and its membranes injured.
_Clinical Features._--The clinical features vary with the level of the
wound and with its depth. In all cases the contraction of the platysma
causes the wound to gape widely, and its edges tend to be turned in.
In a large proportion of suicidal attempts the patient only succeeds
in inflicting one or more comparatively superficial wounds across the
front of the neck. In many cases the haemorrhage from these is
trifling, but if the external jugular and other large superficial
veins are divided, it may be fairly profuse, although it is seldom
immediately fatal, unless the blood is sucked in to the wounded
air-passage.
Occasionally, but rarely, the wound is made _above the hyoid bone_,
and opens directly into the mouth. There may then be sharp haemorrhage
from the base of the tongue or from the lingual and external maxillary
(facial) arteries or their branches in the submaxillary region, and
asphyxia may result from the base of the tongue and the epiglottis
falling back and obstructing the larynx.
The _hyo-thyreoid membrane_ is frequently divided, and the pharynx
thus opened. As the depressor muscles of the hyoid are divided, there
is interference with deglutition and phonation, but respiration is not
affected. In such cases the upper portion of the epiglottis is often
cut off, and the base of the tongue, the tonsil or the soft palate may
be injured. The lingual, external maxillary and superior thyreoid
arteries, and the hypoglossal nerve are also liable to be divided at
this level, but the main vessels of the neck usually escape. There is
pain and difficulty in swallowing, and food and saliva tend to escape
through the wound. Particles of food may pass into the air-passages
and cause violent fits of coughing.
In more severe cases the knife enters the _larynx_ or the _trachea_.
Sometimes the thyreoid cartilage is divided--as a rule only
partly--and the vocal cords are injured; in other cases the trachea is
opened, or it may be completely cut across. The bleeding is serious,
as the superior thyreoid arteries are usually damaged. If the common
carotid and the internal jugular vein also are wounded, the haemorrhage
usually proves fatal. The fatal issue may be contributed to by blood
entering the air-passages and causing asphyxia, or by air being sucked
into the open veins and causing air embolism. The laryngeal branches
of the vagus may be divided and paralysis of the larynx ensue.
In all cases there is more or less dyspnoea and persistent coughing.
The voice is husky, and the patient can only express himself in a
hoarse whisper. There is difficulty in swallowing, and the food may
enter the trachea. When the external wound is small, there may be a
considerable degree of emphysema of the cellular tissue.
The _prognosis_ depends largely on the general condition of the
patient. The majority of those who attempt to take their own lives are
in a low state of health from alcoholic excess, mental worry,
privation or other causes, and many succumb even when the wound in the
neck is comparatively slight. Shock, loss of blood, asphyxia from
blood entering the air-passages, and oedema of the glottis are the
most frequent causes of death soon after the injury. Cellulitis,
inhalation, pneumonia, and delirium tremens are later complications
that may prove fatal.
_Treatment._--The first indication is to arrest haemorrhage, and this
may be done by applying digital compression over the bleeding points.
The bleeding vessels are then sought for and ligated, the wound being
enlarged if necessary.
If the food and air-passages are intact, any muscles that have been
divided should be sutured.
When the epiglottis is cut across in wounds opening into the pharynx,
it should be united, preferably with fine silk sutures, as catgut is
absorbed before healing has time to take place. The wall of the
pharynx and the muscles should then be sutured layer by layer.
When the air-passage is opened, it is usually advisable to introduce a
tracheotomy tube (Fig. 273), and pack gauze round it to avoid the
risk of oedema of the glottis and to prevent blood entering the lungs.
The soft tissues may then be brought together layer by layer.
[Illustration: FIG. 273.--Recovery from Suicidal Cut-throat after low
tracheotomy and gastrostomy.
(Mr. J. M. Graham's case.)]
In all cases the superficial part of the wound should be drained, and
in applying the bandage the head should be flexed on the chest to take
all tension off the stitches. The patient must be kept under constant
supervision lest he should interfere with the dressings, or make a
further attempt on his life. In some cases it is necessary to feed him
through a tube passed into the stomach either through the mouth or
through the nose; when this is not feasible, nourishment must be given
by the rectum, or by a gastrostomy tube (Fig. 273).
_Wounds of the thoracic duct_ have been described with affections of
the lymphatics (Volume I., p. 324), and _wounds of the brachial
plexus_ with injuries of individual nerves (Volume I., p. 360).
INFECTIVE CONDITIONS
#Cellulitis# may occur in any of the cellular planes in the neck, the
most important form being that which occurs under the cervical fascia,
for example in the course of acute infective diseases, such as scarlet
fever, measles, or pyaemia. The pus tends to spread widely throughout
the neck, infiltrating the connective-tissue spaces around the blood
vessels, the air-passages, and the oesophagus. The density and tension
of the cervical fascia cause the pus to burrow downwards towards the
mediastinal spaces of the thorax, where it may give rise to such
complications as empyema, infective pericarditis, or gangrene of the
lung. The pus may also reach the axilla by spread of the infection
along the subclavian vessels.
An acute phlegmonous peri-adenitis sometimes occurs in the loose
cellular tissue around the submaxillary gland, and spreads with great
rapidity through the cellular planes of the neck. The condition--which
goes by the name of _angina Ludovici_--is usually met with in adults,
and appears to originate in some infective focus in the mouth.
_Clinical Features._--In all forms the process spreads rapidly, and
the neck becomes swollen, brawny, and of a dusky red colour. The head
is flexed towards the affected side, and there is pain on movement and
on palpating the swelling. Pus forms early, but, as it is under great
tension, fluctuation can seldom be detected. Respiration may be
interfered with by pressure on the air-passages, or by the onset of
oedema of the glottis, and tracheotomy may be urgently called for.
Swallowing may also be affected by pressure on the pharynx and
oesophagus. Pressure on the important nerves traversing the neck may
give rise to irritative or paralytic symptoms. The main vessels may
become thrombosed or eroded--particularly when the cellulitis is
associated with scarlet fever--and in the latter case copious
haemorrhage may follow incision of the abscess.
There is always marked constitutional disturbance, as evidenced by
rigors, high temperature, a small, rapid pulse, and delirium; and
death may result within a few days from toxaemia.
_Treatment._--In the earliest stages hot fomentations or ichthyol and
glycerine should be applied, but if the process does not begin to
abate within twenty-four hours, and if the swelling becomes brawny in
character, one or more incisions should be made through the deep
fascia where the signs of inflammation are most intense, and the
deeper planes of the neck opened up by dissection. Drainage is secured
by tubes or strips of rubber tissue. If profuse haemorrhage occurs it
may be necessary to ligate the main artery lower in the neck.
#Actinomycosis# manifests itself in the neck as a diffuse, painless
swelling, which slowly infiltrates the superficial structures,
becoming brawny at some places, and at others breaking down and
forming sinuses from which the ray fungus escapes in the discharge.
#Boils and carbuncles# frequently occur on the back of the neck, where
the skin is thick and coarse and is rubbed by the collar.
The affections of the _cervical lymph glands_ have already been
described (Volume I., p. 330).
TUMOURS
#Cystic Tumours.#--A great variety of cystic tumours is met with in
the neck.
#Branchial cysts# are formed by the distension of an isolated and
unobliterated portion of one of the branchial clefts. They usually
form in connection with the third cleft, and are met with in the
region of the great cornu of the hyoid bone, to which the wall of the
cyst is almost always attached. Less frequently they take origin in
the second cleft, and lie below the mastoid process, in which case the
cyst is adherent either to the mastoid or to the styloid process. In
some cases these cysts project towards the floor of the mouth. When
near the skin they are of the nature of _dermoid cysts_, being lined
with squamous epithelium and filled with sebaceous material. When
deeply placed, they are lined by cylindrical or ciliated epithelium
and contain a glairy mucoid fluid.
Although of congenital origin, these cysts do not usually attract
attention till about the age of puberty, when they are noticed as
small, soft, fluctuating tumours over which the skin moves freely.
They grow slowly, but may attain great dimensions. The only treatment
that yields satisfactory results is complete excision.
The _cystic lymphangioma_, _hygroma_, or _hydrocele of the neck_ (Fig.
274), has been described with affections of lymphatics (Volume I., p.
327); and _thyreo-glossal cysts in the neck_ at p. 583.
[Illustration: FIG. 274.--Hygroma of Neck.
(Photograph lent by Mr. J. W. Dowden.)]
_Blood Cysts._--These may originate in a diverticulum of a vein that
has become isolated, or in a cavernous angioma; or they may be due to
haemorrhage taking place into a branchial or thyreo-glossal cyst. The
diagnosis is often only possible by exploratory puncture; and the
treatment consists in complete excision.
_Cystic Bursae._--Cystic degeneration may occur in the supra-hyoid and
thyreo-hyoid bursae, and give rise to a rounded swelling which moves
with the thyreoid on swallowing, and is only troublesome from the
disfigurement it causes. It is treated by excision.
#Solid Tumours#, apart from the common enlargements of lymph glands,
and the various forms of goitre, are not often met with in the neck.
The _circumscribed lipoma_ usually occurs over the nape of the neck or
in the supra-clavicular region. It may attain considerable size, and
from its weight become pedunculated and hang down over the back or
shoulder.
_Diffuse lipomatosis_ usually begins over the nape and spreads more or
less symmetrically till it completely surrounds the neck. As the
new-formed fat is not encapsulated, extirpation of the mass is
difficult and is seldom called for.
[Illustration: FIG. 275.--Lympho-sarcoma of Neck.
(Mr. D. M. Greig's case.)]
_Fibroma_ originating in the ligamentum nuchae, or the periosteum of
the vertebral processes, is of slow growth, but it may attain
considerable size, and on account of its deep attachments the
operation for its removal may be difficult.
_Mixed tumours_ like that described as occurring in the vicinity of
the parotid, and taking origin from branchial rests, are sometimes met
with in the upper part of the anterior triangle.
_Osseous_ and _cartilaginous tumours_ occasionally grow in connection
with the transverse processes of the lower cervical vertebrae.
_Sarcoma_ and _fibro-sarcoma_ of the slowly growing type may develop
from any of the fascial structures in the neck, or from the connective
tissue surrounding the blood vessels. In those taking origin beneath
the sterno-mastoid, there is difficulty in removing them completely on
account of their deep attachments, and when they are found to
infiltrate the surrounding tissues the attempt should be abandoned.
This rule may be relaxed in view of the aid that may be afforded by
the insertion of a tube of radium, which is capable of rendering inert
such portions of the growth as are not capable of being removed.
Sacrifice of the common carotid artery is attended with the risk of
hemiplegia and cerebral softening, especially in persons over fifty;
resection of a portion of the vagus is less dangerous to life than
stimulation by irritation of its fibres; resection of the internal
jugular vein and of the cervical sympathetic cord are factors which
add to the shock of the operation but do not carry with them any
special risk.
_Carcinoma._--The commonest form of primary cancer is the _branchial
carcinoma_, a squamous epithelioma which originates in connection with
the second visceral cleft (Fig. 276). It appears as a rule under the
sterno-mastoid at the level of the hyoid bone, and extends towards the
submaxillary region, infiltrating the muscles and the sheath of the
vessels.
[Illustration: FIG. 276.--Branchial Carcinoma--subsequently removed by
operation.]
It is more common in men than in women, and there is often a history
of a small swelling having been present for many years, or even since
birth. About middle life more active growth begins, the swelling
becomes more fixed and is painful, and once it begins to grow, it
increases rapidly and within a month or two may reach the size of a
child's head. In spite of its size, however, it seldom causes
interference with breathing or swallowing, and it has comparatively
little effect on the general health. Clinically, the induration and
fixation of the tumour suggest its epitheliomatous character, but the
absence of a primary growth in the mouth or pharynx excludes its being
a metastasis in the lymph glands.
Unless completely removed at an early stage, recurrence inevitably
takes place.
Primary carcinoma may also occur in a supernumerary thyreoid, and in
the para-thyreoid glands.
We have met with a case of _paraffin epithelioma_ on the neck, and a
similar type of epithelioma may be met with in a lupus or a burn of
long standing.
#The Thymus Gland.#--The thymus gland begins to diminish in size
towards the end of the second year, and by the time puberty is reached
it has entirely disappeared. In some cases, however, the process of
involution fails to take place, and the gland may even undergo
hyperplasia and exert pressure on the trachea, the great blood
vessels, or the left vagus nerve and its recurrent branch. The
enlargement of the thymus may be part of a general lymphatic
hyperplasia--known as the _status lymphaticus_.
The pressure effects may be entirely referable to the trachea--_thymus
stenosis of the trachea_--giving rise to progressive dyspnoea
accompanied by stridor, with paroxysmal exacerbations during which the
child becomes asphyxiated. It is only expiration that is interfered
with, as with each inspiratory effort the gland is sucked in towards
the mediastinum and so frees the air-passages, while with expiration
it rises again, and, becoming jammed in the upper opening of the
thorax, exerts pressure on the trachea, and during expiration a soft
swelling is sometimes recognisable in the episternal notch. The
paroxysms occur at irregular intervals, and any one of them may prove
fatal. In some cases the symptoms seem to be associated with pressure
on the blood vessels and nerves rather than on the air-passages, and
in these there is distension of the veins and a tendency to syncopal
attacks.
The only way to afford relief is to expose the gland and withdraw it
from behind the sternum by making traction on its capsule. If the
breathing is not thereby improved, the capsule should be opened and
the gland shelled out.
The term _thymic asthma_ has been applied to another form of disturbed
respiration due to a large thymus, which comes on suddenly in infants
otherwise apparently healthy. Without warning, the child seems to
choke, has great difficulty in breathing, with inspiratory stridor and
indrawing of the epigastrium; he rapidly becomes cyanosed, and in the
majority of cases dies in a few minutes--_thymus death_. No
satisfactory explanation of the sudden onset of the symptoms is
forthcoming, but it appears to be associated with something which
suddenly narrows the mediastinal space, such as backward bending of
the head, or venous engorgement of the thymus gland. Cases are
recorded in which an attack has come on during the administration of a
general anaesthetic; in some instances the patient has suffered from
the generalised status lymphaticus.
#Tumours of the Carotid Gland or Glomus Carotica# (_Potato-like tumour
of the neck_).--The carotid gland under normal conditions is about the
size of a grain of corn, and lies to the posterior aspect of the
bifurcation of the carotid. It is sometimes the seat of
_endothelioma_. The tumour has a definite capsule, is moderately firm
and elastic, increases in size slowly and gradually for a time, and
then may grow more rapidly. Its relation to the vessels is
characteristic: as it grows it envelops the common carotid and its
branches, and becomes adherent to the internal jugular vein; and it
may come to implicate the nerves in the neck, particularly the vagus
and its recurrent branch, and the cervical sympathetic.
It gives rise to few symptoms, and in the majority of cases the
surgeon is consulted on account of the disfigurement resulting from
the presence of the swelling in the neck. This swelling is ovoid,
smooth or slightly lobulated; it lies at the level of the bifurcation
of the carotid, and tends to grow upwards rather than downwards; it is
movable from side to side, but not up and down; it lies under the
sterno-mastoid, and the skin is not implicated. There is transmitted
pulsation in the tumour, but no expansion.
The diagnosis has to be made from lymphoma, adenoma, tuberculous
glands, sarcoma, and carcinoma.
In a large proportion of the cases operated upon it has been necessary
to ligate the carotids and to excise portions of the internal jugular
vein, and as severe cerebral symptoms are liable to ensue the
mortality has hitherto been high. Operation is therefore only to be
recommended when the growth is rapid, or the symptoms have become
urgent.