Cervical pathology . Oral surgery treats those procedures that are related in an anatomical and functional way to processes of oral origin. The importance of cervical pathology is due to the fact that some primary processes originating in the mouth can manifest at the cervical level , and the neck has its own pathology that manifests itself in a way very similar to the processes derived from the mouth Hence the importance of differential diagnosis.
CLASSIFICATION OF CERVICAL SURGICAL PATHOLOGY: 1. INFECTIOUS PATHOLOGY:
- nonspecific adenitis.
- Specific adenitis.
- Other adenitis.
- CYSTIC PATHOLOGY:
- cervical fistulas
- TUMOR PATHOLOGY:
- primitive tumors.
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- 1 Infectious Pathology
- 2 Cystic Pathology
- 3 Tumor Pathology
- 4 Sources
- A. NON-SPECIFIC ADENITIS:
appearance of enlarged nodes, normally located in the submaxillary or submental glands and secondary to an infectious process of the face or oral cavity normally.
- Aa ACUTE:
They are very frequent, especially in children, being located in the primary lymphatic drainage region of the acute focus. The causative organisms are pyogenic germs (streptococci, staphylococci). It should be differentiated from diphtheria and scarlet fever.
The entrance door may vary: – Pharynx / rhinopharynx: The most frequent are non-specific pharyngotonsillitis of viral origin. Within bacterial processes, the most frequent are strep throat, followed by staphylococcal tonsillitis. Other processes are: infectious mononucleosis, caused by the Epstein-Barr virus (tonsillitis, diffuse lymphadenopathy on the back of the neck, edema of the uvula, rash and splenomegaly, with lymphomonocytosis), Vincent’s angina, etc.
– Face, neck and scalp skin: Excoriations, impetigo, erysipelas or any superinfected lesion. In exanthematous fever you can find the typical black spot from a tick bite.
– Mouth: oral processes (phlegmon, stomatitis, superinfected gingivitis).
– Ear: otitis media or external. Other causes are: brucellosis, leptospirosis, listeriosis, typhoid fever, etc. Treatment is directed at the bacterial cause and includes a broad-spectrum antibiotic. If the infectious process is not resolved or if the cervical mass fluctuates, incision and surgical drainage is necessary. In case of severe cellulite, parenteral antibiotics associated with NSAIDs.
The evolution of acute adenitis is as follows:
UNINSURATED ADENITIS (follows a fluctuating local infection and the possibility of associated lymphangitis)
SUPPLIED ADENITIS (increase in symptoms and appearance of fistulas and suppuration)
ADENOFLEMON OR CELLULITIS Exacerbation of symptoms with general symptoms. They can be classified according to location: submental, submaxillary, facial, carotid, retropharyngeal, infrahyoid, and nape.
- Ab CHRONICLES:
causal organisms are banal pyogenic germs. Lymphadenopathy is hard, painless, and mobile, so a malignant process can be considered. They are usually associated with mucous and skin infections. Treatment consists of antibiotic therapy.
- 1 B. SPECIFIC ADENITIS:
- Ba ACUTE:
Rubella: more common in childhood but can also occur in adults. It is characterized by a pink macular rash and mainly occipital lymphadenopathy. Measles: red maculopapular rash and cervical polyadenopathy with stomatitis, laryngitis, and Koplick’s spots. Herpes simplex and Zoster: important adenomegalies. Adenoviris Coxackie: Rhinopharyngeal infections associated with lymphadenopathy with little tendency to suppuration.
If they chronify: Infectious mononucleosis (Epstein-Barr): adolescent and young adult. Table of tonsillitis, asthenia, uvula edema, skin rash and splenomegaly (50%) and multiple cervical lymphadenopathy, with highly enlarged and elastic nodes that are typically located in the posterior cervical and occipital region, with spontaneous evolution to healing. The administration of ampicillin causes a pruriform maculopapular rash in 90% of cases. Cat Scratch Fever: A history of cat bite or scratch, initially painful nodes, fever and discomfort, then painless, oozing, fixed lymph nodes that can fistulize. The diagnosis is based on the dermal test, excisional biopsy. The treatment will be ciproploxacin in adults and rifampicin in children.
Toxoplasmosis: Produced by Toxoplasma gondii. Clinic similar to mononucleosis with nuchal, periauricular, and supraclavicular polyadenopathy. Small, mobile nodes and little or no pain. The diagnosis is confirmed by serological tests. The disease cures by itself and does not require treatment except in immunosuppressed patients (Sulfadiazine-pyrimethamine). Actinomycosis: acute and then chronic suppurative submandibular adenopathies due to dental focus. Treatment consists of amoxicillin and drainage of the lesions, if necessary.
They produce painless and firm adenomegalies due to lymph node fibrosis in response to chronic infections. Adenomegalies can converge and become adherent to soft tissues, forming a chronic abscess and fluctuating and ulcerating skin.
– Tuberculosis and Atypical Mycobacteria:
– Mycobacterium tuberculosis: It is the most involved germ that reaches the ganglion hematogenously.
– Mycobacterium Bovis: The germ is transmitted through milk and is exceptional today due to the boiling and pasteurization processes.
– Atypical mycobacteria: M. Kansaii, M. gordonae, M. scrofulaceum, M. avium, M. fortuitum. They only behave as pathogens in children and immunosuppressed.
The clinic is characterized by: – Predominantly cervical involvement, in the submaxillary region or posterior triangle
– Painless and slowly progressive lymph node growth, with few or no general manifestations – The nodes are initially firm, well delimited and discreetly painful on palpation
– As they progress they can form a plastron and become fixed
– Finally they are caseified, forming a cold abscess, which tends to drain spontaneously (if not drained before surgery) a whitish creamy material, causing a chronic fistula (scrofula).
– Chest rx identifies pulmonary TB in <25% of cases. There is a more generalized form that affects multiple nodes, sometimes with toxic syndrome associated with hematogenous spread and that is more frequent in HIV (+) patients.
The diagnosis is based on:
– Rx thorax: Pulmonary tuberculosis (25%). (There is only pulmonary involvement with M. Tuberculosis).
– Reaction to tuberculin +. PAAF to perform:
– Ziehl-Nielsen stain,
– Special cultures for mycobacteria
– Histological examination in search of characteristic granulomatous lesions (Langherhans giant cells and caseous necrosis). This technique has a high diagnostic precision. If FNA is not diagnostic, a lymph node excision-biopsy will be performed. The treatment will consist of: M. Tuberculosis: tuberculostatic 9-12 months M. Bovis or atypical: surgical removal of the affected tissue is recommended, since the response to treatment is very poor. The prognosis is excellent even only with surgical excision.
– Syphilis: in primary syphilis there are satellite adenopathies that are firm and mobile. The puncture of the ganglion, helps the diagnosis.
– Sarcoidosis: mediastinal lymphadenopathy, and less frequent cervical lymphadenopathy.
– Melkersson-Rossenthal syndrome: facial edema, folded tongue with cervical lymphadenopathy.
– AIDS: HIV-infected children have viral and bacterial infections that can present as cervical masses. They also have a higher incidence of lymphomas and Kaposi’s sarcoma. HIV infection, generally 2-6 weeks after infection, can lead to infectious lymphomonocytosis syndrome with fever, adenomegaly, and arthralgia. In these patients there is an increased incidence of lymph node TB and non-Hodgkin lymphomas.
- 1 C. OTHER ADENITIS:
– Nocardiosis: occurs in immunosuppressed patients with dental phlegmon, with lymphadenopathy with suppurative necrosis and abscess formation. Tendency to recurrences and exacerbations.
– Kawasaki disease: in young children with fever, facial edema, conjunctivitis, erythema on the hands and feet, and oral tissues with cervical lymphadenopathy. Kidney and cardiac complications can appear.
2. Cystic Pathology
These are processes of embryonic origin due to cell entrapment.
- A. HYGRAM OR CYSTIC LYMPHANGIOMA:
Dilation of the cavernous one or stop the development of the lymphatic sacs. Present at birth and 90% detectable at the end of the second year of life. Typical in the neck, in a posterior triangle. It is a soft, painless, depressible and lobulated unilateral cervical mass. They are multilocular cavities lined with endothelial cells that continue to produce lymphatic fluid. In this way, its growth goes from gradual to rapid with compression or displacement of adjacent structures.
The diagnosis is confirmed with ultrasound, which reveals the cystic nature of the hygroma. In extensive injuries and with significant compromise of vital structures, computed tomography with intravenous contrast medium is more useful. FNA is also useful. Complete surgical excision is sometimes impossible due to its infiltrative nature. Alternative therapies are intralesional corticosteroid injection, repeated aspiration, incision and drainage, and injection of sclerosing agents.
- B. CYST OF THE TYROGLY DUCT:
Due to abnormalities in the closure of the thyroglossal tract that runs from the base of the tongue to the thyroid isthmus. They are frequently located in the cervical midline, adjacent to the hyoid bone, although it can occur anywhere in the thyroglossal tract. It is the most frequent congenital cervical tumor (70%) and the second most frequent in children after lymphadenopathy. It is mobilized with swallowing and lingual protrusion. It can become infected and fistulize. Cervical ultrasound locates the cyst and the gland. It is also diagnosed by scintigraphy, MRI, and BAAF. Its treatment will be surgical by means of the Sistrunk intervention, in which the fistulous path is followed through the mylohyoid, genihyoid and genioglossus muscles to the blind foramen, and the central part of the hyoid must be resected to avoid recurrences.
- 2 C. BRANCHIAL CYST:
It is a congenital anomaly, of late expression, due to the persistence of a branchial cleft. Branchial cysts appear in the same locations of the sinuses and are sometimes difficult to differentiate from lymphadenopathy or other cervical masses, especially if they are infected.
Cysts of the first cleft are infrequent. Epithelial debris from the second and third branchial arches can cause branchial cysts, which present as fluctuating cervical masses in the young adult. The cysts and sinuses of the second branchial cleft communicate with the tonsillar fossa passing through the bifurcation of the carotid artery, and externalizing along the anterior border of the sternocleidomastoid muscle.
In this way, infections are caused by germs that enter the external ear canal or are carried by saliva to the cyst from the pharynx. They are soft, depressible, and extend deep until reaching the pharyngeal wall. Ultrasound characterizes it as cystic or hypoechoic in content. The treatment of the branchial remains is surgical removal not only for aesthetic reasons but also to avoid infection.
- D. BRANCHIAL FISTULAS:
If the second branchial arch does not grow over the third and fourth branches, the remains of the second third and fourth branchial clefts can maintain contact with the surface through a duct that is the branchial fistula.
- E. DERMOID CYST:
They are malformations that are located in the midline of the neck and that develop from embryonic stem cells. Inclusion cysts containing sebaceous glands and hair follicles are dermoid. Those without these elements are epidermoid, but both types contain sebaceous material and are the consequence of inclusions of ectoderm under the skin surface during the embryonic period.
The most frequent location is at the level of the floor of the mouth. They are usually 15-35 years old, smooth, rounded, firm or soft, painless, with the possibility of infection and fistulization. It is diagnosed through CT and MRI, with detection of fat within the lesion. A differential diagnosis should be made with a thyroglossal cyst (the dermoid cyst does not move upon swallowing and protrusion). Their treatment is surgical removal as they tend to grow.
3. Tumor Pathology
- 1. LYMPHOMAS:
They present as lymphadenopathies in the head and neck. Malignancy more frequent in children (50%). They are lymphoproliferative diseases that are classified into Hodgkin lymphoma and np-Hodgkin. In Hodgkin’s disease, the first symptom is painless, mobile, and elastic lower or supraclavicular cervical adenopathy. Other forms of presentation of lymphomas can be splenomegaly, mediastinal masses, digestive masses, …). Non-Hodgkin lymphomas mainly affect between the fourth and seventh decade and prevalence in males and unknown etiology. Cervical lymphadenopathy and extranodal lesions appear on the amygdala. Also nostrils and sinuses. In 80% of the cases they appear in advanced stages.
Differences between Hodgkin and non-Hodgkin: HODGKIN NO-HODGKIN
-Continuous and / or localized nodal involvement – Discontinuous and generalized nodal involvement
-Rare extranodal disease – Frequent extranodal disease
– Impairment of cellular immunity – Impairment of humoral immunity In the case of lymphadenopathy, a basic analysis and a chest RX will always be performed, and eventually serological tests for mononucleosis, toxoplasmosis and syphilis.
In an adult with a unique and hard supraclavicular mass, the examination will be oriented towards the search for primary lesions in the bronchopulmonary, gastrointestinal, genitourinary, breast, etc. In low cervical or supraclavicular lymphadenopathy, the physical examination should always include a detailed palpation of the breasts, and an abdominal and pelvic examination (digital rectal and vaginal examination) to rule out prostate or gynecological tumors.
In tumors located in the cervical area, an exhaustive ENT examination will be performed. A TEGD, a thyroid scan, and a cranial, cervical, or thoracic CT can be performed. Direct laryngoscopy, esophagoscopy and bronchoscopy with biopsy will be performed of the possible suspicious lesions. When the primary tumor is not identified, random biopsies of the nasopharynx, palatine tonsils, and base of the tongue should be evaluated. If an origin is not recognized, material can be obtained for cytological study of the mass using FNA and, if necessary, perform excisional biopsy. In multiple tumors, a lymphomatous or infectious origin is more likely.
If the diagnosis has not yet been established, a sample of the lymph node must be obtained for AP study. FNA is useful for diagnosing malignancy. In the case of lymphoma, you can specify the degree of malignancy in 75% of cases. It is a harmless, safe and reliable technique in the evaluation of any cervical mass. If a malignant mass is suspected, no other biopsy technique than the FNA is ever performed previously, since we run the risk of producing a tumor seeding or dissemination in surgical wound with increased morbidity and mortality.
In non-Hodgkin lymphoma the treatment will be: – Low grade: RDT and CVP (cyclophosphamide, vincristine and prednisone) – Intermediate grade: CHOP (cyclophosphamide, doxorubicin, vinscristine and prednisone) and RDT – High grade: aggressive QTP, transplant bone marrow.
In Hodgkin lymphoma: RTP and QTP.
- 2. PRIMITIVE TUMORS:
- 2.1. BENIGN VASCULAR TUMORS:
HEMANGIOMA: They appear in the first year of life as cervicofacial soft erythematous macules. Hemangiomas are quite common in the head and neck of children. Although 30% of them are present at birth, many do not become apparent until after the first month of life.
The most affected sex is female, three times more than male. They are usually classified into capillaries, cavernous and mixed, appearing mainly on the face and scalp, and especially on the lips, eyelids, nose, occiput and ears, tending to grow during the first year of life and then gradually return around three or four years
For large hemangiomas or rapidly proliferating lesions, chemotherapy, sclerosing substances, corticosteroids, radiation and laser therapy have been used. LYMPHANGIOMAS: appear in childhood, and mostly before the first year of life. They are characterized by being a fluctuating, diffuse, soft mass, frequently located in the posterior triangle, produced by incomplete development or obstruction of the lymphatic system. Treatment is surgical if the injury is accessible or if it affects vital functions.
CAROTID BODY TUMOR: It is a usually benign tumor, originated in the baroreceptors of the carotid bifurcation. For this reason it is lateral and is palpable in close relation to this vessel as a compressible, pulsating mass that fills up quickly when released and moves laterally, but not vertically. It is solid and when suspected, it should be studied with arteriography. Its treatment is surgical.
- 2.2. NEUROGENIC TUMORS:
NEURILENOMAS AND SCHWANOMAS: they are tumors of neurogenic origin that can occur in any area of the neck, but are located more frequently in the parapharyngeal space and that on physical examination can cause displacement of the amygdala towards the midline. They do not have special diagnostic characteristics, but they can compromise nerves that produce characteristic symptoms such as vocal paralysis if the vagus nerve is compromised or Horner syndrome if the cervical sympathy is compromised. The resonance can show microcystic areas within the mass.
LIPOMAS: They are soft tumors that can be located in different locations of the neck, generally in patients> 35 years. They are made of subcutaneous or submucosal adipose tissue and the diagnosis is confirmed by excisional biopsy.