Tuberculous cervical adenitis

TUBERCULOUS CERVICAL ADENITIS TREATMENT

W. Honorary

Orthopedic

Surgeon,

BY IMMOBILIZATION

GRANT WAUGH,

SUNDERLAND,

IMINUTION or arrest of the functionaI activity of an infected organ constitutes a cardina1 principIe in the treatment of tubercuIosis. As such, it was estabIished in the treatment of surgica1 tubercuIosis earIy in the present century, and became appIied successiveIy to the hip, knee, ankIe and eIbow joints, to the joints of the vertebra1 coIumn, by the use of pIaster or other forms of splinting, and more recentIy by extra articuIar bone grafting; and reached its apotheosis in the induction of artificia1 pneumothorax and thoracopIasty in the treatment of puImonary tubercuIosis. SpIinting of the neck has been advised as after-treatment foIIowing operation (Rose and CarIess), and CaIvC noted that in cases of Pott’s disease of the cervica1 spine any associated gIanduIar enIargement subsided as recovery of the bone infection progressed under pIaster immobiIization. However, so far as I can discover immobiIization as a therapeutic measure per se has not been appIied in the treatment of tubercuIous gIands of the neck. In the foIIowing twenty-one exampIes, which comprise a11 the cases of this condition which have come under my care during the period, immobilization has been the essentia1 feature of treatment. Where the enlargement was solid, i.e., due to caseation without Iiquefaction (eight cases), fixation by pIaster aIone was empIoyed; where fluctuation was present but the skin remained heaIthy (three cases) the fixation was preceded by aspiration; where the skin was red and obviousIy infected, or where a discharging sinus was present, excision of the skin, curettage of the bed and cIosure by fine siIk sutures with

D

M.D.

The Memorial HospitaI, Darlington; Infirmary, SunderIand

Honorary

Assistant

Surgeon,

The Royal

ENGLAND

eIimination of any pocket by deep suturing were empIoyed, foIIowed by the pIaster cast. In every case, the gIanduIar enIargement had disappeared at the cIose of the period noted and so far no recurrence has been found. In two cases of superficia1 tubercuIous uIceration in the scar a few exposures to x-ray were required to comI can confirm HamiIton pIete heaIing. BaiIey’s comment that after a few weeks a Iarge granuIation area contracts down to a Iinear scar when immobiIization of the neck is empIoyed. Several of my sinus cases are Ieft with a scar which is onIy discernibIe on cIose examination. The method of appIying the pIaster case is as foIIows: The head having been washed with weak perchIoride solution to remove dandruff, a pattrass of Gamgee tissue is cut to fit over the vertex and occiput, passing behind the ears. This is carried down to two inches beIow the nippIe in front and to a corresponding IeveI on the back. LateraIIy it stops short of the acromion process. A separate piece of Gamgee encircIes the neck, protruding sIightIy beyond the chin with a square of jaconet beIow the mouth. A pIaster case (CeIIona) is cut in the dry of the same dimensions and shape as the pattrass, and a sIab of six inch wide pIaster bandage for the neck. The Gamgee is now tacked into position by a few stitches and the pIaster case appIied, specia1 care being taken to buiId it up on the sides of the neck and under the chin. A few turns of pIaster bandage are taken round the neck to consoIidate this region. The axiIIae are Ieft free so that movements of the arms are unimpeded, but the Iower borders of the cast are heId by a band of adhesive strap231

Waugh-CervicaI

American Journa.1 of Surgery

232

Adenitis

MAY,1943

surprising how IittIe discomfort is compIained of. After twenty-four hours movement of the jaw becomes suffIcientIy free to aIIow of mastication. If, however, the

ping passed round the body. It is not necessary to use pIaster for this purpose. The whole cast in white pIaster has something of the appearance of the conventiona

TABLE I Cast e No.

4gle

1

CASES

Duration of Condition

:Sex

Year

F

1936

7 months

1936

4 months

WITHOUT

SECONDARY

-

INFECTION

Site and Size of SweIling

Year ofRe exam i natio

(a) Previous Treatment (6) Preliminary Treatment

Period of Immobilization

Comment

_-

3

F

16

4

9

Anterior triangle; orange

14 weeks

1937

4 months

Posterior

triangle

3 months

Anterior triangle; golf ball

2 months

12

M

I937

3 months

7

20

F

1937

8 months

8

‘7

M

‘937

9

II

F

‘937

12

5

F

1937

13

7

M

1938

17

IO

M

‘938

18

I7

1

F

-

Posterior triangIe chain; ffuctuation; matted chain 5 months Anterior triangIe; hen’s egg 6 months Anterior triangIe; smal1 orange; no Auctuation 2 months Anterior triangle; golf ball 4 months Anterior triangIe; matted chain 2 months Anterior triangIe; walnut 5 months Posterior triangIe: mass occupying whote space

~938

F -

8 weeks

M

5

19

Anterior triangIe: hen’s egg

6 weeks

~938

-

-

(a) NiI (b) curettage ctosure

am I

(a) Nil (b) TonsiIIectom:

Y ‘940

No visible or paIpable evidence. Sister of Case 6

(a) U.V. light (b) NiI 1NiI

1939

On active service I2 months No recurrence

IO weeks

1U.V. Light

‘939

No recurrence

14 weeks

I(a) NiI I[b) Aspiration

‘940

t[a)

U.V. Iight Nil I[a) Iodine inunction I[b) Nil

1939

Discharge persisted till 9th week No recurrence

(la) Nil (.b) Nil

r939

weeks

IO weeks 4 months

7 weeks

1939

t[b) IO weeks ‘ecurrence 3 weeks Iater. (6) I 6 weeks. I

7 weeks

-

Madonna’s head-dress. For the purpose of conceaIing the inevitabIe soiIing, it is advantageous to dye the Gamgee (I use red ink) and to paint the pIaster when dry with a coIor of the patient’s choosing. Care shouId be taken to see that the head is in the mean position, neither flexed or extended, whiIe the cast is setting. It is

GIands contained fluid pus; resuIting scar not visible Serving in forces; remaining no evidence No visibIe or palpable evidence No visible or palpable evidence.

(a) U.V. Iight 1940 (b) Tonsillectom: Y (a) U.V. Light 1939 3 yrs. previ0usIy; recurrent, e (6) Nil I(a) U.V. Iight ant I 1940 iodine injection (b) Aspiration

13

Anterior triangle; haze1 nut

‘939

-

‘94’

ImmobiIisation discontinued too earIy; Iatest examination shows fibrous noduIes only: on munition work No recurrence.

-

cast does not fit sufficiently snugly to prevent movement of the head in a11 directions, the patient experiences discomfort from the first, and a fresh cast must be appIied. The first cast remains in situ for four weeks and is then removed for examination. A new cast foIIows for another

Waugh-CervicaI

NEW SERIES VOL.LX, No. 2

Adenitis

TABLE TCase No. _..~

I0

II

‘5

-

Age Sex _

CASES

luration >f condition

iear

18

F

i 12

F

1

IM

I

I month

I ’937

2

938

month

3 month

1938

WITH

Site and Size of Swelling lupra clavicular sinus

interior triangle; abscesses with secondary infection

interior sinus

triangle

American Journal of Surgery

233

II

SECONDARY

Period of Lmmobiliza15 weeks

6 weeks

II weeks

INFECTION

(a) Previous Treatment (6) Preliminary Treatment __-

7

Year bfRee:vami. ” lation _ 0

‘(a)

Jo recurrence in neck but development of TB ankle in 1940 J 0 recurrence

i(

Jo recurrence

a) NiI b) Curettage

‘941

Iodine inunc1940 tion b)TonsiIIectomy; (1 excision of infected skin. Curettage and cIosure a) Aspiration ‘940 and injection I :ormaIin. ? b) Curettage andI closure (a) Nil beyond 1940 dressings (6) Curettage; ab. duction plaster combined with neck immobilisation a) U.V. Iight: ‘941 16) Curettage; 3ipp closure :a) Many forms 1941 including sanatorium I:b) curettage

I( ‘4

111

‘5a

16

6

20

‘939

L2 month

‘osterior triangk r. axilla; multiple sinuses

F

‘939

5 montb

interior triangh infected abscess

9 weeks

M

‘940

‘osterior triangle three sinuses

17 weeks

F

1936

5 montI

4nterior trianglf and parotid are2 sinuses

18 weeks

M

1937

?3 years

F

1939 1941

I

18 years

at least 40 years

4nterior triangle puckered sinuse

(I) Parotid are: tri posterior angIe (2) Anterior tri angle, muItip1 sinuses

-!

- Cases No. 15 and rga are brother

20

weeks

:a) Nil

16) Curettage ant I closure; Bipp

weeks

:a) 3 courses U.V 1938 Iight (6) tonsiltectomy curettage and closure Bipp (I) 11 week! s (a) Many forms 1941 (2) 12 week! (b) Curettage ant3 closure (partial) / 12

sI

and sister.

‘939

rTo evidence of activity after 14 child months; evacuated

\I0 recurrence, scar barely visible -IoIds an impormunition tant sinuses post; remained have for 15 closed months Discharge up to weeks. No 12 evidence beyond scars, which are very inconspicuous remained Had healed at last examination

Suffered a11 her from dislife charging sinuses, which broke out with each pregparotid nancy; and anterior trisinuses angle; remained had healed for 22 when months, triposterior angle sinuses appeared: these are now healed

234

American Journal of Surgery

Waugh-CervicaI

period of four weeks. If by that time the gIanduIar enIargement has become reduced to a series of smaI1 noduIes, a thick bandage of Unna’s paste, reinforced at the sides with cardboard, is worn for three or four weeks Ionger, by which time onIy minute fibrous nodes are with diffIcuIty paIpabIe. I am aware that a tota of twenty-one cases is a somewhat smaI1 series on which to base a method of treatment; but I report it for the consideration of those who have

Adenitis

MAY. 1943

Iarge numbers of such cases to treat, in the beIief that it is founded on a sound principIe, is extremeIy simpIe in appIication and gives at Ieast as much prospect of success as any of the numerous methods of treatment empIoyed up to the present. REFERENCES

ManuaI of Surgery, p. 236, 1908. 2. CALVE. Traitement de TubercuIose de la VertkbrC, 19, I. 3. HAMILTON BAILEY. Surgery of Modern Warfare. P. 679. Livingstone, 1941. I. ROSE

and

CARLESS.

THE tomograph, an instrument by which roentgenologists can visuaIize and IocaIize structures and foreign bodies in three dimensions, should be part of the equipment of every base hospital