Profile of neck cellulitis - Clinician's dilemma

Profile of neck cellulitis - Clinician's dilemma

Ravikumar A, Ezhilarasu PDepartment of ENT & head and neck surgery, SRMC & RI (DU), Porur, Chennai – 600 116, India

Correspondence Address:Ravikumar A Department of ENT & head and neck surgery, SRMC & RI (DU), Porur, Chennai – 600 116 India
ezhilarasup@yahoo.com

Abstract

Cellulitis neck may be the only presenting feature of an underlying disease in the upper aerodigestive tract. Inflammation in the head and neck region spreads through potential neck spaces to the surface by direct extension or by lymphatic spread. Four cases of cellulitis neck who presented in the emergency department and progressed with variable clinical course are reported in this paper. After initial treatment with parenteral broad spectrum antibiotics, investigations revealed underlying disease and appropriate treatment was instituted. The importance of detailed clinical examination, investigations and key management protocols are highlighted.

Keywords: Cellulitis neck; dysphagia; parapharyngeal space; parenteral antibiotics; phonation; transglottic tumour

Case Resport

Case 1
A 50-year-old male patient presented with swelling in the anterior aspect of the neck with restricted mouth opening and dysphagia for 2 days without any difficulty in breathing and change of voice. He was a diabetic on irregular treatment. He was a smoker for past 6 years. Examination showed diffuse cellulitis of left side of neck. Examination of oral cavity, Pharynx and larynx was not possible, because of trismus. Blood examination showed polymorpho nuclear leucocytosis. X-ray neck lateral view showed widened prevertebral shadow from C4 to C6. Meanwhile parenteral broad spectrum antimicrobial therapy was started. The neck swelling decreased in size and the inter incisor distance improved after 2 days of treatment. Videolaryngoscopy revealed an ulceroproliferative growth covered with slough involving the lingual surface of epiglottis, vallecula, extending down into medial wall of left pyriform fossa with fixity of left hemilarynx. Right pyriform fossa was free. Both arytenoids were grossly edematous and the ventricular bands were found hypertrophied with fullness of the left ventricle. Right vocal cord was mobile and no phonatory gap was observed. X-ray chest revealed no abnormality. Direct laryngoscopy and biopsy under local anaesthesia was done. Histopathological examination revealed moderately differentiated squamous cell carcinoma. The case was diagnosed as carcinoma larynx (transglottic) stage III (T3, N0 and M0). Radical radiotherapy was offered as the treatment, after the patient refused surgery. He is on regular follow up.

Case 2
A 52-year-old male patient presented with swelling of the left side of the neck with restricted mouth opening and dysphagia for 3 days without any breathing difficulty and voice change. He was nondiabetic. He was a smoker for past 25 years. Examination showed tender diffuse swelling in the left lateral aspect of the neck. Examination of oral cavity, pharynx and larynx was not possible because of trimus. Blood investigation showed increased neutrophil count. X-ray neck lateral view showed widened prevertebral soft tissue shadow from C4 to C6. Meanwhile parenteral broad spectrum antibiotics was started. The neck swelling decreased in size to a hard nontender 5 ´ 4 cm left submandibular lymphnode. The inter incisor distance improved after 2 days of treatment. Video laryngoscopy did not reveal any lesion in oral cavity, oropharynx or larynx. USG neck revealed mixed echogenic lesion measuring 5.2 x 4.2 cm predominantly solid, located in the left submandibular region. Few cystic spaces/areas of necrosis were noted within. FNAC of the node showed secondary deposits of squamous cell carcinoma. Panendoscopy did not reveal any primary. The case was diagnosed as secondaries neck with occult primary. He was treated with wide field radiotherapy covering possible primary sites and neck with good response. He is on regular follow up.

Case 3
A 58 years male patient presented with diffuse swelling in the left side of the neck, restricted neck movements and minimal voice change for 5 days. He gave history of recurrent respiratory tract infection. Examination showed diffuse tender swelling in the left lateral aspect of the neck. Oral cavity, pharynx were normal. Video Laryngoscopy revealed sluggishly moving left vocal cord. There was incomplete compensation by the right vocal cord on phonation. Parenteral broad spectrum antibiotics reduced the neck cellulitis, revealed three discrete mobile firm nontender lymphnodes around 2.5 cm each in the left side of the neck including one in the posterior triangle and two in the level III region. X-ray chest revealed increased broncho - pulmonary markings. Sputum AFB and mantoux were positive. FNAC of the node showed caseating necrosis. The case was diagnosed as laryngeal tuberculosis and tuberculous cervical lymphadenitis. Patient was treated with antitubercular drugs with good response. He is on regular follow up.

Case 4
A 55-year-old male patient presented with swelling in the left side of neck with fever for 3 days. Patient was hospitalized. Neck examination showed diffuse and tender swelling in the left lateral aspect of the neck. Examination of oral cavity revealed no abnormalities and indirect laryngoscopy showed fullness in the left lateral pharyngeal wall. Rest of the larynx was normal. Blood investigations showed increased neutrophil count. X-ray neck lateral view showed widening of prevertebral shadows from C4 to C6. USG neck showed echogenic shadows in the left side of neck. Patient was diagnosed as left parapharyngeal abscess. Under all aseptic precautions the left parapharyngeal abscess was drained and parenteral broad spectrum antimicrobial therapy started. Patient was treated conservatively thereafter and he recovered completely.

Observation

1.We observed that these cases of cellulitis neck treated with parenteral broad spectrum antibiotics recovered very well without any major surgical intervention. However, a tracheostomy tray was kept ready by the bedside for all patients in case of stridor.

2.Because of the parenteral antibiotic therapy, the cellulitis decreased, revealing the underlying pathology. The lymphnodes in the neck, after the conservative management become prominent and FNAC of the nodes confirmed secondary deposits.

3.The neck nodes of tuberculous origin were not matted on presentation. Antituberculous therapy was instituted after the diagnosis was confirmed.

4.Routine management of parapharyngeal abscess yeilded good results.

Results

l The laryngeal tumour was confirmed to be transglottic and was moderately differentiated squamous cell carcinoma, oncologically stage III (T3, N0 and M0). The patient was offered surgery but refused. So radical radiotherapy and follow up thereafter was advised.

l The patient with secondaries neck with working diagnosis of occult primary was advised to undergo HRCT of neck with and without contrast. However, a proper diagnosis eluded us, so wide field radiotherapy was instituted as a therapeutic tool.

l The tubercular lymphadenitis patient is on regular follow up.

l The patient with parapharyngeal abscess after incision and drainage is doing well on follow up.

Discussion

Cellulitis neck could occur in superficial infection or infection from deep neck spaces. Kevin A. Shumrick and Paperella stated the spread of inflammation from deeper spaces occurs through direct extension or lymphatics in the parapharyngeal space to the surface. The cancers of the transglottic and pyriform sinus frequently invade the thyroid cartilage, cricothyroid membrane and upper cricoid cartilage to involve the extralaryngeal soft tissues. The transglottic lesion in particular may narrow the glottic opening to such degree that stridor and airway obstruction result. But in our first case, there was no stridor or change in voice because of adequate glottic chink and very good right vocal cord compensation. Despite extensive cellulitis of neck, this patient did not have any clinically positive lymphnode enlargement. Also he responded well to parenteral antibiotic therapy indicating good immune response. [3],[4],[5],[6]

In the second patient with occult primary and neck secondaries the initial presentation was probably due to the secondary periadenitis and suppuration, which leads to opening of the tissue planes in the neck mimicking cellulitis of neck. As Bruce A. Scott and Charles M. Steinberg explained,[2] the possible route of spread of infection in case of primary malignancies of upper aerodigestic tract is to permeate through the lymphatic channels (which are already open due to micrometastasis) and those involving the extralaryngeal soft tissues to the surface in the neck to present as cellulitis.

In the patient with tuberculous lymphadenitis, cellulitis of neck was due to the secondary infection and suppuration of the lymphnodes due to caseation necrosis, which was treated with parenteral antimicrobial therapy and antitubercular treatment subsequently.[3],[4],[5],[6]

As explained by DeMarie et al[4] parapharyngeal abscess occurs after the point source of infection spreads in contiguity from either the tongue, teeth, parotids, submandibular glands or tonsils which tracks down to the digastric muscle and alongside to the middle third of sternocleidomastoid to present as an abscess.

Conclusion

l All patients presenting with cellulitis neck should not be viewed as neck space infections alone.l The variability of pathological lesion beneath the cellulitis should be borne in mind.

l In advanced malignancies of larynx and hypopharynx, cellulitis of neck may be the only clinical presentation.l Dysphagia in any form should be investigated in detail.

l Timely intervention in treating such cases will prevent complications and prove to be life saving.

l Aggressive conservative treatment obviates the need for surgical intervention.

Indian Journal of Otolaryngology and Head and Neck Surgery