Oxford Handbook of Clinical Surgery (4 edn)
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Thyroglossal cyst, sinus, and fistula
Key facts
Thyroglossal cyst is a fluid-filled sac resulting from incomplete closure of the thyroglossal duct.
Thyroglossal sinus results from persistence of the whole duct.
Incidence <1%; ♂:♀, 1:1.
The thyroglossal duct arises embryologically between the first and second pharyngeal pouches. It runs as a hollow tube from the foramen caecum on the dorsal surface of the tongue, becoming a solid cord of cells migrating through the tongue and into the midline of the neck. The tract usually passes in front of the hyoid bone and then loops up behind it before descending in the midline of the neck where the cells divide to form the two lobes of the thyroid gland either side of the midline. The duct normally atrophies in the sixth week of gestation.
Clinical features
Usually presents in children or young adults.
Ninety per cent present as a painless midline cyst.
Ten per cent appear on one side of the midline, usually the left.
Seventy-five per cent appear in front of the hyoid bone and the majority of the rest at any point to the root of the neck.
The cyst elevates on protruding tongue if attached to hyoid or if attached to isthmus of thyroid elevates on swallowing.
Five per cent become infected presenting as a painful, red neck swelling.
Fifteen per cent have a fistula to the skin (due to infection or incomplete excision).
Papillary carcinoma of the thyroglossal ductal cells is rare. Treatment is by excision.
Diagnosis and investigations
Ultrasound scan is investigation of choice.
CT scan will often reveal a well circumscribed cyst related to the midline of the hyoid bone.
Fine needle aspiration may reveal a cloudy infected fluid or a straw-coloured fluid.
Treatment
Infected thyroglossal cyst
Majority respond to antibiotics.
Surgical drainage if abscess formed or failure to respond to antibiotics.
Elective excision of the cyst once acute infection has resolved.
Surgery
Excision is recommended for most cysts.
Remove through a transverse midline incision in a skin crease.
Divide the platysma muscle and excise the cyst using sharp and blunt dissection.
On the deep surface, it is attached to the hyoid bone; excise approximately 1cm of the bone in midline, removing any underlying thyroglossal duct epithelium. This is Sistrunk's procedure.
Close the wound in layers with a suction drain.
If there is a fistula or sinus in the neck, excise it through a transverse elliptical incision. Again use blunt dissection and remove the middle part of the hyoid bone (‘Sistrunk procedure’).
Complications
These are usually very few. Remove the drain the next day and discharge the patient.
The important structures that must be considered when operating on the thyroid gland include:
Recurrent laryngeal nerve.
Superior laryngeal nerve.
Parathyroid glands.
Trachea.
Common carotid artery.
Internal jugular vein (not depicted).
The anatomy of the region of the thyroid gland. Reproduced with permission from Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine, 7th edn. Oxford University Press, Oxford.
Branchial cyst, sinus, and fistula
Key facts
Disputed aetiology. Theories include:
Cystic degeneration of epithelial derivatives of the first, second, or third branchial clefts.
Cystic degeneration of epithelial elements in a cervical lymph node.
A branchial fistula is a tract running from the neck skin through to the posterior pillar of the fauces; these are very rare.
A branchial sinus occurs when the lower part of this tract remains open on to the neck skin surface.
A branchial abscess is an infected branchial cyst.
Clinical features
Presents as a neck lump, usually painless.
They typically present in early adulthood.
Sixty to seventy per cent are anterior to the upper third of the sternomastoid muscle with the posterior border lying beneath the sternomastoid. Other sites include:
Parotid gland.
Anterior to the lower two-thirds of the sternomastoid.
Anterior to the pharynx.
In the posterior triangle of the neck.
Two-thirds occur on the left side; 2% are bilateral.
May present with an acute branchial cyst abscess causing pain, increased swelling, and occasionally, pressure symptoms (difficulty swallowing or breathing).
Diagnosis and investigation
For branchial cyst or abscess
Ultrasound scan is first investigation of choice. CT/MRI for complex cases.
Fine needle aspiration biopsy:
Abscesses. Purulent fluid is obtained that may culture organisms.
Cysts. Straw-coloured fluid containing cholesterol crystals.
Treatment
Branchial abscess
Drain via a transverse incision in the neck at the point of maximum convexity.
Suture a Yeates type drain.
Give antibiotics and make no attempt to remove the cyst until the infection has resolved completely.
Branchial cyst
Most cysts are excised to achieve a diagnosis and prevent symptoms or complications.
Place a transverse incision over the cyst, preferably in a transverse skin crease, long enough to match the size of the cyst.
Divide the platysma and the deep fascia over the anterior border of the sternomastoid and retract the muscle posteriorly.
Remove the cyst, usually by blunt/sharp dissection.
Use suction drainage and close the wound in layers.
If the cystic lesion is in the parotid gland and cannot be distinguished from any other parotid lesion, extend a preauricular incision into the neck as for a superficial parotidectomy.
Branchial fistula
Excise a sinus of fistula through a horizontal elliptical incision around the neck opening.
Blunt and sharp dissection of sinus tract as far as possible.
If the upper end of the tract cannot be reached, make a further transverse incision at a higher level (‘stepladder’ incisions).
Sometimes the tract runs between the internal and external carotid arteries and sometimes up to the pharyngeal wall in the region of the middle constrictor.
Close the wounds in layers with suction drainage.
Complications
A branchial cyst at any site often lies near important nerves. Previous infections causing fibrosis will increase the risk of damaging them. The following nerves are at risk:
Hypoglossal nerve (tongue deviates to affected side on protrusion).
Mandibular branch of the facial nerve (movement of lower lip).
Great auricular nerve (numb ear).
Accessory nerve (paralysis of trapezius: weakness of arm abduction, asymmetry, and chronic pain).
Salivary calculi
Key facts
Salivary gland calculi occur most commonly within the submandibular ductal tree (80%), 20% in the parotid.
Composed of calcium phosphate and carbonate; may be related to sialadenitis (inflammation of a salivary gland).
Most common in adults.
No proven relationship with other calculi, e.g. renal.
Clinical features
Pain and swelling of the affected gland on eating and drinking.
If there is partial obstruction of the duct, the swelling can last minutes to several hours.
Complete obstruction leads to persistent swelling and infection.
The patient may also experience colicky pain in the duct when eating.
Examine the gland from behind and feel the swelling by running the finger backwards under the jaw. If you cannot feel a lump, ask the patient to suck a sour sweet and re-examine them
Examine the duct orifice from the front. Ask the patient to open their mouth wide and point their tongue upwards. The ducts lie near the midline at the root of the tongue. Are they red? Is there pus? Can you see an impacted stone?
Examine the gland bimanually from the front. Wear gloves and place the finger of one hand over the gland. The index of the other hand is placed in the mucosal surface of the mandible and the gland palpated between the two.
Diagnosis and investigations
Radiographs of the submandibular gland, parotid gland, and ducts are helpful. Twenty per cent of submandibular and 80% of parotid calculi are radiolucent.
Lower occlusal X-ray of the teeth will show a stone in the distal portion of submandibular duct.
A lateral oblique X-ray or orthopantomogram (OPT) of the mandible will show a calculus in the submandibular gland.
Submandibular duct radiography (sialography) is technically difficult and rarely done.
Parotid sialography may show a filling defect. Sialectasis is often seen. May provide therapeutic benefit due to flushing out of debris in the ductal tree.
Ultrasound scanning of parotid and submandibular glands is often the choice of investigation by head and neck radiologists.
Treatment
Stones in the intra-oral part of the ducts can be removed under local anaesthesia. Steady the stone with a Babcock's forceps and incise directly over it. Remove the stone; leave the duct marsupialized.
Stones within the submandibular gland require removal of the gland itself.
Removal of a calculus from the parotid gland is a rare operation. Most calculi are at the distal end of parotid duct (as it does an ‘S’ bend through buccinator muscle) and can be released by intra-oral incision of parotid duct papilla.
Most parotid gland obstructive/inflammatory disease is treated conservatively with sialogogues and intermittent massage of the gland towards the duct. Duct dilation using lacrimal probes is useful as most strictures/obstruction occur at the ‘S’ portion noted above.
Salivary glands produce: saliva-containing water; electrolytes (especially K+ and HCO3– ); varying amounts of mucus and enzymes.
The parotid is a pure serous gland. It responds to salivary stimuli, e.g. food in mouth, smell. There is little resting flow. The submandibular is mixed with serous and mucous acini, responds to salivary stimuli, and has a resting flow, which contributes along with sublingual and minor glands to maintain mouth moisture.
Saliva functions to lubricate, aid mastication, aid taste, suppress oral bacteria, initiate starch digestion.
Submandibular duct is palpable in the floor of the mouth and enters mouth from gland on the sublingual papilla near the midline.
Parotid duct is palpable over the anterior border of masseter and enters the mouth on the medial wall of the cheek after passing through buccinator muscle via an ‘S’ bend.
The facial nerve trunk lies between the deep and superficial parts of the parotid gland and divides into five branches (pes anseris) within the superficial portion.
Acute parotitis
Key facts
Parotitis is inflammation of the parotid gland. Causes include:
Acute or chronic obstruction (now commonest cause).
Bacterial (ascending parotitis), less common.
Viral infection, e.g. paramyxovirus (mumps), HIV.
Inflammatory disorders, e.g. Sjögren's syndrome, sarcoidosis.
Any cause of inflammation of lymph nodes within the parotid gland.
Most patients develop this condition as an acute episode of a chronic obstructive sialadenitis.
Clinical features
Obstructive parotitis occurs more commonly in adults.
Presents as an acutely painful preauricular swelling.
There is often a history of recurrent, intermittent swelling of the gland.
The gland is usually tender on palpation.
The patient may be toxic with fever and raised WCC, and pus may exude from the opening of the parotid duct opposite the crown of the second upper molar tooth.
Elderly, debilitated, dehydrated patients with poor oral hygiene or who are on anticholinergic drugs are at greatest risk.
Diagnosis and investigations
Plain X-rays to determine whether radio-opaque calculi are present in the duct or gland.
Ultrasound or CT scanning may help differentiate between stones, inflammation, and tumour.
If pus is present, take a bacteriology swab and send it to the lab. The commonest infecting organism is Staphylococcus aureus.
Treatment
Acute parotitis
Most patients respond to antibiotics:
Give amoxicillin 500mg tds, IV if necessary.
Rehydrate dehydrated and debilitated patients.
Good oral nursing care with chlorhexadine mouth rinses.
Review patients by clinical examination after the infection has subsided to make sure that the obstruction was not due to a parotid tumour.
If a parotid abscess develops, it should be drained surgically:
Make an incision over the abscess under general anaesthetic where it appears to be pointing, parallel to the branches of the facial nerve to avoid damaging them.
Open the abscess with sinus forceps and place a Yeates drain in the wound.
Recurrent parotitis
Teach patients with recurrent parotitis to massage the gland in order to express saliva from the duct.
Dilatation of the duct with lacrimal probes can assist drainage.
Remove radio-opaque calculi, if possible.
Advise the patient to keep an emergency supply of antibiotics at home.
If recurrent parotitis persists for months or years, a total parotidectomy is curative.
Salivary gland tumours
Key facts
Salivary gland tumours are rare, accounting for 0.4% of all malignant tumours; 80% arise in the parotid gland.
Clinical features
Most patients present with a slow-growing lump in the affected gland. Pain, paraesthesia (e.g. lingual nerve in submandibular gland), facial palsy (parotid gland) imply malignancy. Salivary tumours of minor glands in upper aerodigestive tract (UADT) present as a lump. Fifty per cent of these are malignant.
Clinicopathological features
Pleomorphic adenoma
Eighty per cent of benign parotid tumours.
♂:♀ 1:1.
Peak incidence 30–50y.
Composed of epithelial and mesothelial cells that form a mucous matrix, often with chondromatous components.
The tumour grows slowly and has no true capsule so that strands of tumour cells protrude into normal surrounding tissue. Local extension may be widespread with recurrence if excision is incomplete.
Malignant change (adenocarcinoma) occurs in 20% after 10y and is seen in asymptomatic deep lobe parotid tumours.
Warthin's tumour (adenolymphoma)
Usually affects men >50y; 10% are bilateral.
Benign and presents as a slow-growing soft swelling.
Successfully treated by wide local excision.
Malignant tumours
Mucoepidermoid tumour
Low grade malignancy, though variable behaviour.
Most grow slowly, invading locally and eventually metastasizing to neck lymph nodes, lung, and skin.
Adenoid cystic carcinoma
A slow growing malignant tumour with indolent behaviour.
Perineural invasion propensity and facial palsy common with extension through stylomastoid foramen. Lung metastasis common.
Often regarded as incurable, but individuals can lead a normal life over 20–30y before succumbing.
Treatment is extensive wide local excision, with nerve/organ preservation where possible. Post-operative radiotherapy has a role. Radiotherapy also has a role in controlling lung symptoms if they arise.
Acinic cell carcinoma
♀ > ♂; slow-growing, but may metastasize unexpectedly. Surgery is the treatment of choice.
Squamous cell carcinoma, adenocarcinomas, and undifferentiated carcinomas
Generally high grade malignant tumours.
Often rapid local invasion into extraparotid tissues and infratemporal fossa, leading to pain and trismus.
There may be skin fixation or ulceration with facial nerve palsy and invasion of the external auditory canal; incurable; palliative radiotherapy.
Diagnosis and investigations
Clinical examination is still of great importance in assessing extent.
CT scanning may help differentiate between stones, inflammation, and tumour.
MRI scanning offers the most sensitive investigation for assessment of local invasion and involvement of surrounding structures.
PET CT is useful for assessing metastases.
Treatment
Benign parotid tumours
Excise the parotid gland superficial to the facial nerve (superficial parotidectomy). Deep lobe tumours should have a facial nerve-sparing total parotidectomy.
Enucleation is inadequate and often leads to local recurrence that is difficult to manage.
Benign tumours in other salivary glands
Excision of the entire gland (e.g. simple submandibulectomy).
Malignant tumours
Radical local excision (to sacrifice or preserve the facial nerve in parotid tumours is controversial).
May be accompanied by neck dissection, especially in parotid tumours.
Complications of parotid surgery
Facial nerve injury (risk varies according to procedure: lowest in primary surgery for benign tumours < redo surgery < surgery for malignancy). Seventy-five per cent neurapraxia with complete or extensive recovery of function; 25% neurolysis with little or no recovery (may be treated by nerve interposition grafting).
Frey's syndrome:
Late complication of surgery in up to 25% of patients.
Facial flushing and sweating of the skin innervated by the auriculotemporal nerve when the patient salivates.
Caused in this case by division of the parasympathetic secretomotor fibres that innervate the parotid gland: they may regenerate erratically to control cutaneous secretomotor functions.
Subcutaneous botox injection is useful.
Prognosis
Recurrence of benign tumours. May develop 20y after surgery, especially in the patient where enucleation, rather than superficial parotidectomy has been performed.
Five-year survival rate for all malignancies approximately 60%.
Head and neck cancer
Key facts
Head and neck cancer refers to cancer of UADT; 90% are squamous cell carcinomas (SCC).
UK incidence 8–15 in 100 000 and rising. Wide geographical variation, e.g. Indian subcontinent: 40% of all cancers.
♂:♀, 2:1, female incidence rising.
Predisposing factors:
Carcinogens. Tobacco, alcohol, betel nut chewing;
Infection. Hyperplastic candidiasis, human papilloma virus (HPV) 16;
Extrinsic factors. UV light in lip cancer;
Intrinsic factors. Diet poor in fruit, vegetables, and fish oils, immunodeficiency/suppression.
Clinical features
Peak incidence 40+y (increasing incidence in younger patients).
Persistent oral ulcer with induration, bleeding, often painful.
Persistent oral swelling, e.g. large tonsil, unexplained loose teeth.
Unexplained earache: common in tongue, oropharyngeal tumours.
Dysphagia, odynophagia occur in oro/hypopharyngeal cancer.
Hoarseness lasting >3 weeks.
Persistent unilateral serosanguineous nasal discharge.
Unresolved head or neck swellings of >3 weeks.
Examination of the neck is mandatory and should include all levels of neck lymph nodes. Bilateral nodal spread common.
Six per cent of patients have a synchronous SCC present in the aerodigestive tract (mouth, larynx, lungs, oesophagus).
Diagnosis, investigations, staging, assessment
Fibre optic nasendoscopy to examine nasopharynx, base of tongue, hypopharynx, larynx.
Fine needle cytology for neck mass.
Imaging. CT of head and neck and chest with MRI in selected cases. PET CT for unknown primary tumours, metastatic disease assessment.
Haematology, biochemistry, ECG, lung function tests as patients usually have high comorbidities.
Examination under anaesthetic (EUA). Measure tumour size, biopsy. Panendoscopy to exclude synchronous tumours of UADT.
Extraction of any diseased teeth, especially if in possible radiotherapy treatment field to prevent osteoradionecrosis.
All patients should be seen by dietician, speech and language therapist, clinical nurse specialist, and restorative dentist.
In TNM system, T1–4 stage is complex and depends on anatomical site; N1–3 stage applies to all sites.
Treatment
Surgery, radiotherapy ± chemotherapy, or combination of all and may be done with curative intent or palliation.
Function and quality of life are important outcomes. Gastrostomy/NGT feeding often required during treatment.
Treatment of primary tumour
Approximately equal cure rate for T1, T2 tumours with surgery or primary radiotherapy. Surgery is usually offered for oral cancer, sometimes for T1 larynx (laser surgery). Radiotherapy ± chemotherapy have better functional outcome in pharyngeal, posterior one-third tongue cancers.
Larger T3, T4 tumours involving bone/cartilage are best managed surgically, e.g. laryngectomy, and often require adjuvant radiotherapy.
Treatment of the neck
N0 necks may have occult nodal metastases, depending on tumour site, e.g. >50% for pharynx, and should have either a selective neck dissection or radiotherapy.
Single node disease (N1) should have either a neck dissection or radical radiotherapy.
Bulky nodal disease (N2, N3) should have a comprehensive neck dissection followed by radiotherapy or vice versa.
Neck dissections
These are either comprehensive or selective. Selective dissection removes groups of nodes likely to have occult metastases. Comprehensive includes radical neck dissection (removal of all five levels of lymph nodes, accessory nerve, internal jugular vein, and sternomastoid muscle) and modified or functional neck dissection:
Type 1 preserves the accessory nerve.
Type 2 preserves the accessory nerve and internal jugular vein.
Type 3 preserves the accessory nerve, internal jugular vein, and sternomastoid muscle.
Reconstruction of surgical defect
Good functional outcome (speech, eating, swallowing) is aim of reconstruction of surgical defect in the UADT.
Options include:
Primary closure, e.g. small tongue tumour.
Local flap, e.g. nasolabial to floor of mouth.
Regional flap, e.g. pectoralis major to retromolar region.
Free microvascular transfer flaps offer great versatility, e.g. radial forearm for lining, fibula for bone, anterior thigh for bulk.
Prosthesis, e.g. obturator for palatal defect.
Prognosis
Crude overall 5y survival is 30–40% and of those deaths, 50% die from other causes, usually tobacco-related.
HPV 16 positive cancers appear to have better outcome.
Facial trauma
Key facts
Eighty-five per cent of facial injuries are from assault, often with alcohol/drugs involved; the remaining from falls, sports, road accidents, industrial injuries.
Ten to twenty per cent have associated head injury, 2% cervical spine injury.
Fracture incidence: nose > zygoma > mandible > maxilla. Panfacial fractures indicate high energy impact or multiple blows.
Emergency situations in facial injuries
As part of 1° and 2° survey, pay special attention to:
Airway. Severely displaced fractures, tissue swelling (which may get worse), blood, dislodged teeth can compromise airway, especially with associated head injury; intubate if in doubt.
Bleeding. Profuse bleeding can occur in midface fractures or deep tongue wounds, requiring early theatre for suturing, nasal packing/fracture stabilization. Swallowed blood is often vomited.
Retrobulbar bleed. May follow even minor injury. Orbital swelling can mask it. Cardinal signs are pain, proptosis, and falling visual acuity. Treatment is lateral canthotomy under LA, then theatre for orbital drainage via infra-orbital incision to open ocular muscle cone; 90min window before blindness sets in.
Key clinical examination points
Examine the eye even if it means opening swollen eyelids: check visual acuity. Any diplopia indicates orbital fat/muscle entrapment in orbital complex fracture. Orbital blow-out fracture may have enophthalmos.
Dental occlusion (bite): ask patient if bite feels normal. If not, then a fracture is likely. Manually check continuity of mandible. Fractures in teeth-bearing segment are compound fractures. In maxilla, grasp upper incisor teeth and any movement suggests maxillary fracture.
Mental nerve or infra-orbital nerve paraesthesia indicates mandibular or orbital floor/zygoma fracture, respectively.
Look for deformity, e.g. nose deviation, flattened cheek, forehead hollow.
Investigations
Imaging. Plain X-rays, OPT, and PA skull for fractured mandible; occipitomental 30°, 45° views for zygoma fracture. For complex fractures, CT with 3D reconstruction. Coronal CT/MRI is useful in orbital complex injuries.
Clinical photographs as a record which may be used in court.
Other tests, e.g. ECG, Hb, U&Es for falls in the elderly.
Treatment
Head injuries, soft tissue lacerations, and direct trauma to the eye take precedence.
Fractures involving the teeth are compound and antibiotics are required, e.g. amoxicillin or erythromycin if allergic to penicillin.
Timing: mandibular fractures involving tooth-bearing segments and any soft tissue lacerations should be treated within 24h. Uncomplicated fractures of orbit/malar/frontal bone/nose/maxilla are best treated when facial swelling has settled. Optimum time is 5–10 days.
All patients with orbital/malar/maxilla fractures must not blow their nose for 10 days to prevent surgical emphysema of soft tissues.
Undisplaced fractures may be treated conservatively. Advise soft diet if tooth-bearing fragments involved.
The aim of active treatment is to restore function and correct any deformity, e.g. diplopia from orbital complex fracture; decompression of any nerves involved in fracture line (infra-orbital, inferior dental, frontal nerves); restoration of dental occlusion to correct bite (mandibular/maxillary fractures); correct deformity (fractured nose/zygoma).
Fractures may be treated by closed reduction, e.g. intermaxillary fixation with wires or open reduction using mini-fracture plates. Surgical access to fractures may be intra-oral, incisions around the eye for orbit, submandibular for mandible, bicoronal to frontal bone.
Patients who have had an unprovoked assault may experience post-traumatic stress disorder and benefit from referral to clinical psychologist.
Neck space infections
Key facts
Ninety per cent of neck space infections are of dental origin, especially lower molar teeth.
Ten per cent are from tonsils and infected epidermoid, branchial, and thyroglossal cysts.
Their importance is risk of airway obstruction, septicaemia, and mediastinitis; mortality risk from overwhelming sepsis.
Anatomy
The investing layer of cervical fascia is attached to mastoid, superior nuchal line, lower border of mandible, hyoid and descends to the clavicle. It splits to enclose sternomastoid and trapezius muscles and thus forms a structural collar to the neck. Medially lie the pharynx, larynx, trachea, and upper oesophagus which is in direct continuity with the mediastinum. As it splits to enclose parotid gland, a deep layer is formed attached to base of skull, merging with the upper end of the carotid sheath and pharyngobasilar fascia posteriorly. It also splits to enclose the submandibular gland with deep layer attached to mylohyoid line. As a result, a number of important anatomical compartments or potential spaces exist (see Fig. 5.2).
Sublingual. Floor of mouth above mylohyoid.
Submental. Anterior upper neck below mylohyoid.
Submandibular. Below mylohyoid around submandibular gland.
Parapharyngeal. Deep to parotid, lateral to pharynx.
Pterygoid. Pterygomaxillary fissure.
The distribution of lymph nodes in the neck. Reproduced with permission from Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicin e, 7th edn. Oxford University Press, Oxford.
These are all interconnected and continue inferiorly down the neck following outside the tough carotid sheath into the mediastinum. Related are buccal and submasseteric spaces that are not connected.
Clinical features
Infection may present as a localized fluctuant swelling or it may present as a spreading cellulitis with a brawny, hard, tender, hot, erythematous mass. Often it is a mixture of both. Necrotizing faciitis is rare and has high mortality.
There is usually a history of toothache, sore throat, previous neck swelling, e.g. branchial cyst.
Cardinal signs of severity include: fever, trismus, hot potato speech, dysphagia, stridor, tachycardia, and respiratory rate increase.
Bilateral sublingual/submental/submandibular swelling (Ludwig's angina) is particularly aggressive.
Investigations
Temperature, HR, BP, respiratory rate.
WCC.
Imaging. OPT if dental cause expected. Ultrasound scan can localize any deep space collection. CT, including chest, is useful in severe cases.
Treatment
Admit if systemically unwell or any cardinal signs of severity as above.
IV antibiotics. Co-amoxiclav or clindamycin if allergic to penicillin.
Contact anaesthetist as may need fibre optic intubation.
Theatre before sunset if systemic sepsis.
Surgical management
Remove cause of infection, e.g. extract offending teeth, incise quinsy of tonsil.
Incise and drain at dependent point any localized abscess.
Send pus sample for culture and sensitivity.
Exploration of neck spaces
Use a submandibular incision, incise platysma and cervical fascia. Using Hilton's method, find lower border of mandible, then explore medially; this is the submandibular space; go anteriorly to open up sublingual space. To open parapharyngeal space and pterygoid space, push forceps up medial ramus of mandible and open forceps. If there is swelling extending to root of neck, make a second incision above clavicle and medial to sternomastoid. Suture in a corrugated type drain.
If intubation difficult or airway compromised, e.g. unrelieved trismus on induction, do a tracheostomy. The swelling often gets worse before it gets better. You may need to re-explore the neck. Book ITU bed in severe cases.
