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TUBERCULOUS GLANDS OF THE NECKBy RONALD REID, M.S.(Lond.), F.R.C.S.(Eng.)

Tuberculosis in the lymphatic glands of theneck is, in this country, a common disease.Though its incidence has declined with the growthof the Public Health Services, it is important be-cause in most instances it is the reaction of thechild to his first contact with tubercle bacilli.The first accurate description of the disease is

by Richard Wiseman, Surgeon to King Charles II,in his book ' Severall Chirurgicall Treatises,'published in i676. It was known as struma orscrofula or king's evil, for it was cured by the'royal touch,' a divine power of kings dating backto the 5th century A.D., and much practicedby the Stuarts, Queen Anne being the last royalhealer. With the introduction of antiseptics andanaesthesia, the treatment of tuberculous glandspassed from the theory of medicine to the practiceof surgery, and during the first decade of thepresent century as much as a third of the surgeons'operations were upon glands of the neck. Thependulum had swung the full arc, vast blockdissections were practiced leaving scars of monu-mental ugliness. Under rational control andtreatment, tuberculosis will no doubt decline inthis country as it has where children are protectedagainst the sources of infection, particularlytuberculous cattle.

Surgical AnatomyA tuberculous gland in the neck is the outward

sign that tubercle bacilli have successfully invadedthe lymphatic tissues related to the upper partsof the respiratory and alimentary tracts. Thenose and naso-pharynx, which conduct, conditionand filter the air, and the pharynx, the commonair and food passage are lined by a vascularmucous membrane containing a rich network oflymphatic tissues and channels. The tissue existsalso in certain aggregations, notably the pharyngealand palatine tonsils. From the mucosa and lym-phoid masses vessels drain into the deep cervicalglands disposed in chains along the great vessels ofthe neck, chains which receive the lymph from allthe superficial glands of the head and neck and arecontinuous below with the glands in the medi-astinum, including the tracheobronchial groupsdraining the lungs.The deep cervical chain is divided into superior

and inferior parts. The superior is divided intotwo groups, medial and lateral to the internaljugular vein. The medial group is in contact withthe pharyngeal wall and extends behind thepharynx to link with glands in the opposite side ofthe neck. One gland, at the lowerborder of theposterior belly of the digastric muscle is known asthe tonsillar gland from the frequency with whichit swells in tonsillitis. The lateral group of deepcervical glands surrounds the spinal accessorynerve and extends out into the posterior triangleof the neck. The lymph from all these passesdown by the lower deep cervical glands to enterthe venous system at the base of the neck.

For convenience of description lymphaticglands are divided into chains and groups but theyare one continuous system through which in-fection may spread in any direction.

Aetiology and PathologyAs Osler stated, the tubercle bacillus is

ubiquitous and capable of long survival outsidethe living body. It causes immeasurable miseryand takes a heavier toll of human lives than anyother disease. The sources of external infectionare phthisical patients and tuberculous cows, fromsputum and infected milk, sources which un-fortunately are often untraceable. Once tubercu-losis has gained a foothold, internal infection orspread within the body proceeds by direct in-vasion, by blood stream dissemination or by trans-mission along the lymphatic channels, if andwhen the natural resistance of the patient cannothold the enemy at bay.

Practically all human beings at some stage oftheir lives, usually in childhood or adolescence,fall victims to tuberculosis and in the fixation ofand resistance to this first contact, the primaryinfection, the lymphatic and endothelial systemsplay the important part. Infection in infancy,before the lymphatic arrangements are fully de-veloped, is often overwhelming, whilst in old age,during the years of decline, tuberculosis againoften pursues a peculiarly rapid and destructivecourse.The two common forms of the bacillus, human

and bovine, both cause tuberculous glands in theneck. Blacklock (I947) has shown that the human

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bacillus is the common variety in town dwellers,who live in crowded dwellings but consume heat-treated milk, whereas in the country where thereis less congestion of population and milk is drunkraw, the bovine bacillus is the rule. His findingsemphasize the need for the control of infectionby public health policy.The tubercle bacillus possesses a remarkable

power of penetrating mucous membranes withoutcausing an immediate and discernible local ret.action. When once established in living tissuethere is an exudative and cellular response and,unless the invaders are destroyed out of hand, theypass by lymphatic channels to the glands whichdrain the affected area. How long this passagetakes is unknown but by the time living bacillihave settled in the glands a general body sen-sitivity has developed. It is now generallyaccepted that tubercle bacilli produce neitherexotoxin nor endotoxin and that the cellular andexudative response to their presence, which variesin intensity from a mild reaction to massive tissuedeath, is essentially an allergic phenomenon. Thisreaction is seen in purest form in the primary in-fection. Secondary lesions, arising by furtherexternal infection or by internal seeding from apre-existing focus, occur in already sensitizedtissue and their development is different from thatof the primary infection and is outside the scopeand purpose of this paper.The primary complex consists of the point of

entry of the tubercle bacilli, the draining lym-phatic glands and the intervening channels. Thereaction in the gland overshadows in its intensitythat at the point of entry which may be anywhereon the surface of the body, but is practicallyalways in the respiratory or alimentary tracts. Ifthea point of entry is in the upper air or foodpassages, the reacting glands are in the neck; ifthe lung be affected, the tracheo-bronchial glandsare involved and may so swell as to obstruct amain bronchus; if the alimentary tract be thesite of penetration, the mesenteric glands enlarge,in some instances with suich violence as to causeascites and symptoms of an acute abdominal crisis.Thete is little doubt that in most cases tuberculousglands in the neck are the glandular component ofa primary complex and being conveniently situatedfor observation their progress can be followed.Bacilli having gained a foothold, an allergic re-sponse develops and the glands enlarge rapidly;oedematous periadenitis binds them to all sur-rounding structures. This violent reaction causesgeneral malaise and pyrexia which usually doesnot reach the high levels, of pyogenic infectionwith which tuberculosis may easily be confused atfirst. In the gland itself, tubercles are formed andtissue death occurs to an extent which depends

upon the two opposing factors of virulence anddose of the bacilli, and the natural resistance ofthe patient. As natural resistance rises the violentreaction subsides, periadenitis recedes and theglands once matted together become discrete;those which have escaped destruction return tonormal. Where there has been necrosis the caseouspus forms a cold abscess which either dischargesto the body surface or is in time encapsuled, in-spissated and calcified. Those bacilli which sur-vive are buried alive in calcium to remain a possibledanger in days to come.

It should not be concluded that all tuberculousneck glands are part of a primary complex in theneck. Tuberculosis may spread to the base of theneck from infected glands in the thorax, which inturn arise from lesions in the lungs or in otherintrathoracic structures. Also there is a form ofdiffuse enlargement of glands arising simul-taneously over wide fields on one or both sides ofthe neck. This form is more- commonly seen inadults and there is little general or local reactionof an exudative character. Rather are the glandsfibro-caseous, firm and discrete from the first;there is no reaction as in the primary complex andit is tempting to suggest that they are secondarylesions due to the late spread along lymphatics oreven to blood stream infection.

Clinical PictureTuberculous glands in the neck is a disease of

childhood but adults and the aged are not immune,and both sexes are equally affected. Tables iand 2 show the incidence in a personal series of200 cases.

30i

..YEAR5

FIG. i.-Incidence in age groups.

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rREID: Tuberculous Glands of the Neck

TABLE 2SEX INCIDENCE

The disease occurs in three clinic(a) Local caseous tuberculous lyr

the upper cervical chain.(b) Local caseous tuberculosis

cervical chain.(c) Diffuse tuberculous lymphade

TABLE 3SITE OF DISEASE

Upper Deep CervicalPosterior TriangleSupraclavicular

Total

Table 3 shows that the first for]common. It is this form which icomplex of childhood, the site of in)the nearby air and food passalcatarrhal infection provides a statesistance in childhood through whicigain an entry.

(a) Caseous tuberculous lymphadernchain is of sudden or gradual onset,ing an acute specific fever. If acuteto distinguish tuberculous fromlymphadenitis, and only the clinicadisease or the response to chemnotherthe etiology.At first the upper cervical gland

tense and matted together to fcrubbery swelling behind the anglThe tonsils are often enlarged andsome swelling of glands on the otineck. If infection is heavy and rthe affected glands break downabscess which escapes from the Ipenetrates the deep fascia and alsurface of the neck, usually at the 14the gland mass about half way do)mastoid muscle. This ' collar-studits deep and superficial loculi ccnarrow neck is characteristic of tubeoverlying skin soon becomes oe(reddened and gives way allowing tcharge. The process is acceleratedseptic infection and at its worst mdestruction of much skin, subcutan4superficial muscle. As the natural I

patient combats the infection, periaand the glands become discrete and:

MalesFemales . .

Total

lightly touched return to normal, leaving theseriously damaged glands as firm nodes behind the

107 angle of the. jaw with maybe other glands en-93 larged in the posterior triangle or down the deep- cervical chain. In time the tuberculous infection200 is overcome, calcium is deposited and the glands

can be felt as stony nodes in an otherwise normal,al forms:- neck, with perhaps a sinus or a puckered scar tonphadenitis of mark the battlefield.

Thus caseous tuberculous lymphadenitis of theof the lower upper chain passes through three stages in the

continuous process of natural repairsnitis. Stage i. This is the acute phase of invasion

when the glands are matted together by peri-adenitis.

Stage 2. Periadenitis has receded leaving the196 glands more discrete, firm and movable.23 Stage 3. All periadenitis has disappeared and a4 few hard stony nodules with or without a sinus

remain.200 (b) Caseous tuberculous lymphadenitis of the

lower cervical chain occurs commonly in adolescentm is the most or later life. The glands are either a solitary in-is the primary fected group or they are the upper nodes of avasion being in chain of tuberculous mediastinal glands and theyges. Perhaps form a tumour in the supraclavicular region deepof lessened re- under the lower end of the sterno-mastoid muscle.h infection can In the acute phase there may be considerable pain

and constitutional disturbance and much peri-itis of the upper adenitis, but in the chronic stage a cold abscess andmaybe follow- sinus are common.it is impossible (c) Diffuse tuberculous lymphadenitis is a diseasestreptococcal distinct from, and far less common than, the other

I course of the forms and occurs at any age. In the young bothrapy may settle sides of the neck may be filled with huge soft

glands. Later the glands are rubbery and re-Is are swollen, semble lymphadenoma or one of the reticuloses.arm a diffuse The glands generally remain discrete and movablele of the jaw. although occasionally several may be mattedthere may be together to form a rubbery tumour. General

ier side of the symptoms are not marked, the progress of theesistance poor disease is slow and the results of surgical excisionand form an are disappointing. In later life slow breakdowngland capsule, and caseation may occur in many glands on oneppears on the or both sides of the neck, forming sinuses or scarower border of tissue without the preceding enlargement and in.wn the sterno- flammation which distinguishes the primary in-L' abscess with fection of childhood.)nnected by a5rculosis. The Differential Diagnosisdematous and The first step in the differential diagnosis is thethe pus to dis- recognition of whether the swelling is of lymphatic1 by secondary glands or otherwise, and the second step is thelay involve the identification of their tuberculous etiology.eous tissue and Swellings other than in lymphatic glands areresponse of the usually easily recognizable and the following con-Ldenitis recedes ditions must be considered:palpable. The - (a) A branchial cyst is a rounded fluctuant,

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flabby swelling in the upper part of the neck nearthe angle of the jaw, of slow progress, detachedfrom the skin and translucent to light. Unlessinfected, signs of inflammation are absent andoccasionally the cyst may communicate with abranchial fistula which traverses the two heads ofthe sternomastoid muscle to surface above thesternoclavicular joint.

(b) Parotid and submaxillary swellings are usuallyinflammatory or associated with calculus. Theyoccur in adult life and tend to become painful atmeal times when the gland is active. X-rays mayshow a stone.

(c) Swellings of the thyroid gland are unlikely tocause confusion for they are situated low down inthe neck near the mid-line and move on swallow-ing with the trachea. A thyroglossal cyst situatednear the hyoid bone may resemble an infectedgland of the sub-mental group.

(d) Cystic hygroma is an uncommon tumouroccurring in the posterior triangle of the neck inchildren. It is soft and translucent without theslightest trace of inflammation.

(e) Actinomy:cosis bovis is a brawny inflammatoryswelling with multiple sinuses which dischargesulphur granules of the ray fungus. It arises any-where in the neck, is not confined to any one tissueand does not cause discrete glandular enlargement.

Swellings of lymphatic glands. i. Inflammatory.(a) Acute septic lymphadenitis is recognized by therapid onset with a high temperature, malaise and ahot brawny swelling of the glands together withthe presence of an infected lesion in the drainagearea including the throat and the scalp. Timealone may distinguish this condition from tuber-culosis in its early stage.

(b) Chronic septic lymphadenitis may be as-sociated with throat infections or with dermatitisand pediculosis of the scalp.

2. Neoplastic disease (a) Secondary carcinomaand branchiogenic carcinoma in lymph glands giverise to hard swellings at an age when glandulartuberculosis is uncommon. Search should be madeby special and general examinations for theprimary lesion in the mouth, pharynx, thyroid andchest.

(b) The reticuloses are new growths arisinganywhere in the reticulo-endothelial system, andgive rise to a discrete rubbery swelling of onegroup of lymphatic glands. Biopsy alone settlesthe doubt.

3. General disease associated with chronic en-largement of lymphatic glands. (a) Hodgkin'sdisease causes enlargement of one group of lym-phatic glands followed by splenomegaly, the Pel-Epstein temperature and eosinophilia.

(b) Glandular fever occurs in childhood and is afebrile disease associated with enlargement of the

neck glands. The Paul Bunnell test and character-'istic changes in the blood count are of diagnosticimportance.The recognition of the etiological factor in

lymphadenitis presents no difficulty if there is asinus, for tubercle bacilli can usually be identifiedin the discharge. The following special diagnostictests may be of assistance in cases of doubt:

i. The Mantoux and Von Pirquet cutaneoussensitivity tests become positive soon after infectionwith tuberculosis, but in the community a positivereaction is the rule. A negative response to thesetests is 'almost conclusive evidence that the glandsare not tuberculous.

2. Aspiration of a cold abscess and examinationof the pus directly, by culture or by guinea pig testmay occasionally be necessary.

3. Biopsy of glands should be avoided if possibleand is rarely necessary except in the diffuse non-caseous forms of tuberculous lymphadenitis, whenit is amply justified.

4. A thorough general clinical survey and X-rayexamination of the chest should never be omitted.

TREATMENTThe treatment of tuberculous glands of the

neck is based upon the principles which time andexperience have firmly established as fundamentalfor all forms of tuberculosis. The patient must beregarded as a whole; the narrow gaze directedupon the swelling in the neck must be broadenedto include the individual who is suffering from aconstitutional disease. All that medicine andsurgery can do is to assist the patient to overcomethe infection; the surgical removal of tuberculousglands is but a step in the general plan of treat-ment and the moment must be carefully chosen.

It is useful to recall once more the naturalprogress of tuberculous lymphadenitis. There isthe first or active phase when the glands are mattedtogether, the second as resolution proceeds andthe -third when resistance has overcome the in-fection leaving encapsulated calcareous debris, theembers of the fire which once raged so fiercely.The aim of treatment is to assist these naturalprocesses of resolution and at a suitable moment toeradicate the diseased tissue. If seen in the earlyphase the patient should be put at rest in bed, ifpossible in a sanatorium or hospital equipped foropen air treatment. Failing this, home conditionsshould be made to approach as near as possible tothe ideal. Rest in the open air with a liberal diet,including extra fats and vitamins, should be con-tinued until the patient's resistance has been-raisedand the periadenitis has receded. To assistresolution calciferol in doses of up to 5o,ooo unitsdaily is of value, but it is doubtful whether a splint

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REID: Tuberculous Glands of the Neck

or plaster collar is helpful, unless it includes theupper part of the chest and head.The response to constitutional treatment is

usually evident in a few weeks, the general healthimproves, the blood sedimentation rate falls,periadenitis subsides and many enlarged glandsresolve. The progress may be assisted by the re-moval of tonsils and adenoids, by the evacuationof a cold abscess or the treatment of secondaryinfection.

If the case is seen at a later stage when theglands are already discrete and clear of peri-adenitis a shorter period of constitutional andother preparatory treatment may suffice to fit thepatient for operation. The treatment of glands inthe root of the neck, while subject to the principlesset out above, depends upon their origin. Ifassociated with disease in the mediastinum or thelung their management becomes part of thetreatment of the more serious lesion. If they arestrictly local they may be excised at the chosenmoment.

In the diffuse and widespread variety of tuber-culous lymphadenitis response to all forms oftreatment is slow; even the most widespread ex-cisions are often followed by recurrence. In thesecases, therefore, treatment must be prolonged andthorough. In some recalcitrant cases radium orradiotherapy may assist resolution or fibrosis ofthe affected glands.

Operative Treatment

(a) AbscessTuberculous pus, when once it has burst out of

the gland, will inevitably find its way to the bodysurface, usually the skin a little below the affectedneck gland, occasionally in the pharynx. Im-pending rupture is recognized by redness andoedema. Aspiration is unsatisfactory for the pusis thick and cannot be completely evacuated;therefore a cold abscess should be incised andcuretted as soon as the probable point of rupture isrecognized. The operation should be done underfull aseptic precautions and the wound sutured;resolution of the glands is accelerated by thisprocedure.

(b) Secondary infectionThis complication requires appropriate chemo-

therapy (usually penicillin, for the streptococcus isthe common organism), and free incision anddrainage.

(c) Excision ofglandsSurgical removal of all the diseased glands is

indicated when time and general constitutionaltreatment have raised the patient's natural re-

sistance to the highest level possible, when peri-adenitis has gone and the glands are discrete.Operations in the early active phase are difficultand dangerous for important structures arematted together and may be damaged, pus may beencountered and wounds only too often breakdown when the stitches are removed.

i. Anaesthesia should be gas, oxygen and etherthrough an endotracheal tube to allow of perfectcontrol of airway and an unemcumbered operationfield. Careful avoidance of respiratory obstruc-tion during induction is important to minimizevascular congestion. The patient is placed uponhis back with the head turned to the sound side,and sandbags placed so as to steady the neck andto throw into prominence the site of operation.

2. Incisions in the neck heal best and leave finelinear scars if placed in the natural transverse linesof the skin. Longitudinal and T-shaped cuts arequite unnecessary and unjustifiable; these scarsare most unsightly. Incisions should be placed overthe affected glands, which are not necessarily deepto a cold abscess or sinus. The upper deepcervical glands should be approached- through anincision just below the angle of the jaw. Thesurgeon should not hesitate to make two or moretransverse incisions if there are many glands orgroups, or if invaded or ugly skin requires removal.The skin incisions should traverse the platysma

muscle which is included in the flaps to be raisedupwards and downwards. Gauze packs soaked ini in 200,000 adrenalin are used to control oozing,and all bleeding points should be tied off as soonas the flaps have been reflected. A mastoid self-retaining retractor is adjusted to spread the woundand the capsule over the gland mass incised untila layer as near as possible to the gland is reached.The recognition of the correct line of cleavage isimportant for if it be adhered to damage to thegreat vessels is unlikely. The gland mass is clearedon one side, the wound there packed with adrenalingauze and the mass cleared elsewhere. Thischange of approach and packing reduces haemor-rhage to a trivial ooze and vessels and nerves canbe identified with ease. All firm and caseousglands should be excised, those soft and gelatinousmay be left behind for they will certainly resolve.It is not always easy to be sure when all affectedglands have been removed and the wound shouldbe carefully palpated, especially in its deeper parts,firm tissue being picked up for examination.

All affected glands having been cleared, anysinus should be curetted and the wound closedwith drainage after careful suture of the muscleand skin.

Results of TreatmentBefore determining a course of action, the

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470 POST GRADUATE MEDICAL JOURNAL October 1949

surgeon should have his aims clearly before him.He must take into account the cost in time,suffering and money and review dispassionatelythe results so far as they are known of the treatmentproposed.The aim in treating tuberculous glands is to

cure the local disease as simply and quickly as isconvenient with achieving freedom from re-currence and safety from future outbreaks oftuberculosis elsewhere in the body.

It has been my good fortune to work at BlackNotley where all forms of tuberculosis are treated,and there is special provision for children withprimary lesions, including neck glands. To mycolleague, Dr. M. C. Wilkinson, the medicalsuperintendent, I owe a great debt for teaching theimportance of principles and for his co-operation.Recently 302 cases have been followed up with thekind assistance of the tuberculosis officers of theEssex County Council, and the results are tabledhelow.

TABLE 4FOLLOW UP OF 302 CASES

Examined Medically .. 294Letter Report ..I .. 8

Total . . .. 302

TABLE 5Longest Follow up 8 yearsShortest Follow up 2 monthsAverage 3 years

TABLE 6GENERAL STATE OF HEALTH AT FOLLOW UP

Good .. 298Bad .. .. .. .. .. .. 2Indifferent .. .. .. .. 2

Total .. .. .. .. .. 302

TABLE 7COSMETIC RESULT

Good .. .. .. .. .. .. 276Bad .. . .. . .. ... I IIndifferent .. .. .. .. .. '5

Total .. .. .. .. .. 302

The tables indicate that the scheme of treatmentdescribed in this paper and carried out for someyears at Black Notley Hospital has yielded resultswhich are, on the whole, satisfactory. The costin time has been an average stay in hospital ofi9 weeks, i6 weeks before operation and threeafterwards. The general health of the patientsfollowed has been good; the cosmetic results havebeen satisfactory, the term ' good' in this con-nection meaning one or more insignificant linearscars. There has been a local recurrence rate ofunder 4 per cent., as shown in Table 8. What ofthe incidence of extra-glandular lesions in latelife ? Table 9 gives a tentative answer to thisquestion.

TABLE 8RECURRENCE OF GLANDS

At Old Site .. . . I INo Recurrence . . . 291Recurrence in Other Glands o

Total . . 302

TABLE 9SUBSEQUENT EXTRA-GLANDULAR LESIONS

None . 299Pulmonary .. .. 2Meningitis I

Total . . 302

The information contained in this table is ofgreat interest and perhaps of profound significance.In only i per cent. of cases followed up for anaverage of three years has there been subsequentextra-glandular tuberculosis and there is a notable

*absence of skeletal and renal infection, the un-doubted sequelae of bacillaemia. Does this indi-cate that a well-treated and healed primary tuber-culous lesion, far from being a hidden source ofdanger, is a shield against further infection ? Theassumption is tempting but many years must passbefore it can be determined.

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NeckTuberculous Glands of the

Ronald Reid

doi: 10.1136/pgmj.25.288.4651949 25: 465-470 Postgrad Med J

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