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End-Results of the Surgical Treatment of 48 Cases of Tuberculous Cervical Adenitis

Frank H. Lahey, Howard M. Clute
1922 Boston Medical and Surgical Journal  
For the purposes of this investigation, all the cases of tuberculous cervical adenitis at the Boston City Hospital for the five years from June, 1915, to March, 1920, and likewise all the cases in private practice of one of us (F. H. L.) were considered,-totalling 132 in number. Owing to the type of patient treated at the City Hospital and the length of time that frequently had elapsed since operation, it was possible to trace but 46 of these cases. Nineteen, or 43.4 per cent., of this series
more » ... ., of this series of 46 were classed as excellent results: they showed no further evidence of tubercular glands, nor did they present any of the disabilities which were found among some of the remaining cases ; with the exception of the scar upon the neck, there was no evidence of the disease or its treatment. In twelve cases, or 26.08 per cent, of the series, we found evidence of paralysis of the trapezius muscle from interruption of the conductivity of the spinal accessory nerve or the third and fourth cervical nerves. Of this group all showed a clearly marked deformity, and only three of the twelve made no complaint of the resulting disability. Two patients in this series came to the City Hospital with a paralysis acquired elsewhere. There was no case in the series with a sinus present at the time of examination. Two cases reported sinuses draining over a year. One sinus had closed unaided, and in the other case the patient has received tuberculin. Five cases showed a paralysis of the depressor ansruli oris muscle. No patient experienced any disability from this lesion, nor did the deformity seem particularly disfiguring. Two cases were reported as having died since operation : one patient of pulmonary tuberculosis; the other of "intestinal trouble." Tenderness over the scar was very marked in one case. This patient had had a complete dissection of the neck. She presented a thin, wide scar and atrophy of the superficial structure over the lower carotid sheath. The vessels were plainly visible under the scar and slight pressure caused pain. In only eight cases did we find glands persisting after the operation : two of these showed evidence of an active process in the remaining glands ; these particular cases have had several recent x-ray treatments" with marked improvement. The twelve eases of spinal accessory paralysis were divided among six different surgeons, indicating the possibility of this accident oc-curring in any hands. In fact, it has occurred in our hands since this investigation was begun, in a patient whose spinal accessory nerve we carefully followed and preserved anatomically intact. The paralysis resulting from the dissection was possibly due to our pinching the nerve to establish its identity. As far as could be ascertained from the records, but two of these cases in which paralysis occurred were of the bloc dissection type of operation. The problem of the treatment of tuberculous cervical adenitis has been by no means a settled one. Surgeons must admit that "bloc dissections" result in spinal accessory or third and fourth cervical nerve paralysis, with consequent functional disability, too often to permit its being resurrected from the oblivion into which it has, for the most part, sunk in the treatment of tuberculous cervical adenitis. On the other hand, hygiene, x-ray, and tuberculin are by no means the sovereign remedial measures we could wish them to be in the treatment of this condition. There exist cases in which not necessarily "bloc dissection," but certainly a very complete neck dissection will be necessary, and, on the other hand, there likewise exist many cases capable of being relieved of this condition by one of the non-surgical procedures cited above. Unfortunately, the great majority of the cases exist in the group just between these two extremes, and it is our belief that in this group combined methods, surgical and non-surgical, must very frequently be employed. We feel, in the first place, that if prompt and active treatment could be instituted and adhered to in cases as soon as they manifest this condition, together with adequate attention to unsatisfactory conditions of tonsils or teeth, and also to other contributing factors, radical surgical measures would rarely be necessary. While we have no personal experience with the application of x-ray therapy in these cases, we have referred for this form of treatment and observed the outcome in a sufficient number of these cases to be convinced that it has a very distinct place in the treatment of this condition, not only as regards the firm, non-necrotic glands, but also for the closure of the tubercular sinuses which have resulted from the drainage of the liquefied ones. Liquefaction will undoubtedly follow radiation of some of the caseating glands, but drainage and, later, radiation of the gland shell, then become possible. Surgery, in our opinion, should not be resorted to in tuberculous adenitis until x-ray therapy has been tried for a considerable period of time-from six months to a yearprovided the disease is not spreading and involving the adjacent glands. While the disease remains confined to a few glands, nothing is lost by continuation of x-ray treatment, and we have been surprised in a few instances by
doi:10.1056/nejm192203021860904 fatcat:q2dbsnrnzzd7hatolnyrd4dz3q