Treatment of cervical lymphatic tuberculosis
I. Overview
Cervical lymphatic tuberculosis is caused by Mycobacterium tuberculosis infection in the lymph nodes of the neck, mostly as an isolated disease, but rarely as a local manifestation of systemic tuberculosis infection. With the increasing incidence of tuberculosis in recent years, cervical lymphatic tuberculosis has become a common disease. Its treatment requires a combination of Chinese and Western medicine and medical and surgical procedures to achieve significant results, so most patients do not receive appropriate treatment, and the course of the disease is prolonged, causing long-term suffering to the majority of patients.
Etiology
Cervical lymphatic tuberculosis is called scrofula in Chinese medicine, which is mostly caused by liver depression and phlegm-dampness coagulation. From the overall point of view, the root cause of the disease is the deficiency of both qi and yin, the loss of glory of the body, the lack of qi and blood, and the deficiency of kidney yin, and liver depression and qi stagnation appear on this basis. Modern medicine generally believes that Mycobacterium tuberculosis is mostly invaded by the oral cavity or tonsils, and no tuberculous lesions are visible at the invasion site. Few of them are secondary to pulmonary or bronchial tuberculosis lesions.
Clinical manifestations
The main manifestation at the onset of the disease is enlarged cervical lymph nodes, which are often found in multiple cases. It can be found on one or both sides of the neck, and in some patients it occurs in the axillary, inguinal or even intra-abdominal lymph nodes. They are usually located in the submandibular and anterior sternocleidomastoid muscles, at the posterior border or on the deep surface. Initially, the enlarged lymph nodes are separated from each other and can move without pain. Gradually, perilymph node inflammation occurs and the lymph nodes adhere to each other. In some patients, the disease continues to progress, and the lymph nodes become cheese-like and liquefied to form a cold abscess, which then ruptures to form a sinus tract or ulcer that does not heal easily, discharging thin pus mixed with bean-like material. The sinus tract opening or ulcerated surface has dark red, submerged skin margins and loose atrophied, pale granulation tissue. In some clinical cases, several of these conditions may coexist. Most patients have no significant systemic symptoms. Cold abscesses and those who have broken down are prone to secondary common bacterial infection to form acute inflammation.
IV. Clinical classification and diagnostic points
There are four types according to local performance.
1.Nodular type: swollen cervical lymph nodes, which may fuse into a mass and not liquefied into a thick.
2. abscess type: all or part of the enlarged lymph nodes liquefy into pus and form a cold abscess.
3.Ruptured type: the abscess breaks down to form a sinus tract or ulcer.
4.Mixed type: two or three types of the above three types of lesions exist simultaneously.
Nodules, abscesses and ulcers are the natural process of regression of the disease. Therefore, some people advocate that instead of typing, the disease should be divided into three stages: nodules, abscesses, and ruptures. However, in our clinical work, we often see cases with nodules for a long time, and we can also see those who become abscesses quickly after the onset of the disease. Therefore, it is considered more reasonable to treat the disease by staging.
The diagnosis of nodular cervical lymphatic tuberculosis is relatively complex: 1.
1. It is necessary to identify whether the mass is an enlarged lymph node. Physical examination plus ultrasound examination can usually identify them clearly.
2. Whether the enlarged lymph node is other diseases: lymphadenitis, lymphoma, solid tumor cervical lymph node metastasis, etc.. Based on symptoms, signs and ultrasound, CT and other examinations can suggest whether the disease is possible. However, pathological diagnosis is still appropriate to confirm the diagnosis. Puncture biopsy or excisional or excisional biopsy can be sent.
For patients with pus formation or rupture, the diagnosis can be made by clinical signs. It is still appropriate to take part of necrotic tissues for pathological examination when performing abscess incision or changing medication at the ruptured area. Pathological support is especially needed for patients with atypical clinical signs due to the combination of common bacterial infections.
For patients with confirmed cervical lymphatic tuberculosis, a systemic examination is required to exclude the presence of metastases at other sites. For patients with abscess type and ruptured type, deep neck involvement should be evaluated, and ultrasound and CT are suggestive.
V. Treatment
(A) Systemic treatment
1. Western anti-TB treatment: commonly used drugs are remifentan, rifampin, ethambutol, streptomycin, etc. A triplet chemotherapy regimen is appropriate. The key point is that the course of treatment must be standardized, and try not to arbitrarily stop or intermittent use of drugs. Apply liver-protective drugs and test liver function at the same time.
2, Chinese medicine treatment: nodule type need to resolve phlegm and soften the firmness. The abscess type should nourish Yin and clear heat, detoxify and soften the firmness. For the ulcerated type, it is necessary to nourish qi and blood, to support the lining of the muscle, and to make the pus disappear and the stasis go away.
(II) Local treatment
1.General treatment.
For the abscess type, whether to cut and drain is debated. Some people choose to puncture and extract pus for local drug injection treatment, but the effect is not good. We believe that the pus can be cut and drained after the formation of pus, in preparation for the next step of surgical treatment: first, the pressure is reduced after the cut, which can slow down the progress of deep sinus tracts. Secondly, the surface skin is protected from further invasion. Thirdly, for combined common bacterial infections, the infection can be brought under control. Drug exchange is required after abscess incision and in patients with ruptured type. When changing the medication, try to clean up the necrotic tissue and keep the drainage open. It should be noted that drug exchange generally cannot achieve the effect of promoting healing.
2.Therbal topical medicine: For nodule type and pus formation, topical ointment can be applied to promote the formation of pus. For those who have local redness and heat with pain, use golden ointment; for those who do not have redness and heat with pain, use punch and ointment. If the abscess is incised and broken, Chinese herbal gauze can be placed into the wound to promote healing by removing stasis and creating muscle. There are many clinical reports, but the general course of treatment seems to be longer. Commonly used medicines: Yuxiang Yuhong Paste, Huayu Decay and Muscle Growth San, Healing New, Compound Huangbai Liquid, etc. Topical creams can sometimes play a good role, if you want to know, you can further consult.
3.Surgical treatment: Cervical lymphatic tuberculosis debridement. It is applicable to the treatment of abscess type and ruptured type of cervical lymphatic tuberculosis. After long-term clinical observation, the following characteristics of the lesion localization are found.
(1) Regardless of whether the pus formation is sufficient or not, there is a large amount of necrotic tissue and inflammatory granulation tissue in the pus cavity. (1) The presence of a large amount of necrotic tissue and inflammatory granulation tissue in the pus cavity, regardless of whether the pus formation is sufficient or not.
(2) The presence of multiple sinus tracts in the pus cavity with deep sinus tracts in the muscle space filled with inflammatory granulation tissue
(3) The wall of the pus cavity and sinus tract is intact, tough, and clearly delineated from necrotic tissue and inflammatory granulation tissue
(4) No cases of invasion of the wall of large blood vessels in the neck have been seen.
The cervical lymphatic tuberculosis debridement surgery created for the above characteristics can achieve the purpose of complete removal of necrotic tissue and inflammatory granulation tissue and strive for one-stage healing.
Preoperative preparation.
(1) For larger abscess type, first incision and drainage for several days; for small abscess, direct surgery is also possible.
(2) preoperative application of antibiotics for combined common bacterial infections.
(3) Pre-operative local drainage is not sufficient to enhance drainage by dilation.
Key points of surgery.
(1) Use cervical plexus anesthesia or intravenous general anesthesia.
(2) Excision of the severely affected skin around the rupture or in the center of the abscess (usually a double curved incision is used to facilitate suturing).