LYMPHADENITIS, ADENOPHLEGMONAS. ABSCESSES OF THE FACE, MOUTH, ORAL LINGUAL GROOVE, HYOID AREA. PHYSICAL THERAPY IN THE TREATMENT OF INFLAMMATORY PROCESSES OF MFA

 

THE LYMPHATICS OF THE HEAD, FACE, AND NECK

The Lymph Glands of the Head (Fig. 602).

The lymph glands of the head are arranged in the following groups:

 

The occipital glands (lymphoglandulæ occipitales), one to three in nu ber, are placed on the back of the head close to the margin of the Trapezius and resting on the insertion of the Semispinalis capitis. Their afferent vessels drain the occipital region of the scalp, while their efferents pass to the superior deep cervical glands.

The posterior auricular glands (lymphoglandulæ auriculares; mastoid glands), usually two in number, are situated on the mastoid insertion of the Sternocleidomastoideus, beneath the Auricularis posterior. Their afferent vessels drain the posterior part of the temporoparietal region, the upper part of the cranial surface of the auricula or pinna, and the back of the external acoustic meatus; their efferents pass to the superior deep cervical glands.

 

FIG. 602– Superficial lymph glands and lymphatic vessels of head and neck.

The anterior auricular glands (lymphoglandulæ auriculares anteriores; superficial parotid or preauricular glands), from one to three iumber, lie immediately in front of the tragus. Their afferents drain the lateral surface of the auricula and the skin of the adjacent part of the temporal region; their efferents pass to the superior deep cervical glands.

The parotid glands (lymphoglandulæ parotideæ), form two groups in relation with the parotid salivary gland, viz., a group imbedded in the substance of the gland, and a group of subparotid glands lying on the lateral wall of the pharynx. Occasionally small glands are found in the subcutaneous tissue over the parotid gland. Their afferent vessels drain the root of the nose, the eyelids, the frontotemporal region, the external acoustic meatus and the tympanic cavity, possibly also the posterior parts of the palate and the floor of the nasal cavity. The efferents of these glands pass to the superior deep cervical glands. The afferents of the subparotid glands drain the nasal part of the pharynx and the posterior parts of the nasal cavities; their efferents pass to the superior deep cervical glands.

The facial glands comprise three groups: (a) infraorbital or maxillary, scattered over the infraorbital region from the groove between the nose and cheek to the zygomatic arch; (b) buccinator, one or more placed on the Buccinator opposite the angle of the mouth; (c) supramandibular, on the outer surface of the mandible, in front of the Masseter and in contact with the external maxillary artery and anterior facial vein. Their efferent vessels drain the eyelids, the conjunctiva, and the skin and mucous membrane of the nose and cheek; their efferents pass to the submaxillary glands.

The deep facial glands (lymphoglandulæ faciales profunda; internal maxillary glands) are placed beneath the ramus of the mandible, on the outer surface of the Pterygoideus externus, in relation to the internal maxillary artery. Their afferent vessels drain the temporal and infratemporal fossæ and the nasal part of the pharynx their efferents pass to the superior deep cervical glands.

The lingual glands (lymphoglandulæ linguales) are two or three small nodules lying on the Hyoglossus and under the Genioglossus. They form merely glandular substations in the course of the lymphatic vessels of the tongue.

FIG. 603– Lymphatics of pharynx. (Poirier and Charpy).

 

The retropharyngeal glands (Fig. 603), from one to three iumber, lie in the buccopharyngeal fascia, behind the upper part of the pharynx and in front of the arch of the atlas, being separated, however, from the latter by the Longus capitis. Their afferents drain the nasal cavities, the nasal part of the pharynx, and the auditory tubes; their efferents pass to the superior deep cervical glands.

The lymphatic vessels of the scalp are divisible into (a) those of the frontal region, which terminate in the anterior auricular and parotid glands; (b) those of the temporoparietal region, which end in the parotid and posterior auricular glands; and (c) those of the occipital region, which terminate partly in the occipital glands and partly in a trunk which runs down along the posterior border of the Sternocleidomastoideus to end in the inferior deep cervical glands.

The lymphatic vessels of the auricula and external acoustic meatus are also divisible into three groups: (a) an anterior, from the lateral surface of the auricula and anterior wall of the meatus to the anterior auricular glands; (b) a posterior, from the margin of the auricula, the upper part of its cranial surface, the internal surface and posterior wall of the meatus to the posterior auricular and superior deep cervical glands; (c) an inferior, from the floor of the meatus and from the lobule of the auricula to the superficial and superior deep cervical glands.

The lymphatic vessels of the face (Fig. 604) are more numerous than those of the scalp. Those from the eyelids and conjunctiva terminate partly in the submaxillary but mainly in the parotid glands. The vessels from the posterior part of the cheek also pass to the parotid glands, while those from the anterior portion of the cheek, the side of the nose, the upper lip, and the lateral portions of the lower lip end in the submaxillary glands. The deeper vessels from the temporal and infratemporal fossæ pass to the deep facial and superior deep cervical glands. The deeper vessels of the cheek and lips end, like the superficial, in the submaxillary glands. Both superficial and deep vessels of the central part of the lower lip run to the submental glands.

FIG. 604– The lymphatics of the face. (After Küttner.)

Lymphatic Vessels of the Nasal Cavities.—Those from the anterior parts of the nasal cavities communicate with the vessels of the integument of the nose and end in the submaxillary glands; those from the posterior two-thirds of the nasal cavities and from the accessory air sinuses pass partly to the retropharyngeal and partly to the superior deep cervical glands.

Lymphatic Vessels of the Mouth.—The vessels of the gums pass to the submaxillary glands; those of the hard palate are continuous in front with those of the upper gum, but pass backward to pierce the Constrictor pharyngis superior and end in the superior deep cervical and subparotid glands; those of the soft palate pass backward and lateralward and end partly in the retropharyngeal and subparotid, and partly in the superior deep cervical glands. The vessels of the anterior part of the floor of the mouth pass either directly to the inferior glands of the superior deep cervical group, or indirectly through the submental glands; from the rest of the floor of the mouth the vessels pass to the submaxillary and superior deep cervical glands.

The lymphatic vessels of the palatine tonsil, usually three to five iumber, pierce the buccopharyngeal fascia and constrictor pharyngis superior and pass between the Stylohyoideus and internal jugular vein to the uppermost of the superior deep cervical glands. They end in a gland which lies at the side of the posterior belly of the Digastricus, on the internal jugular vein; occasionally one or two additional vessels run to small glands on the lateral side of the vein under cover of the Sternocleidomastoideus.

FIG. 605– Lymphatics of the tongue. (Poirier and Charpy.)

The lymphatic vessels of the tongue (Fig. 605) are drained chiefly into the deep cervical glands lying between the posterior belly of the Digastricus and the superior belly of the Omohyoideus; one gland situated at the bifurcation of the common carotid artery is so intimately associated with these vessels that it is known as the principal gland of the tongue. The lymphatic vessels of the tongue may be divided into four groups: (1) apical, from the tip of the tongue to the suprahyoid glands and principal gland of the tongue; (2) lateral, from the margin of the tongue—some of these pierce the Mylohyoideus to end in the submaxillary glands, others pass down on the Hyoglossus to the superior deep cervical glands; (3) basal, from the region of the vallate papillæ to the superior deep cervical glands; and (4) median, a few of which perforate the Mylohyoideus to reach the submaxillary glands, while the majority turn around the posterior border of the muscle to enter the superior deep cervical glands.

The Lymph Glands of the Neck—The lymph glands of the neck include the following groups:

The submaxillary glands (lymphoglandulæ submaxillares) (Fig. 604), three to six iumber, are placed beneath the body of the mandible in the submaxillary triangle, and rest on the superficial surface of the submaxillary salivary gland. One gland, the middle gland of Stahr, which lies on the external maxillary artery as it turns over the mandible, is the most constant of the series; small lymph glands are sometimes found on the deep surface of the submaxillary salivary glands. The afferents of the submaxillary glands drain the medial palpebral commissure, the cheek, the side of the nose, the upper lip, the lateral part of the lower lip, the gums, and the anterior part of the margin of the tongue; efferent vessels from the facial and submental glands also enter the submaxillary glands. Their efferent vessels pass to the superior deep cervical glands.

The submental or suprahyoid glands are situated between the anterior bellies of the Digastrici. Their afferents drain the central portions of the lower lip and floor of the mouth and the apex of the tongue; their efferents pass partly to the submaxillary glands and partly to a gland of the deep cervical group situated on the internal jugular vein at the level of the cricoid cartilage.

The superficial cervical glands (lymphoglandulæ cervicales superficiales) lie in close relationship with the external jugular vein as it emerges from the parotid gland, and, therefore, superficial to the Sternocleidomastoideus. Their afferents drain the lower parts of the auricula and parotid region, while their efferents pass around the anterior margin of the Sternocleidomastoideus to join the superior deep cervical glands.

The anterior cervical glands form an irregular and inconstant group on the front of the larynx and trachea. They may be divided into (a) a superficial set, placed on the anterior jugular vein; (b) a deeper set, which is further subdivided into prelaryngeal, on the middle cricothyroid ligament, and pretracheal, on the front of the trachea. This deeper set drains the lower part of the larynx, the thyroid gland, and the upper part of the trachea; its efferents pass to the lowest of the superior deep cervical glands.

The deep cervical glands (lymphoglandulæ cervicales profundæ) (Figs. 602, 605) are numerous and of large size: they form a chain along the carotid sheath, lying by the side of the pharynx, esophagus, and trachea, and extending from the base of the skull to the root of the neck. They are usually described in two groups: (1) the superior deep cervical glands lying under the Sternocleidomastoideus in close relation with the accessory nerve and the internal jugular vein, some of the glands lying in front of and others behind the vessel; (2) the inferior deep cervical glands extending beyond the posterior margin of the Sternocleidomastoideus into the supraclavicular triangle, where they are closely related to the brachial plexus and subclavian vein. A few minute paratracheal glands are situated alongside the recurrent nerves on the lateral aspects of the trachea and esophagus. The superior deep cervical glands drain the occipital portion of the scalp, the auricula, the back of the neck, a considerable part of the tongue, the larynx, thyroid gland, trachea, nasal part of the pharynx, nasal cavities, palate, and esophagus. They receive also the efferent vessels from all the other glands of the head and neck, except those from the inferior deep cervical glands. The inferior deep cervical glands drain the back of the scalp and neck, the superficial pectoral region, part of the arm (see page 701), and, occasionally, part of the superior surface of the liver, In addition, they receive vessels from the superior deep cervical glands. The efferents of the superior deep cervical glands pass partly to the inferior deep cervical glands and partly to a trunk which unites with the efferent vessel of the inferior deep cervical glands and forms the jugular trunk. On the right side, this trunk ends in the junction of the internal jugular and subclavian veins; on the left side it joins the thoracic duct.

FIG. 606– The superficial lymph glands and lymphatic vessels of the upper extremity.

The lymphatic vessels of the skin and muscles of the neck pass to the deep cervical glands. From the upper part of the pharynx the lymphatic vessels pass to the retropharyngeal, from the lower part to the deep cervical glands. From the larynx two sets of vessels arise, an upper and a lower. The vessels of the upper set pierce the hyothyroid membrane and join the superior deep cervical glands. Of the lower set, some pierce the conus elasticus and join the pretracheal and prelaryngeal glands; others run between the cricoid and first tracheal ring and enter the inferior deep cervical glands. The lymphatic vessels of the thyroid gland consist of two sets, an upper, which accompanies the superior thyroid artery and enters the superior deep cervical glands, and a lower, which runs partly to the pretracheal glands and partly to the small paratracheal glands which accompany the recurrent nerves. These latter glands receive also the lymphatic vessels from the cervical portion of the trachea.

 

Тhe mains ways of flowing lymph from lower and apper lips

Lymphadenopathy

Lymphadenopathy is a term meaning “disease of the lymph nodes.” It is, however, almost synonymously used with “swollen/enlarged lymph nodes”. It could be due to infection, auto-immune disease, or malignancy.

Inflammation of a lymph node is called lymphadenitis. In practice, the distinction between lymphadenopathy and lymphadenitis is rarely made. Inflammation of lymph channels is called lymphangitis. Infectious lymphadenitides affecting cervical lymph nodes are often called scrofula (see Tuberculous cervical lymphadenitis).

Cervical lymphadenopathy in someone with mononucleosis

Types

• Localized lymphadenopathy : due to localized spot of infection e.g., an infected spot on the scalp will cause lymph nodes in the neck on that same side to swell up

• Generalized lymphadenopathy : due to generalized infection all over the body e.g., influenza

• Persistent generalized lymphadenopathy (PGL) : persisting for a long time, possibly without an apparent cause

• Dermatopathic lymphadenopathy : lymphadenopathy associated with skin disease.

Tangier disease (ABCA1 deficiency) may also cause lymphadenopathy.

Cause

Enlarged lymph nodes are a common symptom in a number of infectious and malignant diseases. It is a recognized symptom of many diseases, of which some are as follows:

• Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis, cat-scratch disease).

• The most distinctive symptom of bubonic plague is extreme swelling of one or more lymph nodes that bulge out of the skin as “buboes.” The buboes often become necrotic and may even rupture.

• Infectious mononucleosis is an acute viral infection, the hallmark of which is marked enlargement of the cervical lymph nodes.

• It is also a symptom of cutaneous anthrax, measles and Human African trypanosomiasis, the latter two giving lymphadenopathy in lymph nodes in the neck.

• Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy).^[4]

• Plasma cell variant of Castleman’s disease – associated with HHV-8 infection and HIV infection.

• Mesenteric lymphadenitis after viral systemic infection (particularly in the GALT in the appendix) can commonly present like appendicitis.

• Tumoral:

• Primary: Hodgkin lymphoma and non-Hodgkin lymphoma give lymphadenopathy in all or a few lymph nodes.^[4]

• Secondary: metastasis, Virchow’s Node, Neuroblastoma, and Chronic Lymphocytic Leukemia.

• Autoimmune etiology: systemic lupus erythematosus, rheumatoid arthritis all giving a generalized lymphadenopathy.^[4]

• Immunocompromised etiology: AIDS. Generalized lymphadenopathy is an early sign of infection with human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS). “Lymphadenopathy syndrome” has been used to describe the first symptomatic stage of HIV progression, preceding a diagnosis of AIDS.^[5]

• Bites from certain venomous snakes, most notably the black mamba, kraits, Australian brown snakes, coral snakes, tiger snakes, taipans, death adders, and some of the more toxic species of cobra.

• Unknown etiology: Kikuchi disease, progressive transformation of germinal centres, sarcoidosis, hyaline-vascular variant of Castleman’s disease, Rosai-Dorfman disease, Kawasaki disease, Kimura disease

Benign (reactive) lymphadenopathy

There are three distinct patterns of benign lymphadenopathy:

• Follicular hyperplasia – Seen in infections, autoimmune disorders, and nonspecific reactions.

• Paracortical hyperplasia – Seen in viral infections, skin diseases, and nonspecific reactions.

• Sinus histiocytosis – Seen in lymph nodes draining limbs, inflammatory lesions, and malignancies.

Bilateral hilar lymphadenopathy

Bilateral hilar lymphadenopathy (BHL) is a radiographic term that describes the enlargement of mediastinal lymph nodes. It is easily and most commonly identified by a chest x-ray.

Causes of BHL

The following are causes of BHL:^[6]

• Sarcoidosis

• Infection

• Tuberculosis

• Mycoplasma

• Intestinal Lipodystrophy (Whipple’s Disease)^[7]

• Malignancy

• Lymphoma

• Carcinoma

• Mediastinal tumors

• Inorganic dust disease

• Silicosis

• Berylliosis

• Extrinsic allergic alveolitis

• Such as bird fancier’s lung

• Less common causes also exist:

• Churg-Strauss syndrome

• Human immunodeficiency virus

• Extrinsic allergic alveolitis

• Pneumoconiosis

• Adult-onset Still’s disease

Lymphadenitis

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Lymphadenitis is an infection of the lymph nodes (also called lymph glands). It is a common complication of certain bacterial infections.

Causes

The lymph system is a network of lymph nodes, lymph ducts, lymph vessels, and organs that produce and move a fluid called lymph from tissues to the bloodstream. For more information on this part of the body, see lymph system.

The lymph glands, or nodes, are small structures that filter the lymph fluid. There are many white blood cells in the lymph nodes to help fight infection.

Lymphadenitis occurs when the glands become enlarged by swelling (inflammation), usually in response to bacteria, viruses, or fungi. The swollen glands are usually found near the site of an infection, tumor, or inflammation.

Lymphadenitis may occur after skin infections or other infections caused by bacteria such as streptococcus or staphylococcus. Sometimes it is caused by rare infections such as tuberculosis or cat scratch disease (Bartonella).

Symptoms

• Red, tender skin over lymph node

• Swollen, tender, or hard lymph nodes

Lymph nodes may feel rubbery if an abscess has formed.

Exams and Tests

The health care provider will perform a physical exam, which includes feeling your lymph nodes and looking for signs of injury or infection around any swollen lymph nodes.

A biopsy and culture of the affected area or node may reveal the cause of the inflammation. Blood cultures may reveal spread of infection to the bloodstream.

Treatment

Lymphadenitis may spread within hours. Treatment should begin promptly.

Treatment may include:

• Analgesics (painkillers) to control pain

• Antibiotics to treat any infection

• Anti-inflammatory medications to reduce inflammation

• Cool compresses to reduce inflammation and pain

Surgery may be needed to drain an abscess.

Outlook (Prognosis)

Prompt treatment with antibiotics usually leads to a complete recovery. However, it may take weeks, or even months, for swelling to disappear. The amount of time to recovery depends on the cause.

Possible Complications

• Abscess formation

• Cellulitis (a skin infection)

• Fistulas (seen in lymphadenitis that is due to tuberculosis)

• Sepsis (bloodstream infection)

When to Contact a Medical Professional

Call your health care provider or go to the emergency room if you have symptoms of lymphadenitis.

Prevention

Good general health and hygiene are helpful in the prevention of any infection.

Alternative Names

Lymph node infection; Lymph gland infection; Localized lymphadenopathy

Chronic Lymphadenitis

(Lymph Node Infection; Lymph Gland Infection; Lymph Node Inflammation; Lymph Gland Inflammation)  

• Definition

• Causes

• Risk Factors

• Symptoms

• Diagnosis

• Treatment

• Prevention

 

Definition  

Chronic lymphadenitis is inflammation or infection of a lymph node for an extended time. Lymph nodes are part of the immune system. This system fights and prevents infections. The lymph node’s job is to filter out unwanted substances, such as bacteria and viruses, and help eliminate them from the body.

Lymph nodes occur in clusters in the neck, armpits, and groin. Chronic lymphadenitis may affect one node, several nodes in one area, or nodes in many areas of the body.

The sooner chronic lymphadenitis is treated, the more favorable the outcome, depending on the cause. If you suspect you have this condition, contact your doctor right away.

Swollen Lymph Nodes  

Causes  

Lymph nodes normally swell when fighting off an infection. In cases of more serious infection, the swelling may be prolonged. Lymphadenitis is usually caused by an infection that has spread to the lymph nodes from a skin, ear, nose, or eye infection. Other causes of lymphadenitis include:

• Infection with streptococcal or staphylococcal bacteria

• Tonsillitis

• HIV infection

• Genital herpes

• Mononucleosis

• Juvenile rheumatoid arthritis

• Leukemia or lymphoma

• Sickle cell anemia

• Kawasaki disease

Risk Factors  

Factors that may increase your chance of developing chronic lymphadenitis include:

• Having one of the causes of lymphadenitis

• Close contact with someone who has one of the causes of lymphadenitis

• Age: 12 or younger

• Contact with animals, specifically cats, rats, or cow

Symptoms  

If you experience any of these symptoms, do not assume it is due to chronic lymphadenitis. These symptoms may be caused by other, less serious health conditions.

Symptoms include:

• Swollen, painful, tender, or hard lymph nodes/glands

• The skin over a node is red and warm to the touch

• Fever with the following symptoms:

• Chills

• Loss of appetite

• Heavy perspiration

• Rapid pulse

• General weakness

• Difficulty swallowing

• Difficulty breathing

• Neck stiffness

Diagnosis  

Your doctor will ask about your symptoms and medical history. A physical exam will be done.

Your bodily fluids and tissue may be tested. This can be done with:

• Complete blood cell (CBC) count

• Blood culture

• Biopsy of the lymph node

Images may be taken of your bodily structures. This can be done with ultrasound.

Treatment  

Treatment of chronic lymphadenitis depends on the cause. Talk with your doctor about the best treatment plan for you. Treatment options include the following:

Medications  

• Antibiotics to control infection

• Anti-inflammatory medications to help reduce inflammation and swelling; aspirin may be recommended for adults.

• Note: Aspirin is not recommended for children or teens with a current or recent viral infection. This is because of the risk of Reye’s syndrome. Ask your doctor which other medicines are safe for your child.

• Other treatments specific to the diagnosis

Supportive Care  

Hot, moist compresses on the lymph nodes can help relieve pain.

Surgery  

Surgery may be necessary to drain pockets of pus if they occur.

Prevention  

To help reduce your chances of getting chronic lymphadenitis, take the following steps:

• Seek prompt treatment of bacterial and viral infections. Contact your doctor at the first signs of infection.

• Take steps to prevent getting an infection:

• Practice good hygiene practices, such as washing your hands regularly.

• Avoid close contact with people who are sick.

• Eat a healthful diet that is low in saturated fat and rich in whole grains, fruits, and vegetables.

 

Swollen glands or lymph nodes ieck indicate that the body is trying to fight an ongoing infection or illness. Lymph nodes are small, bean-like tissues that are part of your lymphatic system. They trap viruses, bacteria and other harmful substances circulating in the body.

Besides the neck, lymph nodes are also found in other area of the body, such as the armpits, behind the ears, and in the groin. Your tonsils are also lymphatic tissues that swell when infection occurs.

Normally you cannot feel your lymph nodes in the neck. However, when you are sick, you can feel them swell and you can feel them as soft, round or oval tissues that may be tender to touch. These lumps are usually movable and the skin overlying them may be red and warm. In some cases, the lymph nodes become hard and immovable but not painful or tender. These need further evaluation by your doctor, as these may indicate more serious illness.

Causes of Swollen Lymph Nodes in Neck

Lymph nodes help the body to fight disease or infection, and in the process, they become swollen or inflamed. However, when the infection and inflammation subside, they return to their normal size. If they remain swollen and hard even in the absence of obvious infection, further medical evaluation may be necessary.

The common causes of swollen lymph nodes ieck include the following:

1. Strep Throat

Throat infection caused by strep or tonsillitis can cause lymph nodes in the neck to become swollen and tender to touch. This is often accompanied by difficulty in swallowing, fever and pain.

Treatment usually includes antibiotics to kill the bacteria and over-the-counter nonsteroidal anti-inflammatory drugs to relieve fever and pain.

2. Tooth Abscess

A tooth abscess is an infected area in the root of the tooth where pus develops when bacteria enter the gum. This may be caused by a decayed tooth, periodontal disease where the gum separates from the tooth or trauma to the gum or tooth. A tooth abscess can result in pain, fever, sensitivity to hot food and swollen lymph nodes ieck.

Treatment usually involves the use of antibiotics and pain relievers like acetaminophen and ibuprofen. The dentist may also recommend rinsing your mouth with warm salt water to relieve your discomfort.

3. Lymphoma

This condition is a type of cancer involving the lymphatic system, which can cause lymph nodes ieck to swell. There are two major types: Hodgkin’s lymphoma, which the most common type, and non-Hodgkin’s lymphoma. Lymph node biopsy is needed to diagnose the disease. The enlarged neck nodes are not painful.

Treatment usually involves radiotherapy, chemotherapy and surgery, which are needed to destroy cancer cells. Stem cell transplant is another option for treatment, which helps to replace abnormal bone marrow cells with healthy young cells after being treated with radiation therapy and chemotherapy. Alternative medicine helps in reducing stress and coping with the side effects of cancer therapy. This includes acupuncture, massage, aromatherapy, meditation and other relaxation techniques.

4. Tonsillitis

Inflammation of your tonsils at the back of the throat leads to swollen tonsils, difficulty swallowing, sore throat, and tender, swollen lymph nodes ieck. It is usually caused by a virus, but bacteria may also be the culprit.

Treatment involves the use of antibiotics for bacterial infection and anti-inflammatory drugs. In some cases where tonsillitis becomes a recurrent problem and antibiotics do not seem to work, surgery may be an option to prevent complications.

Home remedies include:

• Rest and plenty of sleep.

• Taking plenty of fluids to prevent dehydration.

• Taking warm liquids and cold treats to soothe sore throat.

• Gargling with salt water.

• Humidifying the air or sitting in your steamy bathroom.

• Sucking on lozenges.

• Avoid throat irritants like cigarettes.

5. Mononucleosis/Mono

This is a common condition caused by a virus called the Epstein-Barr virus (EBV). It usually affects young people and leaves them feeling weak and tired for weeks or even months. It is also called the “kissing disease” because it spreads through saliva, mucus and tears. Symptoms include high fever, sore throat, weakness and swollen lymph nodes ieck. Sometimes the spleen can also become swollen, causing abdominal pain.

Treatment involves getting plenty of rest, taking pain relievers and gargling with salt water. Contact sports and heavy lifting must be avoided to protect the spleen.

6. Other Causes

• Swelling of lymph nodes ieck may also due to:

• Common colds

• Skin infection

• Ear infection

• Upper respiratory tract infection

• HIV/AIDS

• Tuberculosis

• Side effect of certain drugs or vaccine

When to See a Doctor

It is advisable for you to consult a doctor when lymph nodes ieck are accompanied by:

• High fever

• Difficulty swallowing

• Difficulty breathing

• Night sweats

• Unexplained weight loss

• Red skin overlying the swollen lymph nodes

Lymph nodes that are larger than one inch and those that are very tender or hard, or do not improve after a month need to be evaluated by a doctor immediately.

Cervical Lymphadenitis Treatment

Treatment for cervical lymphadenitis depends on the underlying cause. Treatment for cervical lymphadenitis due to a viral infection usually includes warm compresses and nonsteroidal anti-inflammatory medications for pain. Treatment of cervical lymphadenitis due to a bacterial infection is treated with antibiotics. Cervical lymphadenitis caused by cancer may require treatment with chemotherapy or radiation therapy. Chemotherapy drugs kill rapidly growing cancer cells, while radiation therapy uses x-ray beams to destroy cancer cells.

Treatment options for cervical lymphadenitis include:

• Warm compresses

• Nonsteroidal anti-inflammatory medications for pain:

• Ibuprofen (Motrin, Advil, Nuprin, NeoProfen)

• Ketoprofen (Actron, Orudis, Oruvail)

• Naproxen (Anaprox, Naprosyn, Aleve)

  Narcotic pain medication:

• For moderate to severe pain

• For short term use only

  Antibiotics for cervical lymphadenitis:

• Penicillin (Benzathine, Permapen)

• Amoxicillin (Trimox, Amoxil, Biomox)

• Amoxicillin-clavulanate (Augmentin)

• Clarithromycin (Biaxin)

• Vancomycin (Vancocin, Lyphocin)

• Rifampin (Rifadin, Rimactane)

 

Cervical Lymphadenitis

Introduction

  Appropriate management of children who have enlarged lymph nodes ranges from observation and reassurance to extensive diagnostic evaluation and aggressive medical and surgical intervention.  Initial evaluation begins with a thorough history and physical examination.  One can then use a thoughtful approach towards any necessary diagnostic or therapeutic interventions. Lymphadenopathy, or enlargement of lymph nodes, can be caused by proliferation of normal lymphatic tissue, by invasion of inflammatory cells (lymphadenitis), or by invasion of neoplastic cells.  The complex array of lymph nodes of the head and neck defend against infection and often are considered in anatomic groupings based on lymph drainage patterns. Cervicofacial lymph nodes may reside in the anterior triangle forward of the sternocleidomastoid muscle, the posterior triangle

behind the sternocleidomastoid, the submandibular region below the jaw line, the supraclavicular region in the lower neck, and the preauricular and occipital regions. 

Progressively enlarging and nontender lymph nodes may suggest malignancy, especially when located in the posterior triangle. Supraclavicular lymphadenopathy is considered pathologic and should be biopsied. Generalized lymphadenopathy, hepatosplenomegaly, and/or radiographic mediastinal lymphadenopathy suggest systemic illness.  

The discussion below will focus mainly on the common infectious causes of cervical lymphadenitis.

Pathogenesis of Infectious Lymphadenitis

  Microorganisms reach the infected lymph node via lymphatic flow from an inoculation site, by lymphatic flow from adjacent lymph nodes, or by hematogenous spread of systemic infection.  Local cytokine release results in neutrophil recruitment, vascular engorgement, and nodal edema.  Involvement of the soft tissues adjacent to the node can result in cellulitus and abscess formation.  Eventually, the node heals with fibrosis.  Microorganisms that cause subacute or chronic inflammatory changes generally produce less of an inflammatory response. Generalized infectious lymphadenopathy (most commonly caused by viral illness) results iodal hyperplasia without necrosis and resolves spontaneously as the illness resolves.

A helpful classification in determining the etiology of infectious causes of cervical lymphadenitis is considering four categories:  1) acute unilateral cervical lymphadenitis, 2) acute bilateral cervical lymphadenitis, 3) subacute/chronic bilateral cervical lymphadenitis, and 3) subacute/chronic unilateral cervical lymphadenitis.

Acute Unilateral Cervical Lymphadenitis

Acute unilateral cervical lymphadenitis is usually caused by Staphyloccocus aureus or Streptococcus pyogenes (group A) in over 80% of cases.  Submandibular and cervical nodes are most frequently involved and occur most commonly in children between 1 and 4 years of age.  Patients may have a history of recent upper respiratory tract infection or impetigo.  Nodes may be very large (up to 6 cm) and infected children may suffer overlying cellulitus and high fever.  Nodes infected with Staph aureus are more likely to suppurate. 

  Acute unilateral cervical lymphadenitis in the newborn is caused by Staph aureus in most cases.  Another important cause of neonatal acute cervical lymphadenitis is late-onset group B streptococcal infection (Streptococcus agalactiae) – the “cellulitus-adenitis” syndrome.  Onset is between 7 and 90 days of age.  Most affected patients are between 3 and 7 weeks of age, male in 75% of cases, febrile, irritable, and have poor feeding.  Examination reveals tender, erythematous facial or submandibular swelling with ill-defined margins.  Bacteremia is common.

  In children with poor dentition or history of periodontal disease, anaerobes should be strongly considered.  

  A history of a near-by animal bite should prompt suspicion of Pasturella multocida as a possible etiologic agent.

  Tularemia is a febrile illness caused by infection with Francisella tularensis that usually occurs following contact with infected animals (eg, rabbits, pet hamsters; more than 100 species have been implicated), the bite of blood-sucking arthropods, inhalation of organisms in contaminated environments, or ingestion of contaminated water.  The most common clinical presentation is the ulceroglanular form, characterized by a papular lesion in the drainage field of the inflamed lymph node within 72 hours of infection, with painful ulceration following within days.  Glandular tularemia is similar in presentation, but there is no skin lesion.  Most cases in the United States occur in the south-central region.

Acute Bilateral Cervical Lymphadenitis

  Acute bilateral cervical lymphadentitis is the most common clinical presentation.  It is usually caused by benign, self-limited viral upper respiratory infection (eg, adenovirus, influenza virus, enterovirus, RSV).  Symptoms of cough, rhinorrhea, and nasal congestion may suggest these etiologies.  The lymph nodes are small, rubbery, mobile, discrete, minimally tender, and without erythema or warmth.  They are often referred to as “reactive” or “shotty” lymphadenopathy.   Although the clinical course is self-limited, the lymph node enlargement may persist for weeks.  

Group A streptococcal pharyngitis is another common cause of acute bilateral cervical lymphadenitis and generally occurs in children older than 3 years of age. 

Patients complain of sore throat, fever, and difficulty swallowing due to pain.  Headache and abdominal pain are not infrequent complaints. Examination reveals pharyngitis (may or may not be exudative) and tender anterior cervical adenopathy.

Acute bilateral cervical lymphadenitis also is associated with pharyngitis resulting from Mycoplasma pneumoniae.  

  EBV and CMV often cause generalized lymphadenopathy, but may present as acute bilateral cervical lymphadenitis.

Subacute/Chronic Bilateral Cervical Lymphadenitis

 

  Subacute or chronic bilateral lymphadenitis is most often caused by EBV or CMV infection.  EBV causes infectious mononucleosis that can present with fever, exudative pharyngitis, lymphadenopathy, and hepatosplenomagaly.  CMV also causes a mononucleosis-like illness.  Both infections are more likely in school-aged children and adolescents.

  A less common cause of prolonged bilateral cervical lymphadenitis is acquired Toxoplasma gondii infection, although it may also be unilateral.  When symptomatic, it may present as cervical lymphadenopathy and fatique, usually without fever, and is more likely to occur in school-aged children and adolescents.  Adenopathy may be localized or generalized, tender or nontender, and may persist for many months.  This disease usually is benign and self-limited and should be considered in patients in whom infectious mononucleosis is suspected, but who have negative EBV serology.  Oocysts are excreted from the stool of cats, the definitive host for T. gondii.  Human infection occurs by ingesting poorly cooked meat that contains cysts or by inadvertently ingesting oocysts from soil, litter boxes, or contaminated food.

Other uncommon causes of chronic bilateral cervical adentitis include HIV infection, Mycobacterium tuberculosis (although more commonly unilateral), syphilis, brucellosis, and histoplasmosis.  It is important to realize that all of above mentioned infectious etiologies of subacute and chronic bilateral lymphadenitis often are also associated with generalized lymphadenopathy.  

 Subacute/Chronic Unilateral Cervical Lymphadenitis

 

  Subacute or chronic cervical lymphadenitis is usually caused by nontuberculous mycobacterium (NTM – Mycobacterium avium-intracellulare and Mycobacterium scrofulaceum most commonly).  Most NTM infections occur in immunocompetent children younger than 5 years of age.  The organisms are ubiquitous in the environment. 

Infection usually is insidious, with node enlargement occurring over weeks or months, although onset may be very rapid and the clinical course indistinguishable from acute unilateral cervical lymphadenitis.  Infected lymph nodes progress to fluctuance, and the overlying skin often becomes violaceous and thin.  Fever and marked tenderness are unusual.  Untreated lymphadenitis caused by NTM may resolve, but often it progresses to spontaneous drainage with sinus tract formation and scarring.  

  If exposure to kittens or cats is elicited, infection with Bartonella henselae should be considered.  However, such a history is not present in all cases.  This is a relatively common infection caused by inoculation of Bartonella henselae into the skin following a lick, bite, or scratch from a kitten or cat.  Infection usually results in a unilateral, chronic, and tender lymphadenitis most commonly in the cervical or axillary region. 

Constitutional symptoms, when present, are generally mild, with fever occurring in fewer than 50% of patients.  Cat-scratch disease may also manifest as Parinaud oculoglandular syndrome, with conjunctivitis and preauricular or submandibular lymphadenopathy following conjunctival inoculation.  

  Mycobacterium tuberculous (TB) should also be considered in a patient with a persistent unilateral lymphadenitis that fails to respond to appropriate antimicrobial therapy or historically has risk factors for TB exposure or clinical symptoms compatible with TB.  Infection of the cervical nodes is usually caused by extension from the paratracheal nodes to the tonsillar and submandibular nodes.  It also can occur by direct spread from the apical pleura to the supraclavicular nodes.

  Toxoplasmosis can also present as subacute or chronic unilateral lymphadenitis. 

Diagnosis

It is not necessary or possible to identify an organism in all children who have infectious lymphadenitis.  Observation with reassurance often is the most appropriate management course for children in whom self-limited infection is presumed.

Patients who have acute bilateral cervical lymphadenitis are often managed conservatively because infection with respiratory viruses is so common.  Nasopharyngeal viral testing is expensive and seldom helpful.  Bacterial culture of the pharynx is useful as it may identify group A streptococcal infection treatable with penicillin.  For patients in whom systemic or subacute infections are suspected or are febrile and ill-appearing, a complete blood count, blood culture, and measurement of liver transaminases may be indicated.  Serologic studies for EBV, CMV, HIV, Treponema pallidum, Toxoplasma gondii, or Brucella sp can be helpful in selected cases.

Children with acute unilateral cervical lymphadenitis may appear well or may suffer high fever and toxicity.  For well-appearing children in whom Staph aureus or group A streptococcal infection is suspected and have no evidence of abscess formation, a therapeutic trial with an oral antibiotic without diagnostic testing is often appropriate. 

However, attempts should be made to isolate the causative organism in the ill-appearing child who has acute suppurative cervical lymphadenitis.  Ultrasound exam or CT scanning can be useful in evaluating for an underlying abscess and extent of infection. 

Needle aspiration is a reliable means of obtaining material for further diagnostic testing. 

Rarely, an excisional lymph node biopsy may be needed.  Material should be sent for gram stain, bacterial culture (aerobic and anaerobic), as well as mycobacterial and fungal stains and cultures, although these organisms more typically cause chronic lymphadenitis. 

Lymph node tissue should be sent for histopathologic examination.  Blood culture is also indicated in the febrile, ill-appearing child.

Children with subacute or chronic cervical lymphadenopathy often undergo extensive diagnostic evaluation before an etiology is identified.  Special attention should be given to the possibility of TB and HIV disease, and a PPD and serologic testing for HIV should likely be done.  Any material obtained from the affected lymph nodes should be sent for all of the studies mentioned above.  The hematologic and serologic testing noted previously is usually indicated.  Urine antigen tests for Histoplasma capsulatum may also be helpful.

The most common causes of subacute or chronic cervical lymphadenopathy in children are NTM infection and cat-scratch disease, and as mentioned previously, cause unilateral disease.  Blood samples can be sent for an indirect fluorescent antibody test for detection of antibody to Bartonella species.   Patients with NTM lymphadenopathy may have a normal or minimally indurated PPD skin test and a normal chest radiograph. 

NTM infection is diagnosed best using material obtained from a suppurative lymph node, which can be stained and cultured for acid-fast organisms.  Material can also be sent for polymerase chain reaction (PCR) examination to detect B hensalae and NTM infection.

See Table 1 below to review many of the infectious causes of cervical lymphadenitis.  Also, see Table 2 for a differential diagnosis of other noninfectious causes of cervical lymphadenitis and neck swelling.

 

Treatment

 

  Treatment of children who have lymphadenitis will depend on the etiology.  Once the etiology is known, therapy should be initiated after review of current literature and/or consultation with a specialist in infectious diseases if necessary.  Table 3 below is a summary of the management of some of the more common causes of bacterial lymphadenitis.    A total antibiotic course of 10 to 14 days is generally sufficient to treat uncomplicated lymphadenitis caused by Staph aureus or group A streptococcus.  These patients will usually respond to therapy within 72 hours.  Failure to improve should prompt reconsideration of diagnosis and treatment.  Surgery (incision and drainage) may be necessary if an abscess has formed.

Adenophlegmon – acute inflammation of a gland and the adjacent connective tissue.

Information and Resources

Abscess

Abscess Overview

An abscess is a tender mass generally surrounded by a colored area from pink to deep red. Abscesses are often easy to feel by touching. The middle of an abscess is full of pus and debris.

Painful and warm to touch, abscesses can show up any place on your body. The most common sites are in your armpits (axillae), areas around your anus and vagina (Bartholin gland abscess), the base of your spine (pilonidal abscess), around a tooth (dental abscess), and in your groin. Inflammation around a hair follicle can also lead to the formation of an abscess, which is called a boil (furuncle).

Unlike other infections, antibiotics alone will not usually cure an abscess. In general an abscess must open and drain in order for it to improve. Sometimes draining occurs on its own, but generally it must be opened by a doctor in a procedure called incision and drainage (I&D).

Abscess Causes

Abscesses are caused by obstruction of oil (sebaceous) glands or sweat glands, inflammation of hair follicles, or  minor breaks and punctures of the skin. Germs get under the skin or into these glands, which causes an inflammatory response as your body’s defenses try to kill these germs.

The middle of the abscess liquefies and contains dead cells, bacteria, and other debris. This area begins to grow, creating tension under the skin and further inflammation of the surrounding tissues. Pressure and inflammation cause the pain.

People with weakened immune systems get certain abscesses more often. Those with any of the following are all at risk for having more severe abscesses. This is because the body has a decreased ability to ward off infections.

• Chronic steroid therapy

• Chemotherapy

• Diabetes

• Cancer

• AIDS

• Sickle cell disease

• Leukemia

• Peripheral vascular disorders

• Crohn’s disease

• Ulcerative colitis

• Severe burns

• Severe trauma

• Alcoholism or IV drug abuse

Other risk factors for abscess include exposure to dirty environments, exposure to persons with certain types of skin infections, poor hygiene, and poor circulation.

Abscess Symptoms

Most often, an abscess becomes a painful, compressible mass that is red, warm to touch, and tender.

• As some abscesses progress, they may “point” and come to a head so you can see the material inside and then spontaneously open (rupture).

• Most will continue to get worse without care. The infection can spread to the tissues under the skin and even into the bloodstream.

• If the infection spreads into deeper tissue, you may develop a fever and begin to feel ill.

Abscess Treatment: Self-Care at Home

• If the abscess is small (less than 1 cm or less than a half-inch across), applying warm compresses to the area for about 30 minutes 4 times daily can help.

• Do not attempt to drain the abscess by pressing on it. This can push the infected material into the deeper tissues.

• Do not stick a needle or other sharp instrument into the abscess center because you may injure an underlying blood vessel or cause the infection to spread.

 

Dental abscess: Abscessed tooth

Dental abscess overview

A dental  abscess is an infection of the  mouth, face, jaw, or throat that begins as a tooth infection or cavity. These infections are common in people with poor dental health and result from lack of proper and timely dental care.

• Bacteria from a cavity can extend into the gums, the cheek, the throat, beneath the tongue, or even into the jaw or facial bones. A dental abscess can become very painful when tissues become inflamed.

• Pus collects at the site of the infection and will become progressively more painful until it either ruptures and drains on its own or is drained surgically.

• Sometimes the infection can progress to the point where  swelling threatens to block the airway, causing difficulty breathing. Dental abscesses can also make you generally ill, with nausea, vomiting, fevers, chills and  sweats.

Dental abscess causes

The cause of these infections is direct growth of the bacteria from an existing cavity into the soft tissues and bones of the face and neck.

An infected tooth that has not received appropriate dental care can cause a dental abscess to form. Poor oral hygiene, (such as not brushing and flossing properly or often enough) can cause  cavities to form in your teeth. The infection then may spread to the gums and adjacent areas and become a painful dental abscess.

Dental abscess symptoms

• Symptoms of a dental abscess typically include pain, swelling, and redness of the mouth and face. With an advanced infection, you can suffer nausea, vomiting, fever, chills and diarrhoea.

• The signs of dental abscess typically include, but are not limited to, cavities, gum inflammation, oral swelling, tenderness with touch, pus drainage, and sometimes difficulty fully opening your mouth or swallowing.

When to seek medical care

If you think you have an abscess, call your dentist. If you cannot reach a dentist, go to a hospital’s A&E department for an evaluation, especially if you feel sick.

• If an infection becomes so painful that it cannot be managed by nonprescription medicines, see your dentist for an assessment.

• If you develop fever, chills, nausea, vomiting or diarrhoea as a result of a dental abscess, see your dentist or doctor.

If you have intolerable pain, difficulty breathing or swallowing, any of the symptoms of a dental abscess when you dentist’s surgery is closed, seek other medical advice.

Examination and tests

A doctor or dentist can determine by physical examination if you have a drainable abscess. X-rays of the teeth may be necessary to show small abscesses that are at the deepest part of the tooth. Signs observed by the doctor, including nausea, vomiting, fever, chills or diarrhoea, may indicate that the infection has progressed to the point where it is making your whole body sick.

Dental abscess treatment – self-care at home

• People who have cavities or toothaches can take paracetamol or nonsteroidal anti-inflammatory medicines, such as ibuprofen, as needed for relief of pain.

• If an abscess ruptures by itself, warm water rinses will help cleanse the mouth and encourage drainage. 

Medical treatment

The dentist or doctor may decide to cut open the abscess and allow the pus to drain. Unless the abscess ruptures on its own, this is the only way that the infection can be cured. People with dental abscesses are typically prescribed painkillers and sometimes antibiotics to fight the infection. An abscess that has extended to the floor of the mouth or to the neck may need to be drained in the operating theatre under anaesthesia.

 

Next steps – follow-up

With dental abscess, as with each and every illness, comply with your dentist’s or doctor’s instructions for follow-up care. Proper treatment often means reassessment, multiple visits, or referral to a specialist. Cooperate with your dentist or doctor by following instructions carefully to ensure the best possible health for you and your family.

 

Prevention

Prevention plays a major role in maintaining good dental health. Daily brushing and flossing, and regular dental checkups can  prevent tooth decay and dental abscess.

• Remember to brush and floss every day as advised.

• If tooth decay is discovered early and treated promptly, cavities that could develop into abscesses can usually be corrected.

• Avoidance of  cigarette smoking and excess alcohol consumption can help too.

Outlook

The prognosis is good for resolution of a small dental abscess, once it has ruptured or been drained. If the symptoms are improving, it is unlikely that the infection is getting worse. Proper follow-up care with your dentist is mandatory for reassessment of your infection and for taking care of the problem tooth.

• Care might include extracting the tooth or having root canal treatment performed on it.

• Dental abscesses that have extended to the floor of the mouth or to the neck can threaten a person’s airway and ability to  breathe and may be life-threatening unless they are properly drained.

Abscess

(continued)

When to Seek Medical Care

Call your doctor if any of the following occur with an abscess:

• You have a sore larger than 1 cm or a half-inch across.

• The sore continues to enlarge or becomes more painful.

• The sore is on or near your rectal or groin area.

• You have a fever of 101.5°F or higher.

• You have a red streak going away from the abscess.

• You have any of the conditions listed above.

Go to a hospital’s Emergency Department if any of these conditions occur with an abscess:

• Fever of 102°F or higher, especially if you have a chronic disease or are on steroids, chemotherapy, or dialysis

• A red streak leading away from the sore or with tender lymph nodes (lumps) in an area anywhere between the abscess and your chest area (for example, an abscess on your leg can cause swollen lymph nodes in your groin area)

• Any facial abscess larger than 1 cm or a half-inch across

Exams and Tests

The doctor will take a medical history and ask for information about the following:

• How long the abscess has been present

• If you recall any injury to that area

• What medicines you may be taking

• If you have any allergies

• If you have had a fever at home

• The doctor will examine the abscess and surrounding areas. If it is near your anus, the doctor will perform a rectal exam. If an arm or leg is involved, the doctor will feel for a lymph gland either in your groin or under your arm.

Medical Treatment

The doctor may open and drain the abscess.

• The area around the abscess will be numbed with medication.

• It is often difficult to completely numb the area, but in general local anesthesia can make the procedure almost painless.

• You may be given some type of sedative if the abscess is large.

• The area will be covered with an antiseptic solution and sterile towels placed around it.

• The doctor will cut open the abscess and totally drain it of pus and debris.

• Once the sore has drained, the doctor will insert some packing into the remaining cavity to minimize any bleeding and keep it open for a day or two.

• A bandage will then be placed over the packing, and you will be given instructions about home care.

• Most people feel better immediately after the abscess is drained.

• If you are still experiencing pain, the doctor may prescribe pain pills for home use over the next 1-2 days.

Next Steps: Follow-up

Follow carefully any instructions your doctor gives you.

• The doctor may have you remove the packing yourself with instructions on the best way to do this. This may include soaking or flushing.

• Be sure to keep all follow-up appointments.

• Report any fever, redness, swelling, or increased pain to your doctor immediately.

 

Abscess

(continued)

Prevention

Maintain good personal hygiene by washing your skin with soap and water regularly.

• Take care to avoid nicking yourself when shaving your underarms or pubic area.

• Seek immediate medical attention for any puncture wounds, especially if:

• You think there may be some debris in the wound

• You have one of the listed medical conditions

• You are on steroids or chemotherapy

Outlook

Once treated, the abscess should heal.

• Many people do not require antibiotics.

• The pain often improves immediately and subsides more each day.

• Wound care instructions from your doctor may include wound repacking, soaking, washing, or bandaging for about 7 to 10 days. This usually depends on the size and severity of the abscess.

• After the first 2 days, drainage from the abscess should be minimal to none. All sores should heal in 10-14 days.

Synonyms and Keywords

abscess, abscesses, boils, carbuncles, furuncles, hidradenitis suppurativa, pilonidal abscess, pustules, whiteheads

 

 

How physiotherapy works 

The aim of physiotherapy is to help restore movement and normal body function in cases of illness, injury and disability.

As well as treating a specific problem, your physiotherapist may also suggest ways you can improve your general wellbeing – for example, by taking regular exercise and maintaining a healthy weight for your height and build. 

Physiotherapists take a holistic approach, looking at the body as a whole rather than focusing on the individual factors of an injury or illness.

For example, back pain can be caused by a number of different things, including:

• poor posture

• inherited spinal deformity

• bending or twisting awkwardly

• overstretching

• standing for long periods

• lifting or carrying objects incorrectly

A physiotherapist will look at your individual situation. As well as treating the problem, they may also suggest things you can do on a daily basis to help relieve pain and discomfort.

For example, if you have lower back pain, maintaining good posture and doing core stability exercises to strengthen stomach and lower back muscles may help.

Read more about treating back pain.

Physiotherapy approaches

Physiotherapists use a wide range of treatment techniques and approaches. Some of these are described below.

Movement and exercise

Physiotherapists use therapeutic exercises designed to strengthen the affected body area. They need to be repeated regularly, usually daily, for a set number of weeks.

As well as specific exercises, gentle activities such as walking or swimming may be recommended if you are recovering from an operation or sports injury that affects your mobility.

For someone with a mobility problem caused by a condition such as a stroke, a physiotherapist may suggest doing exercise that targets the affected area of the body.

For example, studies have shown that circuit class therapy is an effective method of rehabilitation after a stroke. Compared with other types of exercise, it can help improve a person’s ability to walk further, longer and faster, as well as help with their balance.

There is also strong evidence to show physical activity can help manage and prevent more than 20 different health conditions. For example, physically active adults have been shown to have a significantly lower risk (up to 50%) of developing major health conditions such as coronary heart disease, stroke, diabetes and cancer.

Manual therapy techniques

Manual therapy involves using the hands to mobilise joints and soft tissues. It is suitable for most people and can be used to:

• improve blood circulation

• help fluid drain from parts of the body more efficiently

• improve movement of different parts of the body

• relieve pain and help relaxation

There is evidence to show manual therapy is beneficial in treating some types of musculoskeletal conditions, such as long-term back pain (where the pain lasts for longer than six weeks).

For example, the National Institute for Health and Clinical Excellence (NICE) advises that manual therapy can be used to treat persistent lower back pain.

In appropriate cases, massage may also be used as part of your treatment programme. Evidence suggests massage can be useful for a range of health conditions, including helping to reduce some of the symptoms of cancer and the side effects of cancer treatment.

A three-year-long American study carried out in 2004 looked at the effects of massage therapy on 1,300 people with cancer. Results showed that massage therapy significantly reduced the symptoms of pain, sickness, tiredness, anxiety and depression in all participants.

Other techniques

Other techniques that can help to ease pain and promote healing include:

• acupuncture – fine needles are inserted into specific points of the body. Acupuncture may be used alongside other physiotherapy techniques to help reduce tissue inflammation and pain, and to promote recovery.

• transcutaneous electrical nerve stimulation (TENS) – a TENS machine is a small, battery-operated machine that delivers an electric current to the affected area via two electrodes. The tingling sensation produced by the current can help block or suppress pain signals to your brain.

• ultrasound – high-frequency sound waves can treat deep tissue injuries by stimulating blood circulation and cell activity. It is thought it can help reduce pain and muscle spasm, as well as speed up healing.

Scientific evidence to support the above treatments is limited. For example, there is not enough firm evidence to say for sure whether TENS is a reliable method of pain relief.

Some people have reported that TENS has been effective for them, but it seems to depend on the condition and the individual. TENS is not suitable for people with a pacemaker or other type of electrical implant.

Aquatic therapy (hydrotherapy)

Aquatic therapy is a form of physiotherapy carried out in water – usually a warm, shallow swimming pool or special hydrotherapy pool. It is often used with children and adults who have physical and learning disabilities.

Aquatic therapy can improve blood circulation, relieve pain and relax muscles.

As with other treatment techniques, aquatic therapy may prove beneficial in certain cases, but again there is limited evidence to show that it is an effective method of pain relief in all cases.

Ultrasound in Physiotherapy

Ultrasound is high frequency sound waves, greater than 20,000 Hz.  Therapeutic ultrasound is in the frequency range  of 0.9 – 3 MHz.
The utilization of ultrasound has been a 20th century phenomenon.  In addition to its use by the military to detect submarines, it was also used in the 1930’s  for emulsification, and atomization of particles in a gas.  Since then, ultrasound  has been used therapeutically for its effects of cavitation, stable and unstable bubble formation, and a phenomenon called acoustic streaming or microstreaming.

Ultrasound is used to:

• break up scar tissue and adhesions

• reduce inflammation, swelling and calcium deposits

• create a deep heat to a localized area to ease muscle spasms (much deeper than can be achieved with a hot pack – up to 5 cm) 

• increase soft tissue extensibility prior to stretching and exercise

• facilitate healing at the cellular level

• speeds metabolism and improves blood flow

• reduces nerve root irritation

• at low intensities can speed bone healing

• enhance transcutaneous drug delivery by phonophoresis

The main piece of equipment is a high-frequency generator, which provides an electrical current through a cable to a transducer which contains a piezoelectric crystal. This crystal when exposed to the current will vibrate at a given frequency,  expanding and contracting, which produces the necessary compression wave.  By using a different frequency  the therapist can target tissues at different depths for either healing or destruction,  or simply use the device to reduce pain. Although simple in principle, the use of ultrasound as a therapeutic modality requires a comprehensive  understanding of its effects on the body tissues and of the physical mechanisms by which its effects are produced.  The lower the frequency used, the deeper is the penetration of the waves into the body. By varying the frequency from continuous to intermittent, the amount of heat applied can likewise be controlled by the physiotherapist.

For instance, contusions are one of the most frequent and debilitating injuries encountered in sports medicine. Although contusions may be caused by shearing and tension between over-stressed body parts, the most common cause is compression of soft tissue, usually when it is crushed between bone and some hard surface. This almost invariably involves capillary rupture and infiltrative bleeding, followed by edema and inflammation.  This usually involves hematoma  or “pooling” of blood, and occasionally myositis ossificans can result as a complication if not treated. This is a  syndrome in which the body starts laying down painful calcium deposits within the muscle.  Quick and effective treatment is crucial in sports injuries. Proper and efficient healing is essential to the health and career of any athlete, regardless of how minor or major the injury. Basic treatment involves the application of ice to contain the immediate inflammation, followed by timely applications of ultrasound to reduce the subsequent edema and further stimulate the healing process.

Ultrasound is effective in treating wounds in both the inflammatory and the proliferative stages. Ultrasound causes a degranulation of mast cells resulting in the release of histamine. Histamine and other chemical mediators released from the mast cell are felt to play a role in attracting neutrophils and monocytes to the injured site. These and other events appear to accelerate the acute inflammatory phase and promote healing.

In the proliferative phase of healing, ultrasound effects fibroblasts and stimulates them to secrete collagen. This accelerates the process of wound contraction and increases the tensile strength of the healing tissue.  Connective tissues will elongate better if both heat and stretch are applied. Continuous ultrasound at higher therapeutic intensities provides an effective means of heating deeper tissues prior to stretching them.
Its effectiveness has been enhanced over the years by studies which help determine optimum techniques and patterns of application, and a wide range of injuries have shown to be responsive to this  non-invasive therapy.

Treatment of Pain and Inflammation

herapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include heat therapy, cold therapy, electrical stimulation, traction, massage, and acupuncture. For therapists, whether to use heat or cold therapy is often a personal choice, although cold therapy seems to be more effective for acute pain.

Heat therapy:

Heat increases blood flow and makes connective tissue more flexible. It temporarily decreases joint stiffness, pain, and muscle spasms. Heat also helps reduce inflammation and the buildup of fluid in tissues (edema). Heat therapy is used to treat inflammation (including various forms of arthritis), muscle spasm, and injuries such as sprains and strains.

Heat may be applied to the body’s surface or to deep tissues. Hot packs, infrared heat, paraffin (heated wax) baths, and hydrotherapy (agitated warm water) provide surface heat. Heat may be generated in deep tissues by electric currents (diathermy) or high-frequency sound waves (ultrasound).

 

Cold therapy (cryotherapy):

Applying cold may help numb tissues and relieve muscle spasms, acute low back pain, and acute inflammation. Cold may be applied using an ice bag, a cold pack, or fluids (such as ethyl chloride) that cool by evaporation. The therapist limits the time and amount of cold exposure to avoid damaging tissues and reducing body temperature (causing hypothermia). Cold is not applied to tissues with a reduced blood supply (for example, when the arteries are narrowed by peripheral arterial disease).

Electrical stimulation:

If muscles lack proper nerve input (because of a peripheral nerve injury, spinal cord disorder, or stroke), the muscles quickly waste away (atrophy), and become stiff and contracted (spastic). Electrical stimulation by electrodes placed on the skin causes the muscles to contract, providing a form of exercise that helps prevent atrophy and spasticity.

One form of electrical stimulation—called transcutaneous electrical nerve stimulation (TENS)—uses low current that does not cause muscles to contract. TENS may be useful for chronic back pain, rheumatoid arthritis, a sprained ankle, shingles, or a localized area of pain. For TENS, a handheld, battery-powered device produces the current, which is applied through electrodes placed on the skin. The device produces a tingling sensation but is not painful.

TENS may be applied several times a day for 20 minutes to several hours, depending on the severity of the pain. Often, people can be taught to use the TENS device at home as needed. Most people tolerate the therapy well, but not all people experience pain relief. TENS may cause abnormal heart rhythms (arrhythmias). Thus, people who have a severe heart disorder or a pacemaker should not use it. TENS should not be applied to or near the eyes.

Traction:

Neck (cervical) traction may be used in a hospital, rehabilitation center, or at home to treat chronic neck pain due to cervical spondylosis, disk prolapse, whiplash injuries, or torticollis. Traction is more effective when people are sitting than when they are lying in bed. A system that uses a motor is usually most effective. Typically, traction is combined with other physical therapy, including exercises and manual stretching. Although cervical traction devices are available through consumer catalogues, therapists should select the type of device and determine the amount of weight to be used. People should not use such devices alone. A family member should be available to release the weight gently, which reduces the risk of injury.

Massage:

Massage may relieve pain, reduce swelling, and help loosen tight (contracted) tissue. Only a licensed massage therapist should perform massage for treatment of an injury. Massage should not be used to treat infections or thrombophlebitis.

Acupuncture:

Thieedles are inserted through the skin at specific body sites, often far from the site of pain. The needles may be twirled rapidly and intermittently for a few minutes, or a low electric current is applied through the needles. Acupuncture may stimulate the brain to produce endorphins. Endorphins, produced naturally in the brain, block pain sensations and reduce inflammation (see Complementary and Alternative Medicine (CAM): Acupuncture). Acupuncture is sometimes used with other treatments to manage chronic pain and to help with rehabilitation after stroke. Acupuncture should be done by a certified acupuncturist and with sterile needles.