Tuberculosis remains a major global health problem and persistent lymphadenitis or incorrect treatment may result in sinus formation. We present a case of a large anterior neck sinus caused by tuberculous lymphadenitis. We designed an anterolateral thigh myocutaneous flap with 6 × 5 cm of skin and 10 × 7 cm of muscle for the reconstruction of the large sinus. The descending branch of the lateral circumflex femoral artery and 2 venae comitantes were anastomosed with superior thyroid arteries and two anterior neck veins. The patient experienced complete survival of the flap and did not complain of any discomfort. The donor site healed well, and weakness of the lower limb was absent. In conclusion, an anterolateral thigh myocutaneous flap is a good choice for the reconstruction of a neck sinus caused by tuberculous lymphadenitis.
Tuberculosis (TB) is the second most common infectious disease associated with mortality worldwide [1, 2]. The World Health Organization estimates that two billion people in the world have latent TB, and up to 3 million people die of TB every year . The most common extrapulmonary manifestation of this disease still occurs in peripheral lymph nodes [2, 4]. Cervical lymph nodes are the most commonly involved and is the sole site involved in 25–35% of cases . Persistent lymphadenitis may result in abscess and chronic sinus formation, termed scrofula, and may persist despite appropriate anti-tuberculous treatment . In adult patients, some authorities recommend excisional surgery as the primary approach for diagnosis and cure . We present a rare case of a 46-year-old man with a large anterior neck sinus caused by tuberculous lymphadenitis, which was repaired using an anterolateral thigh (ALT) myocutaneous flap.
A 46-year-old man presented to our hospital for the treatment of a large anterior neck sinus. He was diagnosed with pulmonary TB and cervical lymphadenitis in a secondary low-volume institution 26 years ago. Excision was performed for the involved cervical lymph nodes; however, the incision failed to heal after the surgery, and the wound discharged a large amount of thick, putrid, and purulent fluid. The wound healed following dressing changes for more than one year, but a large sinus formed.
Physical examination revealed a large anterior neck sinus superior to the suprasternal notch. The wall of the sinus was epithelialized with a black-brown epidermis, which was thin and movable, and a strong pulse was visible (Fig. 1a and Online Resource 1). The water filling test demonstrated that the sinus volume was 50 ml (Online Resource 2). Computed tomography (CT) revealed a large cavity posterior to the sternum, and the trachea, brachiocephalic artery, right common carotid artery and left common carotid artery constituted the back wall of the sinus (Fig. 2a and b). He had no other systemic complaints, no current medical issues, and no allergies; he was also not taking any medications.
An ALT myocutaneous flap was used for the reconstruction of the neck sinus. The perforator was detected with a handheld Doppler device before the operation. We designed the myocutaneous flap to increase the flap bulk to 6 × 5 cm of skin and 10 × 7 cm of muscle (Fig. 3a). The descending branch of the lateral circumflex femoral artery and 2 venae comitantes were isolated and transected (Fig. 3b). Superior thyroid arteries and two anterior neck veins were used as donor vessels (Fig. 3c). Anastomosis of the artery was performed first, followed by anastomosis of the vein. The epidermis of the sinus was excised, and the muscle tissue was used to fill the large dead space; the skin of flap was sutured to the surrounding skin.
The patient experienced complete survival of the flap with no complications (Fig. 1b). Swallowing, breathing and neck movement were normal. He did not complain of any discomfort, and the flap color matched the color of the recipient site. CT revealed that the cavity located posterior to the sternum disappeared without the presence of a dead space (Fig. 2c). After 3 months, a shallow pit formed due to atrophy of the myocutaneous flap atrophy (Fig. 1c); the water filling test revealed that the pit volume was 5 ml, which suggested that the tissue atrophy rate was 10%. Donor site defect was closed primarily and healed well with slight scarring 3 months after surgery. Although some portions of the vastus lateralis muscle were raised, weakness of the lower limb was absent. Other donor site morbidities, such as dog ears, numbness, compartment syndrome, and muscle herniation, were absent.
However, surgery, without the use of rifampicin and pyrazinamide, was one of the preferred treatments for peripheral lymph node TB until the early 1990s [3, 6, 7]. In 1997, the World Health Organization recommended a six-month regimen for the treatment of patients with category III TB, which includes lymph node TB; subsequently, reports concerning the use of surgery for the treatment of cervical tuberculous lymphadenitis after 1993 have been absent . In our case, a large sinus formed and failed to heal after surgery. A neck sinus caused by lymphadenitis is usually located adjacent to the main neck vessels, and it easily to results in massive hemorrhage, because of accidental vessel rupture. Therefore, it is necessary to repair the neck sinus.
In 1984, Song et al. were the first to report the ALT flap, and they described their experience in the treatment of patients with had head and neck burn contractures . Since then, the ALT flap has gradually become popular and workhorse for reconstruction in the head and neck area for many microsurgeons worldwide, especially in Asia . The following are some of the reasons for the increasing popularity of the ALT flap for soft tissue reconstruction: it can be easily harvested, and it has low donor site morbidity, versatility, excellent tissue volume of tissue, and a generous pedicle length and diameter [10,11,12,13]. The flap may be designed as a myocutaneous, fasciocutaneous, adipofascial, or even a suprafascial flap resulting in its multiple applications . Wei et al.  reported their experience with 672 ALT flaps, which represents the largest series to date, and demonstrated the reliability of the technique.
The widespread use of ALT flaps in the Caucasian population is limited because of the increased thickness of the subcutaneous layer of the thigh due to obesity . In our study, the patient was very thin (weight: 175 cm, height:58.5 kg), which may have been caused by TB; since the sinus was large, we had to engineer a myocutaneous flap using a portion of the vastus lateralis muscle to increase the flap bulk. The nerve that supplied the vastus lateralis muscle and origins and terminations losted. Therefore, the flap atrophied by approximately 10%, thus forming a shallow pit three months after surgery. We suggest that the tissue volume should be 10% larger than the sinus volume.
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This work was funded by grants from the National Natural Science Foundation of China (81801925).
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Electronic supplementary material
The large anterior neck sinus. The sinus was superior to the suprasternal notch, and a strong pulse was visible. (WMV 1350 kb)
The water filling test. The sinus volume was measured by a water filling test, and the result showed that the volume was 50 ml. (WMV 2119 kb)
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Jiao, H., Liu, L., Gan, C. et al. Anterolateral Thigh Myocutaneous Flap for Reconstruction of a Large Anterior Neck Sinus Caused by Tuberculous Lymphadenitis: a Case Report. SN Compr. Clin. Med. (2020) doi:10.1007/s42399-019-00152-8
- Anterolateral thigh myocutaneous flap