How do I differentiate between a cervical abscess and scrofula in a patient presenting with a neck mass?

Differentiating Cervical Abscess from Scrofula

A tender, rapidly enlarging neck mass with fever and acute symptoms suggests a cervical abscess, while scrofula (tuberculous lymphadenitis) typically presents as a painless, slowly progressive mass with minimal constitutional symptoms, though these features can overlap and require systematic evaluation.

Key Clinical Distinguishing Features

Cervical Abscess Presentation

• Acute onset with rapid enlargement over days 1
• Tender to palpation - tenderness strongly suggests inflammatory/infectious process rather than malignancy 1
• Fever >101°F commonly present 1
• Associated symptoms: neck pain, throat pain, difficulty swallowing 1
• Skin changes: erythema, warmth, fluctuance 2
• Often follows recent upper respiratory infection or dental infection 1

Scrofula (Tuberculous Lymphadenitis) Presentation

• Insidious onset with slow progression over weeks to months 3, 4, 5
• Painless or minimally tender mass 4, 5
• Constitutional symptoms often absent in modern presentations 5
• Multiple matted nodes more common than single discrete node 5
• Upper deep jugular chain most frequently affected 5
• Classic "cold abscess" with discharging sinus is now uncommon due to earlier presentation 5
• Risk factors: HIV/immunosuppression, recent immigration from endemic areas (Southeast Asia, Mexico), minorities 3, 6

Diagnostic Algorithm

Initial Clinical Assessment

• Complete head and neck examination including oral cavity, oropharynx, and scalp inspection for primary infection source 1
• Palpate for mass characteristics: size, consistency, mobility, tenderness, fluctuance 1
• Assess for systemic symptoms: fever, weight loss, night sweats 1, 6
• Risk factor assessment: TB exposure, HIV status, immigration history, immunosuppression 3, 6, 4

First-Line Imaging

• Contrast-enhanced CT neck is the preferred initial imaging modality for adult neck masses, particularly when infection or malignancy is suspected 1
• CT findings for abscess: rim enhancement, central low attenuation, perilesional inflammation 7
• CT can identify dental source and evaluate extent of deep neck infection 1
• Ultrasound may be sufficient for superficial infections and can guide aspiration 2

Diagnostic Testing for Scrofula

• Tuberculin skin test (Mantoux): positive in 92% of tuberculous cervical adenitis cases, typically >15mm 4, 5
• Chest radiograph: abnormal in only 14-16% of cervical TB cases 4, 5
• Fine needle aspiration (FNA): first-line tissue diagnosis with high sensitivity 1, 4, 5
  • Positive diagnosis in 93% of tuberculous adenitis (52/56 patients) 5
  • Should be performed with ultrasound guidance if available 1
• Mycobacterial culture: grows Mycobacterium tuberculosis in 50% of cases but takes weeks 4
• Histopathology: shows caseating granulomas, diagnostic in nearly all cases 4

Critical Management Distinctions

Cervical Abscess Management

• Broad-spectrum antibiotics covering oral and skin flora immediately 2, 7
• Aspiration or surgical drainage if abscess confirmed on imaging 2, 7
• Rapid clinical improvement expected within 2-3 weeks 1

Scrofula Management

• Tuberculous cervical adenitis: responds to 6-month short-course antituberculous chemotherapy 5
• Atypical mycobacterial adenitis: may require surgical excision as primary treatment 3, 8
• Critical distinction: M. tuberculosis vs atypical mycobacteria determines medical vs surgical approach 3, 8
• Surgery rarely needed for tuberculous adenitis except for diagnostic excision biopsy 5
• Wide-bore needle aspiration preferred over incision and drainage for abscesses 5

Common Pitfalls to Avoid

• Assuming all tender masses are simple abscesses: scrofula can present with pain and rapid enlargement when complicated by secondary infection 6, 4
• Missing tuberculosis in the differential: the classic "scrofula" presentation with cold abscess and discharging sinus is now rare due to earlier presentation 5
• Delaying FNA: this should be performed early as first-line histologic assessment for any persistent neck mass 1, 4
• Inappropriate incision and drainage: for tuberculous adenitis, this can lead to chronic draining sinuses and should be avoided 8, 5
• Assuming negative chest X-ray excludes TB: 84-86% of cervical TB patients have normal chest radiographs 4, 5

When to Suspect Scrofula Over Simple Abscess

• Mass persists or enlarges despite appropriate antibiotic therapy for presumed bacterial infection 1
• Painless or minimally tender mass in high-risk patient (HIV, immigrant from endemic area) 3, 6
• Multiple matted nodes without clear acute infectious source 5
• Positive tuberculin test with neck mass 4, 5
• FNA showing granulomatous inflammation 4, 5