The patient came to the clinic 29-August-2018 with a huge mass in the right side of the neck for 4 months, which is growing in size. CT-scan bad quality performed 04-July-2018 showing the mass lateral to the right ICA.

On examination: The patient is neurologically free, except for the pain due to mass effect. 50 cc of the fluid compartment was evacuated and sent for thorough investigations without conclusive results. The patient was empirically covered with antibiotics.

The patient was thoroughly investigated and MRI of the brain was uneventful. MRI of the soft tissues of the cervical spine showing the mass with the ICA and external jugular veins pushed medially. The patient then came 19-January-2019 telling that the mass reappeared the last month and 25 ml was evacuated and Vancomycin injected to the cavity and covered with antibiotics. The patient then came 01-February-2020 with mass growing the last 3 weeks and the mass is bigger than before reaching the lower edge of the right mandible with pain. The wall of the mass now thick and around 15 ml of thick fluid was sent for histology. It was 80x66 mm in diameter with thick capsule. The histology could give the conclusion, that it is actinomyces infection with sulphur granules formation. New MRI with contrast with MRA of the cervical spine were requested.

Incision over the the mass above and parallel to one of near by passing creases. The capsule of the mass is severely adherent to the surrounding structures, for what sharp dissection of the medial part and separation of right ICA and EJV was anticipated. The running above the right accessory nerve was dissected and preserved. The deeply pushed hypoglossal nerve was preserved. Total resection of the mass was achieved. Routine closure of the wound.

Smooth postoperative recovery. The hypoglossal and accessory nerves working properly.

The conservative treatment was failed and surgical removal of the lesion was necessary to prevent dissemination of the lesion to other organs.

The surrounding inflammatory process caused massive adhesions around the mass, making it difficult and challenging to dissect and preserve important anatomical structures.