Fiddler's neck is an

occupational disease An occupational disease or industrial disease is any chronic ailment that occurs as a result of work or occupational activity. It is an aspect of occupational safety and health. An occupational disease is typically identified when it is shown th ...

that affects

violin The violin, sometimes referred to as a fiddle, is a wooden chordophone, and is the smallest, and thus highest-pitched instrument (soprano) in regular use in the violin family. Smaller violin-type instruments exist, including the violino picc ...

and

viola The viola ( , () ) is a string instrument of the violin family, and is usually bowed when played. Violas are slightly larger than violins, and have a lower and deeper sound. Since the 18th century, it has been the middle or alto voice of the ...

players. It is a

cutaneous condition A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this sys ...

usually characterized by redness, thickening, and inflammation on the left side of the neck below the angle of the jaw where the instrument is held.

Acne Acne ( ), also known as ''acne vulgaris'', is a long-term Cutaneous condition, skin condition that occurs when Keratinocyte, dead skin cells and Sebum, oil from the skin clog hair follicles. Typical features of the condition include comedo, ...

-like lesions and

cysts A cyst is a closed Wikt:sac, sac, having a distinct Cell envelope, envelope and cell division, division compared with the nearby Biological tissue, tissue. Hence, it is a cluster of Cell (biology), cells that have grouped together to form a sac ...

may form at the site due to foreign body reactions, and infections may also occur due to poor hygiene. The primary causes of fiddler's neck are constant friction and local pressure. It is well known among professional

orchestra An orchestra (; ) is a large instrumental ensemble typical of classical music, which combines instruments from different families. There are typically four main sections of instruments: * String instruments, such as the violin, viola, cello, ...

musicians but is "not well recognized by dermatologists", and a red mark on the left side of the neck under the jaw "functions as an identifying sign" of a violinist or violist "in public without seeing the instrument"''.'' Although the presence of fiddler's neck is sometimes used as an indicator of a violinist's skill, or 'battle scars' from constant practice, many violinists never develop fiddler's neck, due to differences in skin sensitivity, playing habits, and the materials used in the construction of the instrument. An accomplished professional player could practice hard their whole life and never develop fiddler's neck.

Signs and symptoms

Fiddler's neck usually involves highly localized lichenification, mild

hyperpigmentation Hyperpigmentation, also known as the dark spots or circles on the skin, is the darkening of an area of Human skin, skin or nail (anatomy), nails caused by increased melanin. Causes Hyperpigmentation can be caused by sun damage, inflammation, or ...

, and

erythema Erythema (, ) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not associated with pathology inc ...

where the chin rest or instrument body presses against the skin of the neck. Other signs and symptoms include scale buildup,

cyst A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubb ...

and

scar A scar (or scar tissue) is an area of fibrosis, fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other Organ (anatomy), organs, and biological tissue, t ...

formation,

papules A papule is a small, well-defined bump in the skin. It may have a rounded, pointed or flat top, and may have a dip. It can appear with a stalk, be thread-like or look warty. It can be soft or firm and its surface may be rough or smooth. Some ...

and pustules related to local infection, and focal

edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...

. In Blum & Ritter's study in West Germany (1990), they found that 27% of their population had only minor issues, 72% had a palpable mass at the site, and 23% reported pain and other signs of inflammation such as

hyperthermia Hyperthermia, also known as overheating, is a condition in which an individual's body temperature is elevated beyond normal due to failed thermoregulation. The person's body produces or absorbs more heat than it dissipates. When extreme te ...

, pulsation, and cystic, pustular, or papular lesions. Size of masses were an average of 2 cm in diameter ranging up to 4 cm, some being associated with purulent drainage, continuous discharge, and crusting. Dystrophic calcinosis cutis has also been reported. Other serious sequelae include sialolithiasis of the

submandibular gland The paired submandibular glands (historically known as submaxillary glands) are major salivary glands located beneath the floor of the mouth. In adult humans, they each weigh about 15 grams and contribute some 60–67% of unstimulated saliva sec ...

and adenolymphoma of the

parotid gland The parotid gland is a major salivary gland in many animals. In humans, the two parotid glands are present on either side of the mouth and in front of both ears. They are the largest of the salivary glands. Each parotid is wrapped around the m ...

. The

histopathology Histopathology (compound of three Greek words: 'tissue', 'suffering', and '' -logia'' 'study of') is the microscopic examination of tissue in order to study the manifestations of disease. Specifically, in clinical medicine, histopatholog ...

of fiddler's neck frequently shows

hyperkeratosis Hyperkeratosis is thickening of the stratum corneum (the outermost layer of the epidermis, or skin), often associated with the presence of an abnormal quantity of keratin,Kumar, Vinay; Fausto, Nelso; Abbas, Abul (2004) ''Robbins & Cotran Pathol ...

and

acanthosis The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and hypodermis. The epidermal layer provides a barrier to infection from environmental pathogens and regulates the amount of water relea ...

, along with plugging of follicles. Histiocytic infiltration with granulomas to foreign body and follicular cysts are also common. Foreign body granulomas are thought to derive from abrasion of the wooden surface of the chin rest and its absorption into the superficial dermis. The location and complex mechanism of causation for fiddler's neck give rise to a wider spectrum of skin changes when compared to contact dermatitis from more common irritants. Fiddler's neck can be differentiated from

rosacea Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, en ...

and sarcoid reaction with granulomas.

Causes

The proximal causes of fiddler's neck are friction and pressure, but both repetitive shearing stress and occlusion with consequent trapping of sweat give rise to progressive damage. This damage along with poor hygiene predisposes the area to local infection, and such infection can progress to scarring and other long-term effects. Hot weather is reported to exacerbate fiddler's neck, as are tiredness, playing emotional music, and playing in smaller groups where individual stress is higher.

Type I hypersensitivity Type I hypersensitivity (or immediate hypersensitivity), in the Hypersensitivity, Gell and Coombs classification of allergic reactions, is an allergic reaction provoked by re-exposure to a specific type of antigen referred to as an allergen. Type ...

reactions may also be involved, particularly to

rosewood Rosewood is any of a number of richly hued hardwoods, often brownish with darker veining, but found in other colours. It is hard, tough, strong, and dense. True rosewoods come from trees of the genus '' Dalbergia'', but other woods are often ca ...

and

ebony Ebony is a dense black/brown hardwood, coming from several species in the genus '' Diospyros'', which also includes the persimmon tree. A few ''Diospyros'' species, such as macassar and mun ebony, are dense enough to sink in water. Ebony is fin ...

in the chinrest and tailpiece, as well as to

varnish Varnish is a clear Transparency (optics), transparent hard protective coating or film. It is not to be confused with wood stain. It usually has a yellowish shade due to the manufacturing process and materials used, but it may also be pigmente ...

of the instrument body when chinrests are not used and to

rosin Rosin (), also known as colophony or Greek pitch (), is a resinous material obtained from pine trees and other plants, mostly conifers. The primary components of rosin are diterpenoids, i.e., C20 carboxylic acids. Rosin consists mainly of r ...

deposits on the instrument and on chin cloths. Nickel or other metal allergies are common causes if the chin rest has a metal clip that comes into constant contact with the skin. Rosin exposure in particular may lead to abietic acid dermatitis.

Diagnosis

Differential diagnoses

The differential diagnoses of fiddler's neck include

branchial cleft cyst A branchial cleft cyst or simply branchial cyst is a cyst as a swelling in the upper part of neck anterior to sternocleidomastoid. It can, but does not necessarily, have an opening to the skin surface, called a fistula. The cause is usually a devel ...

, disease of the

salivary glands The salivary glands in many vertebrates including mammals are exocrine glands that produce saliva through a system of Duct (anatomy), ducts. Humans have three paired major salivary glands (Parotid gland, parotid, Submandibular gland, submandibula ...

, tumors of the

psoriasis Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by patches of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small localized patches to complete b ...

lichen planus Lichen planus (LP) is a chronic inflammatory and autoimmune disease that affects the skin, nails, hair, and mucous membranes. It is not an actual lichen, but is named for its appearance. It is characterized by polygonal, flat-topped, violaceous p ...

contact dermatitis Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes ...

herpes simplex Herpes simplex, often known simply as herpes, is a viral disease, viral infection caused by the herpes simplex virus. Herpes infections are categorized by the area of the body that is infected. The two major types of herpes are Cold sore, ora ...

and similar infections, and

insect bites and stings Insects (from Latin ') are hexapod invertebrates of the class Insecta. They are the largest group within the arthropod phylum. Insects have a chitinous exoskeleton, a three-part body (head, thorax and abdomen), three pairs of jointed legs ...

especially from fleas.

Treatment

Treatment for fiddler's neck is unnecessary if it is painless and shows minimal swelling, particularly since minor cases are taken as a mark of pride. But fiddler's neck may lead to worse disorders. The primary methods of treatment involve adjustments to playing of the instrument: * good hygiene for the affected area and for the instrument * use of a clean

cotton Cotton (), first recorded in ancient India, is a soft, fluffy staple fiber that grows in a boll, or protective case, around the seeds of the cotton plants of the genus '' Gossypium'' in the mallow family Malvaceae. The fiber is almost pure ...

cloth that is changed frequently *use of a comfortable pad to absorb sweat and reduce friction between the instrument and skin * use of a shoulder rest to reduce pressure below the jaw * a suitable chin rest, especially one carved or molded for the individual * covering or changing potentially allergenic materials on the instrument. * shifting the chin rest to the center of the body over the tailpiece * smoothing coarse surfaces to reduce abrasion * for males, growing a beard to avoid folliculitis

Surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

is necessary for sialolithiasis, parotid tumors, and cysts.

Cervical lymph nodes Cervical lymph nodes are lymph nodes found in the neck. Of the 800 lymph nodes in the human body, 300 are in the neck. Cervical lymph nodes are subject to a number of different pathological conditions including tumours, infection and inflamma ...

that are larger than 1 cm must be biopsied. Connective tissue can be removed by excision when a non-inflamed mass is large, and there is generally little recurrence. Infections should be treated conservatively, and causative species should be identified through smear and culture for appropriate antibiotic selection. Reduction of playing time may be helpful for cases without inflammation, but in 30% of cases this did not improve the symptoms.

Prevalence

Fiddler's neck does not usually form unless the musician is practicing or playing for more than a few hours each day, and only seems to develop after a few years of serious playing. Thus, when not infected or otherwise problematic, fiddler's neck may be known as a benign ''practice mark'' and may be worn proudly as an indication of long hours of practice. Blum & Ritter (1990) found that 62% of 523 professional violinists and violists in

West Germany West Germany was the common English name for the Federal Republic of Germany (FRG) from its formation on 23 May 1949 until German reunification, its reunification with East Germany on 3 October 1990. It is sometimes known as the Bonn Republi ...

experienced fiddler's neck, with the percentage among violists being higher (67%) than among violinists (59%). Viola players are believed to be more predisposed to developing fiddler's neck than violinists because the viola is larger and heavier, but this has not been empirically confirmed. The development of fiddler's neck does not depend on preexisting skin problems, and Blum & Ritter find that only 23% of men and 14% of women in their study reported cutaneous disorders in other parts of the face (mainly acne and

eczema Dermatitis is a term used for different types of skin inflammation, typically characterized by itchiness, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened ...

) that were independent of playing the violin or viola. Fiddler's neck may exacerbate existing acne, but acne may also be limited solely to the lesion and not appear elsewhere. Nonetheless, musicians with underlying dermatologic diseases like acne and eczema are more endangered by fiddler's neck than others. Males may develop

folliculitis Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on hair-covered skin. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head. A ...

boils A boil, also called a furuncle, is a deep folliculitis, which is an infection of the hair follicle. It is most commonly caused by infection by the bacterium ''Staphylococcus aureus'', resulting in a painful swollen area on the skin caused by an ...

due to involvement of

beard A beard is the hair that grows on the jaw, chin, upper lip, lower lip, cheeks, and neck of humans and some non-human animals. In humans, beards are most commonly seen on pubescent or adult males, though women have been observed with beards ...

hair.

References

External links

{{Occupational safety and health Occupational diseases Violins