Fiddler's Neck: A Review

Abstract

Fiddler's neck is a common dermatologic condition associated with instrument use in violin and viola players. It typically manifests as a submandibular and/or supraclavicular lesion. It is a benign condition, but it may be mistaken for lymph-edema or a salivary gland malignancy. Otolaryngologists who treat patients with fiddler's neck should be aware of appropriate management protocols and the need to avoid surgical excision. We obtained informed consent from 3 violinists to present their cases as specific examples of fiddler's neck. In addition, we present a literature review based on our PubMed search for articles about this instrument-induced dermatitis. The literature suggests that submandibular fiddler's neck is caused by mechanical pressure and shear stress on the skin and that it can present as erythema, scarring, edema, and lichenification. Supraclavicular fiddler's neck, on the other hand, is caused by allergic contact dermatitis, and it can present as an eczematous, scaly, and/or vesicular lesion. In most cases, a good history (especially of string instrument use), physical examination, and a patch test are sufficient to diagnose this condition. Management of fiddler's neck includes a topical steroid, proper instrument handling, neck padding, changing the instrument's materials, and/or reducing the amount of playing time. Surgical excision is usually not advisable.

Fiddler’s neck: Cultural influences modify clinical presentation influences

“…A patch test can be performed to determine allergy to metals, varnish, resins and exotic woods. Rarely, a biopsy may be needed to exclude other skin diseases [10] .…”

“…The submandibular form is more commonly seen and it usually develops under the angle of the mandible where the instrument comes in contact with the chin while the supraclavicular form is usually seen on the upper chest [9] . At times, there can be associated intense oedema and thus it may be difficult to differentiate from lymphadenopathy, malignancy, or pathology of the salivary glands [8][9][10][11] . Fiddler's neck marks function as an "identifying sign" of a violinist in public view without seeing his/her instrument.…”

Metal Detection Tests: Preventive Tools for “Fiddler's Neck”

“…We applaud Myint et al for highlighting the two types of Fiddler's neck and their differing etiologies: mechanical shear stress and pressure for submandibular fiddler's neck, and contact dermatitis for supraclavicular fiddler's neck. 1 The prevalence of nickel sensitization in the United States is estimated to be 8.6% of adults, 2 a figure represented by 14.7% of professional musicians, especially in string players and plucking instrumentalists. 3 Gamblicher et al evaluated 412 respondents from German Universities of music and performing arts and found 21.6% had an instrument-related skin disorder.…”

“…Supraclavicular fiddler's neck can be confirmed with a epicutaneous patch test. 1 Myint et al also astutely note that while the allergic contact dermatitis can be caused by a reaction to the raw materials of the chin rest, such as the rosin, cane reed, or exotic woods, nickel is the most common allergen of supraclavicular fiddler's neck. The skin reacts predominantly to the metal brackets that attach the chin rest to the base of the violin or viola.…”

“…The skin reacts predominantly to the metal brackets that attach the chin rest to the base of the violin or viola. 1 According to Caero et al, sweat accumulated from hours of practicing can further erode the metal, leading to accelerated nickel release. 5 Myint et al also discuss the management of supraclavicular fiddler's neck caused by the chin rest.…”