Chapter 61

### Introduction

There are approximately 800 lymph nodes in the body; no fewer than 300 of them lie in the neck and inflammation of these is exceedingly common.

McNeil Love, Co-editor of Bailey & Love's Short Practice of Surgery, 1965

In the management of lumps in the neck it is important to distinguish between the various midline and lateral causes, especially cervical lymphadenopathy, which may be caused by occult malignancy, such as in the aerodigestive tract. With increasing ageing in the population the number of patients presenting with a malignant neck lump is also increasing. The neck is divided into anterior and posterior triangles by the sternomastoid muscle and the anatomical areas are helpful in identifying the origin of the primary lesion (see FIG. 61.1).

###### FIGURE 61.1

Lymph glands (site of the nodes) of the neck including common sources of adenopathy (excluding lymphomas)

Key facts and checkpoints

• Most neck lumps are reactive lymph nodes—to concurrent infection.

• Lymph nodes are normally palpable in children between 3 and 8 years of age; soft, mobile nodes up to 1 cm in diameter are commonly felt in the anterior and posterior triangle. A node >2 cm is considered to be enlarged. Some cervical glands are very prominent, especially tonsillar nodes.

• These prominent nodes often enlarge during intercurrent viral infection.

• Causes of neck swellings are lymph nodes 85%, goitres 8%, others 7%.1

• Solitary nodules in the thyroid move on swallowing.

• Consider the possibility of tuberculosis, especially with exposure in endemic areas and in immunocompromised people.

• A knowledge of the areas drained by lymph nodes is important (see FIG. 61.1).

• Examination must extend beyond the neck for lymphadenopathy.

• To examine cervical nodes slightly rotate head and palpate with palmar aspect of fingers.

• Palpate submental area with head slightly flexed.

• Biopsy of a complete lymph node is necessary to establish diagnosis for unknown or suspicious causes but do not consider it as the first step in diagnosis.2

• Other investigations are chest X-ray and FBE. Bone marrow biopsy or fine-needle aspiration of thyroid nodule or other masses may be considered. Fine-needle aspiration biopsy (FNAB) which is a relatively simple procedure, is the single most helpful investigation for diagnosing the cause.3 If cytology reveals malignant squamous cells, the primary lesion may lie in the skin, lung, larynx, pharynx, ear or oesophagus.

### A diagnostic approach

A summary of the diagnostic strategy model is presented in Table 61.1.

Table 61.1

Neck lumps: diagnostic strategy model

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