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Probability diagnosis

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Lymphadenitis (reaction to local infection)

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  • acute: viral or bacterial

  • chronic: MAIS (atypical tuberculosis), viral (e.g. EBM, rubella)

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Prominent normal lymph nodes

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Goitre

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Sebaceous cyst

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Lipoma

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Sternomastoid tumour (neonates)

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Serious disorders not to be missed

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Vascular:

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  • carotid body tumour or aneurysm

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Infection:

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  • ‘collar stud’ abscess (atypical TB)

  • tuberculosis of cervical nodes (‘King’s evil’)

  • HIV/AIDS of nodes

  • actinomycosis

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Cancer/tumour

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  • lymphoma (e.g. Hodgkin)

  • leukaemia

  • thyroid nodule (adenoma, cancer, colloid cyst)

  • metastatic nodes

  • salivary gland tumours

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Pitfalls (often missed)

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Parotitis

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Thyroglossal cyst

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Lymphatic malformation ‘cystic hygroma’ (children)

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Cervical rib

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Rarities:

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  • sarcoidosis

  • branchial cyst (child)

  • torticollis

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Key history

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This depends on the age of the patient but should include in all ages a history of upper respiratory infection, lower respiratory infection, possible Epstein–Barr, HIV, cytomegalovirus and tuberculosis infection. Consider red flags such as weight loss, dysphagia, history of cancer and increasing size of the lump. Note any response to antibiotics given for a throat or upper airways infection.

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Key examination

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  • Careful palpation of lymph nodes areas and matching the site of any lymphadenopathy with a ‘map’ of areas drained by the nodes

  • Examine the lump according to the classic rules of look, feel, move, measure, auscultate and transilluminate

  • Palpate the midline anterior area for thyroid lumps and the submental area for submandibular swellings

  • Note the consistency of the lump: soft, firm, rubbery or hard

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Key investigations

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  • FBE

  • ESR/CRP

  • CXR

  • TFTs (of thyroid swelling)

  • Fine needle aspiration biopsy of thyroid nodules

  • Lymph node biopsy

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Thyroid and primary tumours: imaging techniques (if necessary to assist diagnosis) include:

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  • ultrasound

  • axial CT scan (esp. in fat necks)

  • MRI scan (distinguishes a malignant swelling from scar tissue or oedema)

  • tomogram of larynx (malignancy)

  • barium swallow (pharyngeal pouch)

  • sialogram

  • carotid angiogram.

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Diagnostic tips

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  • The 20:40 guideline rule according to age:

    • 0–20 years: congenital, inflammatory, lymphoma, TB

    • 20–40 years: inflammatory, salivary, thyroid, lymphoma

    • >40 years: lymphoma, metastases.

  • The 80:20 rule: most neck lumps (80%) are benign in children while the reverse applies to adults.

  • Causes of neck swelling are lymph nodes (85%), goitre (8%), others (7%).

  • Suspicious lymph nodes are >2.5 cm diameter especially if firm or hard and less mobile.

  • Consistent rules: hard—secondary carcinoma; rubbery—lymphoma; soft—sarcoidosis or infection; tender and multiple—infection.

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