Chapter 61: Neck lumps

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).

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

The key components of the history, examination and investigations follow.

History

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.

Examination

• Careful palpation of lymph node 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

Investigations

• FBE

• ESR/CRP

• CXR

• TFTs (of thyroid swelling)

• Fine needle aspiration biopsy of thyroid nodules

• Lymph node biopsy

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

• 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

The 20:40 and 80:20 rules^3,4

• The age of the patient is a helpful guide, as causes of neck lumps can be roughly categorised by the ‘20:40 rule’:

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

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

  • – >40 years: lymphoma, metastases, i.e. neck lumps are malignant until proven otherwise

• Most neck lumps (80%) are benign in children while the reverse applies to adults.

• Imaging techniques that may assist diagnosis include axial CT scan (especially in fat necks), MRI scan (distinguishes a malignant swelling from scar tissue or oedema), tomogram of larynx (laryngocele or malignancy), barium swallow (pharyngeal pouch), sialogram and carotid angiogram.⁵

A basic suggested approach for the patient presenting with a neck lump is summarised in FIGURE 61.2.

• There are many causes, varying from local infections to lymphoproliferative disorders.

• Most malignant nodes in the supraclavicular area have their primary tumour below the clavicle.

• Eighty-five per cent of malignant nodes in the anterior triangle have their primary tumour in the head and neck.²

• Always search for:

  • – other nodes at distant sites

  • – possible primary source of infections or neoplasia

  • – hepatosplenomegaly

• Hodgkin lymphoma usually presents with rubbery, painless nodes in the neck.

• Most swellings are lateral.

Consistency of enlarged nodes

Rules of thumb are:^5,6

• hard: secondary carcinoma

• rubbery: lymphoma

• soft: sarcoidosis or infection

• tender and multiple: infection

Causes of cervical lymph node enlargement (lateral cervical swelling)

Acute cervical lymphadenitis

• Acute viral lymphadenitis

• Acute bacterial lymphadenitis—coccal infection

Chronic lymph node infection

• MAIS lymphadenitis (atypical tuberculosis)

• Tuberculosis

• Viral infection, e.g. EBM (see FIG. 61.3), rubella, cytomegalovirus, HIV

• Toxoplasma gondii infection

• Cat-scratch disease—Bartonella henselae infection

Neoplastic lymphadenopathy

• Lymphomas, esp. Hodgkin lymphoma

• Leukaemia

Metastatic

• Check mouth, pharynx, sinuses, larynx, scalp, oesophagus, stomach, breast, lungs, thyroid and skin. A working rule is upper neck—from skin to upper aerodigestive tract; lower neck—from below clavicles (e.g. lung, stomach, breast, colon).

• Examples:

  • – occipital or pre-auricular—check scalp

  • – submental—check mouth, tongue, teeth

  • – submandibular—check floor of mouth

  • – left supraclavicular (under sternomastoid)—consider stomach (Troisier sign)

  • – deep anterior cervical—consider larynx, thyroid, oesophagus, lungs

Types and causes

Widespread

• Sebaceous cysts

• Lipomas

Midline

• Thyroid nodule (moves upon swallowing)

• Thyroglossal cysts (moves upwards on tongue protrusion)

• Dermoid cyst (beneath chin)

Anterior triangle

• Branchial cyst (in upper part):

  • – usually adulthood (20–25 years)

• Carotid body tumour:

  • – opposite thyroid cartilage

  • – smooth and pulsatile

  • – can be moved laterally but not vertically

  • – usually 40–60 years

  • – requires excision (with care)

• Carotid aneurysm

• Lateral thyroid tumours

Posterior triangle

• Developmental remnants:

  • – cystic hygroma

  • – branchial sinuses and cysts

• Pancoast tumour (from apex lung)

• Cervical rib

Submandibular swellings

• Submandibular salivary gland

• Cervicofacial actinomycosis (lumpy jaw syndrome):

  • – chronic granulomatosis infection due to Gram-positive Actinomyces israelii

  • – forms a multilocular abscess (pus has ‘sulphur granules’)

  • – infection follows dental extraction or poor dental hygiene, esp. severe caries

  • – treat with high-dose penicillin G, 4 months

Sternomastoid tumour

Refer CHAPTER 91.

Pharyngeal pouch

• A soft, squelchy, indefinite mass

• Base of left neck

• History of difficulty in swallowing

Thyroid nodule

The most likely cause of a solitary thyroid nodule is the dominant nodule in a multinodular goitre.

Other causes include a true solitary nodule—adenoma, follicular carcinoma or solitary carcinoma—and a colloid cyst. Malignancy must be excluded.

• Ultrasound

• FNAB (may resolve a cystic lesion)

• TFTs

Eighty per cent of neck lumps are benign while 20% are malignant. Benign lumps usually occur in the anterior triangle, while malignant lumps are more likely in the posterior triangle. The common midline lump in children is the thyroglossal cyst.³ Consider sternomastoid tumour (fibrosis) in infants (see CHAPTER 92).

Lymphadenopathy

• Most enlarged lymph nodes are either ‘normal’ or local infections (mainly viral), especially if <2 cm diameter, and not hard or fixed.

• Inflammatory nodes may be caused by infection in the tonsils, the teeth or other oral or nasopharyngeal cavities.

• They are of concern if supraclavicular node enlargement and fever <1 week.

• Suspicious nodes are >2.5 cm, with firmer consistency than normal and less mobility (investigate especially with biopsy).

• Consider bacterial infection with abscess formation in infants and children with large (2–4 cm) tender masses.

MAIS lymphadenitis^4,8

• Child usually 2–3 years of age

• Caused by Mycobacterium avium-intracellulare-scrofulaceum (MAIS) infection

• Produces chronic cervical lymphadenitis and collar stud abscesses

• A relatively common infection of cervical nodes, yet often unrecognised

• Painless swelling due to development of a cold abscess in healthy child

• Nodes enlarge over 4–6 weeks prior to erupting into a ‘cold’ abscess and the overlying skin has a purplish discolouration, which is an indication for surgical treatment

• Common sites are submandibular, tonsillar and pre-auricular nodes

• Invariably unilateral, confined to one lymph node group

• No pulmonary involvement

• Unresponsive to antimicrobials: treatment is by surgical excision of abscess and underlying lymph nodes

Acute bacterial lymphadenitis

• Usually coccal infections—Staphylococcus, Streptococcus

• Can progress to abscess formation (fluctuant): requires drainage

• A persisting lump, depending on its location and size

• A lymph node or group of nodes that are abnormally enlarged and fail to respond to antibiotics