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A summary of the diagnostic strategy model is presented in TABLE 61.1.
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The key components of the history, examination and investigations follow.
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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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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
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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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Red flag pointers for neck lumps
>40 years, esp. >70 years
Nodes >2.5 cm
Nodes >3–4 cm ? malignancy
Tender mass
Purple discolouration (collar-stud abscess)
Single, gradually enlarging node
Fixed to skin without punctum
Associated dysphagia
Hard midline thyroid lump
Patient at risk of malignancy and HIV
Exposure to tuberculosis
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The 20:40 and 80:20 rules3,4
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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
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A basic suggested approach for the patient presenting with a neck lump is summarised in FIGURE 61.2.
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CERVICAL LYMPHADENOPATHY
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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:
Hodgkin lymphoma usually presents with rubbery, painless nodes in the neck.
Most swellings are lateral.
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Consistency of enlarged nodes
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hard: secondary carcinoma
rubbery: lymphoma
soft: sarcoidosis or infection
tender and multiple: infection
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Causes of cervical lymph node enlargement (lateral cervical swelling)
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Acute cervical lymphadenitis
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Chronic lymph node infection
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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
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Neoplastic lymphadenopathy
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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
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NECK LUMPS NOT DUE TO LYMPH NODE SWELLING7
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Thyroid nodule (moves upon swallowing)
Thyroglossal cysts (moves upwards on tongue protrusion)
Dermoid cyst (beneath chin)
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Submandibular swellings
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A soft, squelchy, indefinite mass
Base of left neck
History of difficulty in swallowing
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The most likely cause of a solitary thyroid nodule is the dominant nodule in a multinodular goitre.
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Other causes include a true solitary nodule—adenoma, follicular carcinoma or solitary carcinoma—and a colloid cyst. Malignancy must be excluded.
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