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How to Treat
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Anatomy
History and
examination
Investigations —
uses and
limitations
Case studies
The authors
Neck lumps
Background
LUMPS and swellings in the neck
are common and are encountered
frequently in general practice.
Patients presenting with neck
lumps are often fearful of cancer,
and the morbidity associated with
delayed or incorrect diagnosis must
not be underestimated.
A diagnosis may be possible based
on clinical examination alone but,
more commonly, investigations are
required to clarify the diagnosis and,
in particular, to exclude or confirm a
diagnosis of malignancy.
It is important that the possibility
of a diagnosis of cancer is not overlooked and that the pathway of
referral for patients with cancer in
the neck is appropriate and swift.
In children, neck lumps are common
but rarely malignant. They are often
caused by reactive lymph node
enlargement. Benign reactive lymph
node enlargement is less common in
adults.
Small lymph nodes less than a centimetre in diameter may be found in
the neck, axilla or groin in adults,
but progressive enlargement should
ring alarm bells. A safe rule is that
any adult with a lump in the lateral
neck has cancer until it is proved
otherwise.
Any adult with a lump
in the lateral neck has
cancer until it is
proved otherwise.
Suggested workup for patients presenting with neck lump or swelling
DR CERI HUGHES,
fellow, Sydney Head and Neck
Cancer Institute.
PROFESSOR
CHRISTOPHER O’BRIEN,
director, Sydney Cancer Centre
and Sydney Head and Neck
Cancer Institute.
History
Clinical examination
Fine-needle aspiration biopsy
CT scan
What next ? Where do I refer?
It is important that adults with lateral neck lumps are not subjected to
lengthy trials of observation or antibiotic therapy. Diagnostic efforts should
be focused on excluding malignancy.
A diagnosis can readily be made
in the vast majority of cases, through
careful history-taking combined with
a thorough clinical examination.
Fine-needle aspiration biopsy (FNAB)
and CT scan (see Investigations —
uses and limitations, page 35) should
be considered the most useful investigations before referral to a specialist
centre.
Multidisciplinary clinics
Treatment of cancer of the upper aero-digestive tract requires a multidisciplinary
approach. When a diagnosis of cancer in the neck is made, the patient should be
referred to a head and neck specialist who participates in a multidisciplinary
clinic.
There is strong evidence that delayed referral, or diagnostic and therapeutic
involvement with non-expert clinicians, can lead to poorer outcomes in the
treatment of head and neck cancers.
Multidisciplinary head and neck clinics are usually attached to major teaching
hospitals. This may be an important issue for rural patients and their doctors, and
appropriate referral may necessitate enquiry about the nearest specialist unit.
Patients who need to attend for assessment and treatment may face additional
difficulties with accommodation arrangements. Prior discussion with clinicians at
the receiving hospital will help to make this process easier.
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Relevant anatomy
A BASIC knowledge of head and
neck anatomy is important in clinical
diagnosis. By convention, anatomical
regions in the neck are described as
triangles.
The anterior triangle extends from
the sternocleidomastoid muscle to
the midline. The posterior triangle
is formed by the trapezius muscle
posteriorly and the posterior border
of the sternocleidomastoid muscle,
which forms the anterior limit of the
triangle.
A clear idea of possible anatomical
and pathological structures within
each triangle or level helps in diagnosis and assists with identification
of normal anatomical structures that
can be confused with pathological
lumps.
For descriptive purposes the cervical lymph nodes are grouped into
five levels (table 1, figure 1). This
assists head and neck oncologists
with staging and treatment.
The use of accurate and consistent terminology encourages a
common language to be used
between clinicians when patients are
referred for specialist opinion.
Distinguishing normal anatomy
from pathology
Normal anatomical structures can
come to the attention of patients
and create anxiety about a possible
pathological cause. Careful exami-
Figure 1: Lymph node levels in
the neck.
Table 1: Lymph node levels
thyroid cartilage to elevate also,
highlighting the position of the thyroid cartilage in relation to other
structures.
Level I
Submandibular and submental triangle
Level II
Upper jugular chain (base of skull to hyoid bone in a vertical plane)
Level III
Mid-jugular chain (from hyoid to cricoid)
Mastoid process
Level IV
Lower jugular chain (from cricoid to clavicle)
Level V
Posterior triangle (bounded by the trapezius and posterior of the
sternocleidomastoid, lying along the course of the accessory
nerve)
This bony process behind the ear
lobe may be mistaken for a posterior auricular or parotid mass.
Careful examination bilaterally
and determination of its relationship to the sternocleidomastoid
muscle, tensed on turning the head
to the opposite direction, helps to
differentiate the mastoid from
other structures.
nation, mindful of normal anatomy,
may help prevent misdiagnosis.
Some of the structures that can
cause confusion are listed below.
Normal submandibular gland
An enlarged or ptotic submandibular
gland (a normal feature in elderly
patients) may easily be confused
with an upper jugular chain lymph
node or neck mass.
Bimanual palpation, with a finger
placed intra-orally while the other
hand palpates the neck, will enable
the gland to be palpated or balloted
easily.
This allows the gland to be differentiated from neck masses; the
submandibular gland will feel firm,
not hard, and will have a lobular
texture.
Angle of mandible and masseter
hypertrophy
A prominent angle of the mandible
can easily be mistaken for a lump
in the upper neck. Careful palpation with comparison to the contralateral side is helpful.
Ask the patient to clench their
teeth. This will cause contraction
of the masseter muscle and help
correctly identify the angle of
mandible.
Lateral process of C1
The lateral processes of the cervical
vertebrae (particularly C1) may be
palpable posterior to the angle of
the mandible, especially in thin
individuals and those who have
undergone neck dissection previously (they have little tissue
between the lateral process and the
skin).
Awareness of this anatomical fact
is useful but, if there is any doubt, a
specialist opinion should be sought.
Greater cornu of the hyoid
This may be prominent in thin
patients and appear as a hard neck
mass in the submandibular region.
Palpation of the neck bilaterally
allows the hyoid to be moved laterally from side to side and will
differentiate the hyoid from possible pathology.
Supraclavicular fat pad
A prominent fat pad in the supraclavicular region can be mistaken
for a lymph node mass, but its consistency is usually softer than
lymph node tissue.
Superior cornu of thyroid cartilage
This can be palpated easily in some
patients and may be confused with
a neck lump. On swallowing, elevation of the larynx will cause the
History and examination
HISTORY and clinical
examination are fundamental to early and accurate
diagnosis. The age of the
patient, the duration of the
history and the anatomical
location of the lump in the
neck are important.
Causes of neck lumps, according to age
Infant
Neoplastic
Adolescent
Adult
Neoplastic
(parotid, thyroid)
Lyphoma (Hodgkin’s)
Metastatic cancer,
lymphoma (Hodgkin’s/
non-Hodgkin’s), thyroid
Infective/inflammatory
Non-specific
lymphadenitis
Non-specific lymphadenitis,
cat scratch disease,
toxoplasmosis, atypical
mycobacteria, mumps
(viral parotitis)
Glandular fever, dental
infection, cat scratch
disease, toxoplasmosis,
mumps (viral parotitis)
Dental infection, HIV
lymphadenopathy,
toxoplasmosis, cat
scratch disease,
TB
Congenital
Cystic hygroma,
vascular malformation,
congenital torticollis
Dermoid cysts, vascular
malformations
Thyroglossal cyst,
branchial cysts
Congenital
sebaceous cyst
Younger patients
Children commonly present
with a short history of
tender, enlarged lymph
nodes, suggesting an infective process (eg, viral
pharyngitis, acute tonsillitis,
atypical mycobacterial lymphadenitis), or multiple
small non-tender nodes, particularly in the posterior triangle, suggesting a subclinical viral infection.
Soft swellings in the neck
are uncommon, usually congenital and may be due to
conditions such as lymphangioma (cystic hygroma) or
vascular malformations.
Congenital torticollis may
present as a lateral neck
swelling and should also be
considered in this age group.
Localised swellings in the
thyroid or parotid glands in
children are uncommon and
malignancy needs to be
excluded.
Adolescents often develop
acute inflammatory lymphadenopathy, particularly in
the jugulo-digastric region,
that may be bacterial in origin
(eg, tonsillitis) or viral (eg,
glandular fever). They can
also develop lymphoma, particularly Hodgkin’s disease.
Child
Prominent lymph nodes
that are non-tender and
enlarge progressively should
be treated with suspicion.
Multiple small nodes occurring in the posterior triangle
tend to be due to subclinical
viral infections.
Adults
Clinical evaluation of adults
with lateral neck lumps is
aimed at excluding cancer.
Middle-aged people who
smoke and drink alcohol are
at higher risk of having
mucosal cancers of the oral
cavity, oropharynx or laryngopharyngeal region.
Eighty per cent of these
cancers will be related to use
of tobacco and alcohol and
the relationship of these is
synergistic, with the risk in
patients who drink and
smoke about 35 times that
of teetotal non-smokers.
Tobacco use alone increases
the risk about tenfold, and
alcohol at an intake of
100g/day (12 units) can
increase the risk sixfold.
Associated symptoms such
as ear pain (referred from the
posterior oropharynx), voice
change, dysphagia or weight
loss should be sought.
Always ask for a history
of any previously treated
cancer of the skin, lip, oral
cavity or other mucosal sites,
as there is a higher incidence
of second primary tumours
in those who use tobacco
and/or alcohol.
Adult Asian patients with
enlarged neck nodes will may
have either nasopharyngeal
cancer or tuberculosis.
Elderly patients, especially
those with fair skin, may
have a history of previous
skin cancer.
A lump in the neck, especially in the submandibular
region or the upper neck,
involving the external jugular
node or tail of parotid may
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represent metastatic cutaneous malignancy from
squamous cell carcinoma or
melanoma.
In an immunocompromised patient, a neck lump
may be an indicator of systemic disease, and the possibility of HIV-related lymphadenopathy should always
be considered if specific risk
factors are present.
Examination
Examination should include
thorough and systematic palpation of the neck bilaterally, with the patient seated
in a chair if possible and
with the neck relaxed.
A thorough examination
of the oral cavity with adequate lighting should also be
carried out, as metastatic
cancers may be related to
primary oral squamous cell
carcinomas.
Oral cancers may be preceded by an identifiable and
often longstanding leukoplakia (white patch, see box,
page 34). In these cases early
identification and appropriate referral are essential and
improve prognosis.
When examining the
oropharynx, a deep-lobe
parotid tumour may present
as an easily seen unilateral
posterior swelling on the
pharynx. Taking a biopsy of
the lump via an intra-oral
approach is a common pitfall and in no circumstances
should these masses be biopsied before referral.
The anatomical triangle of
the neck involved should be
noted, as this may assist in
differential diagnosis.
If the lump moves on
swallowing it must lie deep
to the pre-tracheal fascia and
is likely to be thyroid in
origin.
In the case of upper anterior neck lumps, movement
accompanying tongue protrusion may indicate a thyroglossal cyst as the most
likely diagnosis.
The site of a lump in relation to the sternocleidomastoid muscle may also be
helpful. Tumours in the tail
of the parotid gland lie
superficial to this muscle and
so remain easily palpable
when the muscle is contracted by turning the head
to the opposite side.
In contrast, lumps contained within the jugular
chain of lymph nodes are
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How to treat – neck lumps
from previous page
difficult to palpate when the
sternocleidomastoid is contracted.
Anterior neck swellings
(figure 3)
Figure 2: Triangles, lymph node levels and normal lymph nodes in the neck.
Submandibular nodes
Lateral neck lumps (figure 2)
Submandibular triangle.
The main anatomical structures in the submandibular
triangle are the submandibular salivary gland and the
submandibular lymph nodes,
which lie anterior and posterior to the facial vessels (prevascular and post-vascular
nodes) as they cross the jaw.
These nodes are a
common sight of reactive
enlargement in children and
adolescents but they may
also be a site of metastatic
disease from cutaneous
cancer of the face and lips
and, less commonly, from
cancer of the oral cavity in
adults.
There are three groups of
paired major salivary glands:
the parotid, submandibular
and sublingual glands. These
are accompanied by many
hundreds of minor glands
distributed throughout the
entire oral cavity.
Swellings of the submandibular salivary gland
are usually acute and related
to eating. These are due
most commonly to a stone
obstructing the submandibular duct.
They usually produce
intermittent swelling that
arises during eating and
resolves slowly after meals.
Painless
progressive
swelling of the submandibular gland, however, raises the
possibility of tumour.
Cancer of the salivary
glands is relatively rare —
benign tumours occur more
commonly. There is no clear
evidence of specific risk factors for salivary gland
cancer, but environmental
factors such as radiation and
viruses, along with genetic
factors, are probably important.
The most frequently
encountered salivary tumour
is a benign pleomorphic adenoma. In contrast to parotid
tumours (see below), up to
50% of submandibular
tumours are malignant. The
incidence of malignancy in
sublingual gland swellings is
about 80%.
An uncommon submandibular swelling that frequently poses diagnostic difficulty is a plunging ranula,
caused by extravasation of
mucoid saliva from a disrupted sublingual gland in
the floor of the mouth.
Instead of the mucoid
saliva collecting in the floor
of the mouth and causing a
swelling under the mucosa
(a ranula), the mucus makes
its way into the subcutaneous space in the anterior
submandibular region.
Diagnosis is by a combination of clinical features
and appropriate imaging
such as CT.
Removal of the sublingual
gland via the mouth is the
34
Parotid gland
Posterior belly of digastric muscle
Upper jugular
node
Submental
nodes
Jugulo-digastric node
Anterior belly of
digastric muscle
Spinal accessory
nerve and nodes
Hyoid bone
Jugulo-omohyoid node
Trapezius
Sternocleidomastoid muscle
Omohyoid
muscle
Lower jugular nodes
Figure 3: Anatomical sites of anterior neck lumps.
Submental node
Submandibular
nodes
Branchial cyst (or
other level-II mass,
eg, lymph node)
Hyoid bone
Thyroglossal cyst
Thyroid
cartilage
Pyramidal lobe of thyroid
Thyroid gland
Thyroid
nodules
Sternocleidomastoid
muscle
Trachea
Do not biopsy
neck lumps
INCISION and excision
biopsy of neck lumps should
not be carried out in a
non-specialist environment.
If the lump proves to be
malignant, inappropriate
biopsy could lead to difficulty
in later treatment and
increased risk of recurrence.
The key investigations for
all neck lumps, following
history and clinical
examination, are FNAB
(see page 35) and CT scan
with contrast.
| Australian Doctor | 5 August 2005
curative operation for plunging ranula.
The other common soft
tissue swelling that may
occur in this region is a
lipoma, but this has a characteristic soft feel and bosselated surface texture.
Swellings around the parotid
region.
In contrast to infective and
inflammatory swellings of
the submandibular gland,
those of the parotid gland
are not very common.
Viral infections (eg,
mumps) and bacterial infections (frequently secondary
to salivary obstruction) can
occur and the history is usually of acute pain and
swelling.
Tumours have a longer
clinical course and are usually painless.
About 85% of primary
parotid tumours are benign.
The most common salivary
tumour is a pleomorphic adenoma in younger adults and
Warthin’s tumour in older
adults.
Patients with benign
parotid tumours should be
referred for surgery, as pleomorphic adenomas have
malignant potential when
they are large or have been
present for many years.
In Australia the most
common malignant tumour
within the parotid gland is
metastatic skin cancer from
either SCC or melanoma.
Globally the most common
primary malignancy is
mucoepidermoid carcinoma,
followed by adenoid cystic
carcinoma.
In all cases, involvement
of the skin or facial nerve
weakness is an ominous sign
and should trigger urgent
referral.
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Lumps in the anterior compartment of the neck can
occur in the submental
region or the upper or lower
anterior neck. Lumps in the
submental triangle are usually enlarged lymph nodes
and may be reactive or neoplastic.
In young adults Hodgkin’s
disease needs to be excluded,
while in older adults metastatic cancer, particularly
from cancers of the lip or
from an asymptomatic cancer
of the floor of the mouth,
should be considered.
Tuberculous lymphadenopathy may also develop in
the anterior neck.
Swellings around the
hyoid bone are most likely
to be a thyroglossal cyst
(thyroglossal duct remnant).
About 80% of these lie
below the level of the hyoid
bone and an important clinical feature is that they elevate with protrusion of the
tongue. Often they sit to the
left of the midline rather
than in the centre of the
neck.
Dermoid cysts can also
occur in the midline, anywhere from the chin to the
jugular notch. These are
congenital, benign and usually contain thick white
paste-like material of epithelial origin, which gives them
a ‘doughy’ consistency on
palpation.
Dermoids are usually
quite superficial, lying in the
subcutaneous tissue, outside
the anterior neck muscles.
The most frequently
encountered swellings in the
central compartment of the
neck are thyroid nodules.
These are rarely in the midline unless the nodule occupies the isthmus or pyramidal lobe, so they tend to sit
to one side of the midline.
The important clinical
feature of a thyroid nodule
is that the lump elevates
with swallowing, which is
diagnostic of a thyroid
swelling.
When there are multiple
thyroid lumps (multinodular
goitre) the risk of malignancy is low at about 5%.
The incidence of malignancy
is higher (10-20%) in a solitary thyroid lump, especially
when >4 cm diameter, and
in males.
Correlating pathological nodes
with a primary site
The location of metastatic
lymphadenopathy may be
specific to the site of the primary tumour. Oral cancer
most frequently metastasises
to level II (see table 1)
whereas thyroid cancer
rarely metastasises to level II.
This information can be
especially helpful in finding
the location of a possible primary tumour when only
metastatic disease is clinically apparent. This occurs
in about 10% of head and
neck cancer patients.
Leukoplakia and
erythroplakia (white
and red patches)
THE terms leukoplakia and
erythroplakia are descriptive
and are clinical diagnoses.
Pathologically these lesions
vary and may represent
changes ranging from
benign hyperkeratosis to
invasive carcinoma, with
differing degrees of epithelial
dysplasia in between.
Erythroplakia is a red
patch, which can occur as
part of, or as a separate
lesion to, leukoplakia. Both
should be considered
pre-malignant lesions
(erythroplakia carries the
highest risk).
Areas of leukoplakia and
erythroplakia can contain
areas of invasive carcinoma
or be associated with a
clinically apparent
carcinoma. Therefore, what
appears as leukoplakia or
erythroplakia can present
with metastatic disease if
part of the lesion has
undergone invasive change.
Patches with suspicious
features such as bleeding or
induration should be
referred for appropriate
assessment.
Online resources
The Sydney Head and
Neck Cancer Institute:
www.shnci.org
Australia New Zealand
Head and Neck Society:
www.anzhns.org
British Association of
Head & Neck
Oncologists:
www.bahno.org.uk
National Institute for
Health and Clinical
Excellence:
www.nice.org.uk (search
under ‘head and neck’ for
‘guidelines for improving
outcomes in head and
neck cancer’)
Support group for
Patients with Oral and
Head and Neck Cancer:
www.spohnc.org
National Cancer Institute
(American government
cancer site, follow links
to head and neck cancer
for useful patient and
clinical information):
www.cancer.gov
Changing faces (patient
support site):
www.changingfaces.org.uk
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Investigations — uses and limitations
Fine-needle aspiration
biopsy
FNAB provides the most
useful information in investigating head and neck
lumps. It is widely available
and may be carried out by a
surgeon, radiologist or specialist pathologist trained in
its use (the local hospital
pathology department usually has information on who
carries out FNAB in rural
areas).
The accuracy of the technique is above 90% but
varies with the quality of the
sample and the experience of
the cytologist.
False positives are rare but
false negatives may occur. If
a lump is clinically suspicious, a negative FNAB
should be repeated.
FNAB is the investigation
of choice to provide information that aids diagnosis
and to guide surgery.
In some circumstances a
surgeon may use excision
biopsy to establish a diagnosis when FNAB has been
unhelpful, but it is important
to remember that excision
biopsy can compromise
future neck dissection if, for
example, the lump is a
metastasis from an SCC.
FNAB is available nearly
everywhere and we feel
strongly that to promote
excision biopsy in a non-specialist centre is inappropriate.
The diagnosis of thyroid
lumps is greatly assisted by
FNAB. Metastatic cancer in
lymph glands can be diagnosed with a high degree of
accuracy from adequately
obtained specimens.
The differentiation of reactive lymphadenitis from lymphoma is sometimes difficult
and oncologists will rarely
base treatment on an FNAB
result alone, often requiring
formal excision to provide
histopathology.
In the diagnosis of cystic
neck masses, the presence of
squamous cells in both
benign branchial cysts and
necrotic metastases may
make differentiating between
these two entities difficult.
Figure 4: CT scan demonstrating a pathologically enlarged
lymph node (large arrow) lying in front of the left
submandibular salivary gland (small arrow). FNAB
demonstrated atypical lymphocytes, and the lymph node was
excised. The diagnosis was non-Hodgkin’s lymphoma.
Figure 5: CT scan showing a pathologically enlarged right
submandibular salivary gland (large arrow), while the
contralateral submandibular salivary gland is of normal size
(small arrow). The mass was painless and slowly growing over
two years. A FNAB suggested a pleomorphic adenoma and this
was proved on excision.
Positron emission
tomography
Ultrasound
Although ultrasound differentiates well between solid
and cystic masses, it contributes little to the diagnosis
of neck lumps. It is very
useful in evaluating the thyroid gland to determine
whether or not a nodule is
solitary or part of a multinodular goitre.
Ultrasound is also useful
as an aid during FNAB
when a neck lump is small
or difficult to localise by palpation. Its benefits include
ease of access, low cost and
not exposing the patient to
ionising radiation.
demonstrates relational
anatomy in addition to
pathological and benign
lesions (figures 4 and 5). The
use of IV contrast enhances
diagnostic capability, and CT
without contrast is of limited
usefulness.
Spiral or helical CT scanning allows faster, higherquality image acquisition
with less radiation exposure.
CT may also assist FNAB by
accurately localising the
lesion to be sampled, helping
to avoid damage to vital
structures during the sampling procedure.
Computerised tomography
Magnetic resonance
imaging
CT is very helpful in investigating neck lumps because it
netic field that aligns the
nuclei of hydrogen atoms
within matter. If the protons
are then hit with a short, precisely tuned burst of radio
waves, they will momentarily
flip around.
In the process of returning to their original orientation, they resound with a
brief radio signal of their
own.
The intensity of this emission reflects the number of
protons in a particular ‘slice’
of matter and helps to determine the consistency and
nature of the tissue imaged
and whether or not there is
an injury or some disease
process present.
Information collected
from MRI can be weighted,
allowing excellent differentiation between tumour and
normal anatomy.
MRI has particular
strength when accurate
information on soft tissue
pathology is required and
this can be enhanced further
by contrast agents such as
gadolinium.
The use of magnetic resonance angiography is very
helpful in assessing vascular malformations in the
head and neck.
MRI has none of the risks
associated with ionising
radiation but has specific
contraindications because of
the strong magnetic field
used (eg, cardiac pacemaker,
vascular aneurysm clips,
shrapnel, metallic debris in
the eye).
PET imaging, or PET scan, is
a diagnostic examination
that involves the acquisition
of physiological images
based on the detection of
positrons emitted from a
radioactive substance administered to the patient (18FDG
[fluorodeoxyglucose]).
The emissions are detected
by a gamma camera and tissues that are metabolising
glucose rapidly, such as
tumours, are highlighted.
PET is particularly valuable
in investigating metastatic
disease with unknown primary source and for detecting recurrent tumour. It
should not be used as a firstline investigation.
Chest X-ray
This forms an important part
of the diagnostic workup of
patients with neck lumps,
particularly when malignancy is considered a possible diagnosis.
It is important to remember that many patients at
risk of cancer of the upper
aero-digestive tract are also
at risk of primary synchronous lung tumours because
of the shared association of
these conditions with
tobacco use.
MRI uses a powerful magwww.australiandoctor.com.au
Sentinel node biopsy
Although sentinel lymph
node biopsy has been used
successfully in the management of melanoma and
breast cancer, it does not
generally apply to the management of clinically palpable neck disease. However, it
has been used to help identify patients with occult neck
disease resulting from
mucosal SCC (several longterm prospective trials are
still underway).
The theory is that lymphatic drainage from a primary tumour may be limited
to a set of regional nodes
and the ‘first-stop’ nodes
within this region can be
identified by the use of
radioactive tracers such as
technetium.
The localisation of suspect
lymph nodes allows accurate sampling of only the
most likely nodal sites for
metastasis. Decisions are
then made about more
extensive lymph node dissection or adjuvant treatment if indicated.
Infectious causes of neck
lumps
Glandular fever
Glandular fever is an infectious disease common in
younger patients and is
caused by the Epstein-Barr
virus. It is usually passed on
via infected saliva, and contact with another infectious
case is often elicited in the
clinical history.
Lymphadenopathy is usually bilateral, with associated
systemic symptoms or rash.
Heterophil antibody tests
such as the Paul-Bunnell or
Monospot tests are used in
diagnosis.
IgM heterophil antibodies
are usually detectable in the
first three months of infection
and this may be accompanied
by an atypical lymphocytosis
on peripheral blood sampling.
More specific serological
testing looks for IgM to viral
capsular antigen, or IgG to
viral capsular antigen combined with negative serology
for antibody to viral nuclear
antigen.
Toxoplasmosis
Toxoplasmosis is caused by
the protozoan Toxoplasma
gondii, which is usually present in the faeces of an
affected cat or is passed on
by contaminated food or
water. It is a common disease although most patients
remain asymptomatic.
Lymphadenopathy may be
the only symptom, and a history of possible contact with
infected material should be
sought in suspected cases.
Culture for this organism
is not commonly performed.
Serology for Toxoplasmaspecific IgM in the acute
phase and seroconversion to
Toxoplasma-specific IgG is
a more useful test.
Silver staining may rarely
enable diagnosis from tissue
samples. Toxoplasma should
be sought particularly if contact with infected faeces of
domestic cats is found on
history-taking.
Cat scratch disease
Cat scratch disease is an
infectious disease caused by
the bacterium Bartonella
henselae, which is usually
contracted from the saliva of
infected cats.
Mild systemic illness usually occurs and lymphadenopathy is most often
bilateral. A history of a
scratch or bite from a
domestic cat should be
sought in patients with lymphadenopathy.
Culture is difficult and
may take three weeks. Indirect fluorescent antibody
testing from serum is possible, but cross-reactivity with
other organisms limits specificity.
Histopathology from a
lymph node may demonstrate a mixture of non-specific inflammatory reactions,
including granulomata and
stellate necrosis, with lymphocytic infiltrates and multinucleated giant cells.
Tuberculosis
TB caused by the acid-fast
bacillus Mycobacterium
tuberculosis
is
more
common in patients with a
history of travel to countries
where the disease is endemic
and in immigrant populations.
In patients presenting with
neck lumps a history of possible contact with TB should
always be sought.
Traditional culture and
specific stains such as ZiehlNeelsen are slow and may
delay diagnosis by 6-8
weeks.
The tuberculin skin test
with purified protein derivative (Mantoux test) still has
use, but PCR testing carried
out on tissue specimens can
give a result within 48
hours.
In the case of atypical TB,
frequently caused by the
Mycobacterium avium complex, PCR testing is not
widely available.
When atypical organisms
are suspected modified skin
testing and culture may be
of benefit.
HIV infection
In patients with persistent
lymphadenopathy a lifestyle
history should be sought to
identify possible risk factors
for HIV contact.
In the case of HIV-related,
persistent generalised lymphadenopathy, the presence
of HIV-specific antibody is
usually detected by ELISA,
and confirmation by Western blot testing is usually
required.
5 August 2005 | Australian Doctor |
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How to treat – neck lumps
Authors’ case studies
Case 1. A young adult with a lateral neck lump
Case 4. An adult with multiple nodes
Case 7. An elderly man with a submandibular mass
This 19-year-old girl presented with a two-week history of a
painless swelling in the left jugulo-digastric region. FNAB
demonstrated benign squamous cells, cellular debris and
cholesterol crystals. CT scan demonstrated a well-circumscribed
unilocular mass anterior to the sternocleidomastoid muscle
(arrowed).
This is a typical branchial cyst and would be treated by surgical
excision. In a young adult a clinical diagnosis could probably be
made in most cases, but small tense branchial cysts can be very
difficult to differentiate from lymph node pathology such as in
Hodgkin’s disease.
This man has nasopharyngeal carcinoma with multiple metastatic
lymph nodes in the posterior triangle, bounded by the clavicle
below, sternocleidomastoid muscle anteriorly and the trapezius
muscle posteriorly. Nasopharyngeal carcinoma is the only mucosal
cancer that commonly spreads to the posterior triangle without
nodes elsewhere in the neck being involved (metastatic skin cancer
and lymphoma could also present with this distribution of nodes).
Metastatic lymphadenopathy is the most common presenting
feature for nasopharyngeal carcinoma. This is a rare cancer in
Australia but is more common in some Asian countries, which
places some immigrants to Australia in a higher risk group. It is
thought that nasopharyngeal carcinoma may be due to a
combination of geographical, ethnic and environmental factors
(for example, Epstein-Barr virus).
This elderly man has a large submandibular mass. An SCC of the
cheek was removed one year earlier. FNAB of the mass showed
metastatic SCC, and the CT scan below shows a large cystic mass
with a septum, consistent with metastatic cancer (arrowed).
Case 8. An adult with a
parotid tumour
Case 9. A young woman
with a thyroid nodule
This Asian man, aged 58, had
a two-year history of a
painless slow-growing mass
at the angle of the jaw. FNAB
demonstrated oncocytes and
lymphoid cells, consistent
with a diagnosis of Warthin’s
tumour (a benign adenoma).
This young woman has a
prominent right thyroid
nodule. After history-taking
and a clinical examination,
the appropriate investigations
would be FNAB and serum
TSH level.
Case 2. An adult with a lateral neck lump
This young man had a prominent painless lymph node in the
jugulo-digastric region, which clinically appears similar to the
previous case. FNAB indicated a diagnosis of Hodgkin’s disease.
The choice and order of appropriate tests is usually based on the
provisional diagnosis. In this case, FNAB confirmed the
suspected diagnosis and CT was useful in staging the disease.
Case 5. A young adult with a midline cystic swelling
This woman, aged 25, has a well-localised swelling just below
the hyoid bone, which elevates on protrusion of the tongue. The
CT scan on the right is from another patient, but demonstrates
identical pathology of a well-circumscribed cystic structure
lying anterior to the thyroid cartilage.
This is a thyroglossal cyst and would be treated surgically by
Sistrunk’s operation, a procedure involving removal of the cyst
with the central portion of the hyoid bone.
Management algorithms for children and adults
with neck lumps
Adult with neck lump
History/examination
Likely malignant diagnosis
FNAB
Benign
Observe
Resolves Persists
Case 3. An adult with a lateral neck lump
The man shown is 60 and a heavy smoker. He presented with a
hoarse voice and a large mass in the upper neck. FNAB showed
necrotic debris, which was suggestive but not diagnostic of
metastatic cancer. A CT scan demonstrated a unilocular cystic
mass (arrowed) with an irregular cyst wall. This was metastatic
SCC that has undergone cystic degeneration. The primary
cancer was in the hypopharynx and was asymptomatic.
Case 6. An adult with a discrete lump in the upper
lateral neck
Open
biopsy
Malignant
Lymphoma
Metastatic cancer
Staging
Primary
investigations known
Treat
This 40-year-old male non-smoker presented with a lump in the
upper neck. FNAB identified SCC. A careful search for a primary
tumour by examination under anaesthetic, endoscopy and
targeted biopsies demonstrated a primary SCC of the tonsil.
Such cancers in young non-smokers are believed to be due
to HPV.
Stage
Treat
Primary
unknown
EUA*, endoscopy,
biopsy, CT
Still occult primary
Treat neck and
observe for primary site
Child with a neck lump
History/examination
Likely benign diagnosis
Inflammatory or infective
Congenital or cystic
Treat infection
Fine-needle aspiration
biopsy/CT scan
Observe
*EUA = examination under anaesthesia.
Treat
Summary
THE range of diagnostic possibilities for
tumours and lumps in the head and neck
may seem bewildering but the application
of simple principles — history, examination, appropriate investigation and referral — facilitates accurate diagnosis and
allows timely treatment in almost every
case.
It is important that the doctor of first
36
| Australian Doctor | 5 August 2005
contact, very often the GP, does not overlook the possibility of a diagnosis of malignancy.
GPs should not underestimate the importance of their role, because early diagnosis
and referral to a specialist multidisciplinary team can dramatically influence a
patient’s treatment options and chances of
cure.
Neck lumps — a Diagnostic Guide for GPs
SOME of the information in this article is available in a booklet produced by the Sydney Head and
Neck Cancer Institute, entitled Neck Lumps — a Diagnostic Guide for General Practitioners. The
booklet was distributed free of charge to all divisions of general practice in NSW.
For further information, contact the Sydney Head and Neck Cancer Institute, Royal Prince Alfred
Hospital, Room 6.10, Level 6, Gloucester House, Missenden Road, Camperdown, NSW 2050.
(Web: www.shnci.org.)
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How to treat – neck lumps
GP’s contribution
PROFESSOR SIAW-TENG
LIAW
GP in Shepparton, Vic
Case study
DB, a 20-year-old clerical
assistant, presented with a
soft, slightly tender lump in
the right side of her neck,
first noticed four days earlier.
She reported no other symptoms except for an episode of
bronchitis two months ago,
treated with two courses of
roxithromycin. She did not
smoke or drink alcohol.
There was no relevant family
history of cancers or tuberculosis.
Examination revealed a
group of smooth, somewhat
tender supraclavicular nodes
on the right. There was no
hepatosplenomegaly or other
mass palpable in the abdomen.
An examination of the axillae,
elbows, groin and popliteal
fossae revealed no obvious
lymphadenopathy.
ENT examination was
normal. The trachea was
midline and chest normal on
examination.
Breast examination was
not carried out, despite the
explanation that it was part
of excluding cancer, because
DB said that she had had it
done recently.
An FBE/ESR and CXR
were performed with the following results:
■ FBE was normal and the
ESR of 21mm/hour was
reported as “mildly raised”.
An FBE undertaken at the
emergency department of
the local hospital one month
before the bronchitis when
she had had abdominal
cramps, dizziness and
nausea showed “a mature
neutrophilia possibly due to
an infective or inflammatory
process”. C-reactive protein
was 22 mg/L.
■ The CXR report said,
“Superior mediastinal
adenopathy requires exclusion”.
■ A CT reported, “Superior
mediastinal lymph nodes
are shown ?lymphoma …
paratracheal, posterior
mediastinal and hilar
lymph node chain appear
spared and normal …
Axillary lymph nodes
appear of normal size …”.
DB was referred for
urgent biopsy at a surgical
outpatient department. No
results are yet available.
Questions for the authors
These nodes are in the anterior triangle and at level IV,
according to your terminology. What is the significance
of this in this case?
Isolated nodes at level IV
are uncommon and the practitioner should always consider pathology below the
clavicles when they occur. A
lump in the neck at this site
in a young non-smoker
raises two main possibilities:
lymphoma and metastatic
thyroid cancer.
What are the most likely
diagnoses? What is the optimal management pending a
histological diagnosis?
Lymphoma and metastatic thyroid cancer are the
most likely diagnoses.
Fine-needle aspiration
cytology should be one of
the first investigations, along
with CXR.
Ultrasound of the thyroid
gland and a thyroglobulin
test may be helpful.
How To Treat Quiz
2. When examining a patient with a neck
lump, which TWO statements are correct?
❏ a) The anterior triangle extends from the
sternocleidomastoid muscle to the midline
❏ b) The anterior limit of the posterior triangle
is the trapezius muscle
❏ c) Normal anatomical structures are rarely
the cause of lumps presenting to GPs
❏ d) Level-I lymph nodes are found in the
submandibular and submental triangle
3. Jane, 45, presents with a lateral neck
lump. She has always been very slim
(BMI 18) but is in good health. Which THREE
examination techniques are helpful in
distinguishing normal anatomical structures
from significant pathology?
General questions for the
authors
In rural and regional areas,
imaging facilities are often
limited. Apart from excluding pulmonary and thoracic
pathology, how useful is a
CXR?
It should be remembered
that lung cancer is common
and lethal.
The use of CXR in management is relevant in nearly
every neoplastic disease (perhaps with the exception of
limited skin malignancy).
We would certainly recommend its use in this case.
Should GPs, particularly
rural and regional GPs, be
trained and supported to do
FNAB? What is the evidence
to support this strategy over
and above the specialistbased model?
Our view is that there is
no strong argument for GPs
to be trained in FNAB. It has
potential complications, the
preparation of specimens is
important and the technique
sensitive, the cytologist
should be very familiar with
the technique for good
results, and image guidance
may be necessary for the
procedure.
The combination of these
factors means that FNAB is
better carried out at specialist centres, where more consistent results can be
obtained.
What is the optimal model
for a multidisciplinary team?
What is the evidence for a
managed team? What are the
attributes of such a team and
the component members that
contribute to effective care?
Could this team could be
coordinated/led by the GP?
Multidisciplinary care
should be led by a cancer
specialist , who may be a surgeon, a medical oncologist or
radiation oncologist.
The cancer specialist
ACKNOWLEDGEMENT
The authors would like to
thank Bob Haynes and the
audiovisual department at
Royal Prince Alfred Hospital,
Sydney, for their help in
preparing the illustrations
used in this article.
Complete this quiz to earn 2 CPD points and/or 2 PDP points by marking the correct answer(s)
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❏ a) Examination of the opposite side of the
neck as well as the side with the lump
❏ b) Examination of the patient in a seated
position with the neck relaxed
❏ c) Asking the patient to contract the
sternocleidomastoid muscle by turning their
head to the same side as the lump
❏ d) Asking the patient to swallow
6. Which TWO signs or symptoms would you
be most likely to look for in this man?
❏ a) Leukoplakia or mucosal cancer in the
mouth
❏ b) Ear pain and voice changes
❏ c) Involvement of the skin or facial nerve
weakness
❏ d) Infection with HPV
4. Jim, 45, presents with a lateral neck lump.
Which ONE factor in his history would be
least likely to increase the chance of his
lump being malignant?
❏ a) Smoking
❏ b) Occupation
❏ c) Alcohol
❏ d) Previous lip SCC
7. Erica, 45, has recently noticed an anterior
neck lump just to the side of the midline.
Which TWO examination techniques or
investigations would be most likely to help in
her diagnosis?
❏ a) Thyroid uptake scan
❏ b) Observing whether the lump moves with
tongue protrusion
❏ c) Observing whether the mass moves on
swallowing
❏ d) Investigation with thyroid function and TSH
tests.
5. Patrick, 70, presents with a painless mass
in the lateral neck that is persistent and
constant in size. The differential diagnosis
would be most likely to include which
THREE conditions?
❏ a) A ptotic submandibular gland
❏ b) A stone obstructing the submandibular
gland
❏ c) The greater cornu of the hyoid
❏ d) Metastatic SCC
should form part of a team
that includes other medical
specialists and allied health
care professionals relevant to
the particular cancer (for
example, specialist nurses,
social workers, speech
pathologists, dentists, etc).
In rural areas it may not
be possible to access multidisciplinary teams as easily
as it is in cities, but it should
be remembered that patients,
particularly those with
advanced and complex disease, benefit from multidisciplinary care.
It is probably not feasible
for such teams to be GP-led,
but GPs should be encouraged
to be part of the teams, ensuring good communication
especially in:
Planned treatment pathways.
Co-ordinating patients
requirements on return to
the community.
In a palliative care setting.
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Neck lumps — 05 August 2005
1. Which TWO statements about neck lumps
are correct?
❏ a) Neck lumps in children are rarely
malignant and are often reactive lymph nodes
❏ b) In an adult with a lateral neck lump,
cancer should always be excluded
❏ c) In adults it is appropriate to treat neck
lumps with several courses of antibiotics
❏ d) Classifying the anatomical position of the
lump does not aid diagnosis
All these activities took place
over 10 days, with a busy
patient and a busy group
practice, involving three
part-time doctors. Is this
management timely?
We would consider that
10 days is an entirely appropriate time in which to workup this patient.
In rural areas diagnostic
facilities may be located a
long distance from the
patient’s home, as may be
specialist centres.
8. Charles, 50, presents with a painless
swelling in the parotid gland. When
discussing this condition with him, which
information is correct (choose TWO)?
❏ a) Most tumours of the parotid gland do not
require surgery.
ONLINE
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❏ b) In Australia, metastatic cancers from SCC
or melanoma are the most common
malignant tumour in the parotid gland
❏ c) Persistent parotid swellings are usually
caused by infection or inflammation
❏ d) Bacterial infections of the parotid gland are
usually associated with acute pain and swelling
9. James, 22 and of Asian descent, presents
with a new anterior neck swelling. On careful
questioning, he reports having male sexual
partners. When considering diagnosis, which
THREE conditions would be most important to
exclude?
❏ a) Hodgkin’s disease
❏ b) Tuberculous lymphadenopathy
❏ c) Dermoid cyst
❏ d) HIV
10. After history and examination, which TWO
of the following investigations are most likely
to be useful in establishing the correct diagnosis in a patient presenting with a neck
lump?
❏ a) FNAB
❏ b) Excision biopsy in your rooms
❏ c) Computerised tomography
❏ d) PET imaging
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