Download Neck Lumps : Clinical Guidelines

Neck Lumps : Clinical Guidelines
See also
Retropharyngeal abscess : Guideline
*Prior to reading this guideline*
Any neck lump associated with any respiratory symptoms need
URGENT ENT review
Introduction
There are many causes of lumps in the neck. The most frequently seen lumps or
swellings are enlarged lymph nodes, which can be caused by bacterial or viral
infections, malignancy, and other rare causes. Most head and neck lumps result from
congenital or inflammatory processes
Enlargement of the submandibular salivary glands (under the jaw) may result from
infection or malignancy. Lumps in the muscles of the neck -- almost always in the
front of the neck and involving the sternocleidomastoid muscle -- result from injury or
torticollis. Lumps in the skin or just below the skin are often caused by cysts,
including sebaceous cysts.
The thyroid gland may also produce a lump, multiple lumps, or swelling in the neck
as a result of thyroid disease or malignancy. Most cancers of the thyroid gland are
extremely slow-growing and often curable by surgery even if they have been present
for several years.
Causes
Anterior triangle
Lymphadenopathy
Primary infection –
Secondary infection -
Bacterial :
1. Streptococcus pyogenes(grp A strep)
2. Other types of bacterial pharyngitis
(sore throat from a bacterial infection)
3. Retropharyngeal abscess
4. Cat scratch disease
5. Mycobacterial (TB and atypical)chronic presentation
6. Actinomycosis (rarely)
Viral :
1. Infectious mononucleosis (EBV)
2. HIV disease
3. AIDS
4. Rubella (German measles)
5. Viral pharyngitis – Adenoviruses,
CMV
6. Herpes infections
7. Toxoplasmosis
lymphadenitis
Malignant
1. Hodgkin's disease
2. Non-Hodgkin's lymphoma
3. Leukemia
Thyroid
1. Graves' disease
2. Goiter
Thyroglossal cysts
Dermoid cyst
Branchial cyst
Posterior triangle
Lymph nodes (as above)
Cystic hygroma
Sternomastoid tumours
Parotid swellings
Salivary Gland Enlargement
Infection
Mumps
Stone in salivary duct
Salivary gland tumor
Assessment
1. Clinical History
To include history of :
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Always ask how long lump has been present, is it changing - lumps of <3
weeks duration are most likely due to a self-limiting infection and do not
require further investigation
Lump pain
Other generlised symptoms
Recent tonsillitis, skin lesion
Has a course of antibiotics been tried
Cat scratches
2. Clinical examination
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Examine patient sitting down on a chair, examining carefully the whole of the
scalp, the back of the neck and behind and within the ears. Palpate the lymph
nodes of head and neck - are they tender, fibrous, hard or rubbery, fixed or
mobile?
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For submandibular lumps examine the mouth and salivary glands, looking for
oral malignancies or sources of infection e.g. abscesses:
Retract lips with gloved fingers or wooden spatula and examine lips, teeth,
gums and lining of cheeks with torch.
If parotid disease suspected identify orifice of parotid duct and palpate with
head tilted backwards.
Examine tongue and floor of mouth with tongue first protruding and then
elevated inside the mouth.
Bimanually palpate lumps in floor of mouth, submandibular area and cheeks.
For lumps in the parotid region test and record the integrity of the facial nerve.
Always look for any generalised lymphadenopathy, and liver or splenic
enlargement.
Height, Weight, Surface area
Temp, pulse etc.
3. Investigations
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Any neck lump associated with any respiratory symptoms
need URGENT ENT review
If clinically unwell consider FBC CRP Blood Culture, Throat Swab
Investigations of persistent lumps may involve fine needle aspirate or
excision biopsy, to be sent to histology and microbiology for routine and
mycobacterial culture.
Consider CXR and ultrasound
Consider MRI/CT.
Consider sending a serum sample for Bartonells henslae serology if strong
history suggesting cat scratch disease
Management
Any neck lump associated with any respiratory symptoms need
URGENT ENT / Senior review
If patient well :
1. Oral antibiotics 10 day course : Amoxicillin
2. If possibly infectious mononucleosis (teenager) then consider
penicilin V
3. Erythromycin if allergic
Review after course of antibiotics
Arrange biopsy if node is >2cm and persistent, if node is rapidly
enlarging or painful.
If Patient systemically unwell :
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Admit to ENT ward D34
Complete above blood investigations
Consider neck imaging
Start IV antibiotics : first line
a. If pharyngitis IV Benzylpenicillin
b. If source unclear IV Cefuroxime and
Metronidazole
For further microbiology advice contact microbiology.
For age appropriate antibiotic doses see BNF for children
Contact Numbers :
Paeduatric Medical SHO :
Paediatric Medical Registrar :
Ear Nose Throat Registrar :
Pager 843151
Pager 843150
Contact Via Switch
References
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www.surgical-tutor.org.uk
www.nlm.nih.gov/medlineplus
www.patient.co.uk
www.nlm.nih.gov/medlineplus/ency/article/003098.htm
Essential Surgery 3rd edition. Burkitt HG and Quick CRG. Churchill
Livingstone 2002