Editing Neck lump



== Anatomical clues ==
{| class="wikitable"
|'''Lymph node group'''
|'''Anatomic areas drained'''
|-
|Occipital
|Posterior scalp
|-
|Postauricular
|Temporal and parietal scalp
|-
|Preauricular
|Anterior and temporal scalp, midface, nose, anterior ear canal and pinna, lateral conjunctivae
|-
|Parotid
|Forehead and temporal scalp, midface, nose, external ear canal, middle ear, gums, parotid gland
|-
|Submandibular (submaxillary)
|Cheek, nose, lips, anterior tongue, submandibular gland, buccal mucosa
|-
|Submental
|Central lower lip, floor of mouth, tongue
|-
|Superficial cervical
|Skin, lower larynx, lower ear canal, parotid
|-
|Superior deep cervical
|Tonsil, adenoid, posterior scalp and neck, tongue, larynx, hypopharynx, thyroid, palate, nose, esophagus, paranasal sinuses, nasopharynx, other cervicofacial nodes
|-
|Inferior deep cervical
|Dorsal scalp and neck, nasopharynx, superficial pectoral region of the arm, superior deep cervical
|}


== Differential diagnosis ==

* Developmental
** Inclusion cyst
** Thyroglossal duct cyst
*** In or near midline, typically just below hyoid, along the thyroglossal tract between the thyroid and base of tongue
*** Can become infected
*** Protrusion of tongue should result in cephalad movement of lesion
*** 1% harbour malignancy
*** Excision of cyst is indicated (Sistrunk procedure)
** Congenital vascular malformations
** Branchial cleft cyst
*** Congenital, generally present with infection following URTI
*** First branchial cleft: inferior to auricle or just below angle of mandible
*** Second: inferior to angle of mandible on anterior border of SCM and communicate with tonsillar tissue (by far most common type)
*** This: anterior on SCM, but lower than second cleft cysts.
*** Should be excised with care
** Cystic hygroma
** Laryngocele
** Teratoma
** Bronchogenic cyst
* Infectious
** Bacterial lymphadenitis
** Viral (EBV, HIV, etc)
** Protozoal (toxoplasmosis, leishmaniasis)
** Fungal (histoplasmosis, blastomycosis, coccidioidomycosis)
* Benign neoplasia
** Lipoma
** Thyroid nodule/diffuse goitre
** Parathyroid adenoma
** Fibroma
** Neurofibroma
** Sebaceous cyst
** Benign salivary tumours (pleomorphic adenoma, Warthin's tumour)
* Malignancy
** Lymphoma
** Carotid body tumour
** Thyroid cancer
** Malignant salivary tumours (mucoepidermoid, adenoid cystic)
** Parathyroid cancer
** Plasmacytoma
** Carcinoid
** Metastasis to cervical lymph nodes (thyroid, SCC, adenocarcinoma, melanoma)
* Miscellaneous
** Sialadenitis, sialolithiasis
** Sjogren's syndrome
** Sarcoidosis
** Aneurysm

== Risk profile ==
Probably infectious - give two weeks broad spectrum Abx (ADF) and review. Anything but complete resolution, work up for malignant. 


Probably malignant: any one of

* Duration >2 weeks
* No infectious aetiology
* Size >1.5cm
* Firm
* Fixed/reduced mobility
* Ulceration
* Dysphagia/hoarseness
* High-risk on history:
** Age >40 (malignant until proven otherwise - up to 80% will be!)
** Smoker, alcohol
** Immunosuppressed
** Previous head and neck cancer
** Family history malignancy
** B symptoms

== Examination ==

* Oral cavity
* Bimanual palpation floor of mouth and tongue
* Skin/scalp
* Cranial nerves
* Palpate thyroid
* Movement on swallowing/tongue out
* Position of trachea

== Investigation ==

* FBE/UEC/LFT/CRP
* EBV/CMV serology, or HIV
* USS
* CT neck to better characterise anatomy
* MRI 

== Biopsy: ==

* FNA preferred (avoid open/excisional)
** If first result is unsatisfactory, reasonable to go for a second
* Core biopsy useful if lymphoma suspected
* Excisional biopsy if those are unsuccessful

Look out for cystic lesions - can be non-HPV SCC - if suggestive history and FNA unsatisfactory, may be better for ENT to do an open biopsy

[[Category:ENT]]