Neck lump
Anatomical clues
[edit | edit source]| 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
[edit | edit source]- 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
[edit | edit source]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
[edit | edit source]- Oral cavity
- Bimanual palpation floor of mouth and tongue
- Skin/scalp
- Cranial nerves
- Palpate thyroid
- Movement on swallowing/tongue out
- Position of trachea
Investigation
[edit | edit source]- FBE/UEC/LFT/CRP
- EBV/CMV serology, or HIV
- USS
- CT neck to better characterise anatomy
- MRI
Biopsy:
[edit | edit source]- 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