Neck swellings

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Contents

Introduction

Swellings or lumps in the neck are a common clinical problem. Patients presenting with neck lumps are likely to be fearful that they have cancer. Neck lumps in children are common although rarely malignant, but the situation is quite different in adults. The following rule should apply: an adult with a lump in the lateral neck has cancer until proven otherwise. Adults with lateral neck swellings should not be subjected to lengthy trials of observation or antibiotic therapy; instead, diagnostic efforts should be aimed at excluding malignancy.

Basic knowledge

Most neck lumps can, with a little experience, be diagnosed clinically. It is important to have some knowledge of head and neck anatomy to assist with clinical diagnosis (see Otorhinolaryngology). In The triangles, lymph node levels and normal lymph nodes in the neck. It shows the main muscular anatomy of the neck with the sites of normal, named lymph node groups. In addition, the lymph nodes are subdivided into levels as follows: level I, submandibular and submental triangle; level II, upper jugular chain lymph nodes (including the jugulodigastric lymph node); level III, mid-jugular chain nodes (including the jugulo omohyoid node); level IV, lower jugular chain lymph nodes (including lymph nodes overlying scalenus anterior muscle and those in the supraclavicular fossa); level V, lymph nodes of the posterior triangle, lying along the course of the spinal accessory nerve. the triangles of the neck and the distribution of lymph nodes are shown. The lymph nodes can be grouped into levels and these are shown in roman numerals. Level I consists of the submandibular and submental lymph nodes. Levels II, III and IV are respectively the upper, middle and lower jugular chain nodes. Level II also contains the jugulodigastric lymph node. Level V has the lymph nodes of the posterior triangle. The following facts should be remembered:

  • The jugulodigastric lymph node is commonly enlarged in both inflammatory and malignant conditions. Children with tonsillitis, young adults with glandular fever or Hodgkin's disease and middleaged adults with cancers of the oral cavity and oropharynx can all present with lymphadenopathy at this site.
  • The lymph nodes in the posterior triangle are all distributed along the spinal accessory nerve. These nodes are most commonly involved in benign infective conditions (usually viral) in children and young adults.
  • Metastatic involvement of posterior triangle (spinal accessory) nodes may occur with naso-pharyngeal cancer and skin cancers arising on the posterior scalp, neck and shoulder region.
  • Skin cancer is common in Australia and both melanoma and squamous carcinoma can metastasise to the lymph nodes in the parotid gland, those in the submandibular triangle and those in the posterior triangle.
  • Approximately 80% of lateral neck lumps in adults will be due to metastatic cancer. It is important to examine the possible anatomical primary sites that may lead to metastatic disease in the neck. They are the skin of the head and neck (including the scalp), the lip, the oral cavity, the oropharynx, the post-nasal space (especially in Asian patients), the larynx and hypopharynx.
  • A solitary lump, low in the neck, deep to the sternomastoid muscle in the supraclavicular fossa (level IV) is likely to be a metastasis from a primary cancer below the clavicles, that is, the lung, the oesophagus, the stomach or the pancreas.
    The triangles, lymph node levels and normal lymph nodes in the neck. It shows the main muscular anatomy of the neck with the sites of normal, named lymph node groups. In addition, the lymph nodes are subdivided into levels as follows: level I, submandibular and submental triangle; level II, upper jugular chain lymph nodes (including the jugulodigastric lymph node); level III, mid-jugular chain nodes (including the jugulo omohyoid node); level IV, lower jugular chain lymph nodes (including lymph nodes overlying scalenus anterior muscle and those in the supraclavicular fossa); level V, lymph nodes of the posterior triangle, lying along the course of the spinal accessory nerve.

Clinical assessment

Evaluation of the patient in the office or clinic begins with a careful history, taking into account first the age of the patient and second whether the swelling is in the lateral or anterior compartment of the neck.

Children are likely to present with a short history of either enlarged tender lymph nodes, suggesting an infective or inflammatory process, or multiple small non-tender nodes, particularly in the posterior triangle, suggesting a subclinical viral infection. Long-standing cystic swellings in children suggest a congenital problem, possibly cystic hygroma (also called lymphangioma). Thyroid swellings in children are very uncommon, but 50% of them are malignant when they do occur.

Adolescents can also present with acute inflammatory lymphadenopathy in the jugulodigastric region and occasionally also in the posterior triangle. Glandular fever and viral conditions should be considered. The presence of multiple enlarged lymph nodes is more suggestive of infection. Adolescents, however, can develop lymphomas, particularly Hodgkin's disease and prominent lymph nodes. Those larger than 2 cm should be evaluated to exclude malignancy, especially where the history suggests that there has been progressive slow enlargement. Skin cancers are rare in children and uncommon in adolescents. Young adults can develop melanoma and a history of previous removal of a pigmented skin lesion could be highly relevant.

Other common clinical conditions in adolescents and young adults are:

  • thyroglossal cyst, presenting as a painless swelling at or below the level of the hyoid bone, which elevates on tongue protrusion
  • branchial cyst, presenting at the anterior border of the sternomastoid muscle below the jaw (level II); there is usually rapid painless development of the swelling although secondary infection and inflammation may occur
  • plunging ranula, a cystic swelling in the submandibular region due to extravasation through the mylohyoid muscle of mucoid saliva from a disrupted sublingual gland in the floor of the mouth.

The clinical evaluation of adults with lateral neck lumps is aimed more specifically at the exclusion of malignancy. The history is usually one of painless progressive enlargement of a lymph node. There may be a pre-existing history of skin cancer (squamous carcinoma or melanoma) or treatment for some other malignancy involving the lip, oral cavity, oropharynx or some other mucosal site. Neck lymphadenopathy in an Asian patient should raise the possibility of nasopharyngeal carcinoma; however, tuberculosis is also relatively common among Asian patients who have recently immigrated. The smoking history is important. Mucosal cancers, which are nearly always squamous carcinoma, occur rarely among non-smokers and so a history of heavy tobacco and alcohol use raises the possibility that cervical lymphadenopathy represents metastatic cancer from a mucosal primary squamous carcinoma.

Physical examination

The usual evaluation of lumps involves clarification of the following features: site, size, shape, consistency, deep and superficial attachments, the nature of the surface and the edge of the lump, the presence of fluctuation, pulsation and translumination. In the neck the following issues apply:

  • Which triangle of the neck is involved? (Is the lump in the lateral or anterior compartment of the neck?)
  • Does it move with swallowing? This indicates it is deep to the pretracheal fascia and likely to be thyroid.
  • Does it move with protrusion of the tongue? This applies to upper anterior neck lumps, and the physical sign refers to thyroglossal cysts.
  • What is the relationship to the sternomastoid muscle? This final point is important for differentiating lumps in the upper neck. Tumours in the tail of the parotid gland will lie superficial to the sternomastoid muscle and, when the muscle is contracted by turning the head to the opposite side, the lump will remain easily palpable. By contrast, an upper jugular chain (level II) lymph node, lying deep to the sternomastoid muscle, will become less obvious and more difficult to palpate when the head is turned to the opposite side.
  • Where the neck lump appears to be an enlarged lymph node, either benign or malignant, the possible sources of infection or malignancy should be searched for.

Sites of common anterior compartment swellings are shown in The anterior compartment of the neck showing the trachea, thyroid gland and laryngeal framework consisting of the thyroid cartilage and hyoid bone. This area is made up of the two anterior triangles of the neck, each consisting of the area bounded by the jaw superiorly, the anterior board of the sternomastoid muscle posteriorly and the midline medially. The sites of various anterior and anterolateral neck lumps are shown.

The anterior compartment of the neck showing the trachea, thyroid gland and laryngeal framework consisting of the thyroid cartilage and hyoid bone. This area is made up of the two anterior triangles of the neck, each consisting of the area bounded by the jaw superiorly, the anterior board of the sternomastoid muscle posteriorly and the midline medially. The sites of various anterior and anterolateral neck lumps are shown.

Fine-needle aspiration biopsy

Fine-needle aspiration biopsy is the single most important test in the evaluation of neck lumps, particularly in adults who may have malignancy. It is usually necessary to carry out needle biopsy of tender lymph nodes in children; however, non-tender swellings in the central and lateral compartments of the neck in adolescents and adults should be evaluated by needle biopsy as the initial investigation. Metastatic malignancy can usually be diagnosed with a very high degree of accuracy. In general, reactive lymphadenopathy can be distinguished from lymphoma on needle biopsy; however, occasionally atypical lymphocytes are identified and it is necessary to carry out an excision biopsy of the node to clarify the diagnosis. Branchial cysts mainly occur in young adults and when they are aspirated thick creamy fluid is removed along with benign squamous cells. Under the microscope cholesterol crystals and cellular debris are visible. Branchial cysts occasionally occur in middle-aged adults, otherwise at risk of metastatic cancer, and it can sometimes be difficult to distinguish between metastatic squamous carcinoma with central necrosis and a benign branchial cyst on cytology. Excision of the lump may be necessary.

Fine-needle biopsy is also the best initial investigation of the thyroid swellings. The presence of colloid, normal follicle cells and haemosiderin-laden macrophages is consistent with the presence of a colloid nodule. The presence of papillary structures raises the possibility of papillary carcinoma, while a finding of multiple follicle cells in a microfollicular pattern with very little colloid indicates that the nodule is a solid follicular lesion. In this setting it is necessary to completely remove the lump (by thyroid lobectomy) to differentiate between follicular adenoma and follicular carcinoma.

Fine-needle aspiration biopsy is very safe and the risk of tumour implantation along the needle tract is negligible.

Ultrasound

In general, ultrasound is not particularly useful in the evaluation of head and neck lumps. Ultrasound can differentiate between solid and cystic masses and can indicate whether or not there are multiple enlarged lymph nodes or the presence of multiple nodules in the thyroid gland. Ultrasound, however, rarely assists in clarifying the diagnosis.

Computed tomography

Computed tomography (CT) scans are far more helpful than ultrasound in assisting with the diagnosis of neck swellings, especially when they are larger than 2 cm. Computed tomography scanning can provide an idea of the consistency of a lump along with its size and anatomical relations. Computed tomography scans showing common pathological processes in the neck. Each has a typical appearance. (A) Large lipoma neck deep to sternomastoid muscle and impinging on the parapharyngeal region. Note that the lesion is black, the same as the subcutaneous fat. (B) Thyroglossal cyst. Note the smooth-walled, well-circumscribed cystic mass closely attached to the anterior part of the right thyroid cartilage lamina. (C) Branchial cyst. This is a smooth-walled, well-circumscribed cyst deep to the sternomastoid muscle in the right neck in a young patient. It must be differentiated from metastatic squamous carcinoma with cystic degeneration (see (E)). (D) Plunging ranula. This cystic swelling is more dense than subcutaneous fat but less dense than the soft tissue of the adjacent submandibular salivary gland (small black arrow). It is due to extravasation of mucoid saliva from the sublingual gland into the submandibular space and through the mylohoid muscle. (E) Metastatic squamous carcinoma of the neck with cystic degeneration. Note that this is also cystic but, unlike the branchial cyst (see (C)), the wall of the lesion is irregular. (F) Large mass of metastatic squamous carcinoma in the right neck. This is a predominantly solid mass with little cystic degeneration. shows a series of CT scans of common neck lumps, demonstrating the typical radiological appearance.

Computed tomography scans showing common pathological processes in the neck. Each has a typical appearance. (A) Large lipoma neck deep to sternomastoid muscle and impinging on the parapharyngeal region. Note that the lesion is black, the same as the subcutaneous fat. (B) Thyroglossal cyst. Note the smooth-walled, well-circumscribed cystic mass closely attached to the anterior part of the right thyroid cartilage lamina. (C) Branchial cyst. This is a smooth-walled, well-circumscribed cyst deep to the sternomastoid muscle in the right neck in a young patient. It must be differentiated from metastatic squamous carcinoma with cystic degeneration (see (E)). (D) Plunging ranula. This cystic swelling is more dense than subcutaneous fat but less dense than the soft tissue of the adjacent submandibular salivary gland (small black arrow). It is due to extravasation of mucoid saliva from the sublingual gland into the submandibular space and through the mylohoid muscle. (E) Metastatic squamous carcinoma of the neck with cystic degeneration. Note that this is also cystic but, unlike the branchial cyst (see (C)), the wall of the lesion is irregular. (F) Large mass of metastatic squamous carcinoma in the right neck. This is a predominantly solid mass with little cystic degeneration.

Excision biopsy

If a diagnosis cannot be confirmed on fine-needle aspiration biopsy, an excision biopsy may be necessary to confirm or exclude malignancy. Care should be taken not to spill tissue or break up a lymph node in the course of biopsy because malignant cells may be implanted into the surrounding tissue. The biopsy incision should be oriented in a natural skin crease in such a way that the biopsy scar can be excised in a subsequent operation. Furthermore, care must be taken not to damage related anatomical structures, for example, the spinal accessory nerve in the posterior triangle and the marginal mandibular nerve in the submandibular triangle, during excision biopsy procedures.

Chest X-ray

Chest radiology is important in young adults, when lymphoma is the possibility, and in all adults. It may demonstrate mediastinal widening or primary or secondary lung neoplasms. It should be remembered that lung cancers are more common than mouth and throat cancers and that smokers, who are at risk for head and neck cancers, are also at risk of having lung cancer.

Treatment

The management algorithm for neck lumps is summarised in the decision-making flow chart (Management algorithm for neck lumps.). Following the history, physical examination and investigations, a diagnosis can usually be made. Excision of the lump may be necessary and if the lump proves to be benign, the excision biopsy is likely to be curative. Some benign lumps (e.g. reactive lymph nodes, lipomas and sebaceous cysts) may be simply observed and left untreated. Other benign lumps require removal either for patient comfort, cosmesis, or to avoid future problems. Branchial cysts, thyroglossal cysts, plunging ranulas, dermoid cysts, some lipomas and sebacous cysts, and benign salivary and thyroid swellings fall into this category.

Management algorithm for neck lumps.

Once a diagnosis of malignancy is made, definitive treatment is necessary. Lymphoma requires further staging investigations and treatment by chemotherapy, radiotherapy or both.

The treatment of metastatic cancer depends on the type of cancer and whether or not the primary site can be identified.

If the primary cancer is found (skin or mucosa of the upper aerodigestive tract), it should be treated definitively with the metastatic neck disease. If a primary cancer cannot be found and the fine-needle aspiration biopsy shows metastatic squamous carcinoma, a thorough investigation of the upper aerodigestive tract should be carried out with biopsies of potential occult primary sites. These include the nasopharynx, tonsil and tongue base. When the primary site is still not identified, the metastatic disease in the neck requires treatment by surgery, with or without post-operative radiotherapy.

When metastatic adenocarcinoma is identified by fine-needle aspiration biopsy an attempt should be made to determine whether there is a treatable primary cancer; for example, in the thyroid gland or a salivary gland. Adenocarcinomas from the prostate, breast or abdomen that metastasise to the neck lymph nodes, are not curable and so radical treatment to the neck is not warranted. Also, an extensive work-up in an asymptomatic patient should not be carried out when metastatic adenocarcinoma is diagnosed, as cure is unlikely.

The operation used to treat cancer in the neck is called neck dissection. Neck dissections can vary in their extent and according to which anatomical structures are preserved (see Otorhinolaryngology). Radiotherapy is given after surgery when multiple lymph nodes are involved with metastatic disease or when there is evidence of spread outside the lymph node capsule (extracapsular spread).
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