Neck Lumps : Clinical Guidelines

Neck Lumps : Clinical Guidelines

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 – 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

Secondary infection - 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 :

· 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

· 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?

· 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

· 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 :

1. Admit to ENT ward D34

2. Complete above blood investigations

3. Consider neck imaging

4. 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 : Pager 843151

Paediatric Medical Registrar : Pager 843150

Ear Nose Throat Registrar : Contact Via Switch

References

· 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