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How to Treat.   EARN CPD OR PDP POINTS PULL-OUT SECTION Complete How to Treat quizzes online at australiandoctor.com.au/cpd Neck lumps in adults INTRODUCTION Dr Gregory Shein (left) ENT Registrar, Royal Victorian Eye and Ear Hospital, Melbourne, Vic. Dr Gurfateh Sandhu (centre) Surgical Senior Resident Medical Officer, Royal Prince Alfred Hospital, Sydney, NSW. Dr Ian Jacobson (right) Paediatric and Adult Otolaryngology and Head and Neck Surgeon, Prince of Wales Hospital, Sydney, NSW and Sydney Children’s Hospital, Sydney, NSW. A NEW neck lump in an adult patient is a common presentation in general practice. A neck lump may be defined as “an abnormal lesion that is below the mandible, above the clavicle, and deep to the skin”. 1 Neck lumps are a notoriously challenging presentation and may be caused by a wide spec- trum of aetiologies, including infec- tive, inflammatory and neoplastic processes, which require specific management. In many cases, several differen- tial diagnoses remain after history and examination. Fear of missing a crucial diagnosis may lead to unnec- essary investigations and special- ist referrals. However, presuming a neck lump is benign risks delaying diagnosis and treatment outcomes if the lump is subsequently found to be malignant. In many instances a neck lump may be the only mani- festation of a head and neck cancer. This How to Treat outlines a system- atic approach to the investigation and management of the most com- mon neck lumps occurring in adults. It proposes clear criteria for referral to a head and neck surgeon, and out- lines new developments in the man- agement of head and neck cancer. EPIDEMIOLOGY THERE are no precise figures on the proportion of adult patients present- ing to their GP with a neck lump. Given that about 5-10% of patients in Australia present to their GP with an upper respiratory tract infection, the presence of cervical lymphadenop- athy is a common presenting com- plaint or incidental finding. 2 Malignant lymphadenopathy from a head and neck primary site or lymphoma is the most common aeti- ology for a persistent non-infectious lateral neck mass in adults. 3 Head and neck cancers arise from the pharynx, larynx, paranasal sinuses, oral cavity and salivary glands. In Australia, about 5000 new cases of head and neck cancer are diagnosed each year. In 2017, there were 1026 deaths from head and neck cancer, representing 2.1% of all deaths from cancers. 4 Thyroid masses, including cancers, are typically treated as a separate disease entity. In Australia, an estimated 3330 patients will be diagnosed with thyroid cancer in 2018. 5 This How to Treat will con- sider thyroid nodules and goiters only briefly. Further information regarding their investigation and management is available under Fur- ther reading. AETIOLOGY A DIVERSE array of conditions may cause a neck lump in an adult. Table 1 lists the main aetiologies. Determining the aetiology of a neck lump may be further simplified by considering whether a neck lump is situated in the central (anterior) or lateral neck. Table 2 lists the most common aetiologies for anterior and lateral neck lumps. The ‘rule of 80’ for neck lumps states that about 80% of non-thyroid neck masses in adults are neoplastic, and that 80% of these neoplastic masses are malignant. At least 80% of these malignancies in adults are squamous cell carcino- mas, and the other 20% are of pri- mary lymphoid origin. 6 INSIDE Epidemiology Aetiology Diagnosis and investigations Management Prognosis The future Case study Copyright © 2018 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means without the prior writ- ten permission of the publisher. For permission requests, email: [email protected]