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18 HOW TO TREAT: NECK LUMPS IN ADULTS

18 HOW TO TREAT: NECK LUMPS IN ADULTS

7 SEPTEMBER 2018 australiandoctor. com. au
On initial assessment, one of the important distinctions to make is whether the aetiology of a neck lump is inflammatory / infective in nature. In some circumstances this may be difficult to determine. A malignant neoplasm may also give rise to secondary infection of a malignant lymph node, confounding the clinical assessment of the patient. Therefore, close monitoring of all patients presenting with a neck lump is imperative.
Infective / inflammatory
REACTIVE LYMPHADENOPATHY
The lymphatic channels of the neck
are the primary drainage basin for
infectious processes of the face and
upper aerodigestive tract.
Inflammation of cervical lymph
nodes( reactive lymphadenopathy)
commonly occurs as part of an immunological
response to an upper respiratory
tract infection, tonsillitis,
sinusitis or dental infection. Cervical
reactive lymphadenopathy is typically
self-limiting and resolves spontaneously
over several weeks.
Similar findings on examination
are present whether the primary
infection is viral or bacterial. Common
bacterial infections leading to cervical
lymphadenitis include Staphylococcus spp. and Streptococcus spp. Consider lymphadenopathy due to Mycobacterium tuberculosis( TB) in immunocompromised patients or in patients from countries with a high burden of TB.
Common viral infections causing reactive lymphadenopathy include adenovirus, rhinovirus, Coxsackievirus A and B and parainfluenza, Epstein-Barr virus( EBV), Cytomegalovirus( CMV), Bartonella hense-
Figure 1. Lateral view of an enlarged submandibular gland.( above)
Figure 2. Thyroglossal duct cyst; a common central neck lump.( left)
lae( cat-scratch disease) and HIV. In
EBV and CMV infections, the lymph
nodes of the posterior neck are classically
involved. With cat-scratch
disease and HIV, the lymphadenopathy
often develops weeks after initial
inoculation.
SALIADENITIS AND SIALOLITHIASIS There are three major pairs of salivary glands in the head and neck: the parotid; submandibular; and sublingual glands. Sialadenitis refers to inflammation of a salivary gland, and this can be acute or chronic. Sialadenitis can arise as a result of bacterial or viral infection, as a complication of radiotherapy, or from an autoimmune condition such as Sjogren’ s disease. Dehydration and medications that reduce saliva production may also predispose patients to sialadenitis. anomalies are more common. They include thyroglossal duct cysts, associated with infection or spontaneous discharge.
Table 1. Common central and lateral neck lumps
Bacterial infections typically involve
a single gland, most commonly the
parotid. Staphylococcus aureus is the
most commonly implicated organism.
Viral sialadenitis, particularly from
mumps, occurs more commonly in
children.
Sialolithiasis refers to salivary
branchial cleft anomalies, plunging
ranulas and dermoid cysts.
A thyroglossal duct cyst is the most
common congenital anomaly of the central neck. 9 The thyroglossal duct descends from the base of tongue in
utero into the lower neck to form the
thyroid gland before involuting. A fail-
Dermoid cysts are benign soft tissue
cysts of embryonic origin typically
arising in the central neck. Ranulas are
cysts originating from the sublingual
salivary gland( see figure 3). They may
extend down into the neck, forming
a plunging ranula, and typically present
as a painless, slow-growing lump
Benign
Central neck
Thyroglossal duct cyst
Thyroid nodule or goitre
Dermoid cyst
Lateral neck
Reactive lymphadenopathy
Branchial cleft cyst
Sialadenitis or sialolithiasis
duct obstruction due to an impacted
calculus. Patients typically present
with pain and swelling in the region
of the affected gland. Secondary
suppurative sialadenitis due to duct
ure of involution results in a remnant
thyroglossal duct cyst. These masses
commonly present as painless cystic
swellings in the region of the hyoid
bone, but are also prone to infection.
10, 11 under the mandible.
Other common nonvascular cysts
causing neck lumps include epidermal
and sebaceous cysts. They also often
become infected as seen in figure 4.
Lipoma
Neurofibroma
Paraganglioma
Neuroma
obstruction is common. The submandibular
glands are most commonly
affected( see figure 1).
Congenital and developmental
Congenital and developmental masses
of the neck tend to present in children,
but should be considered in young
adults. They can be subdivided into
They typically elevate with the larynx
on swallowing and with tongue protrusion
( see figure 2).
Branchial cleft anomalies including
cysts and, less commonly, sinuses
and fistulae, arise in the lateral part of
the neck. They occur due to a failure
of obliteration of the second branchial
cleft in utero. Branchial cleft cysts
present as a soft, slow-growing and
Vascular malformations typically
present in childhood but may
occasionally be diagnosed in early
adulthood. They include capillary
malformations, lymphatic malformations
, venous malformations and
10, 12 arteriovenous malformations.
Thyroid lumps
Benign and malignant thyroid
Malignant
Malignant lymphadenopathy including lymphoma
Salivary gland neoplasm
Malignant lymphadenopathy including lymphoma
Salivary gland neoplasm
Lymphoma
Sarcomas
non-vascular and vascular anomalies. 7
Nonvascular congenital
painless lump along the sternocleidomastoid
muscle. They are often
masses present as a central neck
lump( see figure 5). Most PAGE 20
Adapted from Nugent and El-Deiry 7