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HOW TO TREAT 21
australiandoctor.com.au 7 SEPTEMBER 2018
Figure 5.
A thyroid goitre
presenting as
a central neck
lump. (left)
Box 1. History-taking for neck
lumps
• Patient age
• Lump characteristics: size,
growth pattern, skin changes,
tenderness
• Associated symptoms: fever,
night sweats, dysphagia,
dysphonia, odynophagia,
haemoptysis and dyspnoea and
otalgia
• Past medical history of
– Head and neck cancer
– Skin cancers
– Head and neck surgery or
radiotherapy
– Immunocompromised
state including diabetes
mellitus, HIV or autoimmune
conditions
• Smoking and alcohol
consumption
DIAGNOSIS AND
INVESTIGATIONS
History
HISTORY-taking should aim to deter-
mine whether an infective/inflam-
matory, congenital or neoplastic
aetiology is responsible for the neck
lump. A warm, tender neck lump
present for less than two weeks, cou-
pled with symptoms such as fever,
cough, sore throat and rhinorrhoea,
or odontalgia, are suggestive of lym-
phadenitis. Neck masses that fluctu-
ate in size or have been present for a
long time are more likely to be con-
genital. A non-infectious mass pres-
ent for more than two weeks without
signs of improvement raises the con-
cern for malignancy.
Also establish the presence of any
constitutional symptoms associated
with lymphoma including fever, night
sweats and weight loss.
Determine the patient’s tobacco
and alcohol consumption, which are
the two most significant risk factors
for head and neck SCC, and ask about
the presence of any immunosuppres-
sive conditions including diabetes
and HIV.
Thyroid cancer, salivary cancer
and HPV-associated oropharyngeal
cancer usually occur in the absence
of more classical risk factors for can-
cer. Consider these conditions in all
adult patients with a history sugges-
tive of a non-infectious aetiology for
their neck lump.
A summary of the key points to
elicit on history-taking are summa-
rised in box 1.
Examination
Clinical examination requires an
appreciation of key anatomical struc-
tures of the neck, their location and
surface landmarks (see figure 8).
The major structures that can be
palpated in the midline from supe-
rior to inferior are the hyoid bone, the
thyroid cartilage with its notch, the
cricoid cartilage and the trachea.
The two lobes of the thyroid gland
lie laterally over the cricoid and thy-
roid cartilages.
The parotid glands lie over the
angle of the mandible. They are nor-
mally difficult to palpate.
The submandibular salivary
glands are located just below the
Metastases to lymph nodes within
the parotid gland may also occur. In
Australia, the most common parotid
malignancy is from metastatic cuta-
neous SCC. 27,30
Figure 6.
Cervical
triangle
anatomy
with common
lymph node
locations and
drainage areas.
(bottom)
body of the mandible. Normal sub-
mandibular glands are often palpable
in thin individuals.
The essential elements of exami-
nation for patients with a neck lump
are listed in box 2. With the patient
seated, begin with a general inspec-
tion for any facial swelling or asym-
metry. Carefully examine the skin of
the head and neck for any malignant
skin lesions — a relatively common
cause for malignant cervical lym-
phadenopathy in Australia. 28,31
Next, proceed to examination
of the neck lump. Determine if it is
located in the central or lateral neck.
Assess for tenderness, warmth, tex-
ture and firmness. Aim to deter-
mine whether the lump represents an
enlarged node or another anatomical
structure. Then, working medially to
laterally, palpate each cervical lymph
node group.
Lymph nodes that are fixed and
firm or larger than 1.5cm are of
greatest concern for malignancy. 29,1
Metastatic lymph nodes are often
generally firm because of an absence
of tissue oedema. However, a soft,
cystic lump does not exclude the pos-
sibility of malignant lymph node.
Supraclavicular lymph node enlarge-
ment may also be found with pri-
mary lung, oesophagus or stomach
malignancy.
Remove any dentures prior to
examining the oral cavity. Using a
tongue depressor and light, systemat-
ically examine each subsite, looking
for ulceration or superficial swellings.
Examine for any evidence of tonsil
asymmetry or signs of pharyngitis.
Grasp the tongue with gauze to
examine all its surfaces and palpate
for any submucosal lesions. Using a
gloved finger, palpate over the floor of
mouth, buccal mucosa and palate.
If there is any suggestion of lym-
phoma, palpate the axillary, epitroch-
lear and inguinal lymph nodes.
Using an otoscope, examine the
anterior nasal cavity looking for any
masses, suspicious for a neoplasm.
Complete the assessment by examin-
ing the ears.
Investigations
Investigations aim to distinguish
between the differential diagnoses
for the patient’s neck lump.
Mild viral and bacterial infections
of the head and neck do not require
further investigation. If a severe
infective process is evident, perform
serology including an FBC. If EBV
is clinically suspected, also test for
the presence of heterophile antibod-
ies with the Monospot test. In cases
where the diagnosis is unclear, per-
form EBV IgM and IgG serology. 30,32
If extrapulmonary Mycobacterium
tuberculosis is suspected, seek advice
from an infectious diseases special-
ist physician about further investiga-
tions and management. 31,33
Salivary gland pathology deemed
likely due to an inflammatory process
(sialadenitis and sialolithiasis) should
be imaged with an ultrasound in the
first instance, looking for a stone or
abscess that requires drainage. If a
salivary gland neoplasm is suspected,
or suggested on ultrasound, the pat-
ent should undergo CT or MRI of the
Box 2. Approach to clinical
examination for neck lumps
• General appearance
– Facial asymmetry
– Skin lesions
• Neck lump
– Inflammatory/infective or
non-infectious
– Location: central vs. lateral
– Characteristics: tenderness,
mobility, tethering, skin
changes
• Oral cavity
– Sequentially examine the
floor of mouth, teeth and
gingiva, buccal mucosa,
lateral trigone, hard palate,
soft palate and tongue
– Look for signs of primary
tumour: mucosal ulceration,
bleeding, erythroplakia, tonsil
asymmetry
• Nasal cavity: for signs of
epistaxis or nasal masses
• Ears: auricles and external
auditory canals