Australian Doctor Australian Doctor 7th September 2018

24 HOW TO TREAT: NECK LUMPS IN ADULTS

7 SEPTEMBER 2018 australiandoctor. com. au

PAGE 22

PROGNOSIS

SIMPLE bacterial or viral reactive lymphadenopathy usually shows signs of resolution within two weeks. The prognosis of patients diagnosed with head and neck SCC depends on the primary site involved, the stage of disease at time of diagnosis, and the patient’ s age and comorbidities. 38 In Australia, the five-year survival rate for these cancers is 69 %. 4 Extensive surgical resections and wide fields of irradiation are often associated with significant morbidity and reduction in quality of life. Patients diagnosed with HPV-positive oropharyngeal cancers tend to have better overall survival and higher rates of cure compared with patients with HPV-negative SCC. 39 The overall fiveyear survival rate for primary salivary gland neoplasm is about 70 %. 40 The prognosis for thyroid cancer is better, with a 96 % five-year relative survival rate at diagnosis. 4

THE FUTURE

THE approach to managing head and neck SCCs is rapidly changing. Minimally invasive techniques using endoscopic, laser and robotic techniques are being developed to resect head and neck cancer, with reduced morbidity. An increasing number of clinical trials are investigating the role of immunotherapeutic agents, including angiogenesis inhibitors

1. Which TWO are the most common causes of a persistent non-infectious lateral neck mass in adults? a Thyrotoxicosis. b Malignant lymphadenopathy from a head and neck primary site. c Lymphoma. d Upper respiratory tract infection.

2. Which THREE are common causes of lateral neck lumps? a Reactive lymphadenopathy. b Dermoid cyst. c Sialadenitis or sialolithiasis. d Salivary gland neoplasm.

3. Which TWO statements regarding neck lumps in adults are correct? a Cervical reactive lymphadenopathy is typically self- limiting and resolves spontaneously over a period of weeks. b With cat-scratch disease and HIV, the development of lymphadenopathy often occurs weeks after initial inoculation. c In EBV and CMV infections, the submandibular lymph nodes are classically involved. d Bacterial infections of a salivary gland typically involve a single gland, most commonly the sublingual.

4. Which TWO are features of a thyroglossal duct cyst? a This is the most common

Key points

and other molecularly targeted agents, for these SCCs.

The role of HPV vaccination in preventing oral HPV infection and oropharyngeal SCC is another area of intense focus in head and neck cancer research. Preliminary studies have demonstrated that HPV vaccination decreases oral HPV infection, which indicates that HPV vaccines may be efficacious in preventing oral HPV infection. 41

CASE STUDY

MARIO, 72, presents with a lump on the right side of his neck. He first noticed it about three months ago and it has been slowly growing in size. He is otherwise well and cannot recall any infective symptoms before the lump first appeared.

He reports no voice changes, swallowing difficulties, or shortness of breath.

He smokes a pack of cigarettes a day and has done so for the past 50

How to Treat Quiz.

• Neck lumps in an adult patient are a common presentation to GPs.

• Presume that a new neck lump in an adult is a malignancy until proven otherwise.

• A thorough history, examination and targeted investigations are required to narrow the differential diagnoses for a neck lump.

• Where a malignant mass is suspected, arrange a CT of the head and neck with contrast and ultrasound-guided fine needle biopsy, along with urgent referral to a head and neck surgeon.

• HPV-positive oropharyngeal SCCs are increasing in prevalence, and often occur in the absence of classical risk factors or features of malignancy.

congenital anomaly of the central neck. b This presents as a soft, slowgrowing and painless lump along the sternocleidomastoid muscle. c The thyroglossal develops in utero to form the sublingual salivary gland. d They typically elevate with the larynx on swallowing and with tongue protrusion.

5. Which TWO statements regarding neoplasms in the neck are correct? a Salivary gland tumours are the most common subcutaneous neoplasm encountered in adults. b Benign neurogenic tumours occur more rarely than benign salivary gland tumours. c Unilateral nasal obstruction, epistaxis or a unilateral middle ear effusion may indicate the presence of a nasopharyngeal carcinoma. d A significant history of smoking and HPV exposure are the greatest risk factors for developing head and neck SCC.

6. Which THREE associated features are suggestive of lymphadenitis? years, and drinks three schooners of beer per day.

CPD POINTS

Mario’ s tongue lesion.

Examination reveals a firm lump just below the body of the mandible on the right. It is not tender when palpated. On examining his oral cavity, a firm, ulcerated 3cm lesion along the right lateral aspect of his tongue is noted( see image). Mario states

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a Odontalgia. b Rhinorrhoea. c Fluctuant mass. d Fever.

7. Which TWO statements regarding examination of the neck are correct? a The major structures that can be palpated in the midline from superior to inferior are the thyroid cartilage with its notch, the cricoid cartilage, the hyoid bone and the trachea. b The parotid glands are often palpable in thin individuals. c Supraclavicular lymph node enlargement may also be found with primary lung, oesophagus or stomach malignancy. d Lymph nodes that are fixed and firm or larger than 1.5cm are of greatest concern for malignancy.

8. Which THREE statements regarding the investigation of a neck lump are correct? a Mild viral and bacterial infections of the head and neck do not require further investigation. b Fine needle biopsies do not have a role in the investigation of a neck lump. c If a salivary gland neoplasm

• We have a new How to Treat website( www. howtotreat. com. au) where you can read this article and take the quiz to earn CPD points.

• Each article has been allocated 2 RACGP QI & CPD points and 1 ACCRM point.

• RACGP points are uploaded every six weeks and ACCRM points quarterly. that it has been there for a long time and has not resolved despite various topical treatments.

You suspect a tongue cancer with cervical lymph node spread, and refer Mario urgently to a head and neck surgeon. The surgeon performs a biopsy of the tongue lesion and it is found to be a SCC.

NECK LUMPS IN ADULTS

is suspected, or suggested on ultrasound, the patient should undergo CT or MRI of the gland. d In adults with suspected congenital or developmental masses, initially arrange a CT of the neck with contrast.

9. Which THREE statements regarding the management of neck lumps are correct? a Initial management of sialolithiasis involves rehydration, warm compresses, sialogogues and analgesia. b Bacterial sialadenitis can be managed with clindamycin and other conservative measures. c Adjuvant radiotherapy and chemotherapy are rarely indicated in the treatment of head and neck cancer. d In general, for primary head and neck cancer with cervical lymph node metastases, the primary lesion is surgically removed and a cervical neck dissection is performed.

10. Which THREE are indications for referral to a head and neck surgeon? a Mumps in an adult. b Non-infectious neck lump present for more than two weeks. c Clinical suspicion of a malignant neck lump. d New diagnosis of head and neck neoplasm.

No other abnormal lesions are identified on flexible nasendoscopy. His case is presented at a multidisciplinary head and neck cancer meeting. Based on the stage of his disease, a partial glossectomy( excision of the tongue) and ipsilateral neck dissection are performed. Clear margins are achieved and only one out of the 35 dissected lymph nodes harbour metastatic SCC. There is no extracapsular spread, perineural spread or vascular invasion. On this basis, adjuvant therapy is not required.

On review by his GP six months after surgery, Mario has some mild phonation difficulties, but has otherwise made an excellent recovery.

This case illustrates the importance of a thorough examination of the head and neck region in patients presenting with a neck lump. In 50 % of patients presenting with malignant neck cervical lymph nodes, the primary tumour can be found on clinical examination. 3 This case also demonstrates the importance of prompt referral. Delays in referral may result in further progress and require more extensive surgery as well as radiotherapy. Both of these may compromise the patient’ s functional outcome.

CONCLUSION

THE presentation of a neck lump in an adult patient is a common and, at times, challenging complaint. A systematic approach to neck lumps ensures a structured and timely approach to investigation and management. Refer a patient with a persistent non-infectious neck mass to a head and neck surgeon urgently for review. This is particularly important given the rising incidence of HPV-positive oropharyngeal head and neck SCCs in young patients without classical risk factors for cancer.

Australian Doctor Australian Doctor 7th September 2018 | Page 24

24 HOW TO TREAT: NECK LUMPS IN ADULTS

24 HOW TO TREAT: NECK LUMPS IN ADULTS

How to Treat Quiz.