Australian Doctor Australian Doctor 7th September 2018

24 HOW TO TREAT : NECK LUMPS IN ADULTS

7 SEPTEMBER 2018 australiandoctor . com . au

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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 .