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How to Treat Pull-out section

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EARN CPD POINTS Complete How to Treat quizzes online (www.australiandoctor.com.au/cpd) or in every issue – see page 38.

inside Anatomy History and examination Investigations — uses and limitations Case studies

The authors

Neck lumps Background LUMPS and swellings in the neck are common and are encountered frequently in general practice. Patients presenting with neck lumps are often fearful of cancer, and the morbidity associated with delayed or incorrect diagnosis must not be underestimated. A diagnosis may be possible based on clinical examination alone but, more commonly, investigations are required to clarify the diagnosis and, in particular, to exclude or confirm a diagnosis of malignancy. It is important that the possibility of a diagnosis of cancer is not overlooked and that the pathway of referral for patients with cancer in the neck is appropriate and swift. In children, neck lumps are common but rarely malignant. They are often caused by reactive lymph node enlargement. Benign reactive lymph node enlargement is less common in adults. Small lymph nodes less than a centimetre in diameter may be found in the neck, axilla or groin in adults, but progressive enlargement should ring alarm bells. A safe rule is that any adult with a lump in the lateral neck has cancer until it is proved otherwise.

Any adult with a lump in the lateral neck has cancer until it is proved otherwise.

Suggested workup for patients presenting with neck lump or swelling

DR CERI HUGHES, fellow, Sydney Head and Neck Cancer Institute.

PROFESSOR CHRISTOPHER O’BRIEN, director, Sydney Cancer Centre and Sydney Head and Neck Cancer Institute.

History

Clinical examination

Fine-needle aspiration biopsy

CT scan

What next ? Where do I refer? It is important that adults with lateral neck lumps are not subjected to lengthy trials of observation or antibiotic therapy. Diagnostic efforts should be focused on excluding malignancy. A diagnosis can readily be made in the vast majority of cases, through careful history-taking combined with a thorough clinical examination. Fine-needle aspiration biopsy (FNAB) and CT scan (see Investigations — uses and limitations, page 35) should be considered the most useful investigations before referral to a specialist centre.

Multidisciplinary clinics Treatment of cancer of the upper aero-digestive tract requires a multidisciplinary approach. When a diagnosis of cancer in the neck is made, the patient should be referred to a head and neck specialist who participates in a multidisciplinary clinic. There is strong evidence that delayed referral, or diagnostic and therapeutic involvement with non-expert clinicians, can lead to poorer outcomes in the treatment of head and neck cancers. Multidisciplinary head and neck clinics are usually attached to major teaching hospitals. This may be an important issue for rural patients and their doctors, and appropriate referral may necessitate enquiry about the nearest specialist unit. Patients who need to attend for assessment and treatment may face additional difficulties with accommodation arrangements. Prior discussion with clinicians at the receiving hospital will help to make this process easier.

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Relevant anatomy A BASIC knowledge of head and neck anatomy is important in clinical diagnosis. By convention, anatomical regions in the neck are described as triangles. The anterior triangle extends from the sternocleidomastoid muscle to the midline. The posterior triangle is formed by the trapezius muscle posteriorly and the posterior border of the sternocleidomastoid muscle, which forms the anterior limit of the triangle. A clear idea of possible anatomical and pathological structures within each triangle or level helps in diagnosis and assists with identification of normal anatomical structures that can be confused with pathological lumps. For descriptive purposes the cervical lymph nodes are grouped into five levels (table 1, figure 1). This assists head and neck oncologists with staging and treatment. The use of accurate and consistent terminology encourages a common language to be used between clinicians when patients are referred for specialist opinion.

Distinguishing normal anatomy from pathology Normal anatomical structures can come to the attention of patients and create anxiety about a possible pathological cause. Careful exami-

Figure 1: Lymph node levels in the neck.

Table 1: Lymph node levels

thyroid cartilage to elevate also, highlighting the position of the thyroid cartilage in relation to other structures.

Level I

Submandibular and submental triangle

Level II

Upper jugular chain (base of skull to hyoid bone in a vertical plane)

Level III

Mid-jugular chain (from hyoid to cricoid)

Mastoid process

Level IV

Lower jugular chain (from cricoid to clavicle)

Level V

Posterior triangle (bounded by the trapezius and posterior of the sternocleidomastoid, lying along the course of the accessory nerve)

This bony process behind the ear lobe may be mistaken for a posterior auricular or parotid mass. Careful examination bilaterally and determination of its relationship to the sternocleidomastoid muscle, tensed on turning the head to the opposite direction, helps to differentiate the mastoid from other structures.

nation, mindful of normal anatomy, may help prevent misdiagnosis. Some of the structures that can cause confusion are listed below. Normal submandibular gland

An enlarged or ptotic submandibular gland (a normal feature in elderly patients) may easily be confused with an upper jugular chain lymph node or neck mass. Bimanual palpation, with a finger placed intra-orally while the other hand palpates the neck, will enable the gland to be palpated or balloted easily. This allows the gland to be differentiated from neck masses; the submandibular gland will feel firm, not hard, and will have a lobular texture. Angle of mandible and masseter hypertrophy

A prominent angle of the mandible

can easily be mistaken for a lump in the upper neck. Careful palpation with comparison to the contralateral side is helpful. Ask the patient to clench their teeth. This will cause contraction of the masseter muscle and help correctly identify the angle of mandible.

Lateral process of C1

The lateral processes of the cervical vertebrae (particularly C1) may be palpable posterior to the angle of the mandible, especially in thin individuals and those who have undergone neck dissection previously (they have little tissue between the lateral process and the skin). Awareness of this anatomical fact is useful but, if there is any doubt, a specialist opinion should be sought.

Greater cornu of the hyoid

This may be prominent in thin patients and appear as a hard neck mass in the submandibular region. Palpation of the neck bilaterally allows the hyoid to be moved laterally from side to side and will differentiate the hyoid from possible pathology.

Supraclavicular fat pad

A prominent fat pad in the supraclavicular region can be mistaken for a lymph node mass, but its consistency is usually softer than lymph node tissue.

Superior cornu of thyroid cartilage

This can be palpated easily in some patients and may be confused with a neck lump. On swallowing, elevation of the larynx will cause the

History and examination HISTORY and clinical examination are fundamental to early and accurate diagnosis. The age of the patient, the duration of the history and the anatomical location of the lump in the neck are important.

Causes of neck lumps, according to age Infant Neoplastic

Adolescent

Adult

Neoplastic (parotid, thyroid)

Lyphoma (Hodgkin’s)

Metastatic cancer, lymphoma (Hodgkin’s/ non-Hodgkin’s), thyroid

Infective/inflammatory

Non-specific lymphadenitis

Non-specific lymphadenitis, cat scratch disease, toxoplasmosis, atypical mycobacteria, mumps (viral parotitis)

Glandular fever, dental infection, cat scratch disease, toxoplasmosis, mumps (viral parotitis)

Dental infection, HIV lymphadenopathy, toxoplasmosis, cat scratch disease, TB

Congenital

Cystic hygroma, vascular malformation, congenital torticollis

Dermoid cysts, vascular malformations

Thyroglossal cyst, branchial cysts

Congenital sebaceous cyst

Younger patients Children commonly present with a short history of tender, enlarged lymph nodes, suggesting an infective process (eg, viral pharyngitis, acute tonsillitis, atypical mycobacterial lymphadenitis), or multiple small non-tender nodes, particularly in the posterior triangle, suggesting a subclinical viral infection. Soft swellings in the neck are uncommon, usually congenital and may be due to conditions such as lymphangioma (cystic hygroma) or vascular malformations. Congenital torticollis may present as a lateral neck swelling and should also be considered in this age group. Localised swellings in the thyroid or parotid glands in children are uncommon and malignancy needs to be excluded. Adolescents often develop acute inflammatory lymphadenopathy, particularly in the jugulo-digastric region, that may be bacterial in origin (eg, tonsillitis) or viral (eg, glandular fever). They can also develop lymphoma, particularly Hodgkin’s disease.

Child

Prominent lymph nodes that are non-tender and enlarge progressively should be treated with suspicion. Multiple small nodes occurring in the posterior triangle tend to be due to subclinical viral infections.

Adults Clinical evaluation of adults with lateral neck lumps is aimed at excluding cancer. Middle-aged people who smoke and drink alcohol are at higher risk of having mucosal cancers of the oral cavity, oropharynx or laryngopharyngeal region. Eighty per cent of these cancers will be related to use of tobacco and alcohol and the relationship of these is synergistic, with the risk in patients who drink and smoke about 35 times that of teetotal non-smokers. Tobacco use alone increases the risk about tenfold, and

alcohol at an intake of 100g/day (12 units) can increase the risk sixfold. Associated symptoms such as ear pain (referred from the posterior oropharynx), voice change, dysphagia or weight loss should be sought. Always ask for a history of any previously treated cancer of the skin, lip, oral cavity or other mucosal sites, as there is a higher incidence of second primary tumours in those who use tobacco and/or alcohol. Adult Asian patients with enlarged neck nodes will may have either nasopharyngeal cancer or tuberculosis. Elderly patients, especially those with fair skin, may have a history of previous skin cancer. A lump in the neck, especially in the submandibular region or the upper neck, involving the external jugular node or tail of parotid may

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represent metastatic cutaneous malignancy from squamous cell carcinoma or melanoma. In an immunocompromised patient, a neck lump may be an indicator of systemic disease, and the possibility of HIV-related lymphadenopathy should always be considered if specific risk factors are present.

Examination Examination should include thorough and systematic palpation of the neck bilaterally, with the patient seated in a chair if possible and with the neck relaxed. A thorough examination of the oral cavity with adequate lighting should also be carried out, as metastatic cancers may be related to primary oral squamous cell carcinomas. Oral cancers may be preceded by an identifiable and

often longstanding leukoplakia (white patch, see box, page 34). In these cases early identification and appropriate referral are essential and improve prognosis. When examining the oropharynx, a deep-lobe parotid tumour may present as an easily seen unilateral posterior swelling on the pharynx. Taking a biopsy of the lump via an intra-oral approach is a common pitfall and in no circumstances should these masses be biopsied before referral. The anatomical triangle of the neck involved should be noted, as this may assist in differential diagnosis. If the lump moves on swallowing it must lie deep to the pre-tracheal fascia and is likely to be thyroid in origin. In the case of upper anterior neck lumps, movement accompanying tongue protrusion may indicate a thyroglossal cyst as the most likely diagnosis. The site of a lump in relation to the sternocleidomastoid muscle may also be helpful. Tumours in the tail of the parotid gland lie superficial to this muscle and so remain easily palpable when the muscle is contracted by turning the head to the opposite side. In contrast, lumps contained within the jugular chain of lymph nodes are cont’d next page

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How to treat – neck lumps from previous page

difficult to palpate when the sternocleidomastoid is contracted.

Anterior neck swellings (figure 3)

Figure 2: Triangles, lymph node levels and normal lymph nodes in the neck. Submandibular nodes

Lateral neck lumps (figure 2)

Submandibular triangle. The main anatomical structures in the submandibular triangle are the submandibular salivary gland and the submandibular lymph nodes, which lie anterior and posterior to the facial vessels (prevascular and post-vascular nodes) as they cross the jaw. These nodes are a common sight of reactive enlargement in children and adolescents but they may also be a site of metastatic disease from cutaneous cancer of the face and lips and, less commonly, from cancer of the oral cavity in adults. There are three groups of paired major salivary glands: the parotid, submandibular and sublingual glands. These are accompanied by many hundreds of minor glands distributed throughout the entire oral cavity. Swellings of the submandibular salivary gland are usually acute and related to eating. These are due most commonly to a stone obstructing the submandibular duct. They usually produce intermittent swelling that arises during eating and resolves slowly after meals. Painless progressive swelling of the submandibular gland, however, raises the possibility of tumour. Cancer of the salivary glands is relatively rare — benign tumours occur more commonly. There is no clear evidence of specific risk factors for salivary gland cancer, but environmental factors such as radiation and viruses, along with genetic factors, are probably important. The most frequently encountered salivary tumour is a benign pleomorphic adenoma. In contrast to parotid tumours (see below), up to 50% of submandibular tumours are malignant. The incidence of malignancy in sublingual gland swellings is about 80%. An uncommon submandibular swelling that frequently poses diagnostic difficulty is a plunging ranula, caused by extravasation of mucoid saliva from a disrupted sublingual gland in the floor of the mouth. Instead of the mucoid saliva collecting in the floor of the mouth and causing a swelling under the mucosa (a ranula), the mucus makes its way into the subcutaneous space in the anterior submandibular region. Diagnosis is by a combination of clinical features and appropriate imaging such as CT. Removal of the sublingual gland via the mouth is the

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Parotid gland Posterior belly of digastric muscle Upper jugular node

Submental nodes

Jugulo-digastric node

Anterior belly of digastric muscle

Spinal accessory nerve and nodes

Hyoid bone Jugulo-omohyoid node

Trapezius

Sternocleidomastoid muscle Omohyoid muscle Lower jugular nodes

Figure 3: Anatomical sites of anterior neck lumps. Submental node Submandibular nodes

Branchial cyst (or other level-II mass, eg, lymph node)

Hyoid bone Thyroglossal cyst

Thyroid cartilage Pyramidal lobe of thyroid Thyroid gland Thyroid nodules

Sternocleidomastoid muscle

Trachea

Do not biopsy neck lumps INCISION and excision biopsy of neck lumps should not be carried out in a non-specialist environment. If the lump proves to be malignant, inappropriate biopsy could lead to difficulty in later treatment and increased risk of recurrence. The key investigations for all neck lumps, following history and clinical examination, are FNAB (see page 35) and CT scan with contrast.

| Australian Doctor | 5 August 2005

curative operation for plunging ranula. The other common soft tissue swelling that may occur in this region is a lipoma, but this has a characteristic soft feel and bosselated surface texture. Swellings around the parotid region. In contrast to infective and inflammatory swellings of the submandibular gland, those of the parotid gland are not very common. Viral infections (eg, mumps) and bacterial infections (frequently secondary to salivary obstruction) can occur and the history is usually of acute pain and swelling. Tumours have a longer clinical course and are usually painless. About 85% of primary parotid tumours are benign.

The most common salivary tumour is a pleomorphic adenoma in younger adults and Warthin’s tumour in older adults. Patients with benign parotid tumours should be referred for surgery, as pleomorphic adenomas have malignant potential when they are large or have been present for many years. In Australia the most common malignant tumour within the parotid gland is metastatic skin cancer from either SCC or melanoma. Globally the most common primary malignancy is mucoepidermoid carcinoma, followed by adenoid cystic carcinoma. In all cases, involvement of the skin or facial nerve weakness is an ominous sign and should trigger urgent referral.

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Lumps in the anterior compartment of the neck can occur in the submental region or the upper or lower anterior neck. Lumps in the submental triangle are usually enlarged lymph nodes and may be reactive or neoplastic. In young adults Hodgkin’s disease needs to be excluded, while in older adults metastatic cancer, particularly from cancers of the lip or from an asymptomatic cancer of the floor of the mouth, should be considered. Tuberculous lymphadenopathy may also develop in the anterior neck. Swellings around the hyoid bone are most likely to be a thyroglossal cyst (thyroglossal duct remnant). About 80% of these lie below the level of the hyoid bone and an important clinical feature is that they elevate with protrusion of the tongue. Often they sit to the left of the midline rather than in the centre of the neck. Dermoid cysts can also occur in the midline, anywhere from the chin to the jugular notch. These are congenital, benign and usually contain thick white paste-like material of epithelial origin, which gives them a ‘doughy’ consistency on palpation. Dermoids are usually quite superficial, lying in the subcutaneous tissue, outside the anterior neck muscles. The most frequently encountered swellings in the central compartment of the neck are thyroid nodules. These are rarely in the midline unless the nodule occupies the isthmus or pyramidal lobe, so they tend to sit to one side of the midline. The important clinical feature of a thyroid nodule is that the lump elevates with swallowing, which is diagnostic of a thyroid swelling. When there are multiple thyroid lumps (multinodular goitre) the risk of malignancy is low at about 5%. The incidence of malignancy is higher (10-20%) in a solitary thyroid lump, especially when >4 cm diameter, and in males. Correlating pathological nodes with a primary site

The location of metastatic lymphadenopathy may be specific to the site of the primary tumour. Oral cancer most frequently metastasises to level II (see table 1) whereas thyroid cancer rarely metastasises to level II. This information can be especially helpful in finding the location of a possible primary tumour when only metastatic disease is clinically apparent. This occurs in about 10% of head and neck cancer patients.

Leukoplakia and erythroplakia (white and red patches) THE terms leukoplakia and erythroplakia are descriptive and are clinical diagnoses. Pathologically these lesions vary and may represent changes ranging from benign hyperkeratosis to invasive carcinoma, with differing degrees of epithelial dysplasia in between. Erythroplakia is a red patch, which can occur as part of, or as a separate lesion to, leukoplakia. Both should be considered pre-malignant lesions (erythroplakia carries the highest risk). Areas of leukoplakia and erythroplakia can contain areas of invasive carcinoma or be associated with a clinically apparent carcinoma. Therefore, what appears as leukoplakia or erythroplakia can present with metastatic disease if part of the lesion has undergone invasive change. Patches with suspicious features such as bleeding or induration should be referred for appropriate assessment.

Online resources
The Sydney Head and Neck Cancer Institute: www.shnci.org
Australia New Zealand Head and Neck Society: www.anzhns.org
British Association of Head & Neck Oncologists: www.bahno.org.uk
National Institute for Health and Clinical Excellence: www.nice.org.uk (search under ‘head and neck’ for ‘guidelines for improving outcomes in head and neck cancer’)
Support group for Patients with Oral and Head and Neck Cancer: www.spohnc.org
National Cancer Institute (American government cancer site, follow links to head and neck cancer for useful patient and clinical information): www.cancer.gov
Changing faces (patient support site): www.changingfaces.org.uk

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Investigations — uses and limitations Fine-needle aspiration biopsy FNAB provides the most useful information in investigating head and neck lumps. It is widely available and may be carried out by a surgeon, radiologist or specialist pathologist trained in its use (the local hospital pathology department usually has information on who carries out FNAB in rural areas). The accuracy of the technique is above 90% but varies with the quality of the sample and the experience of the cytologist. False positives are rare but false negatives may occur. If a lump is clinically suspicious, a negative FNAB should be repeated. FNAB is the investigation of choice to provide information that aids diagnosis and to guide surgery. In some circumstances a surgeon may use excision biopsy to establish a diagnosis when FNAB has been unhelpful, but it is important to remember that excision biopsy can compromise future neck dissection if, for example, the lump is a metastasis from an SCC. FNAB is available nearly everywhere and we feel strongly that to promote excision biopsy in a non-specialist centre is inappropriate. The diagnosis of thyroid lumps is greatly assisted by FNAB. Metastatic cancer in lymph glands can be diagnosed with a high degree of accuracy from adequately obtained specimens. The differentiation of reactive lymphadenitis from lymphoma is sometimes difficult and oncologists will rarely base treatment on an FNAB result alone, often requiring formal excision to provide histopathology. In the diagnosis of cystic neck masses, the presence of squamous cells in both benign branchial cysts and necrotic metastases may make differentiating between these two entities difficult.

Figure 4: CT scan demonstrating a pathologically enlarged lymph node (large arrow) lying in front of the left submandibular salivary gland (small arrow). FNAB demonstrated atypical lymphocytes, and the lymph node was excised. The diagnosis was non-Hodgkin’s lymphoma.

Figure 5: CT scan showing a pathologically enlarged right submandibular salivary gland (large arrow), while the contralateral submandibular salivary gland is of normal size (small arrow). The mass was painless and slowly growing over two years. A FNAB suggested a pleomorphic adenoma and this was proved on excision.

Positron emission tomography

Ultrasound Although ultrasound differentiates well between solid and cystic masses, it contributes little to the diagnosis of neck lumps. It is very useful in evaluating the thyroid gland to determine whether or not a nodule is solitary or part of a multinodular goitre. Ultrasound is also useful as an aid during FNAB when a neck lump is small or difficult to localise by palpation. Its benefits include ease of access, low cost and not exposing the patient to ionising radiation.

demonstrates relational anatomy in addition to pathological and benign lesions (figures 4 and 5). The use of IV contrast enhances diagnostic capability, and CT without contrast is of limited usefulness. Spiral or helical CT scanning allows faster, higherquality image acquisition with less radiation exposure. CT may also assist FNAB by accurately localising the lesion to be sampled, helping to avoid damage to vital structures during the sampling procedure.

Computerised tomography

Magnetic resonance imaging

CT is very helpful in investigating neck lumps because it

netic field that aligns the nuclei of hydrogen atoms within matter. If the protons are then hit with a short, precisely tuned burst of radio waves, they will momentarily flip around. In the process of returning to their original orientation, they resound with a brief radio signal of their own. The intensity of this emission reflects the number of protons in a particular ‘slice’ of matter and helps to determine the consistency and nature of the tissue imaged and whether or not there is an injury or some disease process present. Information collected from MRI can be weighted, allowing excellent differentiation between tumour and normal anatomy. MRI has particular strength when accurate information on soft tissue pathology is required and this can be enhanced further by contrast agents such as gadolinium. The use of magnetic resonance angiography is very helpful in assessing vascular malformations in the head and neck. MRI has none of the risks associated with ionising radiation but has specific contraindications because of the strong magnetic field used (eg, cardiac pacemaker, vascular aneurysm clips, shrapnel, metallic debris in the eye).

PET imaging, or PET scan, is a diagnostic examination that involves the acquisition of physiological images based on the detection of positrons emitted from a radioactive substance administered to the patient (18FDG [fluorodeoxyglucose]). The emissions are detected by a gamma camera and tissues that are metabolising glucose rapidly, such as tumours, are highlighted. PET is particularly valuable in investigating metastatic disease with unknown primary source and for detecting recurrent tumour. It should not be used as a firstline investigation.

Chest X-ray This forms an important part of the diagnostic workup of patients with neck lumps, particularly when malignancy is considered a possible diagnosis. It is important to remember that many patients at risk of cancer of the upper aero-digestive tract are also at risk of primary synchronous lung tumours because of the shared association of these conditions with tobacco use.

MRI uses a powerful magwww.australiandoctor.com.au

Sentinel node biopsy Although sentinel lymph node biopsy has been used successfully in the management of melanoma and breast cancer, it does not generally apply to the management of clinically palpable neck disease. However, it has been used to help identify patients with occult neck disease resulting from mucosal SCC (several longterm prospective trials are still underway). The theory is that lymphatic drainage from a primary tumour may be limited to a set of regional nodes and the ‘first-stop’ nodes within this region can be identified by the use of radioactive tracers such as technetium. The localisation of suspect lymph nodes allows accurate sampling of only the most likely nodal sites for metastasis. Decisions are then made about more extensive lymph node dissection or adjuvant treatment if indicated.

Infectious causes of neck lumps Glandular fever

Glandular fever is an infectious disease common in younger patients and is caused by the Epstein-Barr virus. It is usually passed on via infected saliva, and contact with another infectious case is often elicited in the clinical history. Lymphadenopathy is usually bilateral, with associated systemic symptoms or rash. Heterophil antibody tests such as the Paul-Bunnell or Monospot tests are used in diagnosis. IgM heterophil antibodies are usually detectable in the first three months of infection and this may be accompanied by an atypical lymphocytosis on peripheral blood sampling. More specific serological testing looks for IgM to viral capsular antigen, or IgG to viral capsular antigen combined with negative serology for antibody to viral nuclear antigen. Toxoplasmosis

Toxoplasmosis is caused by the protozoan Toxoplasma gondii, which is usually present in the faeces of an affected cat or is passed on by contaminated food or water. It is a common disease although most patients remain asymptomatic. Lymphadenopathy may be the only symptom, and a history of possible contact with infected material should be sought in suspected cases. Culture for this organism is not commonly performed. Serology for Toxoplasmaspecific IgM in the acute phase and seroconversion to Toxoplasma-specific IgG is

a more useful test. Silver staining may rarely enable diagnosis from tissue samples. Toxoplasma should be sought particularly if contact with infected faeces of domestic cats is found on history-taking. Cat scratch disease

Cat scratch disease is an infectious disease caused by the bacterium Bartonella henselae, which is usually contracted from the saliva of infected cats. Mild systemic illness usually occurs and lymphadenopathy is most often bilateral. A history of a scratch or bite from a domestic cat should be sought in patients with lymphadenopathy. Culture is difficult and may take three weeks. Indirect fluorescent antibody testing from serum is possible, but cross-reactivity with other organisms limits specificity. Histopathology from a lymph node may demonstrate a mixture of non-specific inflammatory reactions, including granulomata and stellate necrosis, with lymphocytic infiltrates and multinucleated giant cells. Tuberculosis

TB caused by the acid-fast bacillus Mycobacterium tuberculosis is more common in patients with a history of travel to countries where the disease is endemic and in immigrant populations. In patients presenting with neck lumps a history of possible contact with TB should always be sought. Traditional culture and specific stains such as ZiehlNeelsen are slow and may delay diagnosis by 6-8 weeks. The tuberculin skin test with purified protein derivative (Mantoux test) still has use, but PCR testing carried out on tissue specimens can give a result within 48 hours. In the case of atypical TB, frequently caused by the Mycobacterium avium complex, PCR testing is not widely available. When atypical organisms are suspected modified skin testing and culture may be of benefit. HIV infection

In patients with persistent lymphadenopathy a lifestyle history should be sought to identify possible risk factors for HIV contact. In the case of HIV-related, persistent generalised lymphadenopathy, the presence of HIV-specific antibody is usually detected by ELISA, and confirmation by Western blot testing is usually required.

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How to treat – neck lumps Authors’ case studies Case 1. A young adult with a lateral neck lump

Case 4. An adult with multiple nodes

Case 7. An elderly man with a submandibular mass

This 19-year-old girl presented with a two-week history of a painless swelling in the left jugulo-digastric region. FNAB demonstrated benign squamous cells, cellular debris and cholesterol crystals. CT scan demonstrated a well-circumscribed unilocular mass anterior to the sternocleidomastoid muscle (arrowed). This is a typical branchial cyst and would be treated by surgical excision. In a young adult a clinical diagnosis could probably be made in most cases, but small tense branchial cysts can be very difficult to differentiate from lymph node pathology such as in Hodgkin’s disease.

This man has nasopharyngeal carcinoma with multiple metastatic lymph nodes in the posterior triangle, bounded by the clavicle below, sternocleidomastoid muscle anteriorly and the trapezius muscle posteriorly. Nasopharyngeal carcinoma is the only mucosal cancer that commonly spreads to the posterior triangle without nodes elsewhere in the neck being involved (metastatic skin cancer and lymphoma could also present with this distribution of nodes). Metastatic lymphadenopathy is the most common presenting feature for nasopharyngeal carcinoma. This is a rare cancer in Australia but is more common in some Asian countries, which places some immigrants to Australia in a higher risk group. It is thought that nasopharyngeal carcinoma may be due to a combination of geographical, ethnic and environmental factors (for example, Epstein-Barr virus).

This elderly man has a large submandibular mass. An SCC of the cheek was removed one year earlier. FNAB of the mass showed metastatic SCC, and the CT scan below shows a large cystic mass with a septum, consistent with metastatic cancer (arrowed).

Case 8. An adult with a parotid tumour

Case 9. A young woman with a thyroid nodule

This Asian man, aged 58, had a two-year history of a painless slow-growing mass at the angle of the jaw. FNAB demonstrated oncocytes and lymphoid cells, consistent with a diagnosis of Warthin’s tumour (a benign adenoma).

This young woman has a prominent right thyroid nodule. After history-taking and a clinical examination, the appropriate investigations would be FNAB and serum TSH level.

Case 2. An adult with a lateral neck lump This young man had a prominent painless lymph node in the jugulo-digastric region, which clinically appears similar to the previous case. FNAB indicated a diagnosis of Hodgkin’s disease. The choice and order of appropriate tests is usually based on the provisional diagnosis. In this case, FNAB confirmed the suspected diagnosis and CT was useful in staging the disease.

Case 5. A young adult with a midline cystic swelling This woman, aged 25, has a well-localised swelling just below the hyoid bone, which elevates on protrusion of the tongue. The CT scan on the right is from another patient, but demonstrates identical pathology of a well-circumscribed cystic structure lying anterior to the thyroid cartilage. This is a thyroglossal cyst and would be treated surgically by Sistrunk’s operation, a procedure involving removal of the cyst with the central portion of the hyoid bone.

Management algorithms for children and adults with neck lumps Adult with neck lump History/examination Likely malignant diagnosis FNAB Benign Observe Resolves Persists

Case 3. An adult with a lateral neck lump The man shown is 60 and a heavy smoker. He presented with a hoarse voice and a large mass in the upper neck. FNAB showed necrotic debris, which was suggestive but not diagnostic of metastatic cancer. A CT scan demonstrated a unilocular cystic mass (arrowed) with an irregular cyst wall. This was metastatic SCC that has undergone cystic degeneration. The primary cancer was in the hypopharynx and was asymptomatic.

Case 6. An adult with a discrete lump in the upper lateral neck

Open biopsy

Malignant Lymphoma

Metastatic cancer

Staging Primary investigations known Treat

This 40-year-old male non-smoker presented with a lump in the upper neck. FNAB identified SCC. A careful search for a primary tumour by examination under anaesthetic, endoscopy and targeted biopsies demonstrated a primary SCC of the tonsil. Such cancers in young non-smokers are believed to be due to HPV.

Stage

Treat

Primary unknown EUA*, endoscopy, biopsy, CT Still occult primary

Treat neck and observe for primary site

Child with a neck lump History/examination Likely benign diagnosis Inflammatory or infective

Congenital or cystic

Treat infection

Fine-needle aspiration biopsy/CT scan

Observe

*EUA = examination under anaesthesia.

Treat

Summary THE range of diagnostic possibilities for tumours and lumps in the head and neck may seem bewildering but the application of simple principles — history, examination, appropriate investigation and referral — facilitates accurate diagnosis and allows timely treatment in almost every case. It is important that the doctor of first

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contact, very often the GP, does not overlook the possibility of a diagnosis of malignancy. GPs should not underestimate the importance of their role, because early diagnosis and referral to a specialist multidisciplinary team can dramatically influence a patient’s treatment options and chances of cure.

Neck lumps — a Diagnostic Guide for GPs SOME of the information in this article is available in a booklet produced by the Sydney Head and Neck Cancer Institute, entitled Neck Lumps — a Diagnostic Guide for General Practitioners. The booklet was distributed free of charge to all divisions of general practice in NSW. For further information, contact the Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital, Room 6.10, Level 6, Gloucester House, Missenden Road, Camperdown, NSW 2050. (Web: www.shnci.org.)

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How to treat – neck lumps GP’s contribution

PROFESSOR SIAW-TENG LIAW GP in Shepparton, Vic

Case study DB, a 20-year-old clerical assistant, presented with a soft, slightly tender lump in the right side of her neck, first noticed four days earlier. She reported no other symptoms except for an episode of bronchitis two months ago, treated with two courses of roxithromycin. She did not smoke or drink alcohol. There was no relevant family history of cancers or tuberculosis. Examination revealed a group of smooth, somewhat tender supraclavicular nodes on the right. There was no hepatosplenomegaly or other mass palpable in the abdomen. An examination of the axillae, elbows, groin and popliteal fossae revealed no obvious lymphadenopathy. ENT examination was

normal. The trachea was midline and chest normal on examination. Breast examination was not carried out, despite the explanation that it was part of excluding cancer, because DB said that she had had it done recently. An FBE/ESR and CXR were performed with the following results: ■ FBE was normal and the ESR of 21mm/hour was reported as “mildly raised”. An FBE undertaken at the emergency department of the local hospital one month before the bronchitis when she had had abdominal cramps, dizziness and nausea showed “a mature neutrophilia possibly due to an infective or inflammatory process”. C-reactive protein was 22 mg/L. ■ The CXR report said, “Superior mediastinal adenopathy requires exclusion”. ■ A CT reported, “Superior mediastinal lymph nodes are shown ?lymphoma … paratracheal, posterior mediastinal and hilar lymph node chain appear spared and normal … Axillary lymph nodes

appear of normal size …”. DB was referred for urgent biopsy at a surgical outpatient department. No results are yet available.

Questions for the authors These nodes are in the anterior triangle and at level IV, according to your terminology. What is the significance of this in this case? Isolated nodes at level IV are uncommon and the practitioner should always consider pathology below the clavicles when they occur. A lump in the neck at this site in a young non-smoker raises two main possibilities: lymphoma and metastatic thyroid cancer. What are the most likely diagnoses? What is the optimal management pending a histological diagnosis? Lymphoma and metastatic thyroid cancer are the most likely diagnoses. Fine-needle aspiration cytology should be one of the first investigations, along with CXR. Ultrasound of the thyroid gland and a thyroglobulin test may be helpful.

How To Treat Quiz

2. When examining a patient with a neck lump, which TWO statements are correct? ❏ a) The anterior triangle extends from the sternocleidomastoid muscle to the midline ❏ b) The anterior limit of the posterior triangle is the trapezius muscle ❏ c) Normal anatomical structures are rarely the cause of lumps presenting to GPs ❏ d) Level-I lymph nodes are found in the submandibular and submental triangle 3. Jane, 45, presents with a lateral neck lump. She has always been very slim (BMI 18) but is in good health. Which THREE examination techniques are helpful in distinguishing normal anatomical structures from significant pathology?

General questions for the authors In rural and regional areas, imaging facilities are often limited. Apart from excluding pulmonary and thoracic pathology, how useful is a CXR? It should be remembered that lung cancer is common and lethal. The use of CXR in management is relevant in nearly every neoplastic disease (perhaps with the exception of limited skin malignancy). We would certainly recommend its use in this case. Should GPs, particularly rural and regional GPs, be trained and supported to do

FNAB? What is the evidence to support this strategy over and above the specialistbased model? Our view is that there is no strong argument for GPs to be trained in FNAB. It has potential complications, the preparation of specimens is important and the technique sensitive, the cytologist should be very familiar with the technique for good results, and image guidance may be necessary for the procedure. The combination of these factors means that FNAB is better carried out at specialist centres, where more consistent results can be obtained. What is the optimal model for a multidisciplinary team? What is the evidence for a managed team? What are the attributes of such a team and the component members that contribute to effective care? Could this team could be coordinated/led by the GP? Multidisciplinary care should be led by a cancer specialist , who may be a surgeon, a medical oncologist or radiation oncologist. The cancer specialist

ACKNOWLEDGEMENT The authors would like to thank Bob Haynes and the audiovisual department at Royal Prince Alfred Hospital, Sydney, for their help in preparing the illustrations used in this article.

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❏ a) Examination of the opposite side of the neck as well as the side with the lump ❏ b) Examination of the patient in a seated position with the neck relaxed ❏ c) Asking the patient to contract the sternocleidomastoid muscle by turning their head to the same side as the lump ❏ d) Asking the patient to swallow

6. Which TWO signs or symptoms would you be most likely to look for in this man? ❏ a) Leukoplakia or mucosal cancer in the mouth ❏ b) Ear pain and voice changes ❏ c) Involvement of the skin or facial nerve weakness ❏ d) Infection with HPV

4. Jim, 45, presents with a lateral neck lump. Which ONE factor in his history would be least likely to increase the chance of his lump being malignant? ❏ a) Smoking ❏ b) Occupation ❏ c) Alcohol ❏ d) Previous lip SCC

7. Erica, 45, has recently noticed an anterior neck lump just to the side of the midline. Which TWO examination techniques or investigations would be most likely to help in her diagnosis? ❏ a) Thyroid uptake scan ❏ b) Observing whether the lump moves with tongue protrusion ❏ c) Observing whether the mass moves on swallowing ❏ d) Investigation with thyroid function and TSH tests.

5. Patrick, 70, presents with a painless mass in the lateral neck that is persistent and constant in size. The differential diagnosis would be most likely to include which THREE conditions? ❏ a) A ptotic submandibular gland ❏ b) A stone obstructing the submandibular gland ❏ c) The greater cornu of the hyoid ❏ d) Metastatic SCC

should form part of a team that includes other medical specialists and allied health care professionals relevant to the particular cancer (for example, specialist nurses, social workers, speech pathologists, dentists, etc). In rural areas it may not be possible to access multidisciplinary teams as easily as it is in cities, but it should be remembered that patients, particularly those with advanced and complex disease, benefit from multidisciplinary care. It is probably not feasible for such teams to be GP-led, but GPs should be encouraged to be part of the teams, ensuring good communication especially in:
Planned treatment pathways.
Co-ordinating patients requirements on return to the community.
In a palliative care setting.

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Neck lumps — 05 August 2005 1. Which TWO statements about neck lumps are correct? ❏ a) Neck lumps in children are rarely malignant and are often reactive lymph nodes ❏ b) In an adult with a lateral neck lump, cancer should always be excluded ❏ c) In adults it is appropriate to treat neck lumps with several courses of antibiotics ❏ d) Classifying the anatomical position of the lump does not aid diagnosis

All these activities took place over 10 days, with a busy patient and a busy group practice, involving three part-time doctors. Is this management timely? We would consider that 10 days is an entirely appropriate time in which to workup this patient. In rural areas diagnostic facilities may be located a long distance from the patient’s home, as may be specialist centres.

8. Charles, 50, presents with a painless swelling in the parotid gland. When discussing this condition with him, which information is correct (choose TWO)? ❏ a) Most tumours of the parotid gland do not require surgery.

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❏ b) In Australia, metastatic cancers from SCC or melanoma are the most common malignant tumour in the parotid gland ❏ c) Persistent parotid swellings are usually caused by infection or inflammation ❏ d) Bacterial infections of the parotid gland are usually associated with acute pain and swelling 9. James, 22 and of Asian descent, presents with a new anterior neck swelling. On careful questioning, he reports having male sexual partners. When considering diagnosis, which THREE conditions would be most important to exclude? ❏ a) Hodgkin’s disease ❏ b) Tuberculous lymphadenopathy ❏ c) Dermoid cyst ❏ d) HIV 10. After history and examination, which TWO of the following investigations are most likely to be useful in establishing the correct diagnosis in a patient presenting with a neck lump? ❏ a) FNAB ❏ b) Excision biopsy in your rooms ❏ c) Computerised tomography ❏ d) PET imaging

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NEXT WEEK You can back next week’s How To Treat being a winner — problem gambling is on the table. The author is Professor Alex Blaszczynski, professor of psychology, school of psychology, University of Sydney; head, department of medical psychology, Westmead Hospital, NSW; co-director, University of Sydney Gambling Research Unit; and recipient of the 2004 senior research investigator’s award from the National Centre for Responsible Gambling, Division of Addiction, Harvard University, Boston, MA.

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| Australian Doctor | 5 August 2005

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