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June 09, 2012

Added By :
Dr Vincent Tan Eng Soon

A neck lump is any lump, bump, mass or swelling in the neck. It is something that commonly brings a patient to his doctor.
“Doctor, I have a neck lump !” 

A neck lump is any lump, bump, mass or swelling in the neck. It is something that commonly brings a patient to his doctor. One of the major concerns is : “DOCTOR,  IS THIS A CANCER?”  As such, all neck lumps in children and adults should be checked without undue delay.
Congenital head and neck lumps or masses can arise during early years or may present later in life. These include embryological remnants since ‘in utero’ (while you are still in your mother’s womb) eg. thyroglossal duct cyst, dermoid cyst or branchial anomalies among others.

As illustrated in the picture, the head and neck region is made up of many different structures and many of these structures can either get infected giving rise to a lump or grow into a tumour over time, whether cancerous or otherwise. Examples of these structures include:
•    Skin
•    Subcutaneous  tissue under the skin
•    Lymph nodes or lymphatic tissue
•    Nerves
•    Vessels (veins or artery)
•    Salivary glands (eg. parotid, submandibular gland)
•    Thyroid gland
•    Bones (eg jaw bone)

Infection can arise as a result of infection by viruses, bacteria or fungus. Occasionally, the lymph node becomes necrotic, and an abscess forms. In our region, tuberculosis (TB), due to infection from a special type of bacteria known as mycobacterium, is also quite common and becoming increasingly more prevalent. Besides being notoriously difficult to detect, it can masquerade as infection in any parts of the body, commonly in the lungs and the neck lymph nodes.
Cervical lympadenitis (inflammation of the lymph nodes in the neck) is very likely the most common cause of an inflammatory mass in the neck. This condition is characterized by painful enlargement of normal lymph nodes in response to infection or inflammation, commonly due to upper respiratory infection such as a cold or sinus infection
On the other hand, tumours (known as ‘neoplasm’ from a medical perspective) can be benign i.e non-cancerous or malignant i.e cancerous. Some of these benign/non-cancerous tumours can arise spontaneously without any particular triggering factor. On the other hand, malignant tumours are what is commonly known as CANCERS. Cancers are commoner in adult (still possible in younger age group but less likely). Benign tumours are more commonly slow-growing while cancerous tumours generally grow much faster and may even invade the skin. The likelihood of the lump being a cancer increases as adults age, particularly for people who smoke or drink significant amounts of alcohol. However, most lumps in adults are not cancers (fortunately)

Common risk factor for cancer include:
•    chronic smoking, betel nut chewing, tobacco chewing,
•    chronic alcohol consumption
•    immunodeficiency
•    Human papilloma virus (HPV) viral infection
•    poor dentition
•    industrial or environmental exposures
•    family history.

Head and neck masses are malignant, or cancerous, if they spread to surrounding tissue. In the head and neck, cancers may be either primary or secondary. Primary tumors originate in the head or neck itself, including the thyroid, throat, larynx, salivary gland, brain, or other locations. Primary cancers of the head and neck typically spread to the lymph nodes in the neck, presenting as neck swellings. (to complicate matters, these swellings as look and feel just like a node swelling due to an infection of the neck !). Your doctor may call these neck nodes as “metastatic” or “secondary” neck nodes.
Secondary neck nodes can also less commonly have spread from primary cancers in other parts of the body outside the head or neck region eg lung, breast, kidney, or from the skin.

What will your ENT doctor do?
Some of these swellings look the same on the surface even though they may differ significantly in terms of their nature. Therefore your doctor will normally start by asking you more details about your swelling. History of the lump that your doctor is interested in are:
•    Where is the lump located?
•    Is it the first time you are having this or is it a recurrent or chronic problem
•    When did this lump arise ? Since birth, childhood or later in life ?
•    Has it been growing bigger? Over how many weeks, months or years?
•    Is there pain ?
•    Is it a hard lump or relatively soft, pliable, bag-like (cystic) mass?
•    Is the entire neck swollen or just a specific spot over the neck?
•    What other symptoms are present eg. discharge ?
•    Was there any preceding surgery or trauma ?
•    Do you have compressive symptoms like difficulty breathing, swallowing?
•    How is your appetite and weight ever since you noticed the swelling?
•    Any associated symptoms like:
o    rashes
o    change of voice ?
o    growth in the mouth
o    swollen tongue
o    blood in the saliva or phlegm
o    changes in the surrounding skin
o    persistent ear pain or ear pain while swallowing

Your doctor will usually proceed to examine your swelling further. Next, endoscopic assessment via rigid or flexible scope (also called FNPLS-flexible naso-pharyngo-laryngoscopy) to assess the mucosa (inner lining) of your nostrils to the voice box may be necessary to exclude tumour growth or any compression/compromise of your upper aerodigestive tract.
Other investigations may also be necessary to identify the exact nature of your neck mass:
a) Fine-needle aspiration cytology (FNAC) – FNAC is the most accurate test for evaluating these swellings

Using a syringe with certain manoeuvres and techniques, your specialist will remove some microscopic content from your swelling for further detailed pathological examination in the laboratory. FNAC can be done in the clinic itself. This procedure is usually tolerable and pain is minimal. Under the microscope, the constituting cells collected can be further studied to give more vital information about your swelling. In 80-90% of cases, a confident diagnosis can usually be made. Complications like bleeding or hematoma are very rare. The risk of cancer seeding using FNAC is negligible as evidenced by many years of medical research. Rarely, false-positive (i.e "positive"ly recognised pathology in the absence of actual disease) or false-negative (i.e failure to recognised pathology when in fact disease is actually present) results may also occur.

Alternatively, , FNAC can be more accurately performed under ultrasound guidance, called ultrasound-guided FNAC. It is more superior for deep-seated masses as the ultrasound allow a real-time precise targeting of the needle into the lesion in question (analogy is a soldier wearing a night-vision infra-red goggle in pitch-black darkness shooting at a target !)

The advantages of ultrasonography is that it is rapid, inexpensive, versatile, no ionizing radiation (eg. CT scan, X ray) is applied, does not require injection of contrast medium and can be easily repeated when necessary.

Ultrasound guided fine needle aspiration cytology (FNAC) is a safe diagnostic procedure in which any structure visualized can be reached quickly and precisely by a fine needle in any desired plane with constant visualization of the needle tip during insertion

b) Biopsy – if the swelling is small, your doctor may further advise you to have it fully removed i.e an excisional biopsy. The whole swelling is removed for further detailed pathological examination in the laboratory to arrive at a diagnosis. In rare instances, part (and not the entire) of your swelling is removed i.e incisional biopsy may be necessary for a more definite diagnosis. However, the risk of cancer seeding i.e cancer cells spreading to your skin is much higher. Therefore incisional biopsy is done in very specific conditions only.
Radiological imaging  eg. ultrasound, contrast-enhanced computed tomographic (CT) scan, magnetic resonance imaging (MRI) scan may be needed to evaluate these masses further. These scans assesses the extent of the swelling. The signal generated (intensity, echogenicity, density), margins of the swelling, it can provide more information about the nature of the swelling.
PET (Positron Emission Tomography) scan which involves injection with a radioactive tracer is useful to identify cancer deposits in the whole body, whether it has spread to other distant organs in the body or the primary site of cancer.  It can also be used after treatment to know if the cancer has been fully eliminated or residual cancer deposit still exists somehere elase in the body.
If cancer is confirmed, staging of the cancer is mandatory to know the local, regional and distant extent of the disease in order to plan the treatment of the disease. Staging may involve an examination under anaesthesia (in the operating room), radiological imaging procedures and more laboratory tests.

What about treatment ?
Treatment depends very much on the cause of your lump.
An initial single course of antibiotics can be prescribed in cases where your swelling is due to infection, usually presenting with fever, painful mass and reddened overlying skin. In children, most neck lumps are caused by treatable infections. However, treatment should start quickly to prevent complications or the spread of infection. Follow-up is advised to ensure the complete resolution of the swelling.
In the event an abscess (i.e collection of pus) forms, a formal surgical drainage procedure, known as incision and drainage is necessary and the wound is allowed to heal with regular dressing.
Excisional biopsy should be considered when a neck mass persists beyond four to six weeks after a single course of a broad-spectrum antibiotic. Generally, benign neck cysts and masses are usually removed by surgical excision. This can be done under local or general anaesthesia. A watch-and-wait management can also be adopted if the mass is deemed to be benign and malignancy is excluded definitely.
As for head and neck cancers, after the cancer is staged, it may be treated by some combination of surgery, radiation therapy, and chemotherapy, depending on their nature and site of disease. Treatment plan may differ between different doctors and centres.

Prepared by:
Resident Consultant ENT, Head and Neck Surgeon,
KPJ Klang

MD (UKM), A.M. (Mal), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), MS ORL-HNS (UKM),
Postgraduate  Certificate  in Allergy (Southampton, UK)
Fellowship in Rhinology (Singapore)
Fellowship in Head and Neck Surgery (Amsterdam)
Mobile: +6012-3760728
email: ENTdrvincenttan@gmail.com

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Dr Vincent Tan Eng Soon
DOHNS RCS Edinburgh (UK), PG Cert.in Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore), Fellow, Head and Neck Oncology , MRCS Edinburgh (UK), MS ORL-HNS (UKM), MD (UKM)
Speciality : ENT/ Otorhinolaryngology
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