A painless single enlarged node is a malignancy until proven
Other symptoms vary by cause.
Enquire as to cause.
- thorough systems review of all relevant structures.
Systemic features, e.g. fevers, sweats, weight loss, fatigue.
Site, size, shape, surface, edges, consistency, pulsatility,
mobility, fluctuance, pain, tenderness, lymph nodes.
- accurate site localization with knowledge of neck anatomy
- measure mass size accurately.
Thyroid swellings move upwards.
Ventral lumps attached to the hyoid (eg thyroglossal cysts) move up
on swallowing and tongue protrusion.
Multiple lumps almost always lymph nodes.
Examine the full head and neck, including oral cavity.
Special attention to the aerodigestive mucosa, especially lymphoid
region of nasopharynx, base of tongue and oropharynx
Palpation includes bimanual exam of floor of mouth and neck to
identify abnormalities deep to normal mucosa.
Neurological exam of cranial nerves required.
Reactive lymphadenopathy and primary, unusual or atypical
Flexible Fibreoptic Laryngoscopy
- especially for patients with suspicious features / risk factors
FNA / biopsy. Allows rapid cytopathological diagnosis.
Must be done before any empiric therapy attempted.
- unless possibility of being vascular
- enter with slight negative pressure with a 20mL syringe and a 21g
- hold mass in thumb and forefinger, use multiple angled passes
under negative suction; 3-4 aspirates
- reduce suction and remove syringe prior to removing the needle
- discard any blood
- squirt onto a slide, then that slide is smeared with a second
- promptly fix with ethanol or formalin before cells dessicate
--> best if a cytopathologist is on site to check specimen
- sensitivity and specificity approach 90%, and are highest for
thyroid masses and solid carcinomas.
If nodes are cystic, need to biopsy the cyst wall with USS guidance
USS first - accessible and no rads.
- cystic or not?
USS / CT often useful.
- contrast enhanced CT with fine slices of 3-5mm
MRI useful for soft tissue involvement or iodine allergies.
- may show certain lesions more accurate, e.g. carotid body
CXR in selected cases
- atypical infections and granulomas.
Role of PET Used for finding primary sources when endoscopies unhelpful.
Characterize extent of disease when previous known history of head
and neck malignancy.
- fusion PET/CT more useful tool; allows for accurate anatomical
localization of lesions.
--> accurate for occult cervical mets.
PET inappropriate when primary malignancy diagnosed.
- FNA the lesion
Broadly dependent on identification and diagnosis.
When infectious inflammatory, tissue diagnosis when ABx fail to
When neoplastic, tissue diagnosis essential and thorough search for
- occasionally no identifiable primary; consider PET and MDT review
EUA Most lesions can be diagnosed in the clinic; in some, EUA is
- e.g. if FNA unhelpful and clinical concern
Aids inspection of all mucosal surfaces
Biopsies under controlled settings
If <40, then medical management usually warranted in first
Biopsy first in pts >40
1. Many neck lumps are deep to platysma and may involve important
- open biopsy under GA preferred
2. Incision lines in transverse relaxed skin tension lines
- should be sufficient to get safe exposure to important structures,
e.g. muscles, great vessles, CNs
- neurovascular injury
- chyle leak
- nerves X, XI, XII at risk, as well as marginal branch of VII and
--> VII and XI most commonly injured Marginal branch of VII courses up from main trunk in parotid
to cross mandible and ultimate innervate lower lip depressors
-avoid region of body of mandible to reduce risk to this nerve; incisions
two finger-breadths below inferior edge of mandible CN XI exists in cranial base of jugular foramen
- passes over internal jugular as it travels to trapezius
- identify as it innervates SCM, if anterior border of digastric
skeletonized and fascia followed to SCM; n. is deep to posterior
belly of digastric.
- alternatively, along posterior of SCM about 2cm superior to Erb's
point; intersection of great auricular and posterior border of SCM
--> very superficial course in posterior neck, where easily
--> avoid cutting any structure passing through posterior neck
that is greater than 2mm CN XII passes levels I and II deep in the neck
- descends between IJV and carotid artery before innervating the
- surrounded by venae conniventes under posterior belly of digastric
--> may be damaged when controlling bleeding from the venae;
inadvertently clamped Thoracic duct lies in lower neck
- deep in inferomedial aspect of left supraclavicular region
- duct runs behind the common carotid and empties into the IJV near
its junction with the subclavian vein
- there are also chyle-containing lymphatics in the right neck that
should be controlled during dissection
- all tissue between phrenic and vagus should be dissected to avoid
a chyle fistula
--> manage chyle leaks with low-fat diet and medium-chain
--> somatostatin may help to augment closure of a delayed chyle
--> rarely, surgical intervention needed
4. Carotid body paraganglionoma
- high risk surgery; tertiary specialist job
- do not biopsy
- CNs at risk.
- usually achievable with subadventitial dissection and without