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The lymph nodes in the neck frequently enlarge
by benign hyperplasia in response to infection and inflammation
The lymph nodes in the neck, particularly those in the jugular region, respond
to local inflammation and infection by reactive hyperplasia, which is either
follicular or parafollicular in pattern. Common sources of primary infection
include the tonsils, teeth, pharynx, sinuses and, occasionally, the ear.
Reactive lymph node enlargement may also occur when there has been localized
skin inflammation, e.g. in the scalp or behind the ear. Three important diseases
may present with benign lymph node enlargement in the neck.
Infectious mononucleosis (glandular fever) is often associated with severe
inflammation of the tonsils. The diagnosis can be confirmed by examination of
the peripheral blood film for atypical mononuclear cells, and by the Paul-Bunnell
In cases of cervical tuberculosis the lymph nodes are often matted and inflamed.
They may be slightly fluctuant, and in neglected cases they even point and
discharge onto the surface ('scrofula').
Toxoplasmosis usually develops in a juvenile or a young adult. Patients with
toxoplasmosis may have circulating atypical lymphocytes, rather like patients
with infectious mononucleosis. In a fully developed case the lymph node
histology is very characteristic.
The lymph nodes in the neck are a common site for metastatic tumour deposition
The jugular nodes are the eventual drainage site for many of the mucosal
structures in the head and neck, as well as the skin of the head and scalp.
Consequently they are a common site for metastatic carcinoma deposits from sites
such as the lip, tongue, mouth, nasopharynx, oropharynx, larynx, salivary
glands, and thyroid. Attempts at complete surgical removal of tumours in these
sites often include a block dissection of the lymph nodes of the neck on the
affected side; where the primary tumour has crossed the midline, the nodes of
the other side are also dissected.
The supraclavicular lymph nodes are important sites for metastatic tumour
deposition from primary tumours in the bronchus, breast and (on the left side)
stomach (Troisier's node).
Enlargement of one or more lymph nodes in the neck may be a presenting symptom
of some types of malignant lymphoma
In toxoplasmosis, small granulomas form within the lymph node and may encroach
on germinal centres.
It is important that students know the differential diagnosis of lumps in the
A simple approach is based on the precise location of the lump in the neck,
together with its texture (solid or cystic).
The location of solid lumps can be divided into:
• Related to thyroid gland, e.g. multinodular goitre, solitary thyroid nodule,
thyroid carcinoma, etc.
• Related to submandibular salivary gland, e.g. pleomorphic salivary adenoma,
• Related to the cervical lymph node groups. These occur mainly in the jugular
chain and in the supraclavicular region.
• Related to mandible, e.g. mandibular cysts, abscesses and tumours of both
dental and bone origin.
• Related to carotid bifurcation. These are almost always neuroendocrine tumours
derived from the carotid body, the chemodectoma.
Cystic or fluctuant lumps in the neck are usually either midline or lateral
The most common and important midline cystic lesion is the thyroglossal duct
cyst. This is a remnant left from the migration of the thyroid gland from the
posterior part of the tongue to the neck during embryological development. It
presents in young children, sometimes in the form of a cyst or, occasionally, as
a persistent sinus; it may present in young adult life, when the lesions may be
Occasionally a nodule in the thyroid is fluctuant and is diagnosed as a 'thyroid
cyst'. These 'cysts' are almost always benign adenomas showing central
degenerative changes. The most common and important lateral cystic lesion is the
branchial cyst. Derived from cystic remnants of the branchial arches, it
produces diffuse fluctuant swelling in the lateral aspect of the neck, often
beneath the angle of the mandible.
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