Neck Tumours

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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 test.
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 neck

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, chronic sialadenitis.
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 quite large.

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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