Cervical Lymphadenopathy
By Garry Wilson
Background
The majority of conditions that arise in the neck manifest as swelling. The
importance of effective history taking and physical examination requires no
further stressing from this author, but there are of course certain questions
that can be asked of the patient that will help the clinician come to a
differential, and eventually, a definitive diagnosis of the condition. The most
common cause of swellings in the neck area is an enlarged lymph node, and if
it is deduced that in any given case that it is indeed an enlarged lymph node
that is giving rise to the swelling, the clinician must be sure to gather as much
information as possible as to the nature of the symptoms experienced by the
patient, as the two most common causes of enlargement of lymph nodes in
the neck is infection and tumour metastases, so it is indeed prudent and
necessary to know of the differing symptoms in each case, in order to best
understand the condition.
Systemic illness
Infective causes of the swelling will, in the majority of cases, be indicated by
symptoms such as:
Fever
Stiffness of the neck
General feelings of lethargy and malaise
Neoplastic causes of the swelling often bring such symptoms as:
Loss of appetite
Dysphagia (dependent on specific site)
Persistent dry cough
Hoarseness of the voice
Important Questions To Ask
There are a lot of questions that we can ask as healthcare providers in order to
glean more information from patients, especially when changes they may find
trivial or benign, that for this reason they neglect to mention, which may help
us in making the correct diagnosis. Common questions that can help us arrive
at the correct diagnosis would include questions about:
Changes in appearance of the soft tissues of the mouth and/ or associated pain
Sore throat or pain on swallowing
Dysphagia and if anything exacerbates/ alleviates any difficulty in swallowing
Changes in the voice, i.e. hoarseness, change in pitch, change in volume,
greater effort required in order to talk
Nasal problems such as a blocked or runny nose
Cancers of the head and neck very often metastasise in the lymph nodes of the
neck, so it is important to be aware of the very differing manifestations of
neoplastic and infectious pathologies.
Physical Examination- Site
In order to describe the location of a swelling in the neck, it is easiest to use
the anterior and posterior triangles of the neck.
Anterior triangle
The anterior triangle is defined as the lower border of the mandible, the
anterior border of sternocleidomastoid (SCM) and the midline of the neck.
Posterior triangle
The posterior triangle is bounded by the posterior border of
sternocleidomastoid, the anterior order of trapezius and the clavicle.
In order to properly visualise the triangles in the vast majority of patients, i.e.
those who do not have a very low body fat percentage, it is necessary to have
the patient tense sternocleidomastoid and trapezius simultaneously. This is
done by placing your hand underneath the patient’s chin and asking them to
move their head downwards against the resistance you are offering. To
activate trapezius, the patient should be asked to shrug their shoulders against
the resistance of your hand placed on the shoulder.
The Location Of Lumps Relative To Anatomical Landmarks
Trachea
Swellings that are fixed to the trachea will of course move as the trachea
moves. The easiest way to assess movement of the trachea is during
swallowing, and this can of course be facilitated by asking the patient to take a
few gulps out of a glass of water.
Muscles
If you suspect that a lump is associated with a muscle, you should palpate the
lump with the muscles in both a relaxed state and when tensed.
Causes Of Cervical Lymph Node Enlargement
Enlarged lymph nodes are the primary cause of swellings in the neck, and
although it may appear that only one node is swollen or tender, it is likely that
adjacent nodes are also suffering from some degree of pathology.
The 4 main causes of cervical lymph node enlargement are:
-Infection
-Metastases
-Primary Reticuloses
-Sarcoidosis
Infection
Infection can be split into bacterial and viral aetiologies, and include such
ailments as tonsillitis and glandular fever.
Metastases
Tumours from anywhere in the head and neck, as well as tumours from sites in
the chest and abdomen can all metastasise via the cervical lymph tissue.
Primary Reticuloses
Neoplasms can occur in lymph tissues, and can be either benign (lymphoma) or
malignant (lymphosarcoma).
Sarcoidosis
Sarcoidosis is the collection of granulomas in a tissue, the neck being a very
common site in sufferers of the disease. The exact cause of sarcoidosis is yet to
be fully established, but amongst the hypotheses are thyroid disease, with
sarcoidosis being one of the sequelae, and autoimmune disease, especially
coeliac disease.
I will now discuss neck lumps of very differing aetiologies, which will give a
more clinical idea of how different lumps present and the key differences in
the presentations that will allow us as practitioners to distinguish between
them and diagnose accordingly.
Non- Specific Inflammatory Lymphadenopathy
This commonly presents in children, and follows recurrent bouts of tonsillitis.
The most common symptom is a painful lump in the digastric triangle, and
patients often present complaining of a sore throat, which is exacerbated by
swallowing. Due to the young age of the patient, it is often noticed by the
parent of the child, especially if the child starts snoring, which is common, and
an acute difficulty in breathing brought about by the presence of the
inflammation. The pain on swallowing means the patient is normally reluctant
to eat, and exhibits a general feeling of malaise, and the parents often note
that the patient is crying more than usual and is generally more lethargic.
This is a classic presentation of infected lymph nodes, and is not confined to
children, but this is just an example. The enflamed nodes in cases of infection
are normally tender and have several systemic effects, with a feeling of malaise
and weight loss/ reticence to eat amongst the most common.
Cancerous Lymph Nodes
Cervical metastases are extremely common in cancers of the head and neck,
and it is of paramount importance for any healthcare provider to perform a
thorough examination of the patient to try and ascertain the primary neoplasm
if the patient is unaware that they may indeed have a cancerous growth.
Again, asking probing questions about any changes the patient has noticed in
their body at all may give some clues as to the site of the neoplasm, and
indeed possibly an idea as to how long it has been present. One of the, for
want of a better term, problems, with cancerous growths are that they are
often painless; this is often reflected in how long some patients take to seek
the help of a doctor or dentist with the problem, a common misgiving being
that if it is painless, it must be fairly innocuous. Sadly, this is not always the
case. Although the lump itself may be painless, it may be that the associated
symptoms are what has compelled the patient to seek help, such as a possible
sudden difficulty in swallowing, a hoarse voice, although these are just
examples, and other symptoms do occur, such as a sore throat. Due to the high
concentration of epithelia in the head and neck region, it is most often
carcinomas that metastasise via the lymphatic system. Cancerous nodes tend
not to be warm or cause discolouration of the skin, unlike infected nodes (in
accordance with the cardinal signs of inflammation- calor, rubor, tumor, dolor
and functio laesa). Another key means of distinguishing cancerous nodes from
infected ones is in their hardness. Cancerous nodes are normally very hard;
whereas infected ones, although they can also be hard, tend to fluctuate under
palpation.
Carotid Body Tumour
This is the third and final type of lump in the neck that will be reviewed in this
article, as it offers us the chance to look at a structure other than the lymph
nodes, and serves as a reminder that not only the cervical lymph nodes are the
source of lumps in the neck, but also, in this case, one of the 2 arteries that
supply the brain, and a large portion of the head and neck area as a whole. It is
a tumour of the chemoreceptor tissue in the carotid body, which is important
in the monitoring and regulation of blood oxygen and carbon dioxide levels,
and hence heart rate. Patients are very rarely under the age of 40, and will
complain of a slowly- growing lump in the anterior triangle, adjacent to the
anterior border of sternocleidomastoid. The lump is likely to pulsate, which,
considering its location, is hardly surprising. When palpating the lump, great
care must be taken not to apply too much pressure in the region of the carotid
artery, as a vasovagal episode may ensue. In fitting with the symptoms earlier
described in cases of neoplastic changes on the neck, the lump should not be
hot, nor should the overlying skin be discoloured. It is very rare that carotid
body tumours become malignant, but as in any case of suspected neoplasm,
this should not be ruled out.
Conclusion
This has been a brief run- through of some of the various pathologies that can
manifest as a lump in the neck, and I hope that I have been able to help
distinguish between the differences in the underlying causes, and therefore
help improve understanding of these conditions and how we as healthcare
professionals can then alter our response and subsequent actions in order to
do the best we can by the patient, as we should always be striving to do.