Head and Neck Lumps
Enlarged Neck Lymph Nodes
There are about 150 to 200 lymph nodes on each side of the neck. Any of them can swell due to infection, tumor or inflammation. Enlarged neck nodes must be differentiated from other head and neck lumps such as branchial cysts, parotid and thyroid lumps, cystic hygromas etc.
When a lymph node is enlarged, the first approach is to determine the cause. The simplest investigation is to perform fine needle aspiration cytology (FNA). This quick test will reveal the nature of the neck node in about 95% to 98% of the time. Results can be categorized broadly into reactive (infectious), granulomatous inflammation (eg. tuberculosis, sarcoidosis) and malignancy (undifferentiated, squamous cell carcinoma, lymphomas). A full ENT examination is mandatory in the assessment of an enlarged neck node(s). Sometimes, an excision of the neck node is required when the FNA is not conclusive. Imaging such as CT and MRI scan may be useful in assessing the extent of disease and involvement of other neck nodes that may not be palpable. Treatment is dependent on the cause of the enlargement.
The parotid gland is a largest of 3 sets of major salivary glands (the other two being the submandibular and sublingual glands) and is found below the angle of the jaw. The gland can become enlarged because of infection but tumors are more common. Tumors of salivary glands follow a ‘80% rule’; 80% of salivary gland tumors are found in the parotid gland, 80% of parotid gland tumors are benign (Figure 1), 80% of benign tumors in the parotid gland are pleomorphic adenomas and 80% of minor salivary gland tumors are malignant.
Most parotid gland tumors present as painless lump below the angle of the jaw. A fine needle aspiration cytology is usually performed to determine the nature of the lump. CT and MRI scans may be ordered to give more information.
Although most parotid gland tumors are benign, surgical removal is generally recommended. This allows a complete histological examination of the tumor. In addition, up to 5% of benign tumors can turn malignant over time. Symptoms and signs of malignant tumors are rapid increase in size, hard and painful, fixation of lump to surrounding structures, facial weakness and presence of other neck lumps.
Surgery (Parotidectomy) requires a general anaesthesia and an overnight stay. Risks can be divided in early and late complications. Early complications include infection, haemorrhage and facial weakness (usually temporary in benign tumors) while late complications include gustatory sweating (Frey’s syndrome), tumor recurrence and cosmetic defect.
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Submandibular Gland Lumps
The submandibular salivary gland is situated just under the floor of the mouth and found under the jawline on each side of the neck (Figure 2). The submandibular duct carries saliva from the gland to the mouth where its opening is found in the midline under the tongue. Problems arising from the submandibular gland can be divided into tumor, stones and infections.
Submandibular duct stones makes up 80% of all salivary gland stones. This is attributed to the high calcium concentrations found in the saliva produced by the submandibular gland. Patients present with painful swelling under the jaw especially with meals. The swelling may subside after eating only to recur with the next meal. Some stones may be seen in the mouth but otherwise, a CT scan is needed to confirm its presence (Figure 3). Treatment involves removing the stone. If the stone is seen or felt in the mouth, it can be removed by making an incision in the duct and the stone removed. If the stone is found deeper within the gland substance, then the whole gland needs to be removed.
CT scan showing left submandibular stone (blue arrow) and a dilated duct (red arrow)
Tumors usually present as painless lumps that increase in size over time. Most (about 80%) are benign and the most common is pleomorphic adenoma. A fine needle aspiration (See under Common ENT investigations) performed in the clinic usually confirms the diagnosis. Surgery is the recommended treatment
Infections of the submandibular gland are fortunately not common and are usually secondary to buildup of saliva as a result of a stone. The infection can affect the whole gland (sialadenitis) or form an abscess (collection of pus) within the gland. Treatment involves intravenous antibiotics, drainage of abscess and removing the primary problem eg. stones.
Midline Neck Lumps
Lumps can also arise in the midline of the neck. As a rule, midline lumps or masses are benign. The commonest midline lumps are thyroglossal cysts, thyroid nodules (see under Thyroid Lumps), dermoid (congenital) cysts and lipomas (benign fatty growths). Doctors can distinguish the different lumps from the feel, position and whether it moves with swallowing. Surgical excision is the recommended treatment as these lumps generally grow in size over time.
MBBS (S'pore), FRCS (Edin), FRCS (Glasg) Fellow, Otology / Neurotology (Can)
NUH ENT Conference Jan 2005