In this case-based module, GP with Extended Role in ENT Dr Eason Sivayoham explains how to manage four cases involving presentations of head and neck swellings.
Complete the full module today on Pulse365
Learning objectives
This case-based module will guide you through assessment, diagnosis and management of four presentations of head and neck swellings, including:
• How to approach ‘enlarged glands’, assess likelihood of malignancy and choose appropriate referral options.
• Examination of enlarged thyroid, what features should prompt urgent referral, and tests and appropriate investigations in non-urgent cases.
• Key history and tests when dealing with high-risk, firm, fixed neck lump requiring urgent referral.
• Assessment of pulsatile neck swelling, what differentials to consider and investigations, and appropriate management of carotid body tumour or aneurysm.
Case 1. Young child with persistent enlargement of one cervical lymph node
A mother attends with her three-year-old child. They’d been seen about a month previously when the child had a minor sore throat. At that time, minor cervical lymphadenopathy was noted, but one cervical gland in particular seemed larger than the others. This particular gland seems, if anything, bigger (about 3 x 3 cm), has a slightly reddish tinge and is a little tender though not fluctuant. The child otherwise seems perfectly well.
1. Parents often bring children to see us with concerns about their glands being enlarged, especially in the neck. When can we reassure that all is well, when should we be concerned and how should we monitor the situation?
Paediatric neck lumps present a diagnostic dilemma in primary care and elicit a significant amount of parental concern. They are varied in cause and generally fall into three aetiological categories. These are: congenital; inflammatory; and malignant.
Malignancy presenting as a neck lump in the primary care setting is exceedingly rare, but does happen. These categories are also not mutually exclusive. For example, congenital malformations can exhibit inflammatory features such as would occur in an infected thyroglossal cyst. A thyroglossal duct cyst also has the potential to undergo malignant transformation in less than 1% of cases, though this process is more likely to present in adulthood.
Reactive lymphadenopathy is the most common cause of paediatric neck lumps in the infant and early childhood age groups and will generally resolve within 6 weeks. Taking a careful history and a systematic examination, bearing in mind head and neck anatomy, is essential in making an accurate and timely diagnosis. Simple, uncomplicated reactive lymphadenopathy can be safely observed and reviewed.
Red flags at the time of assessment indicating emergency admission are:
- Fluctuance with signs of sepsis.
- Poor feeding/dysphagia.
- Stridor.
- Voice change.
- Rapidly growing lump/swelling.
2. In a case like this, where one gland seems unusually large and is not resolving, what is the differential diagnosis and what clues might there be to the underlying cause?
In this scenario, the solitary, dominant lymph node would be an indication for clinical concern, indicating a malignant process or persistent localized infection within the lymph node. The overlying erythema is also an indication of a likely evolving phlegmon.
As a rule the following should be considered:
- Reactive lymphadenopathy/suppurating node may be secondary to an infective process such as encapsulated organisms. These are invariably atypical mycobacteria and tuberculosis (TB) – this is the most common clinical manifestation of extrapulmonary TB. Another infective cause, though uncommon is Cat Scratch disease, characterised by an infected dermal entry point with erythema which resolves after 10-14 days, followed by regional, persistent lymphadenopathy.
- Single dominant node of more than 6 weeks’ duration is high risk for malignancy. The main malignancies in this age group are Non-Hodgkin’s and Hodgkin’s lymphoma, rhabdomyosarcoma.
3. How should the GP proceed in terms of investigation? And if referral is deemed necessary, how urgent is it and who should the child be referred to?
In this case, with a single dominant cervical lymph node and time frame of 4-6 weeks, it would be reasonable to consider a urgent cancer pathway referral to a head and neck clinic. However, a chest X-ray on an urgent basis (within 48 hours to help exclude mediastinal lymphadenopathy) and a full blood count in a similar time frame would also be appropriate, as these would provide valuable information to direct the urgent referral to the appropriate pathway, depending on locally defined guidance, such as the head and neck clinic if there are no haematological or mediastinal findings. Should they be present, a discussion or urgent referral to the paediatric clinic would be more appropriate.
Complete the full module including three more cases on Pulse365, logging 1.5 CPD hours towards revalidation
Dr Eason Sivayoham is a GP with an extended role in ENT at Manchester University NHS Foundation Trust. He is also the Co-Chair of ENT UK Community group and represents community ENT on the ENT UK Council
