Biopsy of neck lumps in adults should be preceded by examination of the upper aerodigestive tract

Assessment of Neck Lumps in Relation to Dentistry

Neck lumps have a varied aetiology, from a benign inflammatory cause to the first presenting sign of a malignancy. Patients may present to primary care complaining of a neck lump or they may be identified as an incidental finding during routine examination. This article highlights a structured approach to the initial assessment including history taking, risk factor assessment and clinical examination. Further investigations undertaken in a secondary care setting, such as ultrasound and guided fine needle aspirations, are then discussed. The common congenital, inflammatory, infective, vascular and neoplastic causes of neck lumps and their management and specialist referral pathway are discussed.

Management of neck lumps--a triage model

We report our experience in the out-patient triage of 100 patients presenting with a lump in the neck. The out-patient visit consisted of a general history and examination, assessment of the upper air and food passages and, where indicated, ultrasound and core needle biopsy of the lump. Other investigations were performed as appropriate. One hundred neck lump patients were seen in a 9 month period. Ninety-six of these lumps were diagnosed on an out-patient basis, only four requiring admission for formal excision biopsy. Among the diagnoses were eleven lymphomas, nine parotid neoplasms, nine lymph node metastases, five thyroglossal cysts, and four branchial cysts. Almost half the patients seen had either a reactive lymphadenopathy, or no abnormality. The establishment of a tissue diagnosis on an out-patient basis allowed appropriate referrals to be made and management plans to be formulated. The theoretical risk of seeding of malignant cells in the needle tract is acknowledged and discussed.

Metastatic cervical lymph nodes: general practitioner referral patterns

Premature excision biopsy of a cervical lymph node infiltrated by metastatic carcinoma may compromise patient survival since it is associated with an increased incidence of local wound recurrence and distant metastases. Seventy per cent of such patients have an identifiable head and neck primary, obviating the need for an excision biopsy. It is important therefore that they are examined by surgeons who are experienced in inspecting the upper aerodigestive tract and who are competent in performing definitive head and neck surgery. A questionnaire sent to all general practitioners of an Inner London and a District Health Authority revealed that only 18% and 33% respectively referred patients who they suspected of having a metastatic neck node to a department with an experienced head and neck surgeon. We conclude that greater emphasis on the correct management of these patients at both an undergraduate and postgraduate level may encourage subsequent generations of general practitioners to review their referral patterns.