Red flag symptoms
- Persistent lymph node or nodes for >6 weeks
- Firm, hard lymph node
- Lymph node >2cm in size
- Rapidly increasing in size
- Significant unintentional weight loss, night sweats, appetite loss
- Exposure to HIV or hepatitis
- Unexplained fever in returning traveller
- Breast lumps or symptoms suggestive of bronchogenic cancer
- Associated generalised lymphadenopathy
- Any associated facial swelling
Understanding neck swelling
Cervical lymphadenopathy refers to lymph nodes within the cervical chain. These may also occur in conjunction with lymph nodes in the occipital, submental or submandibular region.
A basic understanding of the anatomy of the neck is essential to formulate a differential diagnosis. The purpose of this article is to provide a systematic approach for excluding serious pathology within the neck.
Patients, particularly children, presenting with neck lumps are not uncommon and the differential diagnoses are broad. Find out why the patient, or the parent, has presented now and establish their main concerns.
Most patients with lumps worry about malignancy, but this is not always the case, so never assume this.
There are many possible causes of lymphadenopathy. It is useful to categorise possible causes as infectious, autoimmune and neoplastic, including the conditions listed in the box. Upper respiratory tract infection (URTI) is the most common reason for seeing cervical lymphadenopathy.
While acute leukaemia may present with cervical lymphadenopathy, chronic leukaemia may present more with non-specific symptoms and abnormalities in blood work or evidence of splenomegaly.
Possible causes include:
- Infectious mononucleosis
- HIV infection
- Dengue fever
- Metastatic disease
- Acute leukaemia
- Systemic lupus erythematosus
- Dental abscess
The history may include the following questions - some of them will be irrelevant to certain patients and, as ever, your questions need to focus on the patient in front of you.
- How long has the lump been present?
- How big is it?
- Is it growing? If so, how rapidly?
- Is the lump tender?
- Does it feel firm or are they able to move it?
- Have they noticed any other lumps, paying attention to the supraclavicular region, axillary region and inguinal canal?
- Is the lump weeping, bleeding or discharging?
- Do they have a history of drenching night sweats, weight loss or appetite loss?
- Is there a history of any recent URTI?
- Have they had any recent dental problems?
- Any significant ENT history such as otalgia, unilateral nasal symptoms or facial pain?
- Any new mouth lesions?
- Are they systemically unwell?
- Is there a history of fever?
- Is there any history of foreign travel?
- Has there been any exposure to TB?
It may be appropriate to enquire about breast lumps, dyspnoea, cough or haemoptysis. It may be necessary to take a detailed sexual history, a detailed smoking history, and history of recreational drug use. An alcohol history will also be relevant alongside a family history.
Your examination will be focused around your history, but may include the following.
Does the patient look unwell? Is there any evidence of cachexia? Are they febrile? Where is the lump?
Palpate for size, shape and consistency. Is it mobile or attached to any surrounding structures or anything underneath? Is it tender? You may wish to see if it transilluminates.
Examine the occipital, submandibular, submental, and pre and postauricular nodes.
ENT examination or examining the lung fields and breasts may be relevant, but this will be determined by the history. Other possible examinations may include the axillary and inguinal nodes, and palpation for hepatosplenomegaly.
- Routine blood tests may include FBC (crucial if you are suspicious of acute leukaemia), U&Es, CRP, ESR, LFTs, monospot test. Specify that you need a blood film if you have significant concerns.
- HIV counselling and testing may be crucial in high-risk patients (three month seroconversion window applies).
- Syphilis (three month seroconversion window applies) and hepatitis screening may also be essential.
- Plain chest X-ray if bronchogenic cancer is suspected.
- Ultrasound scan of the lump. Reports often give a useful idea of whether the lymph glands are concerning or more consistent with reactive lymphadenitis.
- Urine for chlamydia and gonorrhoea.
- Ultrasound scan of the abdomen may also be needed, if you are suspicious hepatosplenomegaly.
- Paul Bunnel test, if positive, indicates infectious mononucleosis which can be managed in primary care.
When to refer
Consider referral if the node:
- has persisted for more than six weeks
- is >2cm and not improving
- is rapidly enlarging
- If you suspect TB, refer urgently to a chest physician. HIV-positive patients or those diagnosed with syphilis or hepatitis will need further urgent assessment through the appropriate specialty. Chlamydia can be treated in primary care but partner notification must be carried out via GUM specialist services.
Consider referral also for:
- Unexplained fever in a returning traveller
- Any significant systemic symptoms
- Generalised lymphadenopathy
- Significant abnormalities on blood work or imaging
- Evidence of hepatomegaly or splenomegaly
- The degree of urgency for referral will depend largely on your findings from the history and the examination. A planned review may be necessary depending on the patient and their level of concern.
Key learning points
- Lymph node >2cm or rapidly increasing in size is a red flag.
- It may be appropriate to enquire about breast lumps, dyspnoea, cough or haemoptysis.
- Identify whether the lump is mobile or attached to any surrounding structures or anything underneath.
- HIV counselling and testing may be crucial in high-risk patients.
- Paul Bunnel test, if positive indicates infectious mononucleosis which can be managed in primary care.
- If you suspect TB, refer urgently to a chest physician.