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A wide variety of causes exist for the frequently occurring problem of neck lumps. Thankfully the majority of causes are benign. However when a neck lump presents itself the patient understandably gets concerned and worried. This is one of the benefits of a neck lump clinic because as the majority of these are benign the patients are reassured and often discharged. The other advantage of a formal neck lump clinic is that if these lumps are sinister and a malignancy is suspected,  it  can be diagnosed rapidly and commencement of treatment can also be coordinated quickly.

Surgical evaluation: The first step in a neck lump clinic is that the surgeon takes a careful history and examines the patient. Examination is not only of the neck lump but also other areas such as the oral cavity,  the back of the tongue, the tonsils and the larynx. The reason for this is that a neck lump may be related to any point of the upper aerodigestive tract and therefore if appropriate all of this aerodigestive tract should be examined.

Radiological Examination: Following the surgical evaluation the surgeon often sends the patient on for an ultrasound examination of the neck. It is critical when this investigation is undertaken that it is done so by an expert Head and Neck radiologist. In my clinic I work with dedicated radiologists who solely examine scans related to the Head and Neck area so their level of expertise assessing a neck lump is far and beyond that of an average radiologist. In addition if required the neck lump can be sampled for cells (fine needle aspiration cytology – FNAC) or sometimes formal pathology can be taken in the form of a tru-cut biopsy. If the neck lump is thought to be malignant, other tests can be made available on the day including CT scans and MRI scans. These are also reviewed by the same expert Head and Neck Radiologists.

Ultrasound guided fine needle aspiration

Cytology Examination: If an FNAC has been taken by the radiologist, then these cells need assessment. Whilst information can be got by looking at them immediately often more needs to be done with them before a formal assessment can be reported. Most importantly in my clinic these cells are looked at by world class cytopathologists allowing for as accurate a diagnosis as can be possible for the patient.

Microscopic appearance of a cancer from fine needle aspiration

Neck lump clinics run successfully not because of the surgeon alone but because of the Team that work together to make the diagnosis – Surgeon, Radiologist and Cytopathologist. Neck lump clinics exist both within the NHS and privately but whatever and wherever you go to it is essential that all three components exist and the level of expertise must be involved to come to an accurate and speedy diagnosis

This is a malignant tumour of salivary gland origin. It may occur in any of the paired salivary glands (submandibular, sublingual or parotid) but also may occur in the minor salivary glands in the upper aerodigestive tract. It is a high grade tumour that if cure  is the aim, the primary treatment is that of surgical resection. This means a parotidectomy if the site of origin is in the parotid gland a extended submandibular gland excision if the tumour is in the submandibular gland and a wide local excision if the tumour is anywhere else. The overall management of these tumours is best undertaken in a Head and Neck Cancer Center.

Radiotherapy can be used as an adjunct to surgery for microscopic disease control but is of little benefit if it is the only upfront treatment of this salivary gland tumour.

Unfortunately patients with adenoid cystic carcinoma can develop distant metastasis many years after surgery typically in the lungs but can also have local nerve spread referred to as perineural invasion.

A lump in the neck or neck lump is a worrying situation for any patient as they often are concerned at the possiblity of cancer. It is important to have a full history and clinical examination undertaken in relation to the neck lump. At the end of this consultation the ENT surgeon can have an idea of risk stratification as to the likelihood of this being benign such a lymph node, a thyroglossal cyst or a branchial cyst or if this is malignant representing a head and neck cancer.

It is imperative that these lumps are seen by ENT surgeons that regularly investigate them, namely with an interest in Head and Neck cancer. This will ensure that the appropriate imaging is undertaken by radiologists who are used to reading scans of the head and neck and also used to taking samples for cytology (examination of aspirates of cells from a lump).

In my clinical practice both in the NHS and privateley I am lucky to be supported by a dedicated Head and Neck radiologist and cytologist, in order to give the patient a rapid diagnosis but with a degree of certainty from clinicians who deal with this every day. It is extremely helpful to the patient with a neck lump to attend one of these rapid access Head and Neck Lump clinics as if benign the patient is reassured immediately and if malignant there is no delay in organising the appropriate investigations.

Freys syndrome is not an uncommon phenomenon after surgery to the parotid gland (parotidectomy). The patient complains of sweating on the cheek, face or neck. Its name comes from a female french neurologist who described the phenomenon.

If warned preoperatively few patients have a problem from the phenomenon. However in some the problem is significant and extremeley problematic. Peole have advocated redivision of the nerves and interposition of soft tissue, the use of Botox or simply the use of antiperspirants in the area.

Freys syndrome occurs because of division of branches of the auricultemporal nerve which carry sympathetic nerve supply to sweat glands and parasympathetic fibres to the parotid. Rerouting causes the abnormal sweating on eating.

In the vast majority of patients the correct treatment is do nothing at all.

Chyle is a milky fluid consisting of lymph / interstitial fluid and emulsified fats. The largest conduit of it is in the thoracic duct that starts in the abdomen ascend to the neck and enters the venous system at the junction of the internal jugular vein and the subclavian vein.

A chyle leak can occur at the time of a neck dissection clearing lymph nodes from the territory where the thoracic duct enters the venous system. A chyle leak has been incurred by every regularly practicing surgeon who undertakes neck dissection. More often than not it occurs when large nodes have to be cleared from the root of the neck where the duct is.

It can lead to a profuse loss of this milky fluid which is protein rich and patients can therefore become fluid depleted and malnourished rapidly with a high output fistula. Special feeds can be instituted to decrease output, pressure can also help decrease output. Surgical exploration can sometimes localise the leak. Occasionally thoracoscopic ligation of the duct in the chest can be undertaken.

This is a serious condition and is best avoided and when incurred should be carefully managed from a surgical and dietetic perspective.

Thyroid cancer is a rare condition. It is should be treated by individuals that work in a multidisciplinary team and therefore manage the condition more frequently.

A number of types of thyroid cancer exist:

Papillary Cancer

Follicular Cancer

Medullary Cancer

Anaplastic cancer

Lymphoma

Papillary and follicular cancers are the most common cancers and thankfully usually have a better prognosis. Treatment has to be planned depending on the staging of the disease and may involve any of the following

Surgical treatment - Hemithyroidectomy,Total thyroidectomy, Neck Dissection

Oncological treatment -Radioactive Iodine, External beam radiotherapy

Medical treatment - Thyroxine

The majority of localised well differentiated cancers are treated with surgery in the form of thyroidectomy followed by radio iodine treatment and then thyroxine treatment. However, treatment has to be tailored to the individual.

A thyroglossal cyst is a benign cyst typically, that is a remnant left behind when the thyroid gland is formed in utero. It is a remnant of the descending tract that is associated with the thyroid gland as it descends in the neck to its normal position.

Typically these cysts present in the first few decades of life with an increase in size. they can become infected where they become enlarged and painful. These cysts require a careful clinical examination followed by an ultrasound related to the cyst itself but also the thyroid gland as occasionally all the thyroid tissue of the patient may be situated in this cyst.

If troublesome it is appropriate to remove the cyst, however it should b undertaken by someone who has experience in performing the operation as there is a high recurrence rate if the operation is not performed correctly. The central portion of the hyoid bone should be removed as part of the operation as during development the descending tract is intimately associated with the hyoid bone and to remove all the tract therefore, requires the removal of this portion of the hyoid bone. The operation is referred to as a Sistrunks procedure, however some people refer to it as an anterior neck dissection as this term covers a wider resection associated with a decreased incidence of recurrence.

A branchial cyst is a benign developmental anomaly that can form in the neck. It typically troubles patients in their first three decades of life with recurrent episodes of enlargenment. These episodes are often triggered by an upper respiratory tract infections.

Diagnosis of a branchial cyst is made on the history as above and clinical examination which usually reveals the lump in the lateral neck partly hidden under the sternocleidomastoid muscle of the neck. Occasionally with a significant infection the overlying skin can be tender and red/inflammed. Radiology in the form of an Ultrasound and aspiration cytology (cells removed from the lump) are also of real help in the diagnosis.

If symptomatic it is appropriate to remove the gland but this operation is not to be underestimated and should be undertaken by a surgeon competent and who regularly performs a neck disssection. I would always perform a selective neck dissection as it allows me to safely protect the important nerves and large blood vessels (carotid artery and jugular vein) very intimateley associated with the branchial cyst.

Cancer of the voicebox (larynx) typically occurs in patients who are smokers. High alcohol intake can be a contributory factor too.

Patients typically present with a change in their voice or sometimes with difficulty in breathing due to a degree of airway obstruction. The voicebox is visualised using nasendoscopy, a fibreoptic telescope passed through the nose to visualise the larynx.This assesment is important as it can help stage the disease and assess options for treatment.

If it is likely that this is an laryngeal cancer investigations are undertaken in the form of a CT scan of the neck and chest and a biopsy under general anaesthetic referred to as a microlaryngoscopy and biopsy.

Once the biopsy is confirmatory then every patient should be discussed in a multidisciplinary team meeting and a decision on the best treatment options can be considered.

Broadly speaking patients fall into a number of categories

Palliative which is aimed at symptom control

Curative which is done with the intention of cure but is never a guarantee. Options in this group include radiotherapy, laser surgery and laryngectomy.

The various functions and levels of lymph nodes are summarized in a previous A & P section under the heading of lymph node biopsy . The different levels are critical to the understanding of the different types of Neck Dissection.

The lymphatics are referred to according to their position in the Head and Neck region.

Level I – Submental and submandibular

Level II – Upper deep cervical

Level III – Mid deep cervical

Level IV – Lower deep cervical

Level V – Posterior triangle

Level VI – Paratracheal

Level VII – Superior mediastinal

Neck Dissection

Lymph nodes in the Head and Neck region are typically the first route of spread of malignant disease in the upper aerodigestive tract. If this happens then the lymph nodes are sometimes considered for surgical removal. This is referred to as a ‘Neck Dissection’. Occasionally even if the neck has no clinically or radiologically proven neck nodes and the risk is high a Neck Dissection may be undertaken to stage the neck.

The degree and seriousness of lymph node spread in Head and Neck Squamous Cell Cancers is graded according to N staging in the TNM staging system.

N1 Single ipsilateral lymph node <3cm

N2a Single ipsilateral lymph node 3-6cm

N2b Multiple ipsilateral lymph nodes <6 cm

N2c Contralateral lymph node

N3 Lymph node >6cm

There are many types of neck dissection that are described. Simply put they can be ordered into the following list.

COMPREHENSIVE

Radical Neck Dissection Levels I-V dissected sacrificing Internal jugular vein(IJV), Accesory nerve and Sternocleidomastoid muscle (SCM)

Modified Radical Neck dissection Levels I-V dissected preserving any of the named three structures above (IJV, accessory nerve or SCM)

Extended Radical Neck Dissection Levels I-V dissected including any other lymph node levels

SELECTIVE

There are a variety of selective neck dissections depending on the site of the primary removing different lymph nodal groups that are likely to drain from the primary.

Surgery can be performed through a variety of skin incisions all of which will leave a scar. Clearly there is always a risk of bleeding and the great vessels (IJV and carotid artery) are in the territory of most neck dissections.

Very importantly there are nerves in the territory of the dissection that sometimes have to be sacrificed. These typically are:

The Accessory nerve:

If injured causes stiffness in the shoulder and some decrease in range of movement.

The Hypoglossal nerve:

If injured causes restriction of movement of that side of the tongue.

The Phrenic nerve:

This nerve supplies the diaphragm movement and is unusual to be injured.

Marginal mandibular nerve:

This is a branch of the facial nerve and is often seen and preserved in the dissection.

Rarely other channels that convey fatty acids from the gut to the venous system can be injured with a neck dissection. This is unusual but can cause problems in the postoperative period.

Most patients will have a drain placed post-operatively which is removed when it’s output decreases significantly. A patient can expect to stay in hospital from 2-5 days after the operation, however this is in the ideal case.

Lymph Node Biopsy - Anatomy & Physiology

Lymph nodes are numerous in the head and neck region. They are a filter for bacteria and viruses but occasionally can become involved either by a malignancy involving the lymphatic system ‘lymphoma’, or as a result of spread of malignancy from the head and neck region.

The lymphatics are referred to according to their position in the Head and Neck region.

Level I – Submental and submandibular

Level II – Upper deep cervical

Level III – Mid deep cervical

Level IV – Lower deep cervical

Level V – Posterior triangle

Level VI – Paratracheal

Level VII – Superior mediastinal

Lymph Node Biopsy - Lymphadenopathy

If someone has persistent lymphadenopathy a cause should be sought. Most commonly lymph nodes are reactive to a variety of infective or inflammatory conditions. It is important that if a lymph node is seen in the neck this should be investigated thoroughly by a surgeon used to the examination of the upper aerodigestive tract. A full oral examination and flexible nasendoscopy should be performed. A Fine needle aspiration should be undertaken of the lymph node to gauge if it harbours malignant cells.

If a lymph node is to be biopsied a suitable one with minimal risk to the patient should be undertaken. Again a surgeon who regularly operates in the Head and Neck will be able to explain to the patient risks associated with a lymph node biopsy. Normally a small incision is made and the lymph node or a group of lymph nodes is sampled and sent for histology.

UK Head and Neck Cancer

Head and Neck Cancer is a spectrum of disease covering malignant disease of the upper aerodigestive tract, salivary glands and thyroid. They comprise of 3% of all the new cancers seen in the UK per year and are therefore relatively rare therefore should be treated by individuals that deal with this spectrum of disease regularly and in a centre that has the complete infrastructure necessary to support a patient through their treatment.

Risk factors for Head and Neck Cancers include:

• Smoking
• Alcohol
• Poor dentition
• Chewing tobacco
• Genetic

Head and Neck Cancer Centre

Head and Neck Cancers by virtue of the fact that they are rare need to be treated through a Centre that has the specialists within it to treat and look after a patient throughout their management plan.

Making the diagnosis of Head and Neck cancer requires skilled clinicians, surgeons and oncologists, used to taking good histories and recognizing risk factors in the history. Appropriate special investigations, reported by experts in their fields is essential. This includes dedicated Head and Neck radiologists to look at the variety of X-Rays taken for patients, dedicated pathologists looking at specimens and biopsies and dedicated cytopathologists looking at cells extracted from head and neck lumps by a process called fine needle aspiration cytology.

Patients should be discussed in a multidisciplinary forum such that unilateral decisions are not made and these will include not just the specialists named above such as the surgeons, oncologists, pathologists and radiologists but also the other very important aspects to a Head and Neck Cancer Centre including Clinical Nurse Specialists, Speech and Language Therapists and Dieticians.

Mr Vaz is a dedicated ENT / Head and Neck surgeon that sees patients with Head and Neck Cancers regularly and channels them through a premier Service at the dedicated Head and Neck Cancer Centre at University College London Hospital. Patients can be seen here and managed both in the private and NHS sectors

This is a huge issue in the UK with local areas being split up into cancer networks and cancer services being delivered with varying levels of expertise and allied health care support. Thankfully this is being regulated by a process called peer review.

The very best treatment for a patient is not just centered around the surgery or the radiotherapy a patient receives. These are very important but there are many more things that are offered to patients in a premier Head and Neck Cancer Centre.

In our Head and Neck Cancer Centre we have excellent surgical staff experienced and trained both nationally and internationally. Our oncologists offer conventional radiotherapy and state of the art IMRT a form of radiotherapy to allow for more accuracy in complicated areas of the Head and Neck. Very importantly however we have world class radiology and cytopathology together with superb histopathology support. In addition we have nursing staff on the ward dedicated to the post operative care of Head and Neck Cancer patients, we have clinical nurse specialists supporting the patients both whilst in hospital and when they leave and we have specialised Speech and Language as well as dietietic services purely attached to the Head and Neck Service alone.

It is clear therefore that the service that can be offered to the Head and Neck Cancer patient from a holistic view point is significantly improved with this dedicated service.