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Neck lump - Management
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When should I admit someone with lymphadenopathy?

  • Admit immediately if the person has symptoms such as difficulty breathing (stridor), or signs of superior vena cava obstruction (swelling of the face and/or neck with fixed elevation of jugular venous pressure), or dysphagia to liquids and solids and signs of aspiration.
Basis for recommendation

This recommendation has been extrapolated from a referral guideline for suspected cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a] and opinion from CKS expert reviewers.

What should I do if infection is suspected?

  • If lymph node enlargement is likely to be in response to local bacterial infection, consider the appropriateness of treating with an antibiotic tailored to the likely underlying source of infection. For more information, see the CKS topics on Boils and paronychia, Otitis externa, Otitis media - acute, Otitis media - chronic suppurative, Sinusitis, and Sore throat - acute.
  • If there is suspicion that a viral infection (for example HIV) is causing lymphadenopathy, consider testing or seeking specialist advice.
  • If the lymphadenopathy is not resolving after 2 weeks, urgently refer to an ear, nose, and throat surgeon for further investigation.
Basis for recommendation

Antibiotic treatment

  • The recommendation to consider treatment with antibiotics if the lymphadenopathy is thought to be due to bacterial infection is based on expert opinion in a narrative review [Schwetschenau and Kelley, 2002].
  • CKS expert reviewers suggest that an infected lymph node deep in the neck can progress to a deep neck abscess and eventually mediastinitis. This supports the recommendation to treat with antibiotics.

Viral infection

  • The recommendation to consider that lymphadenopathy may be due to a viral infection is based on opinion from CKS expert reviewers.

Referral

  • The recommendation to refer the person if lymphadenopathy is not resolving within 2 weeks of antibiotic treatment for presumed bacterial infection is based on expert opinion in a narrative review [Prakash and Hanna, 2002].

What should I do if lymphadenopathy is unexplained?

  • Request investigations if they have not already been done.
  • If any of the following additional features of lymphadenopathy are present, refer urgently (within 2 weeks):
      • Persistence for 6 weeks or more.
      • Lymph nodes increasing in size.
      • Lymph nodes greater than 2 cm in diameter.
      • Widespread nature.
      • Associated splenomegaly, night sweats, or weight loss.
Basis for recommendation

The recommendation on management when the cause of lymphadenopathy is unknown is based on a referral guideline for suspected cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a].

What should I do if malignancy is suspected?

  • Refer urgently (to be seen within 2 weeks)
    • If there are features suggestive of head and neck malignancy (for example an identifiable primary tumour with lymphadenopathy) or the person has lymphadenopathy with negative findings on chest radiography, refer urgently to an appropriate specialist or head and neck clinic.
    • If there are features of haematological malignancy (for example non-tender, rubbery lymphadenopathy in areas other than the neck [such as the axilla], splenomegaly, or systemic symptoms [such as fever, night sweats, weight loss, and pruritus]) refer urgently to a team specializing in the management of haematological cancers.
    • If there are findings suggestive of malignancy on chest radiography, the person should be referred urgently to a team specialising in the management of lung cancer.
Basis for recommendation

This recommendation is based on referral guidelines for suspected cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a].

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