The patient
This four-year-old girl bounced into my office and set to work rearranging my furniture. ‘She seems absolutely fine,' said her mother. ‘But this lump has popped up out of nowhere.'
The easily visible lump – in the right anterior triangle, about a third of the way down the sternocleidomastoid – had grown over a week, perhaps longer. It felt really firm, almost hard. There was no sign of lymphadenopathy elsewhere, and her throat, ears and temperature were all normal.
Two words came into my head: ultrasound scan. I had a chat with the mother, talked through the options and explained I'd organise a scan – which hopefully would show a reactive gland.
Differential diagnoses
• Reactive lymph node
• Lymphoma
• Brachial cleft cyst
• Abscess
• Cystic hygroma.
Of neck lumps in children, over 90% are simply reactive nodes and most resolve in three weeks. In fact, some children have persistent mild lymphadenitis throughout childhood, typically palpated as a solitary gland or group of less than 1cm glands. The upper deep cervical chain – what ENT surgeons call level 2 – is the most common location.
In Hodgkin's lymphoma, 95% of cases present with lymph node involvement, most commonly a neck gland. It follows a bi-modal distribution, the first peak from 15-34 years, the second over 50 years. Only a minority have systemic symptoms.
In non-Hodgkin's lymphoma, two-thirds of cases occur over the age of 60. Malaise, night sweats and weight loss usually accompany the lymphadenopathy. Both conditions are rare overall in those under 20 – although non-Hodgkin's has a slightly higher incidence than Hodgkin's in children.
The most common branchial cleft cyst is in the second cleft – at the junction of the upper and middle thirds of the sternocleidomastoid. These usually present in teenage years, or even later – rather oddly given that they're congenital.
An abscess may develop here when lymphatic drainage becomes impaired, typically infected with Gram positives. Some resolve with antibiotics, but most will point and extrude, or progress and require incision and drainage – being careful not to damage the marginal mandibular branch of the facial nerve.
Cystic hygroma was a possibility, but it is usually seen at birth, so she was a little too old for this diagnosis.
Getting on the right track
The ultrasound showed a 3cm lobulated cystic lesion between the submandibular gland and the sternocleidomastoid, which favoured a type 2 branchial cleft cyst. The radiologist remarked: ‘A reactive nodal abscess is unlikely, given that the rest of the lymph nodes are not enlarged.'
I referred the girl to ENT, but events overtook us as the lump became very red and angry. She was admitted and had an incision and drainage under a GA. But there was no sign of a cyst. It was, in fact, just a simple abscess. Which just goes to show that even experienced radiologists can get it wrong, just like us humble GPs.
At five months' follow-up, the lump has not recurred and the girl remains well.
Dr Oliver Starr is a GP in Stevenage, Hertfordshire
