The patient
A very worried mum brought her 12 year old daughter to see me, explaining that the young girl had developed a noticeable lump in her neck.
Mum thought the swelling had probably been present for some months, and that it increased in size, and became tender, when her daughter had an upper respiratory infection – and she did have a mild sore throat and cough at this presentation.
Otherwise, the girl was perfectly well, had no relevant past medical history and was on no medication. But her mum explained that the child's grandfather had recently been diagnosed with carcinoma of the larynx, which had presented with a cervical node – hence the anxiety.
First instinct
The presentation of ‘normal' childhood cervical lymph nodes, which swell with URTIs, is very common in primary care, and this looked like a typical – albeit impressive – case. There were no abnormal lymph nodes elsewhere and the girl was clearly otherwise well.
Having reassured mum that laryngeal cancer is not a diagnosis we'd entertain in this age group, I decided to play a waiting game. I planned to review her in a few weeks, by which time her URTI should have resolved and her gland, hopefully, would have shrunk back to non pathological proportions.
Differential diagnosis
• Normal cervical node swollen with URTI
• Other cause for lymphadenopathy eg abscess formation, glandular fever, TB, malignancy
• Thyroid swelling
• Branchial cyst
• Cystic hygroma
Of course, cervical lymphadenopathy – even in children – has quite a wide differential, and a non-resolving or enlarging node would suggest a number of other possibilities. The passage of time would help me here, and would also allow for the development of other symptom-clues – although experience told me that these situations usually resolve and usually, in retrospect, represent normal cervical node swelling caused by a simple URTI.
A thyroid swelling seemed very unlikely – the lump was well away from the mid-line and did not move with tongue protrusion or swallowing.
Other possibilities included cystic lesions which GPs encounter so uncommonly that I only vaguely recollected them – such as branchial cysts and cystic hygromas.
The hidden clue
On review, the swelling was identical. The mother had checked with her husband and confirmed that the neck lump had been present for a good year or so, albeit a smaller size – which seemed odd for a ‘normal' cervical node.
Getting on the right track
A repeat examination in the light of this new clue led me to reconsider my original diagnosis. The swelling felt cystic rather than node-like. This meant cystic hygromas and branchial cysts were suddenly front-runners. Cystic hygromas, though, are nearly always present from birth – mum insisted this swelling wasn't – and brilliantly transilluminate – and this one didn't. Which meant a likely diagnosis of a branchial cyst – which was confirmed when the girl had an uneventful excision of the swelling a month or so later.
Dr Keith Hopcroft is a GP in Laindon, Essex
What is the lump on this girl's neck? What is the lump on this girl's neck?
