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Neck Lumps / Lymph Nodes

Neck Lumps

The important concepts in understanding neck lumps are

  • Age

  • Location
  • Solitary or multiple
  • Duration
  • Associated symptoms

Age

The vast majority of lumps in children and young adults will be either inflammatory or congenital.  Single lateral neck lumps in an adult over 40 must be considered cancerous until proven otherwise.


Location

Subcutaneous

  • sebaceous cyst
  • epidermoid cyst

Midline lumps – these are often congenital i.e. present at birth at least in vestigial form.  Under the chin they may represent dermoid cysts, thyroglossal cysts (especially around the hyoid). In the lower neck they may represent thyroid abnormalities and will elevate with swallowing.

Angle of jaw – most of these are parotid lumps.  Most are benign parotid tumours but lymph nodes involved by skin cancer occur increasingly with age.

Under the body of the mandible – usually related to abnormalities of the submandibular gland such as blocked gland, infection, tumour. As with parotid lumps, lymph nodes involved by skin cancer occur increasingly with age. In Polynesian patients in particular, a cystic swelling may be due to a plunging ranula which is due to chronic leakage of mucus from the sublingual gland (under the tongue) into the neck.

Lateral neck – usually are enlarged lymph nodes.  In adolescents and young adults a branchial cyst may come up almost over night and present as a firm swelling in the upper neck. Any persisting lateral neck lump in an adult  must be treated with suspicion for malignancy.  Other possibilities include nerve tumours, carotid body tumours.

Lower neck - in front of or deep to the neck muscles – often represent thyroid abnormalities and will elevate with swallowing.  Most thyroid lumps are benign but still require investigation as some are cancers.

 

Number

Multiple lumps are generally lymph nodes and the most common cause is inflammation e.g. glandular fever, toxoplasmosis.  However multiple non-tender nodes can be due to malignancy either primarily of lymph nodes (lymphoma) or secondarily by spread from a cancer of the head and neck (nodal metastasis).

Duration

Generally lumps that have been present for years are benign but not necessarily so e.g. parotid or thyroid cancers can be quiescent for years before taking on a more aggressive course.

Most inflammatory lumps will begin to resolve within 3 weeks.  Any lumps that are persisting or growing over a few weeks or months must be investigated for malignancy.

Associated Symptoms

Inflammatory nodes are generally associated with systemic symptoms such as tenderness, fever, malaise, sore throat. Serology for glandular fever or toxoplasmosis may be positive.

Lymphomatous nodes can have similar symptoms of fever, night sweats, weight loss, and tenderness.  Any nodes that persist for more than 3 weeks in the absence of a diagnosis should be investigated.

Lateral neck nodes in adults may be metastases from the throat.  These patients may be heavy smokers and may experience throat or ear discomfort, voice change or swallowing difficulty.  Some will have a past history of skin cancers.

 

Branchial cyst

The word branchial comes from the Greek, "bragchia," meaning gills. A cyst refers to a mucosa or epithelium lined structure with no external or visceral openings. A sinus refers to a tract with or without a cyst that communicates to either the gut or skin. A fistula is a tract connecting the gut to the skin.

It arises from embryonic remnants of the second branchial cleft in the neck. It is most common in young adults where it presents as a smooth swelling in front of the anterior border of the sternomastoid at the junction of its upper and middle thirds. The position is characteristic.

The cyst may enlarge during an upper respiratory tract infection and then persist. In the acute stage, it may be tender. On examination, it is usually fluctuant but does not transilluminate. It does not move on swallowing. Other enlarged lymph nodes are absent.

Treatment is by excision. Care must be taken not to damage the carotid vessels and internal jugular vein which usually lie deep to the swelling. Removal may need to be delayed if the cyst is acutely inflamed because of the risk of creating a branchial fistula.

Branchial cyst surgery

The key to this surgery is the complete removal of the cyst lining. Recurrence is then impossible.

If the cyst has been infected and then ruptured or been drained, there is the chance that some of the lining cells have been displaced making surgery more difficult. Furthermore, the cyst is more adherent to other structures in this situation. It is because of this increased complexity of surgery once infection has ensued that Dr McIvor prefers to remove the cyst soon after it appears. He prefers that they do not get infected in the first place...and infection is common in branchial cysts.

The surgery is performed under general anaesthesia. Most patients go home the first post-op day.

When and where will the operation be done?

What must I do in the week before surgery?

What do I do on the day of surgery and what shall I bring to hospital?

What will happen when I go to theatre?

What will happen when I get back to the ward?

Is it a safe operation and what are the side effects?

Dr McIvor has done thousands of  neck operations.  The liklihood of complications is very small for this surgery. There is the possibility of damage to nerves in the area which Dr McIvor will discuss with you. Infection and a small haematoma can also occur but are rare.

Nerves

Nerve damage may lead to an area of numbness and even a weakness of a muscle. The likelihood of a significant unplanned injury is very small but will be discussed with you. Generally the main nerves at risk are the small nerve to the muscles of the lower lip, the nerve to the trapezius (shoulder muscle), and the nerve that supplies touch sensation to the ear.

The nerve to the lower lip muscles (marginal mandibular) lies just below the jaw-line and is at risk from an incision in this location. This could cause a lifting of the lower lip on that side when smiling or opening the mouth widely. Occasionally there can be a tendency to spill liquid from the corner of the mouth when drinking. The likelihood of a permanent injury is very small.

The nerve to the shoulder (accessory) is a large nerve that runs in line from the earlobe to the back of the shoulder-tip. It is therefore at risk from any surgery in this line. Injury can affect the upper range of arm elevation such as when serving at tennis, playing golf, painting the ceiling, hanging out washing etc. The likelihood of a permanent injury is very small.

The nerve to the ear (great auricular) supplies touch sensation to the lower part of the ear and the earlobe. Injury to it causes numbness in this region. It is at risk during procedures in the upper neck below the earlobe. It does not affect hearing or balance. The likelihood of a permanent injury is very small.

Will I have neck stiffness, restricted shoulder movement or pain?

You will feel some discomfort around your jaw-line and experience some stiffness with jaw openeing but you will be given some medication to help ease this. Pain relief may be given in different ways, such as injections, liquid medicine or tablets. Most patients say the discomfort is not as bad as they expected, and after the first day are up and walking around.

Following discharge on the first or second day Dr McIvor prescribes paracetamol and an anti-inflammatory for 5 days which suffices for any discomfort.  After a few weeks you should be back to a good standard of neck and jaw function.

Will I have a scar?

The incision is fine but will heals to leave a fine scar which is not very noticeable.

The scar will be a single curved line in a skin crease in the upper neck and is generally about 10cm in length. In the first 3 months the scar is a red line but after 6-7 months it fades and is generally barely visible

What are the costs for branchial cyst excision?

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist and the hospital and are to be paid separately. 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.

 

What will I look like after branchial cyst excision and what will I be able to do?

  1. You will have a scar running from just below your ear gently curving down and foreward into the neck. This will be covered by a small white dressing so that it is not visible.  Dr McIvor often uses dissolving sutures and skin tapes so that few if any sutures need to be removed.

  2. You will have a small drain from your wound to collect wound fluid which naturally occurs following your surgery. The drains are small plastic tubes which are inserted into the neck at the end of your operation. The long length of tubing outside the neck is attached to a plastic collection bottle into which the fluid drains. Wound drains help to speed up wound healing and reduce infection.

  3. The drain is not painful can be carried around with you. It will usually be removed by a nurse a day after your operation when the drainage is minimal.   Drain removal is not painful.

  4. You will feel some discomfort and stiffness around your neck but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.

  5. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.

  6. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed

    Will I have a sore neck?

    When you wake from the anesthetic you will find that the skin of your neck, jaw line and ear is quite numb as the anesthetist inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

    You may find that your jaw is uncomfortable when you open your mouth wide.  This discomfort usually settles in a few days.

    You will be given medication to take home to relieve the discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

    Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place.

    Will it affect my eating and drinking?

    This surgery will not affect eating or drinking but most patients prefer a soft diet for a day or so if the neck feels a little bruised.

    What care do I need to take regarding my neck wound?

    Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound.

    After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

    The pressure of rubbing the cream in will also help to soften the scar.

    If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP.

    What rest do I need and when should I return to work?

    You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

    You will probably need to take 7-10 days off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for two weeks and then you should see your GP if more time is required.

    What about my medications and tablets?

    Please continue to take the medication you have been prescribed. Generally Dr McIvor will prescribe paracetamol and an anti-inflammatory agent such as voltaren. If you are unable to take anti-inflammatories please discuss this with him.

    Before you go home, if you are unsure about any of the tablets you need to take, please check this with a nurse . Repeat prescriptions can be obtained from your GP.


    What follow-up will there be?

    Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and to discuss the laboratory report of the resected tissue. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 4887349) if you do not receive one shortly following discharge.

Lymph nodes

A lymph node is a small gland involved in the body's lymphatic system, the disease-fighting network spread throughout your body. The lymphatic system also includes the lymphatic vessels, tonsils, adenoids, spleen, thymus and bone marrow.

Size and location

In its normal state a lymph node is the size and shape of a small bean but much softer.   They are all over the body but the greatest concentration is in the head and neck area. There are approximately 150 lymph nodes on each side of the neck with most associated with the internal jugular vein on each side.

Function

Lymph nodes function as the immune system's immigration control and forts. They are there to detect and destroy alien invaders.

Lymph is watery straw-coloured fluid that escapes from blood vessels into the body tissues. You could think of it as an overflow of fluid from the blood vessels and it contains small white blood cells called lymphocytes amongst other things. Lymph also picks up loose material including bacteria and viruses from the tissues.

The lymphoctes act like policemen or immigration officers patrolling an area. They detect unhealthy and foreign cells. The lymph is then drained from the tissues much like rainwater is drained away by a guttering system called lymph vessels or the lymphatics. The lymphatic vessels join up into larger and larger vessels and ultimately empty lymph back into the blood via the internal jugular vein. Along the way, the lymphatics pass through small filtering stations... the lymph nodes. To enter a lymph node is a bit like entering passport control at an airport. Every cell is checked to determine whether it has the credentials to exist in the body. A foreign cell like a bacterium will be detected and cause the lymphocytes in the local lymph node to multiply and to return to the site of infection to fight the invaders much like a unit of immigration officials is mobilised. Lymphocytes also release chemical signals that increase blood flow into the area which increases the number of lymphocytes and chemicals arriving to destroy the foreign cells. This is associated with redness, swelling, and tenderness at the site of invasion and also in the local lymph node. This state is known asinflammation and persists until the targeted cells are destroyed.

Lymphocytes exist either as B cells or T cells. B cells fight infection indirectly by producing plasma cells, which in turn produce antibodies that neutralize foreign invaders. It is as if they " put out a contract " and facilitate the kill. T cells are "enforcers" or "hitmen" and kill foreign invaders directly.

Toxoplasmosis

Toxoplasmosis is an infection caused by the organism Toxoplasma gondii which is one of the world's most common parasites. It is relatively common and most adults have been infected at sometime in their lives and have since developed an immunity to it. Typically it produces "flu-like symptoms such as low fever, malaise, sweats, and swollen glands(lymph nodes). In healthy adults the infection is easily contained and the body's immune system overcomes the organism. The main concerns are infection in pregnancy, infection in immunocompromised states, and differentiating toxoplasmosis from other conditions such as lymphoma that cause similar signs and symptoms .

Life-cycle of the organism

You won't want to hear this, but the host for toxoplasma is the cat and the organism lives in the wall of the cat's gut. Cats get infected by eating uncooked meat of infected animals and that includes not just what you feed them, but also what rodents they catch themselves. The parasite releases eggs which come out in the cat's faeces...so you can imagine how we get infected! Soil gets contaminated and toxoplasma can exist for a year in this state- so wash your hands after gardening and wash fruit and vegetables before eating. Also, while your cat is rather clean he/she still manages to get dirty paws and then walk on your kitchen bench. We are infected by ingesting the eggs. Other animals such as pigs, cows, rodents are infected in the same way. The eggs become small cysts in the muscle of these animals and when that muscle is eaten by cats the cycle repeats itself.

Signs and symptoms

Typically it is manifest as a flu-like illness that is just considered just another bout of flu. Sometimes the swollen lymph nodes are all that is noted and these frequently present as a cluster of nodes in one region of the neck although they can be present on both sides. They are generally only 1-2cm in size and non-tender or only mildy so. Nodes may persist for weeks.

Pregnancy

There is about a 50% chance of a pregnant woman transferring the organism to her foetus during an acute infection. This poses a risk to foetal brain, heart, eye and ear development. It is therefore important for pregnant women to avoid infection (see above life-cycle) and to seek medical advice if infected.

Immunodeficiency

Patients with compromised immune systems (eg. AIDS, organ transplant recipients) are at increased risk from toxoplasmosis which can cause serious brain, eye, lung problems. These patients require specific therapy against the organism.

Diagnosis

Toxoplasmosis is diagnosed by a blood test which detects a high level of antibodies to the organism. Typically specific IgM antibodies to toxoplasma are raised for months before returning to low levels. Once the infection is contained the specific IgG antibodies remain elevated for life thus conatining the organism and indicating immunity.

Treatment

Specific treatment against toxoplasmosis is rarely required. Only in pregnant women and in immunocompromised patients is medication advised.

Can you pass toxoplamosis on to others?

The only human to human transmission that is possible is from mother to foetus. It is not possible for an infected man or a friend to pass it on to a pregnant woman. The cat is the sole host of the organism and infection of humans occurs through ingestion of contaminated food or drink, or contaminated hands transferring it to the mouth.

Glandular Fever / Infectious Mononucleosis

Infectious mononucleosis (mono), or glandular fever, is often called the kissing disease. The label is only partly true. The virus that causes this disease is transmitted through saliva, so kissing can spread the virus, but so can coughing, sneezing, or sharing a glass or food utensil. Mononucleosis isn't as contagious as some other infections, such as the common cold.

The cause of mononucleosis is the Epstein-Barr virus, although similar signs and symptoms are sometimes caused by cytomegalovirus (CMV). Full-blown mononucleosis is most common in adolescents and young adults. Young children usually have minimal symptoms, and the infection often goes unrecognized.

Mononucleosis usually isn't very serious, although the virus remains in your body for life. Most people have been exposed to the Epstein-Barr virus by the time they're 35 years old and have built up antibodies. They're immune and won't get mononucleosis again. Treatment mostly involves bed rest and getting adequate fluids. The Epstein-Barr virus can cause much more serious illness in people who have impaired immune systems, such as people with HIV/AIDS or people taking drugs to suppress immunity after an organ transplant.

Signs and symptoms

Flu-like symptoms such as malaise, fever, headache, sore throat, swollen glands, loss of appetite. Skin rashes and abdominal pain can also occur. The disease tends to be mild in childhood and more debilitating in adulthood where it occasionally requires hospital admission for severe sore throat and dehydration. In adults it is not unusual for the liver and spleen to be inflamed as well and in extreme cases the spleen can be at risk of rupture.

The virus typically has an incubation period of four to six weeks, although in young children this period is shorter. Signs and symptoms such as fever and sore throat usually lessen within a couple of weeks, although fatigue, enlarged lymph nodes and a swollen spleen may last for a few weeks longer.

Investigations

Your doctor may suspect mononucleosis based on your signs and symptoms and a physical examination.

Blood tests

Your doctor may use other blood tests to look for an elevated number of white blood cells (lymphocytes) or abnormal-looking lymphocytes. These blood tests won't confirm mononucleosis, but they may suggest it as a possibility.

A Monospot test may be done to check your blood for antibodies to the Epstein-Barr virus. This screening test gives results within a day. But it may not detect the infection during the first week of the illness. A different antibody blood test requires a longer result time, but can detect the disease even within the first week of symptoms.

Liver function tests may indicate that your liver is inflamed.

Treatment

There's no specific therapy available to treat infectious mononucleosis. Antibiotics don't work against viral infections such as mono. Treatment mainly involves bed rest and adequate fluid intake (plenty of water and fruit juices). Paracetamol helps to relieve fever and sore throat. Don't give aspirin to a child under age 16. Aspirin may trigger a rare but potentially fatal disorder known as Reye's syndrome.

Occasionally, a streptococcal (strep) infection accompanies the sore throat of mononucleosis. You may also develop a sinus infection or an infection of your tonsils (tonsillitis). If so, you may need treatment with antibiotics for these accompanying bacterial infections.

Some people with mononucleosis who take ampicillin (Principen), amoxicillin (Amoxil, Trimox), or amoxicillin and clavulanate (Augmentin) antibiotics may develop a rash, but this doesn't mean that they're allergic to the antibiotic. If needed, other antibiotics that are less likely to cause a rash are available to treat infections that may accompany mononucleosis.

To ease some of your symptoms, such as swelling of your throat and tonsils, your doctor may prescribe a corticosteroid medication such as prednisone

Time-course
Most signs and symptoms of mononucleosis ease within a few weeks, but it may be two to three months before you feel completely normal. The more rest you get initially, the sooner you should recover.

Returning to your usual schedule too soon can increase the risk of a relapse. If you're an athlete, be cautious about returning to strenuous activities or contact sports, especially if your spleen is enlarged, because of the increased risk of rupturing the spleen.

Children with mononucleosis and an enlarged spleen shouldn't engage in vigorous activities, roughhousing or contact sports for the same reason. Rupture of the spleen results in severe bleeding and is a medical emergency. Doctors recommend avoiding contact sports for at least one to two months after you've had mononucleosis, depending on how long it takes your spleen to return to normal size.

Although you may not be able to return to vigorous activities right away, your doctor may recommend gradual exercise to help you rebuild your strength as you recover from mononucleosis.

For the first week, you may be so fatigued that you feel too weak to even get out of bed. But the tiredness lessens with time. Throat soreness is generally the worst for the first five to seven days of illness. Your swollen lymph glands (nodes) should return to normal size by the fourth week of infection.

For young people, having mononucleosis will mean some missed activities — classes, team practices and parties. Without doubt, you'll need to take it easy for a while.

Seek the help of friends and family as you recover from mononucleosis. College students should also contact the campus student health center staff for assistance or treatment, if necessary.

Can I infect others?

If you have mononucleosis, you don't necessarily need to be quarantined. Many people are already immune to the Epstein-Barr virus that causes the disease because of prior exposure to the virus as a child. But plan on staying home from class and other activities until you're feeling better. Mononucleosis is believed to spread through saliva. If you're infected, you can help prevent spreading the virus to others by not kissing them and by not sharing food, dishes, glasses and utensils until several days after your fever has subsided and even longer, if possible.

The Epstein-Barr virus may persist in your saliva for months after the infection. If you've had mononucleosis, don't donate blood for at least six months after the onset of the illness.

There's no vaccine to prevent mononucleosis.

Lymphoma

Lymphoma occurs when the white blood cells (lymphocytes) in the lymphatic system grow abnormally. As disease progresses, it compromises your body's ability to fight infection and it may spread beyond the lymphatic system. The exact cause is unknown although it is likely that abnormal genes play a role in the development of all cancers.

Normally, your white blood cells go through a predictable life cycle. Old lymphocytes die, and your body creates new ones to replace them. With lymphoma, the new cells are abnormal and don't die when they should. They continue to multiply in a malignant process and as they accumulate within a lymph node they cause it to swell as a tumour.

Generally lymphoma starts in a group of nodes in one particular location but with time can spread to other lymph node groups and also to other parts of your lymphatic system including the lymphatic vessels, tonsils, adenoids, spleen, thymus and bone marrow where blood cells are made. Occasionally, lymphoma involves organs outside of the lymphatic system.

Treatment is determined by the typegrade and stage of the lymphoma (see below).

There are two main types of lymphoma: Hodgkin's Lymphoma and non-Hodgkin's Lymphoma (more than seven times as common, and there are 30 sub-types). They are considered separate because they behave slightly differently and are treated differently.

Lymphocytes exist either as B cells or T cells. B cells fight infection by producing specialized plasma cells, which in turn produce antibodies that neutralize foreign invaders. T cells are involved in killing foreign invaders directly. Hodgkin's lymphomas develop from abnormal B cells. Non-Hodgkin's lymphomas occur in B cells about 85 percent of the time. The rest arise in T cells.

In Hodgkin's lymphoma, B cells develop into large abnormal cancerous cells called Reed-Sternberg cells after the two pathologists who first discovered them. Instead of undergoing the normal cell cycle of life and death, these Reed-Sternberg cells don't die, and they continue to produce abnormal B cells in a malignant process. 

Non-Hodgkin's lymphoma has been one of the most rapidly increasing types of cancer. There are more than 30 sub-types. The good news is that although the incidence has increased, so has the survival rate.

Symptoms

Often the only symptom of a lymphoma is having one or more enlarged lymph nodes in the body, often the neck. The swollen nodes are usually painless but they may become infected and present as a red, swollen and tender neck. Abdominal lymph nodes often cause pain in the belly or swelling. Enlarged lymph nodes in the chest cavity are common and may be seen on a chest XRay. Also, with time lymphomas may spread outside the lymph nodes to virtually any part of the body.

"Flu-like" symptoms such as lethargy, fever and sweats, and weight loss may occur before or after the appearance of lymph nodes.

Risk factors

In most cases, people diagnosed with lymphoma don't have any obvious risk factors, and many people who have risk factors for the disease never develop it. Some factors that may contribute to your risk of lymphoma include:

Age 
Non-Hodgkin's lymphoma can occur at any age, but the risk increases with age. It's most common in people in their 60s. 
Hodgkin's disease most commonly affects people between the ages of 15 and 40 and people older than age 55.

Family history
Anyone with a brother or a sister who has the Hodgkin's lymphoma disease faces an increased risk of developing the same disease, though this may be due to similar environmental exposures rather than genetic factors.

Compromised immune system
Having a compromised immune system, such as from HIV/AIDS or from having an organ transplant requiring medications to suppress your immune response, also appears to put you at a greater risk of lymphoma.

Infection 
Having AIDS, in which your immune system is progressively weakened, places you at higher risk.

People who have had illnesses caused by the Epstein-Barr virus, such as infectious mononucleosis, may be four times as likely to develop Hodgkin's disease as people who haven't had a past Epstein-Barr infection.

An infection with the bacterium Helicobacter pylori, which is known to cause stomach ulcers, can cause an immune system response that raises your risk of non-Hodgkin's lymphoma, particularly in the stomach.

Chemicals 
Certain chemicals, such as those used to kill insects and weeds, may increase your risk of developing lymphoma.

investigations

blood tests
Usually, having swollen lymph nodes means you're fighting an infection. Blood tests may rule out an infection (eg. toxoplasmosis, glandular fever) or other disease. The doctor will also want to look at the general blood count, and to check liver function.

needle biopsy
With an enlarged node the initial test is often a fine needle biopsy of the node. This is done as an outpatient and is usually only mildly uncomfortable. The results can take up to a week as the pathologist does many tests on the cells to determine their nature.

nodal excision
If the needle biopsy indicates a lymphoma is likely, the pathologist will request that the node be excised to get more information about the particular type (Hodgkin's vs non Hodgkin's) and grade of lymphoma. If the pathologist sees the classic large abnormal cells known as Reed-Sternberg cells the diagnosis of Hodgkin's Lymphoma is made. The lymphoma may be found to be growing slowly (low grade), growing at a moderate rate (intermediate grade) or growing rapidly (high grade). Knowing the type and grade will go a long way in determining which treatment is best.

CT scans
Scans of the neck, chest, abdomen and pelvis are necessary to determine the stage of the disease i.e. the extent of nodal involvement in the body and whether other organs such as the liver and spleen are involved.

PET scans
Overseas doctors are also increasingly using positron emission tomography (PET) scanning to detect cancer. For this test, a small amount of a radioactive tracer is injected into your body. This tracer is then absorbed by the tissues in your body. Tumors are typically more metabolically active than other tissues, so they absorb more of the tracer. True PET scanning is not yet available in New Zealand

Bone marrow sampling 
Most cases will undergo sampling of the bone marrow of the hip (pelvis) to determine whether the malignant cells are present .

Classifying

Doctors classify non-Hodgkin's disease into about 30 types. Besides the differentiation between B cell and T cell types of the disease, classification is based on several other factors. These include:

Microscopic appearance- the "architecture" of the tissue 
Cellular genetic changes
Cell size
Staining patterns with specific antibody stains
How the cancer cells group together
How fast the cancer grows

Staging

Staging basically describes how widely the tumors have spread and is therefore determined by the scan and bone marrow results. Lower staging means less disease and better cure rates.

Stage I: confined to one group of lymph nodes

Stage II: two separate groups of lymph nodes on one side of the diaphragm

Stage III: involvement of lymph nodes on both sides of the diaphragm

Stage IV: involvemt of other organs such as liver, spleen, bone marrow.

Treatment

As with other cancers, an earlier the diagnosis provides a greater chance for successful treatment. Treatment of lymphomas is directed by specialists in the field of medical oncology or haematology. Once the type, grade, and stage of lymphoma is known and after considering your age and general medical condition, the specialist will recommend a treatment according to a protocol established by the regional oncology centre (Auckland's is based at Auckland City Hospital). This treatment may be in the form of radiotherapy alone, chemotherapy alone, radiotherapy and chemotherapy, and in some cases where the lymphoma is expected to grow very slowly, observation and no treatment unless the tumour starts to cause problems.

Chemotherapy
Doctors use a combination of drugs — given orally or by injection — against fast-growing cancer cells. This treatment is used for intermediate-grade and high-grade lymphomas and advanced stages of the low-grade lymphomas. A single drug may be used if you have a low-grade type of the disease. Hodgkin's lymphomas respond to different drug combinations compared to non-Hodgkin's.

Radiation
High doses of radiation kill cancerous cells and shrink tumors. This treatment is for early stages of low-grade lymphomas. Sometimes, it's used along with chemotherapy on intermediate-grade tumors or to treat specific sites, such as the brain.

Stem-cell transplantation
Lymphomas tend to be sensitive to chemotherapy. However, if lymphoma recurs, higher doses of chemotherapy may be necessary to treat the disease. The amount of chemotherapy that can be given is limited because of the damage chemotherapy does to your bone marrow. In order to avoid this serious side effect, healthy stem cells (those capable of producing new cells) are taken from your blood or bone marrow and frozen. After you undergo very high doses of chemotherapy to kill the lymphoma, the healthy stem cells are thawed and injected back into your body. This treatment is used primarily to treat intermediate, or high-grade lymphomas that relapse after initial, successful treatment.

Observation
If your lymphoma appears to be slow growing, a wait and see approach may be an option. Slowly growing lymphomas with few symptoms may not require treatment for a year or more.


Hodgkin's lymphoma

Hodgkin's disease — also known as Hodgkin's lymphoma — is an uncommon cancer of the lymphatic system, which is part of your immune system. It is named after the British physician Thomas Hodgkin, who first described the disease in 1832 and noted several characteristics that distinguish it from other lymphomas.

Because the symptoms of Hodgkin's are similar to those of other disorders, such as influenza, the disease can be difficult to diagnose. Some distinctive characteristics help diagnose Hodgkin's disease, and these include:

Orderly spread. The pattern of spread is orderly, progressing from one group of lymph nodes to the next.
Only rare "skipping." The disease rarely skips over an area of lymph nodes as it spreads.

diagnosis
A tissue sample (biopsy) of an enlarged lymph node is needed to make the diagnosis. The pathologist looks for changes in the normal lymph node architecture and cell characteristics, including the presence of large abnormal B cells called "Reed-Sternberg cells" after the two pathologists who first discovered them. Instead of undergoing the normal cell cycle of life and death, these Reed-Sternberg cells don't die, and they continue to produce abnormal B cells in a malignant process. The affected lymph nodes may contain only a few of these malignant cells.

 

Advances in diagnosis, staging and treatment of Hodgkin's disease have helped to make this once uniformly fatal disease highly treatable with the potential for full recovery.

 

Lymph node metastasis

A lymph node metastasis is a colony of malignant cells growing within a lymph node but originating from another site. They are multiplying uncontrollably, not dying when they should, and demonstrating an ability to travel down the lymphatic system. As the cells grow they expand the lymph node which appears as a lump in the drainage pathway of that area. A lump in the neck of an adult over the age of 40 (particularly a smoker) must be considered to be a malignancy within a node until proven otherwise .

The cells in our bodies are constantly in a cycle of life of their own. They are formed from the division of other cells. They grow, divide to produce new identical cells and die .... and as they die they are replaced by the division of local cells. It is a finely regulated system. Only so many cells are produced and therefore the various components of our bodies look the same. Cancer develops when the new cells being produced are not quite the same as the parent cell and they don't obey the rules. They divide into other cells when they shouldn't and they don't die when they should. Thus we start to look different in some way eg. a lump develops (from a marked increase in number of cells at a specific site). If these cells also demonstrate an ability to separate and move off to other places they can form colonies of similarly abnormal cells growing in an uncontrolled manner. Such a colony growing at a separate site from the original is a metastasis....more than one are called metastases.

level of node

Cancers of the skin of the head and neck, and of the lining of the nose, mouth and throat may spread to lymph nodes in the neck where they appear as lumps usually under the jaw, or in the upper or mid-neck. The stomach and chest drain to nodes next to them but also to nodes in the lower neck. Thus, lumps in the lower neck occasionally represent lymph node metastases from these organs.

diagnosis

If the primary cancer is obvious eg. a tongue cancer or a skin cancer, it may not be necessary to biopsy the node as the diagnosis can be obtained by a biopsy of the primary.

If a primary cancer is not obvious or if there is some doubt about cancer in the lymph node, generally a needle biopsy will be performed. This is done in the clinic under local anaesthetic and is usually only slightly uncomfortable. Often it is done with the aid of ultrasound to guide the needle accurately into the node.

 

Typical investigations for enlarged lymph nodes

These will depend on your age, symptoms and what other tests you have already had.

blood tests
In children and young adults, having swollen lymph nodes usually means you're fighting an infection. Blood tests may rule out an infection (eg. toxoplasmosis, glandular fever) or other disease. The doctor will also want to look at the general blood count, and to check liver function.

needle biopsy
In an adult with an enlarged node the initial test is often a fine needle biopsy of the node. This is done as an outpatient and is usually only mildly uncomfortable. The results can take up to a week as the pathologist does many tests on the cells to determine their nature.

nodal excision
If the needle biopsy indicates a cancer arising from elsewhere, the doctor wil do other investigations to determine the site of origin. The lump in this situation would be considered a lymph node metastasis.

If the needle biopsy indicates a lymphoma is likely, the pathologist will request that the node be excised to get more information about the particular type (Hodgkin's vs non Hodgkin's) and grade of lymphoma. If the pathologist sees the classic large abnormal cells known as Reed-Sternberg cells the diagnosis of Hodgkin's Lymphoma is made. The lymphoma may be found to be growing slowly (low grade), growing at a moderate rate (intermediate grade) or growing rapidly (high grade). Knowing the type and grade will go a long way in determining which treatment is best.

Ultrasound scan
Dr McIvor may organize an ultrasound or do it himself depending on what he is looking for. This is a simple outpatient procedure that takes about 30 minutes and gives valuable information on the number, shape, size, and location of nodes. It also enables an accurate needle biopsy of a node if required. Ultrasound is painless unless the node is very tender.

CT /MRI scans
Scans of the neck, chest, abdomen and pelvis may be necessary to determine the extent of nodal involvement in the body and whether other organs are involved. In adults over 40, an enlarged node may represent a metastasis from a cancer in the nose, mouth or throat region. The scan will give vital information on the characteristics of both the node and primary tumour.

PET scans
Overseas doctors are also increasingly using positron emission tomography (PET) scanning to detect cancer. For this test, a small amount of a radioactive tracer is injected into your body. This tracer is then absorbed by the tissues in your body. Tumors are typically more metabolically active than other tissues, so they absorb more of the tracer. True PET scanning is not yet available in New Zealand

Neck node excision

Excision of a single lymph node is required when the nature of the disorder cannot be established conclusively by needle biopsy. This allows the pathologist to examine the cells and architecture of the entire node. When lymphoma is diagnosed on a needle biopsy, excision may be necessary to better determine the type and grade of lymphoma.

It may be required when tuberculosis is suspected in an effort to culture the organism and to determine what drugs it will respond to.

Dr McIvor will describe to you the nature of the operation required. Often the lump can be excised under local anaesthetic with or without sedation. Sometimes a general anesthetic is required. The incision is usually small and will be described to you. It will lie in a small skin crease so should heal to leave a fine scar. Usually a dissolving suture is used and a small waterproof dressing applied. Occasionally a small drain is inserted that may remain for a day. Most patients go home with the drain which is removed by a district nurse. Some patients prefer to stay in hospital overnight.

When and where will the operation be done?

What must I do in the week before the surgery?

What do I do on the day of surgery and what shall I bring to the hospital?

What are the costs for neck node excision?

 

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist and the hospital and are to be paid separately. 

 

If the node excision is to be done under local anesthetic without sedation obviously there will only be surgeon and hospital fees.

 

If the procedure is to be under local anaesthetic with sedation, there will also be an anaesthetist fee as Dr McIvor prefers that an anaesthetist can monitor and adjust your level of sedation as necessary leaving Dr mcIvor to concentrate on the operation. A general anaesthetic may be advised by Dr McIvor or requested by the patient.

 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.

What will happen when I go to theatre?

local anaesthesia (awake)

  • Just before going to theatre a checklist is completed by the nurse. You will then be taken either in a wheel chair or walked to the operating theatre, usually by a theatre technician and a nurse.
  • If you have hearing aids you should leave them in and working to facilitate communication during surgery. Dentures and glasses may be worn in theatre.
  • You will be asked to lie down on the operating table and to make yourself comfortable.
  • Dr McIvor will mark the planned incision and infiltrate the operation site with local anesthetic. This will be done slowly to minimise the stinging sensation. A number of infiltrations may be necessary to fully numb the area.
  • During the procedure a nurse will talk to you and may hold your hand for comfort. You will be asked to lie still and any scratching or itching should be done by the nurse.
  • When the operation is over, you will be  taken back to the ward, usually in a wheelchair, by an orderly and a nurse.

local anaesthesia with sedation (awake but sleepy and relaxed - not really aware)

  • Just before going to theatre a checklist is completed by the nurse. You will then be taken on your bed to the operating theatre, usually by a theatre technician and a nurse.
  • Dentures and glasses can be taken out in the anaesthetic room and taken back to the ward by the nurse, or you may like to put them in your locker before your operation.
  • If you have hearing aids you should leave them in and working to facilitate communication during surgery.
  • The anaesthetist will insert a small needle into the back of your hand through which you will be given the medication. The nurse will stay with you until you are sedated.
  • Once sedated, Dr McIvor will infiltrate the operation site with local anesthetic. You will be barely aware of this as the anaesthetist adjusts the sedation to suit. During the procedure you will be either lightly asleep or barely awake and laregely unaware of the surgery. When the operation is over, you will be  taken, on your bed, to the recovery area where a nurse will look after you until you are fully awake.
  • You will then be taken back to the ward, on your bed, by an orderly and a nurse.

general anaesthesia (asleep)

  • Just before going to theatre a checklist is completed by the nurse. You will then be taken on your bed to the operating theatre, usually by a theatre technician and a nurse.
  • Dentures, glasses and hearing aids can be taken out in the anaesthetic room and taken back to the ward by the nurse, or you may like to put them in your locker before your operation.
  • The anaesthetist will insert a small needle into the back of your hand through which you will be given the medication. The nurse will stay with you until you are fully under the sedation or anaesthetic.
  • You will not wake up until the operation is over. You will be  taken, on your bed, to the recovery area where a nurse will look after you until you are awake.
  • You will then be taken back to the ward, on your bed, by an orderly and a nurse.

 What will happen when I get back to the ward?

Will I have a sore neck?

For nodal excisons we generally use lots of local anaesthetic even if sedation or general anaesthetic is employed .  This not only provides good pain relief but reduces the amount of intravenous pain relief the anaesthetist may need to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

Any discomfort usually settles in a few days.

You will be given medication to take home to relieve the discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place.

What care do I need to take regarding my neck wound?

Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound.

After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

The pressure of rubbing the cream in will also help to soften the scar.

If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP

What rest do I need and when should I return to work?

You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

You will probably need to take 1-2 days off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for this period and then you should see your GP if more time is required.

What follow-up will there be?

Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and to discuss the laboratory report of the resected tissue. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 488 7349) if you do not receive one shortly following discharge.

 

Neck dissection


A neck dissection is an operation to remove groups of lymph nodes that may be or are definitely involved by metastastic spread from a cancer. The lymph nodes are removed as an envelope of tissue. The "envelope" lining is a specialised tissue called fascia which separates different areas and structures in the neck. The envelope of tissue that is removed may be from a particular region of the neck, one side of the neck or sometimes from both sides of the neck. Which lymph node regions that are removed is determined by exactly where the primary cancer is located and its type.

For example, a typical cancer on the side of the tongue would require removal of lymph nodes from most of one side of the neck. A cancer in the midline under the tongue would require removal of lymph nodes on both sides of the neck. A cancer of the back of the scalp would require removal of posrerior lymph nodes on one or both sides.



When and where will the operation be done?

What must I do in the week(s) before the surgery?( insurance, hospital, family, work)

What do I do on the day of surgery and what shall I bring to hospital?

What will happen when I go to theatre?

What Will happen when I get back to the ward?

Will it affect my face?

There may be a change in facial contour just below the angle of the jaw as the lymph node tissue it acts as a filler in this area.

The nerve to the lower lip muscles (marginal mandibular) lies just below the jaw-line and is at risk from an incision in this location. This could cause a lifting of the lower lip on that side when smiling or opening the mouth widely. Occasionally there can be a tendency to spill liquid from the corner of the mouth when drinking. The likelihood of a permanent injury is very small.

Will I have neck stiffness, restricted shoulder movement or pain?

You will feel some discomfort around your jaw-line and experience some stiffness with jaw openeing but you will be given some medication to help ease this. Pain relief may be given in different ways, such as injections, liquid medicine or tablets. Most patients say the discomfort is not as bad as they expected, and after the first day are up and walking around.

Following discharge on the first or second day Dr McIvor prescribes paracetamol and an anti-inflammatory for 5 days which suffices for any discomfort.  After a few weeks you should be back to a good standard of neck and jaw function.

Will I have a scar?

The incision is fine but will heals to leave a fine scar which is not very noticeable. The scar may be a single curved line in the upper or mid-neck, two paralleel lines which leaves very fine scars, or a "Y" shaped scar on one side of the neck. The type of incision is largely determined by the nodes that have to be removed but Dr McIvor will discuss this with you.

What are the costs for neck dissection?

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist and the hospital and are to be paid separately. 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.

What will I look like after neck dissection surgery and what will I be able to do?

  1. You will probabaly have a scar running from just below and behind your ear gently curving down and foreward into the neck. There may be a separate incision running down the neck. These will be covered by a small white dressing so that they arenot visible.  Dr McIvor often uses dissolving sutures and skin tapes so that few if any sutures need to be removed.
  2. You will have a small drain from your wound to collect wound fluid which naturally occurs following your surgery. The drains are small plastic tubes which are inserted into the neck at the end of your operation. The long length of tubing outside the neck is attached to a plastic collection bottle into which the fluid drains. Wound drains help to speed up wound healing and reduce infection.
  3. The drain is not painful can be carried around with you. It will usually be removed by a nurse a day or two after your operation when the drainage is minimal.   Drain removal is not painful.
  4. You will feel some discomfort and stiffness around your neck but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.
  5. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.
  6. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed.
  7. Following your operation you may not feel very sociable so it is wise to restrict visitors

    Will I have a sore neck?

    When you wake from the anesthetic you will find that the skin of your neck, jaw line and ear is quite numb as the anesthetist inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

    You may find that your jaw is uncomfortable when you open your mouth wide.  This discomfort usually settles in a few days.

    You will be given medication to take home to relieve the discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

    Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place

    Will it affect my eating and drinking?

    A neck dissection alone will not affect eating or drinking but the operation may be combined with removal of the primary tumour. If the primary surgery involes the mouth or throat there will be healing time and a period of altered feeding or diet. Dr McIvor will discuss this with you

    What care do I need to take regarding my neck wound?

    Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound.

    After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

    The pressure of rubbing the cream in will also help to soften the scar.

    If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP.

    What rest do I need and when should I return to work?

    You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

    You will probably need to take one to two weeks off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for two weeks and then you should see your GP if more time is required

    What about my medications and tablets?

    Please continue to take the medication you have been prescribed and ensure that you have a good supply. If you are unsure about any of the tablets you need to take, please check this with a nurse before you go home. Repeat prescriptions can be obtained from your GP.

    What follow-up will there be?

    Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and to discuss the laboratory report of the resected tissue. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 488 7349)if you do not receive one shortly following discharge.

     

    As you have had neck dissection surgery for cancer then you may need further treatment (e.g. radiotherapy) and an appointment will be arranged for you with an oncologist  to discuss this further.  Regular checks with Dr McIvor will be for at least 5 years.