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Have enlarged submandibular cervical lymph nodes. What could this indicate?

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a month ago, I found some node on my neck and I went to see doctor. The doctor sent me to ultrasound and concludes that I have enlarged submandibular cervical lymph nodes. Two were palpable at this time. I had no preceding illness. There is no history of TB. The nodes are firm and not fixed. The doctor could not detect any other palpable nodes in other parts of my body and there was no organomegaly found, LFF, inflammatory markers and US were normal. Ultrasound shows enlarged nodes in the right submandibular and jugular lymph node chain including a node that did not contain a normal fatty hilum. The nodes were unchanged in size. Also, I feel bad throat as I cough the whole night and could not sleep well. Is it dangerous and urgent? How quickly should I manage this? I plan to go back to my country in 5months time, can I wait till then? I am looking forwards to your help and advice Thank you in advance

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Category: Family Physician-GP
 22 Doctors Online

Hello, with reference to your query, swellings or lumps in the neck are a common clinical form. Patients are likely to be fearful that they have cancer. In children neck lumps are common but rarely malignant, whereas in adults the situation is different. The submandibular and sub-mental lymph nodes are level one. The upper, middle and lower jugular Cham nodes is levels 2, 3 and 4 respectively. The lymph node of the posterior triangle is level 5. The jugular digastric lymph node is commonly enlarged in both inflammatory and malignant conditions. (Glandular fever or Hodgkin's disease). Because of the distribution along the spinal nerve, the lymph nodes of the posterior triangle get enlarged in viral infections. Melanoma or squamous carcinoma can metastasize in the submandibular triangle and posterior triangle. About 80% of lateral neck lumps in adults will be due to metastatic cancer. Before we evaluate the patient, we should have a detail history including his age and where he noticed swelling whether in the lateral or anterior compartment of the neck. The presence of multiple enlarged lymph nodes is more suggestive of infection, but can develop lymphomas particularly Hodge-kin's disease and if the nodes are more than 2 cm, it should be evaluated to exclude malignancy especially when there is new enlargement. Other clinical conditions like Branchial cyst or plunging ranula should be taken into consideration. The clinical evaluation is more specific to exclude malignancy (because of painless progressive enlargement of a lymph node). You should also exclude TB or nasopharyngeal carcinoma in an Asian patient. Smoking history, use of heavy tobacco, and alcohol use should be kept in mind while ruling out any malignancies. When you evaluate any lump, you should clarify its site, size, shape, consistency, deep and superficial attachments, nature of surface and the edge of the lump, presence of fluctuation, pulsation and Translumination. In addition to the above, you should Asses which triangle of the neck is involved, does it move with swallowing or does it move with protrusion of the tongue, relationship to the sterna mastoid muscle and also the possible source of infection should be searched. Regarding the investigations, you should have a complete blood count, sputum examination, chest x-ray, ultrasound rarely assists in clarifying the diagnosis, computed tomography, which is more helpful than ultrasound especially if the swellings are larger than 2 cm and also provides the consistency of a lump along with its size and anatomical relations, depending upon whether it is a large lipoma or thyroglossal cyst or branchial cyst or plunging ranula or metastatic squamous carcinoma of the neck with cystic degeneration or large mass of metastatic squamous carcinoma. Apart from these investigations, you have to do a fine needle aspiration biopsy, when there are non-tender swellings in the lateral compartments of the neck. Metastatic malignancy can usually be diagnosed with a very high degree of accuracy and also you can distinguish lymphoma from reactive lymphadenopathy. This procedure (fine needle aspiration biopsy) is very safe and the risk of tumor implantation is negligible. Even with all these investigations, if a diagnosis is not confirmed, then you can go for an excision biopsy where you should not spill tissue or breakup a lymph node in the cause of biopsy because malignant cells may be implanted into the surrounding tissue and also care must be taken not to damage related anatomical structures during the procedure. As far as the treatment is concerned, it mainly depends on history, physical examination, laboratory investigations, fine needle aspiration biopsy and computed tomography reports. Hence, it is better to see your surgeon and discuss in detail and come to a conclusion before you go back to your country. Do not postpone. Thank you.

Dr. John Monheit
Category: Family Physician-GP
Residecny: North Colorado Family Medicine
Medical School: The Chicago Medical Center
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