What do I do if I have swelling in the neck: Mumps, Lymph nodes, Goiter, Thyroid enlargement.

A person with neck swelling has enlargement of the soft tissues that covers the neck. A neck swelling can also occur as accumulation of fluid, lymph, or inflammatory, or tumor cells in an area under the skin of the neck. Clinically speaking swellings in the region of neck are of great importance as they not only help in diagnosing some serious underlying disease but are also easy to treat if they are benign. Most of the times a simple surgical procedure is all we need.

Neck swelling may be caused by an injury, inflammation, infection, or a benign / malignant tumor. In mild cases of neck swelling, treatment may not be required. If the neck swelling is bothersome, over-the-counter medications such as anti-inflammatory drugs or pain medications or cold compresses may help reduce discomfort and swelling. In more serious cases, a visit to a medical professional may be necessary to determine the cause of neck swelling and appropriate treatment. Seek medical attention if your symptoms of neck swelling, or those of someone you are with, are accompanied by sudden swelling of the face, lips, or tongue, or breathing problems such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, or choking. These symptoms may be signs of a severe allergic reaction.

Anatomy of the neck

Benign skin conditions can cause small areas of the neck to appear swollen. Swelling of the lymph nodes in the neck is a common symptom of many different types of viral and bacterial infections as well as many benign and malignant disorders. Lymph nodes are small organs distributed in the body which collect fluid. They get swollen if inflammatory fluid deposits in them. They are also swollen if cancer cells from an organ reach them in case they are said to have metastasized. In the neck they are present in distinct groups and are almost always show as medium to small size swelling mostly on the sides of the neck and / or under the jaw. Have a look at this illustration, it shows different groups of nodes in and around the neck.

you can see different sets of these lymph nodes like sub-mandibular, and occipital. So their enlargement is either benign or malignant. These nodes are also swollen in cases of TUBERCULOSIS (TB). TB is a treatable disease which affects millions of people all over the world. A biopsy result of the neck swelling, from a pathology laboratory is all you need.

If the swelling is on one or both sides of

Lymph nodes in the neck

the neck just below the ear lobe, it may be MUMPS. In that case immediately consult your doctor. Mumps is a viral infection and can have serious side effects long after the swellings have disappeared. This viral attack  can lead to swelling and pain in the salivary glands (Parotid glands), along with fever, loss of appetite, and fatigue. It mostly occurs in children but can affect us in later life. Remember there is a vaccine against Mumps which protects us from this viral infection.

MUMPS: A viral illness which causes swelling of Parotid glands.

There are some skin causes of neck swelling:

Neck swelling may be caused by a variety of skin conditions including:

• Acne
•  Boils
• Cyst (a benign collection of fluid)
• Lipoma (collection of fatty tissue under the skin; a benign condition)
• Skin infections

Other causes of neck swelling

Neck swelling can also be caused by a variety of other conditions including:

• General infection leading to swollen lymph nodes in the neck region
• Goiter (an enlarged thyroid gland)
• Mumps (viral infection of the salivary glands in the neck)
• Recent neck injury or trauma
• Recent neck surgery

Other causes of lymph node swelling in the neck are the blood cancers like Leukemia, Lymphoma and Hodgkin disease.

In some cases, neck swelling may be a symptom of a serious or life-threatening condition that should be immediately evaluated in an emergency setting. These include:

• Anaphylaxis (severe allergic reaction)
• Angioedema (a severe swelling beneath the skin that can cause breathing difficulty)
• Cancer of the throat, thyroid gland or other structures in the neck

LUMP IN THE NECK WHICH IS DUE TO THYROID ENLARGEMENT (GOITER):

A goiter is an enlarged thyroid gland. Some people with a goiter (but not all) have an under-active or overactive thyroid.  A goiter can mean that all the thyroid gland is swollen or enlarged, or one or more swellings or lumps develop in a part or parts of the thyroid.
The thyroid gland is in the lower part of the front of the neck. It lies just in front of the trachea (windpipe). It has a right and left lobe which are connected together by a narrower band of thyroid tissue. (It is roughly the shape of a butterfly.) You cannot usually see or feel a normal thyroid gland. If the thyroid enlarges it causes a swelling in the neck which you can see – a goiter. There are various causes of goiter and treatment depends on the cause. As such the thyroid swellings can also be classified as benign or malignant. The benign swellings do not cause spread of the disease and are mostly fluid collection in some part of the gland. Hemorrhage in the gland is another example where a neck swelling is observed. Thyroid swellings are prominent and are always situated in front of the neck (see illustration). They may be mobile (moving with swallowing) or fixed. If the swelling is benign   and is mobile, there are chances that it is not dangerous at all and a simple surgical procedure will correct it.

In case of more than one swelling (lumps) in front of the neck which are due to thyroid enlargement, they are called as Multinodular goiter while a single swelling (lump) is termed as simple nodular goiter.

CAUSES OF SIMPLE OR NODULAR GOITER:

Always remember that a thyroid swelling does not mean there is an element of dysfunction also (please see previous blogs about hypothyroidism and hyperthyroidism).

Simple diffuse goiter

They may be there due to IODINE DEFICIENCY in which case they are termed as IODINE DEFICIENCY GOITER. In most of the cases they are diffuse (no nodularity is seen). When there is no nodule palpable in the neck and there is diffuse swelling, it is SIMPLE GOITER. It can also occur at puberty in young girls and is called PUBERTY GOITER.

Diffuse/Simple goiter:

This means that the entire thyroid gland is larger than normal. The thyroid feels smooth but large. There are a number of causes. For example:

• Grave’s disease – an auto-immune disease which causes the thyroid to swell and make too much thyroxine.
• Thyroiditis (inflammation of the thyroid)
• Iodine deficiency. The thyroid gland needs iodine to make thyroxine(T4) and T3. If you lack iodine in your diet the thyroid swells as it tries to make enough of its hormones which are so vital for our bodily functions like metabolism and control our heart rate and many other functions
• Some medicines can cause the thyroid to swell as a side-effect. For example, lithium and treatment of Hepatitis C
• Hereditary factors – some people inherit a tendency for a thyroid to swell. In particular, it may swell at times of life when you may make more thyroxine and T3. For example, when you are pregnant, or during puberty.

Nodular goiter

A thyroid nodule is a small lump which develops in the thyroid gland, in front of the neck. There are two types:

• A multinodular goiter. This means the thyroid gland has developed many lumps or ‘nodules’. The thyroid gland feels generally lumpy.
• A single nodule. Causes include:
  • a cyst (swelling with fluid in it)
  • an adenoma (a solid lesion in the gland composed of glandular cells)
    

    large multinodular goiter

  • a benign or malignant tumor

IF I HAVE GOITER DOES IT MEAN MY THYROID GLAND IS MALFUNCTIONING?

• In many people with a goiter it does not affect the amount of thyroxine T4 or T3 that they make. You are then Euthyroid which means you make the correct amount of these hormones.
• In some people, the goiter is associated with an abnormality of thyroid function. You may make too much thyroxine or T3 (hyperthyroidism) or too little thyroxine or T3 (hypothyroidism) For details please see related posts in this blog.

WHAT STEPS ARE TAKEN TO ASSESS / DIAGNOSE A GOITER:

1. Blood samples are taken to evaluate the amount of circulating thyroid hormones in the body. Normal T4, T3, and TSH means you are Euthyroid while over active and under active thyroid gland is also established and then the treatment starts according to the condition.

2. An ultrasound scan of the thyroid is done. This may be done if you have a single nodule. An ultrasound scan is a safe and painless procedure which uses sound waves to create images of organs and structures inside your body. It can tell if a nodule is a cyst or a solid lump.

3. A radioactive iodine scan. This scan is done (details given in the next post) to establish the uniformity or nodularity of the gland and whether some part of it is HOT or COLD. The hot spots on a radionuclide scan mean this portion of the gland is making more hormones (T4 and T3) than the surrounding gland and a COLD nodule means this area of the gland is not properly functioning. If on scan results there is a COLD NODULE, it is usually suggestive of malignancy (Thyroid cancer) and appropriate medical opinion must be sought immediately.

4. Biopsy: A small piece of tissue (a biopsy) may be taken from a nodule to look at it under the microscope. The biopsy is done by inserting a fine needle into the nodule. (It is like taking a blood sample but the needle is smaller.) It is a simple and safe procedure.

TREATMENT OF GOITER:

• If you have a small goiter, and your thyroid is making the correct amount of thyroxine and T3, then you may not need any treatment. It happens in patients who has simple diffuse goiter
• You will need treatment if you make too much or too little thyroxine T4 or T3
• An operation to remove some or all of the thyroid may be an option in some cases
• Radioactive iodine treatment may be an option for a goitre causing an overactive thyroid. This involves taking a drink, or swallowing a capsule, which contains radioactive iodine (I-131). The radioactive iodine builds up in the thyroid gland. As the radioactivity is concentrated in the thyroid gland, it destroys some thyroid tissue mainly by it beta emissions. If too much of thyroid is destroyed, there is replacement therapy in the form of thyroxine tablets. Their use and the fact that radioactive Iodine treatment is not particularly harmful (it is not given in pregnant or lactating mothers or prospective mothers), this form of treatment for Grave’s disease (toxic goiter) is very useful.
• If you have cancer of the thyroid, you will probably need an operation to remove the cancer and some of the thyroid gland. The strategy to deal with this cancer will be outlined by an Oncologist with the aid of a surgeon.
• Iodine replacement, if the goiter is due to lack of iodine in the diet.

NOTE: If you have any questions, you can always ask the author who is a thyroid diseases consultant.