What is a lymph node and how often does it enlarge?
Lymph nodes are the small filter stations of the immune system, distributed throughout the body. They contain immune cells, and these cells filter microbes, viruses, abnormal cells and foreign substances, allowing the immune response to begin. The body contains hundreds of lymph nodes; a large proportion of them are located in the head and neck region, especially under the jaw, along the sides of the neck and around the collarbone. Because the neck region handles the lymphatic drainage of areas that frequently encounter microbes, such as the mouth, nose, throat and skin, the lymph nodes here enlarge quite often. Particularly in childhood and young adulthood, small, mobile lymph nodes that can be felt in the neck due to frequent upper respiratory infections are extremely common and usually harmless.
What are the symptoms?
Lymph node enlargement is usually noticed as a swelling that can be felt in the neck, under the jaw, behind the ear or above the collarbone. In enlargement due to infection, the swelling is usually soft, mobile and tender or painful when pressed; it is often accompanied by signs of infection such as a sore throat, fever or runny nose. Some patients may have swelling in more than one area at the same time. After the infection passes, the nodes usually shrink back to normal within a few weeks, but sometimes they may stay slightly enlarged without fully returning to their former size; on its own, this is not a cause for concern. By contrast, some swellings may appear as a hard, painless mass that grows over time and feels fixed to the surrounding tissues; findings of this kind require a different evaluation.
Causes and risk factors
The most common cause of lymph node enlargement in the neck is infection. Chief among these are throat infections (pharyngitis, tonsillitis), dental and gum inflammation, sinusitis, middle ear infection and various viral infections. Rarer infections such as cat scratch disease and tuberculosis can also cause regional lymph node enlargement. Non-infectious causes include autoimmune diseases, some drug reactions and diseases of the lymphatic system itself, such as lymphoma. The spread of cancers of the head and neck region (mouth, throat, larynx, thyroid, skin) to the neck lymph nodes is also an important cause; for this reason, newly appearing neck masses in older people with a long history of smoking and alcohol use are evaluated with particular care. In patients whose immune system is suppressed and in people previously diagnosed with cancer, the threshold for evaluation should also be kept lower.
Which findings are warning signs?
Some features suggest that a swelling may be due to a cause beyond a simple response to infection: a swelling that lasts longer than two weeks or does not shrink and keeps growing, a painless, hard mass that does not move when pressed by hand, a size exceeding 2 centimetres, simultaneous swelling in more than one area of the neck, night sweats, unexplained weight loss, long-lasting fever, difficulty swallowing, hoarseness or ear pain. The presence of one or several of these findings together means the patient should see an ENT specialist without delay.
How does the diagnostic process work?
Evaluation begins with a detailed history and physical examination. The physician assesses the location, size, consistency, mobility and tenderness of the swelling; the mouth, nose, throat and salivary glands are reviewed and, where necessary, the nose, throat and larynx are examined endoscopically with a thin camera. The first step in imaging is usually ultrasound of the neck; this method is very valuable for assessing the internal structure and size of the lymph node and whether it has suspicious features. Computed tomography or magnetic resonance imaging may be requested in cases with suspicious findings on ultrasound or that raise clinical concern. For a definitive diagnosis, fine-needle aspiration biopsy is usually performed; in this procedure, a cell sample is taken from inside the node with a thin needle under ultrasound guidance and examined in the pathology laboratory. If the result is inconclusive or clinical suspicion persists, it may be necessary to remove the node completely by surgery and examine it (excisional biopsy). Blood tests and, where necessary, tests for tuberculosis or other infections may also be added to the diagnostic process.
Treatment options
Conservative approach
In enlargement due to infection, treatment is directed at the underlying infection; appropriate antibiotic treatment is sufficient for bacterial infections, and symptomatic support and follow-up for viral infections. During this process the lymph node is not treated separately; it shrinks on its own as the infection subsides. A marked reduction in size is usually expected within 2–4 weeks; a full return to normal may take a few months. If the inflammation progresses and leads to abscess formation, the abscess may need to be drained; this can be done with a minor surgical procedure or by needle aspiration.
Surgical and advanced treatment
If the underlying cause is a malignancy, treatment is guided entirely by that diagnosis; surgery, radiotherapy, chemotherapy or a combination of these may be required, and the treatment plan is drawn up together with the relevant oncology teams. If an autoimmune or systemic disease is found, treatment is arranged in cooperation with the relevant specialty. Lymph nodes may be removed surgically for diagnostic purposes, or when they are recurrent, large or causing discomfort. Surgery is usually performed under local or general anaesthesia through a small incision and requires a day-case procedure or a short hospital stay.
Recovery and follow-up
In lymph node enlargement due to infection, recovery is usually uneventful; most patients return completely to normal within a few weeks. In patients whose enlargement cannot be fully explained or who carry risk factors, follow-up with examination and ultrasound at regular intervals is recommended; usually the first check-up is planned after a few weeks, then, if necessary, at intervals of a few months. If growth, hardening or new findings appear during follow-up, the biopsy may be repeated. In patients diagnosed with a malignancy, the follow-up protocol is determined separately by the treating team according to the type of disease and includes regular imaging and clinical check-ups.
Differences by age group in lymph node diseases
In children and young people, neck lymph node enlargement is largely due to infectious causes; since their immune system is still maturing and they have frequent upper respiratory infections, reactive enlargement of the lymph nodes is considered normal in this age group. By contrast, a newly appearing neck mass in middle-aged and older people, particularly one that is one-sided and hard, should not be evaluated with the same approach; in this age group, the likelihood of malignancy is markedly higher than in children. For this reason, physicians decide on the depth of investigation by considering the patient’s age, smoking and alcohol history and the other features of the mass together. In immunosuppressed patients (after organ transplantation, with drugs used in some rheumatological diseases, or in conditions such as HIV infection), the risk of both infectious and lymphoproliferative disease is increased, so the threshold for evaluation is kept even lower.
A multidisciplinary approach to evaluating a neck mass
The evaluation of a mass found in the neck whose source is unclear is often not limited to a single specialty. The ENT specialist works in cooperation, when necessary, with specialists in pathology, radiology, general surgery, haematology-oncology and infectious diseases. Particularly when the biopsy result points towards lymphoma or a metastatic cancer, additional imaging (such as PET-CT) and evaluation by different specialties may be needed to identify the source of the disease and establish the right treatment plan. This multifaceted approach ensures both that the correct diagnosis is made and that treatment begins without delay.
Frequently asked questions
Is every swelling felt in the neck a serious disease? No. The great majority of neck lymph node enlargements are due to infections and resolve on their own. However, masses that are long-lasting, growing or painless and hard must be evaluated.
When should I see a physician? If the swelling lasts longer than two weeks, keeps growing, is painless and hard, or if there are additional findings such as weight loss, night sweats or hoarseness, you should seek care without delay.
Is fine-needle biopsy painful? The procedure is done with a thin needle, usually does not even require local anaesthesia and takes a few minutes. Most patients feel no discomfort apart from a slight pricking sensation.
Should a lymph node that looks benign on ultrasound be followed up? Yes; particularly for nodes whose cause has not been fully clarified, follow-up ultrasound at certain intervals is recommended; if there is growth or a structural change, biopsy may come into consideration.
Are small lymph nodes felt in the neck normal in children? Yes; because children have frequent infections, it is very common to feel small, mobile and soft lymph nodes, and they usually require no treatment; if there is concern about their size or features, a physician should still be consulted.
If the lymph node biopsy result is benign, can I be completely reassured? Most of the time yes, but if the clinical findings or imaging remain suspicious, your physician may recommend check-ups at certain intervals; the first biopsy may not always be the last word.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.