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with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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Wednesday, November 12, 2008

One Lump or Two?

Some of the more common postings that I encounter on the WebMD ENT message board are concerning lumps and bumps that are usually self-discovered in the neck, around the ear, or even viewed in the mouth or throat. Since lumps could indicate an ominous diagnosis (like cancer – yes, I said it), people are frightened and post for reassurance that it is “…not a tumor”.

As you might imagine, the Internet poses some insurmountable barriers when it comes to making a definitive diagnosis, primarily due to my inability to perform a hands-on examination. A description on a posting – no matter how detailed or graphic – is not sufficient to make this important call. Lumps cannot be identified by appearance, so even if people could post a picture, this would not be helpful. Lump identification starts with palpation – the medical act of feeling it for size, consistency, and mobility – but it doesn’t end with this careful examination. A definitive diagnosis – determining the true nature of a lump – often requires a pathological diagnosis. A specimen may need to be obtained by biopsy (surgically removing a little piece), needle aspiration of cells, or even the complete removal of the lump. Since the vast majority of these worrisome lumps are innocent (not cancers, but merely moles, cysts, warts, skin tags, etc.), based on the medical provider’s examination, watchful waiting may precede any surgical intervention.

Lumps that are deeper in the neck – those that are suddenly tender and movable – are often “reactive lymph nodes“. Lymph nodes are an important part of our immunological defense system, and lymph nodes (we have hundreds of them located all over our bodies) will enlarge in response to infection and/or inflammation in their drainage area. For instance, a lump in the front of the neck, under the jaw, could indicate infection/inflammation somewhere in the throat, tonsils, mouth, teeth, salivary glands, neck, or skin. It is up to your medical provider to search for and locate a source for this reactive event.

Some scary lumps are just normal anatomy. People are often frightened when they feel one of their salivary glands, the thyroid gland, or the tip of the hyoid bone in the neck. Muscles in the neck can also have lumps of spasm or tenderness. In other words, some lumps are supposed to be there.

When women get a breast examination, the medical provider spends a great deal of time digging around in the armpits. Why? The axillary lymph nodes are the drainage area for problems in the breast. A breast cancer will often be detected early by the discovery of a hard lymph node in the armpit.

Infants often have tiny breast buds that frighten new parents. These are due to maternal or breast-feeding hormones and are innocent. Even a tiny amount of breast milk can be expressed from these baby boobies. As children approach puberty, lumps will appear under the breasts of girls that may start on just one side. These little buds are the hallmark of normal breast development.

Even more concerning is when breast lumps called gynecomastia occur in teenage boys. Regardless of our gender, we all produce both male and female hormones. Gynecomastia in young males, though alarming, are very common and tend to resolve spontaneously in a few years. You can always tell the teenage boys that have them. They are often the ones always wearing t-shirts at the swimming pool. Don’t get me wrong, teenage boys like breasts – but not growing on them.

Because of nerve pathways, reactive lymph nodes in the neck or under the jaw can cause pain to be referred to the ear. It is not uncommon for people to present with ear pain and not have an ear problem at all, but rather an infection somewhere else.

Because of their immature (and constantly challenged by colds and other infections) immune systems, children have an abundance of lymph nodes that can be felt. Parents will often feel their own necks for comparison, and be shocked when they do not find any. Children can have so many palpable lymph nodes that their necks feel like a bag of marbles sometimes. Innocent, normal lymph nodes tend to feel soft to firm, moveable, smooth, and round/oval. Once enlarged, they may stay that way for a few weeks, or in some cases, months or even years.

When to be concerned?

Hard, fixed (stays in the same place as if attached to the underlying tissue), irregularly shaped, and growing lumps should ALWAYS be medically evaluated since they may be a hallmark of something more serious, such as a cancer or lymphoma. A very dear friend recently found several hard lumps in her neck that met these criteria. Her doctor sent her for a CT scan of the neck which showed some suspicious changes. A biopsy made the definitive diagnosis. Our friend had lymphoma.

After meeting with the oncologist, a course of chemotherapy was prescribed. A few months later, she is in complete remission. Unlike past generations, lymphomas are now highly treatable.
Sadly, some lumps are cancers. The sooner you consult a medical provider, the sooner you can be properly examined, diagnosed, and treated. Even if your self-discovered lump turns out to be “nothing”, the price of reassurance is worth the cost of an office visit or insurance co-payment. Reassurance cannot be given via the Internet, based on a posting alone. Always err on the side of caution if you find a suspicious lump…anywhere.

I sincerely hope that you hear those Arnold Schwarzenegger words from Kindergarten Cop: “It’s not a toom-a!”

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Posted by: Rod Moser, PA, PhD at 7:31 am

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