3- Throat (Neck lumps) Flashcards
causes of neck lumps in adults
- Normal structures (e.g., bony prominence)
- Skin abscess
- Lymphadenopathy (enlarged lymph nodes)
- Tumour (e.g., squamous cell carcinoma or sarcoma)
- Lipoma
- Goitre (swollen thyroid gland) or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma (a collection of blood after trauma)
- Thyroglossal cysts
- Branchial cysts
causes of neck lumps in children
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
basic anatomy of the neck
There are three descriptions to note the location of a neck lump:
* Anterior triangle
* Posterior triangle
* Midline (vertically along the centre of the neck)
These two triangles are on either side of the sternocleidomastoid muscle.
The borders of the anterior triangle are:
- Mandible forms the superior border
- Midline of the neck forms the medial border
- Sternocleidomastoid forms the lateral border
The borders of the posterior triangle are:
- Clavicle forms the inferior border
- Trapezius forms the posterior border
- Sternocleidomastoid forms the lateral border
differential based on location of lump: midline
- thryoglossal cyst
- thryoid nodule
- goitre
- dermoid cyst
- submental gland pathology
differential based on location of lump: anterior triangle
- reactive lymphadenopathy
- malignant lymphadenopathy
- branchial cyst
- carotid artery aneurys
- carotid body tumour
- submandibular gland pathology
differential based on location of lump: anterior triangle
- reactive lymphadenopathy
- malignant lymphadenopathy
- branchial cyst
- carotid artery aneurys
- carotid body tumour
- submandibular gland pathology
differential based on location of lump: posterior triangle
- reactive lymphadenopathy
- malignant lymphadneoapthy
- cystic hygroma (lymphangioma)
differential based on location of lump: anywhere
- lipoma
- sebaceous cyst
- haemangioma
- skin malignancy
neck lump red flags
In the context of a neck lump, the ‘Red flag’ features raise the suspicion of an underlying head and neck malignancy.
- Hard and fixed lump
- Associated otalgia, dysphagia, stridor, or hoarse voice
- Epistaxis or unilateral nasal congestion
- Unexplained weight loss, night sweats, or fever or rigors
- Cranial nerve palsies
- In children, red flag symptoms also include the presence of a supraclavicular mass, lumps larger than 2cm, and a previous history of malignancy.
neck lump history
- General information about the symptoms (e.g., when the lump first appeared and how quickly it has grown)
- Features that suggest or exclude a particular diagnosis (e.g., night sweats indicating lymphoma)
- Risk factors for that condition (e.g., family history, age and smoking status)
- General fitness for further investigations and treatment (e.g., co-morbidities and medications such as anticoagulants)
two week wait if
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
Examination
When examining a neck lump, the things to establish are:
* Location (anterior triangle, posterior triangle or midline)
* Size
* Shape (oval, round or irregular)
* Consistency (hard, soft or rubbery)
* Mobile or tethered to the skin or underlying tissues
* Skin changes (erythema, tethering or ulceration)
* Warmth (e.g., infection)
* Tenderness (e.g., infection)
* Pulsatile (e.g., carotid body tumours)
* Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
* Transilluminates with light (e.g., cystic hygroma – usually in young children)
A general examination can be used to look for signs of the underlying cause, such as:
* Ear, nose and throat infections (e.g., reactive lymph nodes)
* Weight loss (e.g., malignancy or hyperthyroidism)
* Skin pallor and bruising (e.g., leukaemia)
* Focal chest sounds (e.g., lung cancer)
* Clubbing (e.g., lung cancer)
* Hepatosplenomegaly (e.g., leukaemia)
investigations: blood tests
Blood tests may be helpful depending on the suspected cause of the neck lumps. Not everyone with a neck lump will require blood tests. The choice of test will depend on the suspected cause:
* FBC and blood film for leukaemia and infection
* HIV test
* Monospot test or EBV antibodies for infectious mononucleosis
* Thyroid function tests for goitre or thyroid nodules
* Antinuclear antibodies for systemic lupus erythematosus
* Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
investigations: imaging
- Ultrasound is often the first-line investigation for neck lumps
- CT or MRI scans
- Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)
investigations: biopsy
may be required to gain a tissue sample (histology) to establish the exact cause. This may be with:
* Fine needle aspiration cytology – aspirating cells from the lump using a needle
* Core biopsy – taking a sample of tissue with a thicker needle
* Incision biopsy – cutting out a tissue sample with a scalpel
* Removal of the lump – the entire lump can be removed and examined
Lymphadenopathy
- Enlarged lymph nodes