CNS/ HN - Neck lump

Question 1

Differential diagnosis of Neck Lump

Answer 1

• Pancoast Tumor
• Solitary thyroid nodule
• Neck lump ddx

Probability diagnosis 
Lymphadenitis (reaction to local infection)
•acute: viral or bacterial
•chronic: MAIS (atypical tuberculosis), viral (e.g. EBM, rubella
Prominent normal lymph nodes
Goitre
Sebaceous cyst
Lipoma
Sternomastoid tumour (neonates)

Serious disorders not to be missed
Vascular:
•carotid body tumour or aneurysm

Infection:
•‘collar stud’ abscess (atypical TB)
•tuberculosis of cervical nodes (‘King’s evil’)
•HIV/AIDS of nodes
•actinomycosis

Cancer/tumour
•lymphoma (e.g. Hodgkin)
•leukaemia
•thyroid nodule* (adenoma, cancer, colloid cyst)
•metastatic nodes
•salivary gland tumours

Pitfalls (often missed) 
Parotitis
Thyroglossal cyst
Lymphatic malformation ‘cystic hygroma’ (children)
Cervical rib

Rarities:
•sarcoidosis
•branchial cyst (child)
•torticollis

Question 2

Neck Lump - Key History

Answer 2

Key history

This depends on the age of the patient but should include in all ages

1. a history of upper respiratory infection, lower respiratory infection
2. possible Epstein–Barr
3. HIV
4. cytomegalovirus
5. tuberculosis infection.

Consider red flags such as:

• weight loss
• dysphagia
• history of cancer
• increasing size of the lump.

Note any response to antibiotics given for a throat or upper airways infection.

Question 3

Neck Lump - Key PE

Answer 3

Key examination

•Careful palpation of lymph nodes areas and matching the site of any lymphadenopathy with a ‘map’ of areas drained by the nodes
•Examine the lump according to the classic rules of
- look, feel, move
- measure, auscultate and transilluminate
•Palpate the midline anterior area for thyroid lumps and the submental area for submandibular swellings
•Note the consistency of the lump: soft, firm, rubbery or hard

Question 4

Neck Lump - Key Investigation

Answer 4

Key investigations 
•FBE
•ESR/CRP
•CXR
•TFTs (of thyroid swelling)
•Fine needle aspiration biopsy of thyroid nodules
•Lymph node biopsy

Thyroid and primary tumours: 
imaging techniques (if necessary to assist diagnosis) include:
•ultrasound 
•axial CT scan (esp. in fat necks)
•MRI scan (distinguishes a malignant swelling from scar tissue or oedema)
•tomogram of larynx (malignancy)
•barium swallow (pharyngeal pouch)
•sialogram
•carotid angiogram.

Question 5

Neck Lump - Diagnostic Tips

Answer 5

Diagnostic tips

•The 20:40 guideline rule according to age:
0–20 years: congenital, inflammatory, lymphoma, TB

20–40 years: inflammatory, salivary, thyroid, lymphoma

> 40 years: lymphoma, metastases.

•The 80:20 rule:

most neck lumps (80%) are benign in children while the reverse applies to adults.

• Causes of neck swelling are lymph nodes (85%), goitre (8%), others (7%).
• Suspicious lymph nodes are >2.5 cm diameter especially if firm or hard and less mobile.

•Consistent rules: 
hard—secondary carcinoma; 
rubbery—lymphoma; 
soft—sarcoidosis or infection; 
tender and multiple—infection

Question 6

Differential DIagnosis - Solitary Thyroid Nodule

Answer 6

Differential Diagnosis

• Colloid cyst
• Dominant nodule in a multinodular goiter – most common
• True solitary nodule (adenoma)
• Thyroid Cancer
• Hashimoto thyroiditis
• Lymph Node *
• Thyroglossal cyst *

Question 7

Investigations - Solitary Thyroid Nodule

Answer 7

Investigations
- TFTs and autoantibodies (TSI, TSH autoantibodies – Graves; antimicrosomal and antithyroglobulin antibodies – hashimoto)
- USD (to check whether it is solid, cystic or mixed and locate site where to take biopsy)
- RAIU scan (hot, warm or cold nodule)
o Cold: can be cancer; not taking up isotope scan
o Warm: takes up isotope; can be MNG, Graves,
o Hot: taking up maximum isotope; usually a toxic nodule (hyperthyroidism)
- FNAC (95%): benign, malignant, or indeterminate

Ask a few questions to determine whether patient is hyperthyroid, hypothyroid or euthyroid

IF cancer: go for CXR, CT scan/MRI of the chest to see involvement of mediastinum, airway, and lungs, ECG

Question 8

Management - Solitary thyroid nodule

Answer 8

Management
- Colloid cyst: Aspiration and biopsy of wall of the cyst to look for malignancy; If recurrent, surgeon may remove the cyst
- Dominant nodule of MNG: RAI ablation or thyroidectomy
- Adenoma: watchful waiting > regular reviews with TFTs and USG; if symptomatic or enlarged > surgery
- Carcinoma: total thyroidectomy
Hashimoto thyroiditis (autoimmune): Thyroxine

Question 9

Complications of Thyroid Surgery

Answer 9

Complications of Thyroid Surgery (followup with TFTs, USG and uptake scan)

• Bleeding
• Infection
• Anesthetic complications
• Recurrent laryngeal nerve injury/palsy
• Thyroid crisis/storm
• Tension hematoma
• Hypocalcemia (hyperparathyroid)
• Hypothyroidism (thyroxine)
• Recurrent Hyperthyroidism

Question 10

Obstructive symptoms/Red flags

Answer 10

Obstructive symptoms/Red flags

• Stridor
• Tracheal deviation
• Dyspnea
• Dysphagia
• Neck vein engorgement
• Hoarseness

Question 11

History - Neck Lump

Answer 11

History

• HOPI - Neck lump
• site
• soft or hard?
• mobile?
• painful?
• getting bigger?
• discharge

ASSOCIATED SYMPTOMS

• difficulty in swallowing
• painful swallowing
• voice change / hoarseness
• fever
• loa,low,lbbb
• neck pain
• cough and colds > colour of sputum> blood
• sorethroat
• dob
• chest pain
• vomiting

DDX / RISK FACTORS

• recent URTI infection
• loa, low, lbbb
• night sweats, skin itchiness
• weather preferences
• trauma
• Travel
• Occupation
• Exposure
• Sexual hx

PMH
FH
SADMA