Head and neck swelling

Question 1

ΔΔ neck lump

Answer 1

anywhere?
• lipoma
• sebaceous cyst (epidermoid, often with central punctum)

midline?
• thyroid
• thyroglossal cyst (remnant)
• dermoid cyst (teratoma)

anterior Δ?
• lymph node
• branchial cyst (remants of embryonic)
• parotid tumour
• carotid body tumour/aneurysm (pulsatile)

submandibular?
• lymph
• salivary stone/tumour/sialadenitis-inflamm

posterior Δ?
• cystic hygroma (congenital lymphangioma/lymph-filled-cyst, usually on left)

Question 2

borders of the anterior neck triangle?

Answer 2

midline (|)
lower mandible (-)
anterior sternocleidomastoid (/)
_
|/

Question 3

borders of the posterior neck triangle?

Answer 3

posterior sternocleidomastoid (/)
clavicle (_)
trapezius (|)

/_|

Question 4

Ex: teen presents with palpable painless midline lump which moves up with protrusion of the tongue, and is below the hyoid?

Tx?

Answer 4

thyroglossal cyst
(remnant of thyroid tissue following embryological migration from the foramen caecum of the posterior tongue)

When infected, they can increase in size and become painful

Tx: removal bc can lead to infection or fistula forming

Question 5

Ex: <20 yr old pt with midline lump which is rubbery and feels attached to underlying bone?

Answer 5

dermoid cyst (teratoma)

Question 6

Ex: baby with fluid filled cyst in left posterior triangle?

Tx?

Answer 6

cystic hygroma

surgical resection

Question 7

Ex: >1 lump in anterior triangle?

Answer 7

lymph nodes (>1=lymph)

Question 8

Virchow’s node?

Answer 8

often on L side
lymph node above clavicle
GI/abdominal ca.

Question 9

ΔΔ ↑lymph?

Answer 9

• infection: EBV, TB, HIV
• inflamm: AI
• infiltration: lymphoma, mets (GI, lung)

(Ex hepato-splenomegaly, may be found in lymphoma)

Question 10

Ex: 19 year old presents with lump 1/3 of the way down anterior SCM muscle, containing “glary fluid” of cholesterol crystals?

Answer 10

branchial cyst
(remnant of 2nd branchial cleft)
(removal diff bc of jugular/carotid)
but larger branchial cysts can result in dysphagia, dysphonia, and difficulty breathing

Question 11

RED FLAGS in neck lump Hx?

Answer 11

• > 40 years
• smokers
• painless
• rubbery (?lymphoma)
• hard and fixed lump
• associated otalgia, dysphagia, stridor, or hoarse voice
• epistaxis or unilateral nasal congestion
• unexplained weight loss, night sweats, or fever / rigors
• CN palsies
• in children, a supraclavicular mass, > 2cm, or PMHx malignancy

Question 12

Ix neck lumps?

Answer 12

Bedside:
• Neck Ex
• Virology (monospot)
• Mantoux test (TB)

Bloods:
• FBC, U+E (ΔΔ infection, CA)
• TFTs (ΔΔ goitre)
• +/- LDH (ΔΔ lymphoma)

Imaging:
• US 1st line (+/- FNA)
• Digital subtraction angiography (more accurate) or doppler US (ΔΔ carotid body tumours)
• CT/MRI
• CXR/PET-CT pre-biopsy (ΔΔ CA or mets)

Tissue sampling
• FNA
• incisional biopsy if firm
• if lymphoma is suspected, a core biopsy or an open excision lymph node biopsy will be preferred over FNA (histological diagnosis ΔΔ lymphoma)
• pharynx/larynx lumps biopsy during endo

Question 13

what to remember when Ix a pulsatile mass?

Answer 13

don’t aspirate!
could be carotid aneurysm:
do doppler US

Question 14

what to ask in neck lump Hx?

Answer 14

• time of onset (<3 weeks - reactive EBV etc)
• change in size (bigger, smaller, or unchanged)
• associated Sx (especially red flags: otalgia, dysphagia, stridor, hoarse voice, epistaxis, unilateral nasal congestion, unexplained weight loss, night sweats, fever/rigors)
• smoking status
• alcohol intake
• known radiation exposure

Question 15

Ex: mass is pulsatile and and has a bruit, classically can be moved from side to side but not up and down?
Tx?

Answer 15

carotid body tumour (benign paraganglioma)

conservatively (active monitoring via serial imaging)
or require surgical excision in a specialised unit

Question 16

what to ask in Hx if suspecting lymphoma?

Answer 16

B symptoms (night sweats, weight loss, etc)
enlarged spleen?

Question 17

Ex: >40 yr old with suspicious painless lump in superoposterior area of the anterior triangle?

Answer 17

parotid tumour

Question 18

how to Ex a lump?

Answer 18

SSS CCCC TTTT PS

site, size, shape

colour, contour (edge), consistency, compressibility (fluctuance)

temperature, tenderness, tethering, transilluminance

pulsatility, spread (regional lymph nodes)

Question 19

Qs to ask in the Hx of a lump?

Answer 19

• when and how did you first notice it?
• how has it changed since you first noticed it?
• what Sx does it cause you?
• have you got any more or have you had this before?
• what do you think it is?