Lateral Neck Lumps Flashcards
Differential diagnoses for a lateral neck lump
Artery - carotid artery/subclavian artery aneurysm, carotid body tumour
Nerves - neurofibroma, schwannoma
Lymphatics - lymphatic malformation
Lymph nodes - infective, neoplastic, granulomatous
Salivary glands - infective, autoimmune, neoplasm
Larynx - laryngocele
Pharynx - pharyngeal pouch
Brachial arch remnant - branchial cyst/sinus/fistula
Skin/superficial SC - lipoma, cyst, abscess
Muscle/cartilage/bone - sarcomas,
What are the most common causes of lateral neck lumps in children
75% are benign
Congenital and inflammatory most common e.g. brachial cleft cysts, lymphatic malformations and lymphadenitis
Any malignancy is usually a lymphoma or sarcoma
What are the most common causes of lateral neck lumps in adults
75% are malignant
80% are metastases, rest lymphomas
In the absence of infection, a lateral neck mass is lymphadenopathy due to metastatic carcinoma until proven otherwise
What questions should be asked about the lump
How long as the lump been there
Has the lump gotten bigger, smaller or stayed the same size
Is the lump painful
Are they any other lumps?
What is a lump that has been there for less than a few weeks most likely to be, and what action should be taken if it is more than a few weeks
Infective or inflammatory lymphadenopathy
Must exclude malignancy
What is a lump that has been there for years with little change most likely to be
Most likely benign
What does a lump that progressively grows in size suggest
Malignancy until proven otherwise
Which neck lumps are classically painful
Acute infective lymphadenitis
What does presence of other lumps suggest
Represents either a systemic disease (HIV, EBV -> infectious mononucleosis) or disseminated malignancy e.g. lymphoma
Which symptoms are suggestive of infection
Malaise
Fever
Rigors
Symptoms of the local infection e.g. coryzal, dental abscess pain
Can also present in lymphoma, so time course is useful (acute history favours infection)
Which symptoms are suggestive of head and neck cancer
Not usually associated with weight loss or malaise Dysphonia Stridor Stertor Breathing difficulty Dysphagia Odynophagia Globus Cough/haemoptysis Otalgia UNilateral hearing loss Nasal discharge Epistaxis, lumps or ulcers on the head or face
What aspects of a history may make an infective process more likely
Recent infection (upper resp?)
History of contact with someone infected
Recent trauma, insect bites, animal bites, scratches
What aspects of a history may make a malignant process more likely
Current or previous cancer
Family history of cancer
PReviously had radiotherapy to the neck
Ever been a smoker and/or high alcohol intake
What specifically do you want to know about the location of a lateral neck lump
is it superficial or deep
In the anterior or posterior triangle of the neck
What is its relationship to muscle
Give examples of superficial lateral neck lumps
Lipomas, abscesses, epidermal cysts, dermoid cysts
What lumps will you find in the anterior triangle of the neck (lateral)
Branchial cysts/sinus/fistula Carotid body tumour (chemodectoma) Carotid artery aneurysms Salivary Laryngocele Lymphadenopathy
What lumps will be found in the posterior triangle of the neck
Lymphatic malformation Cervical rib Pharyngeal pouch Subclavian aneurysm Lymphadenopathy
What other features should be asked about the lateral lump
Is it tender/warm
Solid or fluctuant
Is it pulsatile
Is it mobile
Which lateral lumps may be tender
Infected or inflammatory masses
Also at-risk patients-group in TB adenitis
What can lumps be classically divided into in terms of consistency
Hard - malignant
Rubbery - chronic inflammatory lymph node e.g. TB
Soft - acute inflammatory lymph nodes
Fluctuant - branchial cysts, cystic hygromas, pharyngeal pouches, laryngoceles
Which lateral neck lumps are pulsatile
Subclavian or carotid aneurysms
Carotid body tumour are often pulsatile
Which lateral neck lumps may not be mobile
Malignant lymph nodes may be tethered to adjacent structures (TB nodes may appear matted together)
What else should be examined if infectious lymphadenopathy is suspected
Examine the throat, paying particular attention to the tonsils
Examine all lymph nodes of the head and neck
What else should be examined if malignant lymphadenopathy is suspected
Examine the scalp, face, ears, mouth and nose - potential SCC or melanoma
Otalgia in the absence of any pathology is suggestive of malignancy
Examine the breasts and the lungs
Consider palpating for hepatosplenomegaly if lymphoma or chronic lymphocytic leukaemia is supsected
Full abdominal exam if Virchow’s palpable
Endoscopy
What else should be examined if there is parotid swelling
Examine the integrity of the facial nerve (palsy may occur from malignant tumour)
Examine the oral cavity for displacement of the soft palate by a tumour involving the deep love of the parotid
What investigations can be done for a suspected for a lymphadenopathy
Ultrasound - size, shape, echogenicity, vascularity
Fine needle aspiration - for cytological diagnosis, may be USS guided
Core biopsy needed to confirm
Female with swelling (2x2) the right upper anterior triangle, not painful, not attached to SCM, firm, non-tender, transmitted pulse. The lump moves from side to side but not up and down
Carotid Body tumour (chemodectoma)
Located at the carotid bifurcation
What investigations should be done for carotid body tumours
Imaging to determine location - duplex USS, angiography, CT/MRI
Females with sore throat, headache, fever and fatigue. No cough or coryzal symptoms. Febrile on exam, enlarged tonsils and multiple palpable lumps in her neck. 5 are firm and tender, all SC and in the posterior triangle. Relatively mobile and are not warm or pulsatile. There is splenomegaly
Cervical lymphadenitis due to glandular fever caused by EBV
What does EBV infection (glandular fever) present with
Cervical lymphadenitis Tonsilar enlargement Sore throat Splenomegaly Fever
What differentiates the symptoms of EBV and toxoplasmosis and acute cytomegalovirus (CMV)
All will present with splenomegaly and lymphadenopathy, but only EMV accounts for sore throat and swollen tonsils
What investigations should be done for suspected glandular fever due to EBV
FBC (leucocytosis and lymphocytosis)
Heterophil antibody tests (Paul-Bunnell/monospot test)
Blood film (atypical lymphocytes)
What is the treatment for glandular fever due to EBV
Do not give amoxicillin as it will cause a rash
No specific management, just avoid contact sports due to risk of damage to the spleen.
Single palpable lesion in the left anterior triangle, anterior to the SCM. Does not move on swallowing or tongue movement. Smooth, non-tender fluctuant and non-pulsatile. Gradually increasing in size over weeks.
Branchial Cyst
Congenital epithelial cyst that presented due to RTI
Lump in the left anterior triangle which has smooth regular borders and is fluctuant. Non-tender and cannot moved separately from the skin, but mobile over deep tissues. Does not change position on swallow. No punctum overlying the lump. 2-month history
Epidermal cyst
Could be dermoid cyst, but due to punctum more likely to be epidermal
Where will a dermoid cyst be found
Formed at embryological lines of fusion (midline) or following trauma in the neck
A patient presents with intermittent swelling of the parotid gland. What question is important to ask?
Whether the painful swelling is connected to eating
Typical of sialothiasis - salivary gland calculi
What lump is associated with Turner’s syndrome
Cystic Hygroma’s
What lump is associated with Sjrogens syndrome
Non-Hodgkins lymphoma
