Lumps in the neck

Question 1

Description of a neck lump 4s, 4t, 3f, 2l

Answer 1

Site (deep to skin, fascia, muscle), size, shape, shift Temperature, tender, transilumination, thrill Colour, contour, consistency, cough impulse Fluctuating, filling/emptying, flow-bruit Lymph drainage, lumps elsewhere

Question 2

Categories of neck lump surgical seive

Answer 2

Congenital Infectious/inflammatory Granulomatous Neoplastic

Question 3

Acquired causes based on age: <20, 20-40, 40

Answer 3

<20: 1. Congenital, 2. Inflammatory, 3. Neoplastic

20-40: 1. Inflammatory, 2. Congenital, 3. Neoplastic

40: 1. Neoplastic, 2. Inflammatory, 3. Congenital

Question 4

Congenital neck lumps- lateral and midline

Answer 4

Lateral: branchial cleft cyst, lymphatic/venous malformation Midline: thyroglossal cyst, dermoid cyst, laryngocele

Question 5

Infectious/inflammatory differential (8)

Answer 5

Reactive lymphadenitis HIV EBV Kawasaki Kimura Kikuchi Salivary gland calculi, sialedenitis Thyroiditis

Question 6

3 K’s of inflammatory neck lumps

Answer 6

Kawasaki, Kimura, Kikuchi

Question 7

Granulomatous differential (2)

Answer 7

Sarcoidosis Mycobacterium

Question 8

Neoplastic differential

Answer 8

Salivary gland tumor Lymphoma Metastatic Thyroid gland tumor

Question 9

When is a cervical and inguinal LN considered enlarged

Answer 9

>1cm cervical >1.5 cm inguinal

Question 10

Define generalised adenopathy

Answer 10

>2 non contiguous LN- usually systemic illness

Question 11

Indications for LN biopsy

Answer 11

>2cm Systemically unwell Generalised Splenomegaly

Question 12

Causes of cervical lymphadenopathy

Answer 12

Oropharyngeal infection, scalp Mycobacterial lymphadenitis Cat scratch Toxoplasmosis Kawasaki Thyroid

Question 13

Auricular lymphadenopathy causes

Answer 13

Conjunctivitis Eye infection Facial cellulitis

Question 14

Psoterior auricular lymphadenopathy

Answer 14

Otitis media Rubella, parvovirus

Question 15

Supraclavicular lymphadenopathy

Answer 15

Mediastinal malignancy Abdominal malignancy (left) Lymphoma TB

Question 16

Epitroclear lymphadenopathy

Answer 16

Hand/arm infection Lymphoma Sarcoid Syphilis

Question 17

Inguinal lymphadenopathy

Answer 17

UTI Venereal disease Perineal infection Lower extremity suppurative infection

Question 18

Hilar lymphadenopathy

Answer 18

TB, Histoplasmosis, Blastomycosis, Coccidioidomycosis Sarcoid Hodgkin lymphoma Metastatic

Question 19

Axillary lymphadenopathy

Answer 19

Breast cancer Leukemia/lymphoma Cat scratch Brucelliosis

Question 20

Generalised lymphadenopathy- infant, child, adolescent

Answer 20

Infant: Syphilis, Toxoplasmosis, CMV, HIV Child: EMV, CMV, HIV, Toxoplasmosis Adolescent: EBV, HIV, CMV, Toxoplasmosis, Syphillis

Question 21

Some rare causes of generalised lymphadenopathy

Answer 21

Leukemia, SLE, RA, Sarcoidosis, Drug reaction

Question 22

Categorising generalised lymphadenopathy (6)

Answer 22

Leukemia Lymphoma Infections Connective tissue disorders Infiltration Drugs

Question 23

Evaluation of a neck mass- investigations

Answer 23

History and physical examination (head, neck, chest, lungs, abdomen, other lymph nodes) Laboratory- FBC, Mantoux TB (PPD), TFTs/scan Imaging- Neck U/S, CT, angiography, imaging of stomach, bowel, sinuses as indicated by history Biopsy- FNA Identify primary tumor

Question 24

What is MAIS

Answer 24

Atypical Mycobacterial (non-TB) Lymphadenitis

Question 25

Signs and symptoms of MAIS

Answer 25

Fixed lateral neck mass, erythema, stud abscess with discharging sinus in neck

Question 26

Which test is highly positive in MAIS

Answer 26

Mantoux test

Question 27

Management of MAIS

Answer 27

Surgical excision

Question 28

Embryology of branchial cleft cyst

Answer 28

At 6th week developemtn, 2nd branchial arch grows over 3rd and 4th fusing with neighbouring caudal pre-cardial swelling= cervical sinus

Question 29

Types of branchial abnormalities

Answer 29

Fistula, sinus and cyst

Question 30

Clinical features of 2nd branchial cleft malformation

Answer 30

Fistulas in infancy small opening anterior to SCM Cysts smooth, enlarging, painless, lateral neck mass following URTI

Question 31

Clinical features of 1st branchial groove malformations

Answer 31

Pre-auricular pit/sinus

Question 32

Treatment of branchial cleft cyst

Answer 32

Excision

Question 33

Embryology of thyroglossal duct cysts

Answer 33

Thyroid develops from base of tongue as ventral midline diverticulum, caudal to junction of 3rd and 4th branchial arches. It is a vestigial remnant of the tract

Question 34

Clinical features of thyroglossal cyst (presentation, enlarges, movement)

Answer 34

Presents in early childhood as midline swelling, enlarges with URTI and moves up with protrusion of the tongue

Question 35

Management of thyroglossal cyst

Answer 35

Antibiotics to reduce inflammation Complete excision (removal of central hyoid)

Question 36

Why does a thyroglossal cyst need to be removes

Answer 36

Has small neoplastic potential

Question 37

Evaluation of a neck mass

Answer 37

1. HPC

Duration

Painful

Sore throat, URTI, toothache

2. Review of systemc

Swallowing, speaking

Weight loss, fatigue, malaise

Regional/distant cancers->cough. dysphagia

Complete R/V

3. PMHx

HIV

TB

Risk factors

Alcohol

Tobacco

Chronic candidiasis

Poor dental hygeine

3. Examination

Neck lump

Regional

Breast and prostate

Spleen

Stool

Other LNs palpated