Lumps in the Neck and ENT Cancers

Question 1

How should a lump in the neck be investigated?

Answer 1

USS
FNAC (fine needle aspiration cytology) note perform 2 if first negative 
CT
Virology and Mantoux test
FBC and TFTs

Question 2

What are branchial cysts and fistulas?

Answer 2

Embryological cyst in the lateral part of the neck due to failure of fusion of the 2nd branchial cleft or less commonly the 1st, 3rd or 4th clefts. Commonly have openings to the outside forming fistulas and are frequently infected.

Question 3

What are the signs and symptoms of branchial fistulas and cysts?

Answer 3

Slowly enlarging, smooth soft and fluctuant mass that sometimes increase in size after a URTI
Fistulas may become infected
Usually found down the front edge of the sternocleidomastoid muscle near angle of mandible and on the left side
No movement on swallowing and no transillumination
Anechogenic on USS – if echogenic suggest infection of cyst.

Question 4

How should branchial cysts and fistulas be managed?

Answer 4

Conservative treatment i.e. none

Surgical excision

Question 5

What is a thyroglossal duct cyst?

Answer 5

Fibrous cyst that forms from a persistent thyroglossal duct. Most common in people <20yrs old.

Question 6

What are the signs and symptoms of a thyroglossal duct cyst?

Answer 6

Anterior triangle, irregular midline neck mass or lump
Inferior to the hyoid bone
Anywhere from the base of the tongue (foramen cecum) to the suprasternal notch
Mass moves on swallowing and upwards with protruding the tongue
Dysphagia and difficulty breathing
Oral secretions if fistula
Painless, smooth and cystic
Anechogenic on USS – if echogenic suggest infection of cyst.

Question 7

How are thyroglossal duct cysts managed?

Answer 7

Treat thyroid dysfunction

Surgical removal if there are any symptoms

Question 8

What are common causes of lumps in the anterior triangle?

Answer 8

Lymphadenopathy from Lymphoma
Parotid tumour (if superior-posterior portion)
Carotid artery aneurysm, or carotid body tumour

Question 9

What are common causes of lump in the posterior triangle?

Answer 9

Cervical ribs
Pharyngeal pouches
Cystic hygromas
Lymphadenopathy

Question 10

What is the most common histological type of ENT cancers?

Answer 10

90% of head and neck cancers are squamous cell carcinoma. These can include oral cavity, oropharynx, hypopharynx, larynx and trachea.

Question 11

What are the common risk factors for ENT cancers?

Answer 11

Smoking 
Alcohol 
Vitamin A and C deficiency 
Nitrosamines in salted fish 
HPV
GORD

Question 12

How do ENT cancers usually present?

Answer 12

Neck pain/lump 
Hoarse voice >6weeks or sore throat >6 weeks 
Mouth bleeding due to painless ulcers
Mouth numbness
Sore tongue
Patches in the mouth 
Earache/effusion – referred pain
Lumps on the lip, mouth and gum 
Speech change 
Dysphagia

Question 13

When should a 2ww referral be considered for potential laryngeal or oral cancers?

Answer 13

Laryngeal cancer – people who are 45 and over with persistent unexplained hoarseness or unexplained neck lump.

Oral cancers – unexplained ulceration lasting >3 weeks or a persistent unexplained neck lump.

Consider 2WW for those with a lump on the lip or oral cavity or with red or white patches in the oral cavity consistent with erythroplakia or erthroleukoplakia.

Question 14

What do oral cavity and tongue cancers present with?

Answer 14

Uncommon, persistent painful ulcers, white or red patches on the tongue, gums or mucosa, otalgia, odynophagia, lymphadenopathy

Question 15

What do oropharyngeal cancers present with?

Answer 15

Often advanced at presentation, typically smoker, sore throat, sensation of a lump and referred otalgia.

Question 16

What do hypopharyngeal cancers present with?

Answer 16

Rare, lump in throat, dysphagia, odynophagia, referred otalgia and hoarseness. There are some pre malignant disorders such as leucoplakia, and Patterson Kelly brown syndrome.

Question 17

How do laryngeal cancers present?

Answer 17

Typically, older patients, male, smokers with progressive hoarseness, stridor, difficulty or pain in swallowing, haemoptysis and ear pain. In younger patients typically HPV +ve. Can be supraglottic, glottic or subglottic.

Question 18

What investigations should be done for ENT cancers?

Answer 18

Refer urgently for ENT review
Endoscopy
Fine needle aspiration biopsy
CT/MRI of the tumour site

Question 19

When should someone be investigated for thyroid cancer and what investigations are ordered?

Answer 19

If someone has deranged thyroid function and a goitre/thyroid nodule then the following investigations should be done
USS
FNCA
CXR
Autoantibodies

Question 20

What are the two types of thyroid cancers?

Answer 20

60% of thyroid cancers are papillary spreading to the lymph nodes and lungs, often in young females and has an excellent prognosis
25% of thyroid cancers are follicular occurring in middle age and spread via blood to bones and lungs. Usually well differentiated.
Medullary, lymphoma and anaplastic are the remaining 15%

Question 21

How are thyroid cancers managed?

Answer 21

Total thyroidectomy
Radioiodine to kill residual cells
Yearly thyroglobulin levels to detect recurrence

Question 22

What are dermoids?

Answer 22

Derived from pleuripotent stem cells and are located in the midline. Most commonly in a suprahyoid location. They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat.

Question 23

What is a cystic hygroma?

Answer 23

Cystic hygroma is a congenital lymphatic lesion typically seen on the left side that results from from occlusion of lymphatic channels. The painless, fluid filled, lesions usually present prior to the age of 2. They are often closely linked to surrounding structures and surgical removal is difficult. They are typically hypoechoic on USS.