Neck Lump Flashcards
What questions do you want to ask when a patient presents with a neck lump?
- Duration - when did it appear
- Change in size
- Associated features - pain/redness/discharge
- Lumps elsewhere (armpit/groin»_space; lymphoma metastasis)
- Preceding symptoms: particularly coryzal/tonsillitis/pharyngitis (any recent infections/illness)
- Recent travel - particularly to areas where TB is endemic
- Contact with TB patients
- Occupation - petrochemical wood industry
- Exposure to radiation
What are red flag symptoms for the neck and throat?
- Persistent sore throat
- Hoarseness
- Dysphagia
- Odynophagia
- Weight loss, fevers, night sweats, appetite loss
- New unexplained lump
- Ulceration in oral cavity >3 weeks
- Red/red and white patch in oral cavity
- Smoker or previous HPV
What examination would you do for a neck lump?
- Neck exam
- Oral cavity: inspect floor of mouth, tongue, cheek mucosa, dentition, gums and anterior tonsillar pillar (use light source)
- Nasopharynx: fibreoptic endoscope
- Oropharynx: head light and tongue depressor (make sure to check tonsillar fossae)
- Larynx: fibreoptic endoscope, only in ENT clinic, if there are any persistent symptoms relating to the larynx e.g. dysphonia for >6 weeks then urgent referral to ENT
What would a neck lump in reactive lymphadenopathy feel like and how would you treat it?
Rubbery, non-tender and non-fluctuant lump, post-infection.
No red flag symptoms - doesn’t need to be removed and will continue to reduce in size over time, no further treatment.
What are investigations for a neck lump?
- 1st line: US, fine needle aspiration cytology (FNAC) (using US guidance)
- Incisional biopsy if FNAC doesn’t show anything
- CT - very useful
- Excision biopsy - should only be performed as part of wider dissection of all cervical lymph nodes. As in certain circumstances, like excision of a metastatic lymph node, has a detrimental effect on outcome.
- MRI - useful but not 1st line
What are the risk factors for squamous cell carcinoma of the head and neck?
- Betel nut chewing - common in India/Asia and around Pacific, it is carcinogenic and one of the main causes of oropharyngeal cancer around the world
- Alcohol
- Smoking
- Human Papilloma Virus (HPV) - responsible for emergence of head and neck cancers in much younger patients i.e. 20-40s
What are the steps for diagnosing head and neck cancer?
- Panendoscopy + biopsy: examination under anaesthesia of pharynx, larynx and upper oesophagus, this is to find the primary site and obtain tissue for histological diagnosis
- CT skull base to diaphragm to assess event of the primary tumour and to identify any regional or distant metastasis
- MDT meeting
What other symptoms do you want to ask about in a presentation of hoarseness (dysphonia)?
- Dysphagia
- Odynophagia (pain on swallowing)
- Weight loss
- Heartburn or indigestion - GORD can cause inflammation of larynx and dysphonia
- Postnasal drip or other nasal symptoms: excessive nasal discharge can cause dysphonia through excessive throat clearing
- Systemic upset
What are the NICE guidelines for urgent referral 2 week wait of head and neck malignancy?
- Hoarseness >6 weeks
- Oral swellings >3 weeks
- Dysphagia >3 weeks
- Unilateral nasal obstruction, particularly when associated with purulent discharge
- Unresolving neck masses >3 weeks
- Cranial neuropathies
- Orbital masses
What symptoms need to be referred to maxillofacial surgery?
- All red or red and white patches of oral mucosa
- Ulceration of oral mucosa persisting for >3 weeks
- Unexplained teeth mobility not associated with periodontal disease
What would inflammation/neoplasia of the oropharynx cause?
- Sore throat
- Odynophagia
- Dysphagia
What symptoms would lesions inside and outside the larynx cause?
- Inside: dysphonia
- Outside: dysphonia by damage to recurrent laryngeal nerve or vagus nerve»_space; paralysis of vocal folds
What are the common causes of dysphonia?
- Overuse
- Acute laryngitis
- Chronic laryngitis secondary to reflux
- Use of asthma inhalers
- Smoking
- SCC of larynx
- Vocal cord palsy
Why should you examine the neck with dysphonia?
- Lymphadenopathy: may be reactive to infection or neoplastic from metastatic spread of SCC
- Lymphoma can cause generalised lymphadenopathy
- Thyroid disease: benign thyroid disease is rarely associated with dysphonia, except malignant thyroid disease (invades recurrent laryngeal nerve)
What are risk factors for dysphonia?
- Tobacco products - especially smokeless tobacco (risk factor for development of SCC in upper aerodigestive tract)
- Excessive alcohol
- EBV, HPV, GORD
- Vocal abuse i.e. overuse + asthma inhalers are important, although benign
