Neck Lump Flashcards
If you have a patient with a neck lump, what is the first thing you should do?
Identify if it is a lateral neck lump or midline neck lump
What are the structures that could have something wrong with them in a lateral neck lump
Artery, Nerves, lymphatics, lymph nodes, larynx, pharynx, branchial arch remnant, salivary glands, skin/subcutaneous, muscle/cartilage/bone
How does age affect the ddx of lateral neck lump
Children: 75% of neck lumps benign - i.e. congenital/inflammatory lumps. Ddx favours branchial cleft cysts of lymphatic malformations/lymphadenitis. IF malignancy, usually lymphoma/sarcoma
Adults over 40: 75% lateral neck lumps malignant. Most are metastases and some are lymphomas. If other signs of infection absent, lateral neck lump treated as lymphadenopathy
What questions should be asked about the lateral neck lump itself
- How long its been there: less than few weeks = infective/inflammatory lymphadenopathy. More than few weeks = must exclude malignancy. Years with little change = likely benign.
- Lump got bigger/smaller/same size? - if gradually increasing size - treated as malignancy until otherwise proven.
- Lump painful? - painful = acute infective lymphadenitis/infected branchial cyst
- Other lumps present? - if lumps on other parts of body it represents systemic disease or disseminated malignancy
What associated symptoms should the GP enquire about
- Symptoms suggestive of infection? - also ask about time course. Acute symptoms = infection, prolonged hx = ?malignancy
- Any symptoms suggestive of head and neck cancer? - Head and neck cancers not usually related w weight loss/malaise. But symptoms suggestive of H/N cancer are dysphonia, stridor, starter, difficulty breathing, dysphagia, odynophagia, globes, cough, haemoptysis, otalgia, nasal discharge, epistaxis, lumps in that region that have increased in size
Whilst palpating a (lateral neck) lump, what features should be characterised?
- Tender/warm? - tender/warm = infected/inflammatory mass (except tuberculous adenitis)
- Solid/fluctuant? - hard = malignant. rubbery = chronic inflammatory lymph nodes. soft = acute inflammatory lymph nodes. fluctuant lump = branchial cysts/pharyngeal pouch/laryngocele
- Pulsatile? - ?subclavian/carotid aneurysm or carotid body tumour?
- Mobile? - malignant lymph nodes are tethered to adjacent structures, tuberculous lymph nodes appear matted together
What else should you examine if infectious lymphadenopathy is suspected?
Examine throat (especially tonsils) and all lymph nodes of head and neck
What else should you examine if malignant lymphadenopathy is suspected?
- Examine all aspects of the face and mouth for squamous cell carcinoma or melanoma. If patient has otalgia without any pathology detected by otoscopy, this suggests malignancy.
- Examine breasts and lungs
- Hepatosplenomegaly
- If Virchows node palpable, do a full abdominal exam
- Use fiberoptic endoscope to examine nasal cavity, etc
What else should you examine if there is parotid swelling
Examine integrity of facial nerve - invasive malignant tumour may press on facial nerve
Examine oral cavity for soft palate displacement my tumour
Which two investigations are routinely used to investigate lymphadenopathy of a (lateral neck) lump?
- US - use it to determine pathogeneicity of lymph nodes
2. FNA - cytological diagnosis
What are the ddx for a midline neck lump
- Physiological goitre
- Multinodular goitre
- Graves disease
- Hashimotos thyroiditis
- Thyroglossal cyst/thryoid cyst
OR CAN BE NON-THYROID - lipoma, dermoid cyst, epidermal cyst, abscess, lymphoma
What questions should be asked about the midline neck lump
- How long has the lump been there? - sudden appearance = acute haemorrhage into thyroid cyst into thyroid cyst / (rarely) fast growing thyroid carcinoma or subacute thyroiditis. Thyroglossal cysts may “appear” after infection
- Lump bigger/smaller/stayed same size? - rapid size increase = haemorrhage/infection. Slow growing = thyroid neoplasm
- Lump painful? - if painful -> ?subacute thyroiditis / infected thyroglossal cysts / acute haemorrhagic cysts (NB hashimotos thyroiditis may result in discomfort)
Although thyroid cancer is usually painless, anaplastic carcinoma can be painful. Why?
Due to infiltration of surrounding structures e.g. ear pain due vagus nerve involvement
What associated symptoms of a midline neck lump is it important to know about?
- symptoms suggestive of hyper/hypothyroidism
- Symptoms suggestive of compression/invasion - e.g. stridor, dyspnoea, dysphagia, discomfort during swallowing, changes in voice
- Symptoms suggesting infection
What elements of the PMH is it important to know for midline neck lump
- Autoimmune disorders - Graves and hashimotos thyroiditis are autoimmune. Eg autoimmune disorder = T1DM, Addisons disease, pernicious anaemia, vitiligo
- RFs for thyroid malignancy
What aspects of family history is important to know for midline neck lump
- Autoimmune disease
2. Hereditary form of thyroid carcinoma - e.g. medullary thyroid carcinoma
A deep midline neck lump suggests what?
Thyroid gland affected
Superficial would suggest lipoma/dermoid cyst
If there is a midline neck lump that moves on tongue protrusion, what is it indicative of?
Thyroglossal cyst
Diffuse, smooth enlargement of a midline neck lump indicates?
Physiological goitre, Graves, Hashimotos
What is Pembertons sign?
Elevate arms - this causes any retrosternal masses to obstruct the thoracic inlet - results in facial venous congestion)
Exophthalmos is a sign of which thyroid disorder?
Graves
Wasting/proximal myopathy is a sign of?
Hyperthyroidism
What investigations should the GP do for a suspected thyroid disorder?
TSH - high in hypothyroidism / low in hyperthyroidism
LOW TSH = test T3 / T4
HIGH TSH = test TPO antibodies (Hashimotos)
Also test serum TPO - if family hx of thyroid cancer
When should patients be referred to endocrine surgeons/
Euthyroid patient with thyroid nodules
What is the first line investigation of thyroid nodules?
What can be used to guide FNA
FNA
US can be used to guide
CT and MRI are rarely used as a first line investigation for thyroid nodules, except when?
If there is retrosternal extension of a goitre / invasive tumours, haemoptysis
FNA can’t distinguish between benign follicular adenoma and Malignant follicular carcinoma. Hence how are follicular pathologies managed?
- Surgery
- T3 replacement - as the thyroid gland has been removed
- I131 ablation - radioiodine selectively taken up by thyroid cells and destroyed by radiation - eliminates malignant cells
- T4 suppression
Upper midline cystic lesion that is attached to the hyoid bone indicates?
Thyroglossal cyst (most common upper midline neck lesion)
Treated by surgical resection (reduces chance of further infection, decrease chance of carcinoma, cosmesis)
If there is a lump that moves side to side but not up and down, and has a transmitted pulse, what is it likely to be?
What is the treatment for this?
Carotid body tumour
Image carotid body tumour to determine location. Surgical excision is the common treatment
If a patient has multiple firm subcutaneous lumps that are tender, and the patient is febrile, what is the condition likely to be?
What should the doctor do?
Cervical lymphadenitis
Could be caused by EBV which causes glandular fever if there is a sore throat and swollen tonsils.
If no swollen tonsil and sore throat, could be toxoplasmosis and acute cytomegalovirus
GP should consider FBC, heterophil Ab test and blood film
A fluctuant, non-tender lumo n the upper third of the neck anterior to SCM indicates?
Branchial cyst - often presents in early adulthood
How can we tell if the patient has Graves disease as the form of hyperthyroidism
The presence of eye signs is only present in graves disease in the context of hyperthyroid signs
What are the broad treatments available for treating Graves disease
- Antithyroid medication - carbimazole / PTU - given in the hope of remission. Recurrence indicates surgery. Carbimazole may cause agranulocytosis - urgent medical help if signs of infection.
- B-blockers
- Radioiodine
- Total thyroidectomy
Turners syndrome is associated with which neck lump?
Cystic hygroma
Sjogrens syndrome is a RF for which neck lump
Non-hodgkins lymphoma
Describe the pathophysiology of Graves disease
Autoimmune
Antibody mediates stimulation of TSH receptor
Presents as exophthalmos and hyperthyroidism
Describe the pathophysiology of Hashimotos disease
Autoimmune
Antithyroid antibodies
T-cell mediated destruction of thyroid gland
Presents as hypothyroidism
What are the potential complications of thyroidectomy
All complications of surgery in general AND
Injury to recurrent laryngeal nerve - weak, hoarse voice
Injury to superior laryngeal nerve - difficulty adjusting the pitch of phonation
Transient voice changes
Bruising parathyroid gland - transient hypocalcaemia
Hypoparathyroidism
Hyperthyroid storm (BAD)
Post op haemorrhage and airway compromise
