Neck Lump Examination

Question 1

What are the red flags that should raise your suspicion of malignancy in the context of a neck lump?

Answer 1

A hard and fixed mass.
The patient with the neck lump is over 35-years-old.
The presence of a mucosal lesion in the head or neck.
A history of persistent hoarseness or dysphagia.
The presence of trismus.
The presence of unilateral ear pain (referred from tongue base).

Question 2

How should you ask the patient to prepare for the examination?

Answer 2

Ask the patient to sit on a chair for the assessment.

Adequately expose the patient’s neck to the clavicles.

Ask the patient if they have any pain before proceeding with the clinical examination.

Question 3

On the general inspection, what clinical signs are you looking for of underlying pathology?

Answer 3

• Scars
• Cachexia
• Hoarse Voice
• Dyspnoea or stridor -> compression of upper resp tract by neck mass
• Behaviour (anxiety and hyperactivity)
• Clothing -> may be inappropriate for the current temperature
• Expothalmos -> bulging of the eye

Question 4

First is the inspection of the neck lump, what must you do?

Answer 4

Ask the patient to point out the neck lump’s location if relevant.

Inspect the neck lump from the front and side, noting its location (e.g. anterior triangle, posterior triangle, midline).

Question 5

First is the inspection of the neck lump, what must you do?

Answer 5

Ask the patient to point out the neck lump’s location if relevant.

Inspect the neck lump from the front and side, noting its location (e.g. anterior triangle, posterior triangle, midline).

Question 6

What further assessments must you perform if there is an identifiable mass on inspection?

Answer 6

• Swallowing
• Ask them to swallow some water and observe the movement of the mass
• Tongue protrusion
• If you find a midline neck lump or systemic signs indicative of thyroid disease -> must explain that a full thyroid status exam should be performed

Question 7

What are you looking for when you ask the patient to swallow

Answer 7

Ask the patient to swallow some water and observe the movement of the mass:

Thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing.
Lymph nodes will typically move very little with swallowing.
An invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue.

Question 8

What are you looking for when asking for a tongue protrusion?

Answer 8

Thyroglossal cysts will move upwards noticeably during tongue protrusion.

Thyroid gland masses and lymph nodes will not move during tongue protrusion.

Question 9

Next, you need to palpate the neck lump, what are you assessing?

Answer 9

• Site
• Size
• Shape
• Consistency (soft - cyst, hard - malignancy, rubbery - lymph node)
• Mobility - ask the patient to move their head to reveal if it is tethered to the underlying muscle
• Fluctuance - if fluid filled you should feel it bulding out
• Temperature (inflammation or infection)
• Overlying skin changes(erythema or a punctum)
• Pulsatility (suggests vascular)
• Tenderness (infective or inflammatory)
• Transillumination (fluid filled)
• Vascular bruit (vascular aetiology)

Question 10

What is the difference between a branchial cyst and a cystic hygroma?

Answer 10

Branchial cyst vs cystic hygroma

A branchial cyst arises from embryological remnants of the second branchial cleft in the neck. It typically presents in young adults when an upper respiratory tract infection causes it to increase in size. The solitary smooth cyst is most often located in the anterior triangle. It is usually painless but may be painful during acute infection. A conservative approach to management may be taken if the cyst is small or alternatively surgical excision can be performed.

A cystic hygroma is a congenital lymphatic lesion which is typically identified prenatally or at birth. A cystic hygroma can arise anywhere but typically develops in the left posterior triangle of the neck. Cystic hygromas are benign but can be disfiguring and typically require surgical treatment including drainage and use of sclerosing agents to prevent reaccumulation of lymphatic fluid.

Question 11

What do you do next?

Answer 11

Assess the lymph nodes.

Question 12

What is it important to assess for any palpable lymph nodes?

Answer 12

Site: assess the lymph node’s location in relation to other anatomical structures.

Size: assess the size of the lymph node.

Shape: assess the lymph node’s borders to determine if they feel regular or irregular.

Consistency: determine if the lymph node feels soft, hard or rubbery.

Tenderness: note if the lymph node is tender on palpation.

Mobility: assess if the lymph node feels mobile or is tethered to other local structures.

Overlying skin changes: note any overlying skin changes such as erythema.

Question 13

What is the interpretation of different lymph node findings?

Answer 13

Benign lymph nodes: typically less than 1cm, smooth, rounded, non-tender and mobile.

Reactive lymph nodes: typically smooth, rounded, tender, mobile and associated with infective symptoms (e.g. fever).

Lymphadenopathy associated with haematological malignancy: widespread enlarged rubbery lymph nodes.

Lymphadenopathy associated with metastatic cancer: regional lymphadenopathy in lymph node groups draining the affected organ. Lymph nodes typically feel hard, firm, irregular and are often tethered to local structures.

Question 14

Next, we need to palpate the cervical lymph nodes, how do we do this?

Answer 14

1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap.
2. Inspect for any evidence of lymphadenopathy or irregularity of the neck.
3. Stand behind the patient and use both hands to start palpating the neck.
4. Use the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue to assess the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size, consistency and mobility of lymph nodes.

Question 15

What systematic order should you palpate the cervical lymph nodes?

Answer 15

Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but a systematic approach will ensure no areas are missed:

Submental
Submandibular
Tonsillar
Parotid
Pre-auricular
Post-auricular
Superficial cervical
Deep cervical
Posterior cervical
Occipital
Supraclavicular

Question 16

What do you palpate now?

Answer 16

The thyroid gland - palpate each of the lobes and isthmus of the thyroid.

Question 17

How do you palpate the thyroid?

Answer 17

1. Stand behind the patient and ask them to tilt their chin slightly downwards to relax the muscles of the neck to aid palpation of the thyroid gland.
2. Place the three middle fingers of each hand along the midline of the neck below the chin.
3. Locate the upper edge of the thyroid cartilage (“Adam’s apple”) with your fingers.
4. Move your fingers inferiorly until you reach the cricoid cartilage. The first two rings of the trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area.
5. Palpate the thyroid isthmus using the pads of your fingers.
6. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus.
7. Ask the patient to swallow some water, whilst you feel for the symmetrical elevation of the thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass).
8. Ask the patient to protrude their tongue (if a mass represents a thyroglossal cyst, you will feel it rise during tongue protrusion).

Question 18

When palpating the thyroid gland, what characteristics should you assess?

Answer 18

Size: note if the thyroid gland feels enlarged.

Symmetry: assess for any evidence of asymmetry between the thyroid lobes (unilateral enlargement may be caused by a thyroid nodule or malignancy).

Consistency: assess the consistency of the thyroid gland tissue, noting any irregularities (e.g. a widespread irregular consistency would be suggestive of a multinodular goitre).

Masses: note if there are any distinct palpable masses within the thyroid gland’s tissue (e.g. solitary thyroid nodule or thyroid malignancy).

Palpable thrill: assess for evidence of a palpable thrill caused by increased vascularity of the thyroid gland due to hyperthyroidism (suggestive of Graves’ disease).

Question 19

What is a thyroglossal cyst?

Answer 19

Thyroglossal cysts are the most common congenital abnormality of the neck and arise as a result of the persistence of the thyroglossal duct. The thyroglossal duct is the tract by which the thyroid gland descends during embryological development to its final position in the front of the neck. The tongue is attached to the thyroglossal duct, which is why thyroglossal cysts rise during tongue protrusion.

Question 20

If the lump is located in the submandibular region what do you do now?

Answer 20

Palpate the submandibular gland
- Just say that you would do this

Question 21

How would you summarise the findings?

Answer 21

Today I examined Mr Smith, a 32-year-old male. On general inspection, the patient appeared comfortable at rest. There were no objects or medical equipment around the bed of relevance.”

Inspection and palpation were unremarkable, with no masses present. There was also no palpable lymphadenopathy in the cervical region.

In summary this was a normal neck lump examination