Neck lumps

Question 1

Probability diagnosis

Answer 1

Lymphadenitis (reaction to local infection)

• acute: viral or bacterial
• chronic: MAIS (atypical tuberculosis), viral (e.g. EBM, rubella)

Prominent normal lymph nodes

Goitre

Sebaceous cyst

Lipoma

Sternomastoid tumour (neonates)

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• carotid body tumour or aneurysm

Infection:

• ‘collar stud’ abscess (atypical TB)
• tuberculosis of cervical nodes (‘King’s evil’)
• HIV/AIDS of nodes
• actinomycosis

Cancer/tumour:

• lymphoma (e.g. Hodgkin)
• leukaemia
• thyroid nodule (adenoma, cancer, colloid cyst)
• metastatic nodes
• salivary gland tumours

Question 3

Pitfalls (often missed)

Answer 3

Parotitis

Thyroglossal cyst

Lymphatic malformation ‘cystic hygroma’ (children)

Cervical rib

Rarities:

• sarcoidosis
• branchial cyst (child)
• torticollis

Question 4

Key history

Answer 4

This depends on the age of the patient but should include in all ages, history of;

• upper / lower respiratory infection,
• possible Epstein–Barr
• HIV
• cytomegalovirus
• tuberculosis infection

Note any response to antibiotics given for a throat or upper airways infection.

Question 5

Consider red flags such as

Answer 5

weight loss

dysphagia

history of cancer

increasing size of the lump

Question 6

Key examination

Answer 6

Examine the lump according to the classic rules of;

• look
• feel
• move
• measure
• auscultate
• ransilluminate

Note the consistency of the lump: soft, firm, rubbery or hard

Careful matching the site of any lymphadenopathy with a ‘map’ of areas drained by the nodes

Palpate the midline anterior area for thyroid lumps and the submental area for submandibular swellings

Question 7

Key investigations

Answer 7

FBE

ESR/CRP

CXR

TFTs (of thyroid swelling)

Fine needle aspiration biopsy of thyroid nodules

Lymph node biopsy

Question 8

Thyroid and primary tumours: imaging techniques (if necessary to assist diagnosis) include:

Answer 8

ultrasound

axial CT scan (esp. in fat necks)

MRI scan (distinguishes a malignant swelling from scar tissue or oedema)

tomogram of larynx (malignancy)

barium swallow (pharyngeal pouch)

sialogram

carotid angiogram.

Question 9

Diagnostic tips

Answer 9

Causes of neck swelling are;

1. lymph nodes (85%)
2. goitre (8%)
3. others (7%)

The 20:40 guideline rule according to age:

• 0–20 years: congenital, inflammatory, lymphoma, TB
• 20–40 years: inflammatory, salivary, thyroid, lymphoma
• >40 years: lymphoma, metastases.

The 80:20 rule: most neck lumps (80%) are benign in children while the reverse applies to adults.

Suspicious LNs are >2.5 cm diameter esp if firm or hard and less mobile.

Consistent rules:

• hard—secondary carcinoma
• rubbery—lymphoma
• soft—sarcoidosis or infection
• tender and multiple—infection.