Neck Lumps

Question 1

Sequence of events and symptom analysis

Answer 1

Tell me more 
Site- where exactly, point to it
Timeline- when did you notice it, has it changed, bigger or smaller 
Tenderness 
Other lumps 
Previous episodes/ something similar

Question 2

Systems review

Answer 2

ENT- difficulty swallowing, painful swallowing, hoarse voice, earache, sore throat or cold recent, any recent illness at all, haemoptysis, odynophagia, recurrent infections

RS- cough, productive, blood, breathlessness

Haematological- bruising or bleeding, recurrent infections, bone pain

Constitutional- FWARJCNLBBD

Travel abroad recently

Trauma

Thyroid symptoms

HAVE YOU BEEN UNWELL RECENTLY- URTI CAUSING REACTIVE LYMPHADENOPATHY

Question 3

Red flags for a neck lump

Answer 3

Weight loss 
Night sweats 
Heavy smoking history 
Dysphagia 
Odynophagia 
Hoarseness more than 3 weeks 
Unexplained bruising 
Recurrent infections

Question 4

Patients perspective

Answer 4

Feelings and impact

ICE

Question 5

Background information

Answer 5

PMH- ask about lymphoma
SH- do you eat betel nuts or chew tobacco? (Oropharyngeal cancer)
FH

Question 6

Reactive lymphadenopathy

Answer 6

May last 4 weeks and usually associated with signs and symptoms of local infection relative to affected lymph node eg, tonsillitis
Tend to be regular, soft to firm on palpation, and mobile

Question 7

Metastatic head and neck carcinoma

Answer 7

Head and neck cancers tend to metastasise to cervical lymph nodes relative to their location
Underlying Sx of head and neck cancer
Cancerous nodes typically hard and irregular when palpated

Question 8

Lymphoma

Answer 8

B/constitutional symptoms present

Nodes are typically firm and rubbery to palpate

Question 9

TB

Answer 9

Affected lymph nodes are large
Long standing malaise, fever, weight loss, night sweats
Foreign travel or contact with a TB patient
Risks- immunosuppression, alcoholism, IVDU

Question 10

Sialolithiasis (salivary glands obstruction)

Answer 10

Intermittent and post prandial pain and swelling in submandibular or parotid gland
Provoked by dehydration
Secondary infection with redness pain and potentially abscess formation

Question 11

Brachial cyst

Answer 11

Congenital cyst that arises on the lateral aspect of the neck
Smooth, soft, non tender, presents in second or third decade as a smooth slowly growing lateral neck mass that may increase in size after an URTI

Question 12

Cystic hygroma

Answer 12

Congenital multiloculated lymphatic lesion presents either on antenatal screening, at birth or in first 2 years of life
Left posterior triangle of the neck

Question 13

Sebaceous cyst (epidermoid cyst)

Answer 13

Characteristic punctum
Commonly appear on the face, trunk, neck extremities and scalp
Commonly infected- tender lump with discharge

Question 14

Abscess

Answer 14

Red hot fluctuating swelling in a feverish patient

Local spread

Question 15

Thyroid swelling or goitre

Answer 15

Moves on swallowing

Thyroglossal duct cysts move with protrusion of tongue (thyroid swellings don’t)

Question 16

Parotitis

Answer 16

Infection, autoimmune, or obstruction (sialolithiasis)

Pain and enlargement of the gland

Question 17

Carotid artery aneurysm

Answer 17

Large pulsatile mass when palpating the carotid artery

Question 18

Investigations

Answer 18

Clinical examination of all lymph nodes in neck, axilla, and groin, then head and neck exam, look in mouth and investigate naso oro and laryngopharynx with an endoscope
Bloods- FBC blood film coagulation profile
If concerned about malignant- 2 week wait pathway referral to ENT
If likely benign- watchful waiting for a month then follow up
USS with FNA or core biopsy
Staging CT