Neck Lumps Flashcards
Where can neck lumps be located?
There are three descriptions to note the location of a neck lump:
- Anterior triangle
- Posterior triangle
- Midline (vertically along the centre of the neck)
These two triangles are on either side of the sternocleidomastoid muscle.
What are the borders of the anterior triangle?
The borders of the anterior triangle are:
- Mandible forms the superior border
- Midline of the neck forms the medial border
- Sternocleidomastoid forms the lateral border
What are the borders of the posterior triangle?
The borders of the posterior triangle are:
- Clavicle forms the inferior border
- Trapezius forms the posterior border
- Sternocleidomastoid forms the lateral border
Give differentials for neck lumps in adult patients
In adults
- Normal structures (e.g. bony prominence)
- Skin abscess
- Lymphadenopathy (enlarged lymph nodes)
- Tumour (e.g. squamous cell carcinoma or sarcoma)
- Lipoma
- Goitre (swollen thyroid gland) or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma (a collection of blood after trauma)
- Thyroglossal cysts
- Branchial cysts
Give differentials for neck lumps in paediatric patients
Neck lumps in young children may also be caused by:
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
What bony prominences may be present appearing as a neck lump?
It is not uncommon for patients to present worried about a normal bony prominence in the neck. Common areas of concern are the hyoid bone, mastoid process and transverse processes of C1.
What should be asked in the history of a neck lump?
The purpose of taking a history is to gain:
- General information about the symptoms (e.g. when the lump first appeared and how quickly it has grown)
- Features that suggest or exclude a particular diagnosis (e.g. night sweats indicating lymphoma)
- Risk factors for that condition (e.g. family history, age and smoking status)
- General fitness for further investigations and treatment (e.g. co-morbidities and medications such as anticoagulants)
What specific points should be illicited in the examination of a neck lump?
When examining a neck lump, the things to establish are:
- Location (anterior triangle, posterior triangle or midline)
- Size
- Shape (oval, round or irregular)
- Consistency (hard, soft or rubbery)
- Mobile or tethered to the skin or underlying tissues
- Skin changes (erythema, tethering or ulceration)
- Warmth (e.g. infection)
- Tenderness (e.g. infection)
- Pulsatile (e.g. carotid body tumours)
- Movement with swallowing (e.g. thyroid lumps) or sticking their tongue out (e.g. thyroglossal cysts)
- Transilluminates with light (e.g. cystic hygroma- usually in young children)
What specific signs on examiantion may indicate an underlying cause?
A general examination can be used to look for signs of the underlying cause, such as:
- Ear, nose and throat infections (e.g. reactive lymph nodes)
- Weight loss (e.g. malignancy or hyperthyroidism)
- Skin pallor and bruising (e.g. leukaemia)
- Focal chest sounds (e.g. lung cancer)
- Clubbing (e.g. lung cancer)
- Hepatosplenomegaly (e.g. leukaemia)
What are the red flag clinical features of neck lumps that require a two week wait referral?
The NICE guidelines on suspected cancer suggest a referral for two week wait referral for:
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
What are the clinical features of neck lumps that require further investigation via ultrasound?
They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
What blood tests should be ordered for neck lumps? And why?
Blood tests may be helpful depending on the suspected cause of the neck lumps. Not everyone with a neck lump will require blood tests. The choice of test will depend on the suspected cause:
- FBC and blood film for leukaemia and infection
- HIV test
- Monospot test or EBV antibodies for infectious mononucleosis
- Thyroid function tests for goitre or thyroid nodules
- Antinuclear antibodies for systemic lupus erythematosus
- Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
What imaging should be ordered for neck lumps?
Imaging may involve:
- Ultrasound is often the first-line investigation for neck lumps
- CT or MRI scans
- Nuclear medicine scan (e.g. for toxic thyroid nodules or PET scans for metastatic cancer)
Whar are the different methods of biopsying a neck lump?
Biopsy may be required to gain a tissue sample (histology) to establish the exact cause. This may be with:
- Fine needle aspiration cytology- aspirating cells from the lump using a needle
- Core biopsy- taking a sample of tissue with a thicker needle
- Incision biopsy- cutting out a tissue sample with a scalpel
- Removal of the lump- the entire lump can be removed and examined
What is lymphadenoapthy? How can lymphadenopathy be grouped?
Lymphadenopathy refers to enlarged lymph nodes. There are a long list of causes of enlarged lymph nodes, which can be generally grouped into:
- Reactive lymph nodes (e.g. swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis)
- Infected lymph nodes (e.g. tuberculosis, HIV or infectious mononucleosis)
- Inflammatory conditions (e.g. systemic lupus erythematosus or sarcoidosis)
- Malignancy (e.g. lymphoma, leukaemia or metastasis)
Lymphadeopathy of which nodes are the most concerning?
Enlarged supraclavicular nodes are the most concerning for malignancy of the cervical lymph nodes. They may be caused by malignancy in the chest or abdomen and require further investigation.
What features of lymphadenopathy indicate malignancy?
Features that suggest malignancy are:
- Unexplained (e.g. not associated with an infection)
- Persistently enlarged (particularly over 3cm in diameter)
- Abnormal shape (normally oval shaped where the length is more than double the width)
- Hard or “rubbery”
- Non-tender
- Tethered or fixed to the skin or underlying tissues
- Associated symptoms, such as night sweats, weight loss, fatigue or fevers
Briefly describe infective mononucleosis as a cause of lymphadenopathy
Infectious mononucleosis is a cause of lymphadenopathy. It is caused by infection with the Epstein Barr virus (EBV) and most often affects teenagers and young adults. It is found in the saliva of infected individuals and may be spread by kissing or sharing cups, toothbrushes and other equipment that transmits saliva.
How does infective mononucleosis present?
It presents with
- Fever
- Sore throat
- Fatigue
- Lymphadenopathy
Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.
Which antibiotics cause infective mononucleosis to present with a maculopapular rash?
Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.
How is infective mononucleosis diagnosed?
The first-line investigation is the Monospot test. It is also possible to test for IgM (acute infection) and IgG (immunity) to the Epstein Barr virus.
How is infective mononucleosis treated?
Management is supportive. Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).
Briefly describe lymphomas as a cause of lymphadenopathy
Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy).
There are two categories of lymphoma:
- Hodgkin’s lymphoma
- Non-Hodgkin’s lymphoma
