Neck Lumps Flashcards
What are the differentials for a lateral neck lump?
Artery - Carotid artery aneurym, subclavian artery aneurysm, chemodectoma
Nerves - Neurofibroma, schwannoma
Lymphatics - Lymphangioma
Lymph nodes
Larynx - Laryngocele
Pharynx - Pharyngeal pouch
Branchial arch remnant
Skin
What is the most common cause of lateral neck lumps in children?
75% are benign
Congenital and inflammatory are most common
DD weighted in favour of thyroglossal cysts, branchial cleft cysts, cystic hygromas and lymphadenitis
What is the most common cause of lateral neck lumps in adults?
As many as 75% of lateral neck lumps are malignant
Of these 80% are metastases
What questions should be asked about lateral neck lumps
How long had it been there?
Has lump got bigger, smaller or stayed the same size?
Is it painful?
Other lumps?
What are the three main things you are trying to find out when palpating a lateral neck lump?
Is it superficial or deep?
Is it in the anterior or posterior triangle of the neck?
What is its relationship to muscle?
(Nod head/shrug shoulders against resistance)
What are the differentials if a lateral lump is in the anterior triangle?
Branchial cyst/sinus/fistula Carotid body tumour Carotid artery aneurysm Salivary gland Laryngocele
What are the differentials if a lateral lump is in the posterior triangle?
Cystic hygroma
Cervical rib
Pharyngeal pouch
Subclavian artery aneurysm
What other features of a lateral neck lump should be characterised?
Tender and/or warm?
Solid or fluctuant?
Is it pulsatile?
Is it motile?
What examinations should be performed if infectious lymphadenopathy is suspected?
Examine throat and all lymph nodes of the head and neck
What examinations should be performed if malignant lymphadenopathy is suspected?
Examine their scalp, face, ears, mouth and nose for a potential squamous cell carcinoma or melanoma
Examine all the lymph nodes of the head and neck
Examine the breast and the lungs
Full abdo if Virchow’s node is palpable
Fibreoptic endoscopy to examine the nasal cavity, nasopharynx, oropharynx and hypopharynx
What do you examine if there is a parotid swelling?
Examine the integrity of the facial nerve (palsy may result from an invasive malignant tumour)
Examine the oral cavity for displacement of the soft palate by a tumour involving the deep lobe of the parotid
What are the red flag signs for malignant lymph nodes?
Tethered to surrounding tissue
Hard
What are the two routine investigations to assess if a lymph node is malignant?
Ultrasound
Fine needle aspiration
What is the ‘coffin corner’?
A region at the posterior tongue/floor of the mouth where it is notoriously difficult to detect tumours
What are the thyroid differentials of a midline neck lump?
Physiological goitre Multinodular goitre Graves' disease Hashimoto's thyroiditis Thyroglossal cyst Thyroid cyst Solitary adenoma Carcinoma
What are the non-thyroid differentials for a midline neck lump?
Lipoma Dermoid cyst Epidermal cyst Abscess Lymphoma
What are the main questions to ask a patient with a midline neck lump?
How long has the lump been there for?
Has it changed size?
Is the lump painful?
Any other lumps?
What are the main symptoms suggestive of hyperthyroidism?
Irritability/nervousness/restlessness
Increased appetite but weight loss
Diarrhoea
Heat intolerance
Palpitations
Oligomenorrhoea
What are the main symptoms suggestive of hypothyroidism?
Apathetic/blunting of thought/fatigue
Weight gain
Constipations
Cold intolerance
What characteristics should be ascertained regarding a midline neck lump?
Superficial or deep?
Relationship to other structure?
- Move on swallowing?
- Move on tongue protrusion?
- Tethered to neighbouring muscle or skin?
Character of the lump?
- Diffuse, smooth enlargement?
- Solitary, solid nodule?
- Solitary, cystic nodule?
- Multiple nodules?
What are the differentials of a superficial midline neck lump?
Lipoma
Epidermal cyst
Dermoid cyst
Abscess
If a neck lump moves on swallowing, what is it likely to be?
Thyroid based (attached to pretrachial fascia)
If a midline neck lump moves on tongue protrusion, what is it likely to be?
Thyroglossal cyst (attached to the hyoid bone)
If the midline neck lump is a diffuse, smooth enlargement?
Physiological goitre, Graves’, Hashimoto’s or de Quervains thyroiditis
If the midline neck lump is a solitary, solid nodule?
Malignancy is more likely
If the midline neck lump is a single cystic nodule?
Thyroglossal, epidermal, dermoid or thyroid cyst
If the midline neck lump has multiple nodules?
Multinodular goitre is more likely
What are the hand signs of hyperthyroidism?
Fine tremor
Tachycardia/AF
Sweating
Palmar erythema
Thyroid acropachy
Oncholysis
What are the eye signs of hyperthyroidism?
Lid lag
Lid retraction
Exophthalmos
Chemosis
Ophthalmoplegia
What are the signs of hypothyroidism?
Bradycardia
Slow, deep voice
Dry, coarse skin
Loss of outer third of eyebrows
Oedematous looking face
Slow reflexes
What is the interpretation go TSH results? What additional tests should be added?
Elevated TSH is consistent with hypothyroidism
- Request thyroid peroxidase Abs (Hashimoto’s)
Suppressed levels are consistent with hyperthyroidism
- Request free T3 and T4
What is the first line test for investigating thyroid nodules?
Fine needle aspiration
Can be US guided (allows for estimation of nodule size)
Mr Fry is a 23-year-old bartender who presents to his GP concerned about a lump in his neck. On further questioning he reveals that he has noticed a very slight swelling in his neck ‘above his Adam’s apple’ for the past few years. However, the lump has approximately doubled in size over the course of the last week. It is not painful and he is aware of no other lumps. He has recently suffered from an upper respiratory tract infection, and had to take one day off work last week, but is otherwise fit and well. He takes no regular medications and has no known allergies. He smokes 10 cigarettes each day, and consumes
about 35 units of alcohol (as spirits) each week.
On examination, there is an upper midline neck lesion measuring 2 cm × 2 cm. When Mr Fry is asked to stick his tongue out or swallow the lump rises up his neck. It does not appear to be attached to the large neck muscles. The lump has well-defined boundaries and a smooth surface. It feels cystic and is nonpulsatile. It is mildly tender to palpation. The overlying skin appears normal. No other lumps are detected on clinical examination.
Thyroglossal cyst
Mrs Slocock is a 47-year-old housewife who presents to her GP with a lump in her neck. She reports that she has recently noticed a slight swelling in the right side of her neck. She first noticed the lump about 6 weeks ago when she happened to feel her neck (for no particular reason) and noted slight asymmetry.
She has continued to feel the lump every few days but is unsure whether it has changed in size. The
lump is not painful and she is not aware of any other lumps. She reports feeling well, has no significant
past medical history, and takes no regular medicines. She has never smoked, but drinks approximately two bottles of wine per week.
On examination there is a 2 cm × 2 cm lump in the deep tissues of the upper right anterior triangle. The lump does not appear to be attached to sternocleidomastoid. It is firm, non-tender, and has a transmitted pulse. It is possible to move the lump from side to side but not up and down.
Carotid body tumour
Mr Farquhar is a 22-year-old trainee accountant who presents to his GP with a lump in the left side of
his neck. The lump has been present for a couple of weeks and has gradually been increasing in size.
Mr Farquhar remarks that he has had a slight swelling in the same place on two previous occasions, but
the lump was less prominent and gradually disappeared over the course of a week. On specific questioning,
both of these previous episodes corresponded with an upper respiratory tract infection. The last episode was approximately one month ago. His current lump is not painful. His is aware of no other lumps. He is currently well, takes no regular medications, and has no allergies. He is teetotal, does not smoke, and has never smoked.
On examination, there is a single palpable lesion in the left anterior triangle, anterior to the junction
of the superior third and inferior two-thirds of sternocleidomastoid. The lump does not move when Mr Farquhar is asked to swallow or stick out his tongue. The lump is smooth, non-tender, fluctuant, and non-pulsatile. It measures approximately 2.5 cm × 2 cm and is not mobile.
Brachial cyst
What are the anatomical borders of the anterior triangle?
Inferior ramus of the mandible, the posterior border of sternocleidomastoid and the midline of the anterior neck
What are the anatomical borders of the posterior triangle?
Posterior border of sternocleidomastoid, the superior border of the clavicle and the anterior border of trapezius
A patient presents with intermittent painful swelling of the parotid gland on one side of his face. Which single question will you ask him about precipitants of the swelling?
Whether the painful swelling is related to eating
What is the Ann Arbor classification for staging lymphoma?
i) Lymphoma in a single region, usually one lymph node
ii) Lymphoma in two separate lymph node regions on the same side of the diaphragm
iii) Lymphoma on both sides of the diaphragm +/- the spleen
iv) Disseminated extra nodal disease
What is the pathophsiology of Graves’ disease?
Autoimmune, non-destructive, stimulatory thyroid disease
The underlying mechanism is antibody-mediated stimulation of the TSH receptor
What is the pathophysiology of Hashimoto’s disease?
Autoimmune destructive thyroid disease
Antithyroid antibodies are present including antibodies to the TSH R
Underlying mechanism is T-cell mediated destruction of the thyroid gland
Usually presents as hypothyroidism
What are the histological types of thyroid neoplasia? What are most common?
Papillary (~60%) Follicular (~25%) Medullary (~5%) Lymphoma (~5%) Anaplastic Metastatic
What features will raise suspicion of malignancy in patients with a solitary midline neck nodule?
Male Age 70yrs Rapid growth Compression symptoms Previous neck irradiation Family history of MEN
Examination
- Firm, hard nodule
- Fixity to adjacent structures
- Cervical lymphadenopathy
