Neck Lumps Flashcards
List the structures in the neck that can become enlarged leading to the formation of neck lumps.
Arteries Nerves Lymphatics Lymph nodes Salivary glands Larynx Pharynx Branchial arch remnant Skin/superficial subcutaneous tissue Muscle/cartilage/bone
Describe the effect of age on the differential diagnosis of neck lumps.
Young – 75% of neck lumps are benign (usually congenital or inflammatory)
Over 40 yrs – 75% of neck lumps are malignant (80% of these are metastases)
NOTE: as a rule of thumb, in the absence of signs of infection, a lateral neck mass in an adult is lymphadenopathy due to metastatic carcinoma until proven otherwise
List some important questions to ask about the history of presenting complaint.
How long has the lump been there?
Has the lump got bigger, smaller or stayed the same size?
Is the lump painful?
Are there any other lumps?
Describe how the length of time the lump has been around for can help narrow the differential diagnosis.
< few weeks: infective or inflammatory (NOTE: malignant neck lumps may be noticed late)
More than a few weeks: must exclude malignancy
Years with little change: most likely to be benign
How does the size of the lump change in malignancy?
Very slow growing
Except for anaplastic tumours, which grow rapidly
Which types of neck lumps are painful?
Acute infective lymphadenitis
Infected branchial cyst
Why is it important to check for lumps in other parts of the body?
It may indicate systemic disease (e.g. HIV, EBV) or disseminated malignancy (e.g. lymphoma)
List some associated symptoms that are suggestive of infection as the cause of the neck lump.
Malaise
Fever
Rigors
What are the B symptoms of lymphoma?
Fever
Night sweats
Weight loss
List some associated symptoms that may suggest head and neck cancer.
Dysphonia Stridor Stertor Breathing difficulty Dysphagia Odynophagia Globus Cough Haemoptysis Otalgia
List some other features of the history that would suggest that infection is the more likely cause of the neck lump.
History of recent infection (particularly URTI)
Contact with someone who has an infectious disease
Recent trauma, insect bites or animal bites/scratches
List some other features of the history that would suggest that malignancy is the more likely cause of the neck lump.
Previous cancer Family history Previous radiotherapy to the neck Smoking Alcohol
List some types of superficial neck lumps.
Epidermal cyst
Dermoid cyst
Abscess
Lipoma
List some types of neck lump that occur in the anterior triangle.
Branchial cyst/sinus/fistula Carotid body tumour Carotid artery aneurysm Salivary gland pathology Laryngocoele Lymphadenopathy
List some types of neck lump that occur in the posterior triangle.
Cervical rib Lymphatic malformation Pharyngeal pouch Subclavian aneurysm Lymphadenopathy
Describe how the relationship of the lump to surrounding muscles can be tested.
Get the patient to tense the sternocleidomastoid and the trapezius
If the lump is underneath the muscle, it will be concealed when the muscle contracts
Which types of lumps tend to be tender and warm?
Infected or inflammatory lumps
List the diseases that are associated with the following types of neck lumps: Hard Rubbery Soft Fluctuant
Hard Malignant lymph nodes Rubbery Chronic inflammatory lymph nodes (e.g. tuberculosis) Soft Acute inflammatory lymph nodes Fluctuant Branchial cyst Pharyngeal pouch Laryngocoele Epidermal cyst Dermoid cyst
Which types of neck lump may be pulsatile?
Subclavian and carotid artery aneurysms
Carotid body tumours
Describe how the mobility of the neck lumps can give clues about the type of neck lump.
Most lymph nodes are relatively mobile
Malignant lymph nodes appear tethered to surrounding structures
What else should you examine if infectious lymphadenopathy is suspected?
Throat (mainly tonsils)
All lymph nodes in the head and neck
What else should you examine if malignant lymphadenopathy is suspected?
Scalp, face, ears, mouth and nose for potential SCC and malignant melanoma
Otalgia in the absence of anything abnormal on otoscopy suggests malignancy (referred pain to ear)
All lymph nodes in head and neck
Breasts and lungs
Palpate for hepatosplenomegaly (if lymphoma or CLL suspected)
Abdominal examination if Virchow’s node is enlarged
Why is it important to examine the facial nerve if the patient has a parotid swelling?
The facial nerve sits between the superficial and deep lobes of the parotid gland and a malignant tumour of the parotid may cause facial nerve palsy
What method is used to diagnose the cause of lymphadenopathy?
Fine needle aspiration
List the differential diagnosis of midline neck lumps.
- Thyroid Physiological goitre Multinodular goitre Graves’ disease Hashimoto’s thyroiditis Thyroglossal cyst Thyroid cyst Solitary adenoma - Non-thyroid Lipoma Dermoid cyst Epidermal cyst
What is the thyroglossal duct?
A remnant of the connection between the origin of the thyroid gland in the buccal cavity and its normal position in the neck
How does the length of time that the lump has been present help narrow the differential diagnosis?
Sudden appearance = acute haemorrhage into thyroid cyst, rapid-growing thyroid cancer, subacute thyroiditis
NOTE: thyroglossal cysts may have been present for a long time but they may only be noticed due to an infection causing it to grow rapidly
What can cause a rapid increase in the size of a midline neck lump?
Haemorrhage or infection in an existing lump (e.g. cyst)
Which type of thyroid cancer grows rapidly?
Anaplastic cancer
Which midline neck lumps are painful?
Subacute thyroiditis
Infected thyroglossal cyst
Acute haemorrhagic cyst
What should be assumed if an enlarged thyroid gland is accompanied by cervical lymphadenopathy?
Malignant until proven otherwise
List some signs and symptoms of hyperthyroidism.
Weight loss Increased appetite Irritable Diarrhoea Heat intolerance Palpitations Oligomenorrhoea Fine tremor Sweating Palmar erythema Clubbing Onycholysis Lid lad Exophthalmos Proximal myopathy
List some signs and symptoms of hypothyroidism.
Weight gain Fatigue Constipation Cold intolerance Bradycardia Slow, deep voice Slow reflexes
List some symptoms suggestive of compression or invasion of surrounding structures.
Stridor
Dyspnoea
Dysphagia
What does a change in voice suggest?
Malignant invasion of the recurrent laryngeal nerve
List some key features of the past medical history of a patient with a midline neck lump.
Autoimmune disorders – Graves’ and Hashimoto’s both occur more commonly in patients with other autoimmune diseases
Risk factors for thyroid malignancy
List some key features of the family history of a patient with a midline neck lump.
Autoimmune disease
Hereditary forms of thyroid cancer - 25% of medullary thyroid cancer is familial and may occur as part of MEN-2 syndrome
Which types of midline neck lump:
Moves on swallowing
Moves on tongue protrusion
Is tethered to neighbouring muscle or skin
- Moves on swallowing Thyroid lump - Moves on tongue protrusion Thyroglossal cyst - Is tethered to neighbouring muscle or skin Malignant Riedel’s thyroiditis
List the types of midline neck lump that have the following characteristics:
Diffuse, smooth enlargement
Physiological goitre
Graves’ disease
Hashimoto’s thyroiditis
de Quervain’s thyroiditis
List the types of midline neck lump that have the following characteristics:
Solitary, solid nodule
Malignancy
List the types of midline neck lump that have the following characteristics:
Solitary, cystic nodule
Thyroglossal cyst
Epidermal cyst
Dermoid cyst
Thyroid cyst
List the types of midline neck lump that have the following characteristics:
Multiple nodules
Multinodular goitre
What sign may be elicited in patients with retrosternal goitres?
Pemberton Sign – raising the arms above the head causes plethora and facial venous congestion due to thoracic inlet obstruction by a retrosternal mass
Describe how TSH levels may indicate hypo- and hyperthyroidism.
Hypothyroidism – HIGH TSH
Hyperthyroidism – LOW TSH
What might an elevated serum calcitonin suggest?
Medullary thyroid cancer is a tumour of the calcitonin-secreting parafollicular C-cells
NOTE: this is only significant if there is a family history of thyroid cancer (or MEN-2)
FNA is often used to investigate thyroid nodules. What is a disadvantage of using FNA?
It cannot distinguish between benign follicular adenoma and malignant follicular thyroid carcinoma
What other type of scanning is frequently used to identify ‘hot’ and ‘cold’ nodules?
Radionuclide scanning with Technetium-99 or Iodine-123
Outline the treatment of follicular thyroid lesions.
Surgery T3 replacement Iodine-131 ablation T4 suppression Follow-up
What is the name given to tumours of the carotid body?
Chemodectoma
Describe the mobility and character of a chemodectoma.
It moves side to side but not up or down
It may have a transmitted pulse
Slow-growing
What are the characteristic features of glandular fever?
Fever
Sore throat
Lymphadenopathy
Name two other diseases that can cause cervical lymphadenopathy with splenomegaly.
Acute CMV
Toxoplasmosis
List some investigations used to diagnose glandular fever.
FBC – look for leukocytosis and lymphocytosis
Heterophil antibody test – look for agglutination and precipitation
Blood film – look for lymphocytosis and atypical lymphocytes
Describe the typical presentation of a branchial cyst.
A fluctuant, non-tender lump in the upper third of the neck, anterior to the sternocleidomastoid
How are epidermal cysts formed?
They are formed due to blockage of the sebaceous glands
What risk factor greatly increases the likelihood of developing thyroid eye disease in Graves’?
Smoking
Describe some treatments used for Graves’ disease.
Thionamides (propylthiouracil and carbimazole)
Beta-blockers (reduce symptoms of hyperthyroidism)
Radioiodine
Total thyroidectomy
What is a rare but important side-effect of the use of carbimazole?
Agranulocytosis
