Neck Lumps

Question 1

What questions should you ask when assessing a neck lump?

Answer 1

How long has the lump been present?
If < 3 weeks reactive lymphadenopathy from a self-limiting infection is likely

Which tissue layer is the lump in?
Intradermal: sebaceous cyst with central punctum, lipoma

SSS CCC TTT
Site size Surface
Colour
Contour
Consistency
Tenderness
Temperature
Transilluminable

Fluctuance
Fixed
Fields

Pulsatile Expansile Reducible

Question 2

What investigations in neck lumps?

Answer 2

US 
CT
Mantoux
CXR
Fine needle aspiration cytology

Question 3

What is likely in a midline lump in a <20 year old?

Answer 3

Dermoid cyst

Question 4

What is likely if the midline lump moves up on protruding the tongue and is below the hyoid? What is this?

Answer 4

Thyroglossal cyst - fluid filled sac resulting from incomplete closure of the thyroid’s migration path

Surgery

Question 5

What is likely if midline lump > 20 years old

What is if it bony hard?

Answer 5

Thyroid mass - moves upward on swallowing

Chondroma - benign cartilaginous tumour

Question 6

What are the borders of the submandibular triangle?

Answer 6

Above - mandible Below - digastric

Question 7

What is likely if submandibular triangle lump < 20 years?

Answer 7

Reactive lymphadenopathy

Question 8

What should you check if submandibular triangle lump > 20 years? How would you determine this?

Answer 8

Malignant lymphadenopathy 
Firm and non-tender
Fever
Night sweats
Weight loss

TB?

Question 9

What is likely if submandibular triangle lump if it is not a node?

Answer 9

Submandibular salivary stone
Tumour
Sialadenitis - inflammation of salivary glands

Question 10

What are the borders of the anterior triangle?

Answer 10

Between midline, anterior border of sternocleidomastoid and the line between the two angles of the mandible

Question 11

What are branchial cysts? Where do they occur? Investigation? Mx?

Answer 11

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Usually unilateral

Emerge under anterior border of sternocleidomastoid where the upper 1/3 meets the middle 1/3

Develop due to failure of obliteration of the second branchial cleft in embryonic development

Usually present in early adulthood

Investigation: FNAC - acellular fluid with cholesterol crystals

Treat by excision

Question 12

What is a lump in the superoposteriar are of the anterior triangle

Answer 12

Parotid tumour

Question 13

How do laryngocoeles present?

Answer 13

Painless
Males
Made worse by blowing

Question 14

What can an anterior triangle pulsatile lump be?

Answer 14

Carotid artery aneurysm
Tortuous carotid artery
Carotid body tumour (chemodectoma)

Question 15

Describe a carotid body tumour

Answer 15

Move from side to side but not up and down and splay out the carotid bifurcation.
Firm and pulsatile
Suspact andy mass just anterior to the upper 1/3 of sternocleidomastoid

Do MRA

Question 16

What are the borders of the posterior triangle?

Answer 16

Behing sterncleidomastoid
Infront of trapezium
Above clavicle

Question 17

What lumps can occur in the posterior triangle?

Answer 17

Cervical ribs may intrude into this area
Can cause neurological symptoms by compressing brachial plexus or Raynaud’s by compressing the subclavian artery

Pharyngeal pouches can protrude into posterior triangle on swallowing

Cystic hygromas
- congenital lymphatic lesion classically on the left side

Lymphadenopathy if many small lumps

• TB, viruses, HIV, EBV
• Lymphoma - B symptoms?
• Metastases

Question 18

What would you see in lymphoma?

Answer 18

Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly

Question 19

What would you see in a thyroid swelling?

Answer 19

Moves upwards on swallowing

Question 20

What would you see in thyroglossal cyst?

Answer 20

More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected

Question 21

What are features of pharyngeal pouch?

Answer 21

More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Question 22

What are features of branchial cyst?

Answer 22

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood

Question 23

What are features of carotid aneurysm?

Answer 23

Pulsatile lateral neck mass which doesn’t move on swallowing

Question 24

What are complications of thyroid surgery?

Answer 24

Anatomical such as recurrent laryngeal nerve damage.

Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.

Damage to the parathyroid glands resulting in hypocalcaemia.