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Oxford Clinical Cases > Neck Lumps > Flashcards

Neck Lumps Flashcards

1
Q

List the structures in the neck that can become enlarged leading to the formation of neck lumps.

A 
Arteries
Nerves 
Lymphatics 
Lymph nodes 
Salivary glands 
Larynx 
Pharynx 
Branchial arch remnant 
Skin/superficial subcutaneous tissue 
Muscle/cartilage/bone
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2
Q

Describe the effect of age on the differential diagnosis of neck lumps.

A

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

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3
Q

List some important questions to ask about the history of presenting complaint.

A

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?

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4
Q

Describe how the length of time the lump has been around for can help narrow the differential diagnosis.

A

< 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

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5
Q

How does the size of the lump change in malignancy?

A

Very slow growing

Except for anaplastic tumours, which grow rapidly

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6
Q

Which types of neck lumps are painful?

A

Acute infective lymphadenitis

Infected branchial cyst

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7
Q

Why is it important to check for lumps in other parts of the body?

A

It may indicate systemic disease (e.g. HIV, EBV) or disseminated malignancy (e.g. lymphoma)

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8
Q

List some associated symptoms that are suggestive of infection as the cause of the neck lump.

A

Malaise
Fever
Rigors

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9
Q

What are the B symptoms of lymphoma?

A

Fever
Night sweats
Weight loss

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10
Q

List some associated symptoms that may suggest head and neck cancer.

A 
Dysphonia
Stridor
Stertor
Breathing difficulty 
Dysphagia
Odynophagia
Globus
Cough 
Haemoptysis 
Otalgia
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11
Q

List some other features of the history that would suggest that infection is the more likely cause of the neck lump.

A

History of recent infection (particularly URTI)
Contact with someone who has an infectious disease
Recent trauma, insect bites or animal bites/scratches

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12
Q

List some other features of the history that would suggest that malignancy is the more likely cause of the neck lump.

A 
Previous cancer 
Family history 
Previous radiotherapy to the neck
Smoking 
Alcohol
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13
Q

List some types of superficial neck lumps.

A

Epidermal cyst
Dermoid cyst
Abscess
Lipoma

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14
Q

List some types of neck lump that occur in the anterior triangle.

A 
Branchial cyst/sinus/fistula
Carotid body tumour
Carotid artery aneurysm
Salivary gland pathology
Laryngocoele 
Lymphadenopathy
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15
Q

List some types of neck lump that occur in the posterior triangle.

A 
Cervical rib
Lymphatic malformation
Pharyngeal pouch
Subclavian aneurysm
Lymphadenopathy
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16
Q

Describe how the relationship of the lump to surrounding muscles can be tested.

A

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

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17
Q

Which types of lumps tend to be tender and warm?

A

Infected or inflammatory lumps

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18
Q 
List the diseases that are associated with the following types of neck lumps:
Hard
Rubbery
Soft
Fluctuant
A 
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
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19
Q

Which types of neck lump may be pulsatile?

A

Subclavian and carotid artery aneurysms

Carotid body tumours

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20
Q

Describe how the mobility of the neck lumps can give clues about the type of neck lump.

A

Most lymph nodes are relatively mobile

Malignant lymph nodes appear tethered to surrounding structures

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21
Q

What else should you examine if infectious lymphadenopathy is suspected?

A

Throat (mainly tonsils)

All lymph nodes in the head and neck

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22
Q

What else should you examine if malignant lymphadenopathy is suspected?

A

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

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23
Q

Why is it important to examine the facial nerve if the patient has a parotid swelling?

A

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

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24
Q

What method is used to diagnose the cause of lymphadenopathy?

A

Fine needle aspiration

25
Q

List the differential diagnosis of midline neck lumps.

A 
- Thyroid 
Physiological goitre 
Multinodular goitre 
Graves’ disease 
Hashimoto’s thyroiditis 
Thyroglossal cyst 
Thyroid cyst 
Solitary adenoma 
- Non-thyroid
Lipoma
Dermoid cyst 
Epidermal cyst
26
Q

What is the thyroglossal duct?

A

A remnant of the connection between the origin of the thyroid gland in the buccal cavity and its normal position in the neck

27
Q

How does the length of time that the lump has been present help narrow the differential diagnosis?

A

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

28
Q

What can cause a rapid increase in the size of a midline neck lump?

A

Haemorrhage or infection in an existing lump (e.g. cyst)

29
Q

Which type of thyroid cancer grows rapidly?

A

Anaplastic cancer

30
Q

Which midline neck lumps are painful?

A

Subacute thyroiditis
Infected thyroglossal cyst
Acute haemorrhagic cyst

31
Q

What should be assumed if an enlarged thyroid gland is accompanied by cervical lymphadenopathy?

A

Malignant until proven otherwise

32
Q

List some signs and symptoms of hyperthyroidism.

A 
Weight loss 
Increased appetite 
Irritable 
Diarrhoea 
Heat intolerance 
Palpitations 
Oligomenorrhoea 
Fine tremor 
Sweating 
Palmar erythema
Clubbing 
Onycholysis 
Lid lad 
Exophthalmos
Proximal myopathy
33
Q

List some signs and symptoms of hypothyroidism.

A 
Weight gain 
Fatigue 
Constipation 
Cold intolerance 
Bradycardia
Slow, deep voice 
Slow reflexes
34
Q

List some symptoms suggestive of compression or invasion of surrounding structures.

A

Stridor
Dyspnoea
Dysphagia

35
Q

What does a change in voice suggest?

A

Malignant invasion of the recurrent laryngeal nerve

36
Q

List some key features of the past medical history of a patient with a midline neck lump.

A

Autoimmune disorders – Graves’ and Hashimoto’s both occur more commonly in patients with other autoimmune diseases
Risk factors for thyroid malignancy

37
Q

List some key features of the family history of a patient with a midline neck lump.

A

Autoimmune disease

Hereditary forms of thyroid cancer - 25% of medullary thyroid cancer is familial and may occur as part of MEN-2 syndrome

38
Q

Which types of midline neck lump:
Moves on swallowing
Moves on tongue protrusion
Is tethered to neighbouring muscle or skin

A 
- Moves on swallowing 
Thyroid lump
- Moves on tongue protrusion
Thyroglossal cyst 
- Is tethered to neighbouring muscle or skin 
Malignant
Riedel’s thyroiditis
39
Q

List the types of midline neck lump that have the following characteristics:
Diffuse, smooth enlargement

A

Physiological goitre
Graves’ disease
Hashimoto’s thyroiditis
de Quervain’s thyroiditis

40
Q

List the types of midline neck lump that have the following characteristics:
Solitary, solid nodule

A

Malignancy

41
Q

List the types of midline neck lump that have the following characteristics:
Solitary, cystic nodule

A

Thyroglossal cyst
Epidermal cyst
Dermoid cyst
Thyroid cyst

42
Q

List the types of midline neck lump that have the following characteristics:
Multiple nodules

A

Multinodular goitre

43
Q

What sign may be elicited in patients with retrosternal goitres?

A

Pemberton Sign – raising the arms above the head causes plethora and facial venous congestion due to thoracic inlet obstruction by a retrosternal mass

44
Q

Describe how TSH levels may indicate hypo- and hyperthyroidism.

A

Hypothyroidism – HIGH TSH

Hyperthyroidism – LOW TSH

45
Q

What might an elevated serum calcitonin suggest?

A

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)

46
Q

FNA is often used to investigate thyroid nodules. What is a disadvantage of using FNA?

A

It cannot distinguish between benign follicular adenoma and malignant follicular thyroid carcinoma

47
Q

What other type of scanning is frequently used to identify ‘hot’ and ‘cold’ nodules?

A

Radionuclide scanning with Technetium-99 or Iodine-123

48
Q

Outline the treatment of follicular thyroid lesions.

A 
Surgery
T3 replacement 
Iodine-131 ablation 
T4 suppression 
Follow-up
49
Q

What is the name given to tumours of the carotid body?

A

Chemodectoma

50
Q

Describe the mobility and character of a chemodectoma.

A

It moves side to side but not up or down
It may have a transmitted pulse
Slow-growing

51
Q

What are the characteristic features of glandular fever?

A

Fever
Sore throat
Lymphadenopathy

52
Q

Name two other diseases that can cause cervical lymphadenopathy with splenomegaly.

A

Acute CMV

Toxoplasmosis

53
Q

List some investigations used to diagnose glandular fever.

A

FBC – look for leukocytosis and lymphocytosis
Heterophil antibody test – look for agglutination and precipitation
Blood film – look for lymphocytosis and atypical lymphocytes

54
Q

Describe the typical presentation of a branchial cyst.

A

A fluctuant, non-tender lump in the upper third of the neck, anterior to the sternocleidomastoid

55
Q

How are epidermal cysts formed?

A

They are formed due to blockage of the sebaceous glands

56
Q

What risk factor greatly increases the likelihood of developing thyroid eye disease in Graves’?

A

Smoking

57
Q

Describe some treatments used for Graves’ disease.

A

Thionamides (propylthiouracil and carbimazole)
Beta-blockers (reduce symptoms of hyperthyroidism)
Radioiodine
Total thyroidectomy

58
Q

What is a rare but important side-effect of the use of carbimazole?

A

Agranulocytosis

Oxford Clinical Cases (28 decks)

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