Neck lumps pathology

Question 1

What is a branchial cyst?

Answer 1

-Original theory: branchial pouch remnant
-Now: Stratified squamous incorporated into cervical lymph tissue

Originally thought to be a branchial pouch remnant
However, the general consensus has now changed and branchial cysts are thought to be
stratified squamous epithelium incorporated into cervical lymph tissue

Question 2

Where are branchial cysts most commonly found?

Answer 2

-Anterior to upper 1/3rd of the sternocleidomastoid muscle (SCM)
-anterior triangle of the neck
-2% are bilateral

Question 3

When do branchial cysts present?

Answer 3

Most commonly seen in the 2nd - 3rd decade of life

Question 4

How would you describe branchial cyst?

Answer 4

-Firm, smooth swellings
-Can become infected

Question 5

How would you investigate a patient with a branchial cyst?

Answer 5

Fine needle aspirate (FNA)
This can be carried out in the clinic or under ultrasound guidance
MRI / CT neck to assess the extent of the mass and its relationship to major vessels

Question 6

Describe aspirate of branchial cyst

Answer 6

The aspirate is typically straw coloured and rich in cholesterol, although pus may be present
when infected

Question 7

How would you treat a branchial cyst?

Answer 7

Excision. Not to be undertaken lightly!
This must be carried out when the cyst is not infected as this will increase the risk of rupture
and recurrence

Question 8

The next patient has been referred as they have a midline neck swelling that moves when they
protrude their tongue
What is the diagnosis?

Answer 8

Thyroglossal cyst

Question 9

What is a thryoglossal cyst?
When do they present?
How do they present?

Answer 9

-Remnant of thyroglossal duct
-Presents in 1st decade
-Elevate when tongue is protruded

It is a remnant of the thryoglossal duct which represents the embryological path of the thyroid gland from its origin at the base of the tongue (foramen caecum)

The thyroglossal duct is usually obliterated after the descent of the thyroid gland

40% present in 1st decade with mean age of presentation 4 years old. However, they can be
seen much later into adult life

They will elevate when the tongue is protruded due to the embryological origin at the base of the tongue

Can enlarge rapidly if become infected

Question 10

Are thyroglossal cysts always found in the midline?

Answer 10

No.
80 - 90% are in the midline
They can lie anywhere from the chin to the 2nd tracheal ring and be slightly off the midline

Question 11

What other diagnoses should you consider as differential for swelling in midline?

Answer 11

Dermoid cyst
Lymph node
Sebaceous cyst
Thyroid nodule

Question 12

What is the name of the operation to excise a thyroglossal cyst?

Answer 12

Sistrunk’s procedure
The thyroglossal duct surrounds the body of the hyoid bone and it is removed along with the
cyst
If the hyoid bone is not removed then recurrence rate is > 80%

Question 13

The excised thyroglossal cyst is sent for histology. What will the cyst contain?

Answer 13

Most likely lymphoid tissue

It may contain ectopic thyroid tissue and it is essential to fully investigate the lump prior to surgery as the cyst may be the only functioning thyroid tissue that a patient has.

Ultrasound is used to assess the mass but also to look for a normal thyroid gland

Question 14

What is a dermoid cyst?

Answer 14

It is an epithelial lined cyst that lies deep to the skin
They can be:
Congenital: result from inclusion of the epidermis along fusion lines of skin dermatomes
or
Acquired: usually secondary to an injury and skin forced into a wound

Question 15

What are the most common sites for congenital dermoid cyst?

Answer 15

Medial and lateral aspects of the eyebrows
Midline of nose
Midline of neck and trunk

Question 16

How would you treat a dermoid cyst?

Answer 16

Excision but with caution as congenital dermoid cysts may communicate with deep structures
Therefore pre-operative imaging may be required

Question 17

What is a sebaceous cyst?

Answer 17

Epidermoid or pilar cyst

The term sebaceous cyst is not fully correct. Used to describe below:
The correct terminology is either:
An epidermoid cyst: cyst that arises from epidermis
73
or
A pilar cyst: cyst that arises from hair follicles

Question 18

What are the classical clinical features of sebaceous cyst?

Answer 18

Smooth lumps attached to the skin and therefore do not move independently
Often firm consistency
May have a punctum, that may discharge
Can be erythematous and painful when infected.

Question 19

What are the most common sites that sebaceous cysts occur?

Answer 19

Scalp
Face
Neck
Trunk

Question 20

What is the treatment for sebaceous cyst?

Answer 20

Most commonly excised with overlying skin as it contains a punctum

Question 21

What is a lipoma?

Answer 21

It is benign collection of fat cells that is typically found in the subcutaneous layer of skin

Question 22

What are the clinical features of a lipoma?

Answer 22

Soft and slightly mobile
Very slow growing
Most common sites are shoulders and trunk
They are not found on palms or soles

Question 23

What is the treatment of lipomas?

Answer 23

Often no treatment
or
Excision (often for cosmetic reasons)

Question 24

The next patient is an emergency referral from a GP with an acute left side submandibular
swelling

The swelling has arisen over the past 24 hours, it is warm, red and very painful. It was
preceded by 2 days of dental pain

What is the most likely diagnosis of this neck swelling?

Answer 24

Submandibular abscess secondary to a dental cause

Question 25

How would you manage this patient with submandibular abscess?

Answer 25

-Assess floor of mouth for ludwig’s angina
-Perform fibreoptic nasoendoscopy to assess airway
-OPG to check dentition
-Start IV abx
-Refer to maxfax

Examine the oral cavity looking particularly for floor of mouth swelling as this means the
airway is becoming compromised
Perform a fibre optic nasendoscopy to assess the airway. Submandibular abscesses can very
rapidly progress to Ludwig’s Angina
If possible get an orthopantomogram (OPG) to assess the dentition
Start IV antibiotics (based on local guidelines but most commonly amoxicillin and
metronidazole)
Refer urgently to Oral and Maxillofacial team on call

Question 26

What is Ludwig’s angina?

Answer 26

-Cellulitis of soft tissues of neck and floor of mouth
-Spreads throughout both submandibular spaces causing elevation + posterior displacement of tongue
-Leads to airway obstruction
-Mostly requires intra and extra oral drainage with removal of causative tooth
-Can cause airway oedema necessitating surgical airway

It is a clinical diagnosis of cellulitis of the soft tissues of the neck and floor of the mouth.
Cellulitis spreads throughout both submandibular spaces causing elevation and posterior
displacement of the tongue. This leads to airway obstruction.
Dental causes account for > 90% of cases
The majority of cases require intra & extra oral incision and drainage with extraction of the
causative tooth
A small proportion of patients may require a surgical airway as intubation may not be
possible due to airway oedema

Question 27

What is a cystic hygroma?

Answer 27

-Congenital cystic malformation of lymphatic system
-Most commonly in posterior triangle
-Can rapidly enlarge if infected, can interfere with breathing/swalloign

It is a congenital cystic malformation of the lymphatic system
They can develop anywhere in the body but are most common found in the posterior triangle
of the neck
The majority are visible at birth and 90% are detected by 2 years of age
Can rapidly enlarge when infected and this can interfere with breathing and swallowing

Question 28

What is the treatment of cystic hygroma?

Answer 28

Aspiration and injection with a sclerosing agent
or
Surgical excision

Question 29

What is a pharyngeal pouch?

Answer 29

-It is a diverticulum through Killian’s dehiscence.
-Killian’s dehiscence is found between the upper and lower portions of the inferior pharyngeal constrictor muscle

Question 30

Describe the age of presentation and clinical features of a pharyngeal pouch.

Answer 30

Most common in males over 70 years of age
Often no lump in the neck, occasionally a lump that gurgles may be noticed
Patients often present with: regurgitation, halitosis, weight loss and chronic cough

Question 31

How is a pharyngeal pouch investigated?

Answer 31

Barium swallow

Question 32

How is a pharyngeal pouch treated?

Answer 32

If small and asymptomatic then no treatment is required
However if treatment is required then either endoscopic stapling or external approach
excision is performed

Question 33

What general principles should be adhered to when examining and investigating a
patient with a neck lump?

Answer 33

Full ENT exam including fibre optic nasendoscopy –> FNA or core biopsy (US guided if necessary) –> further imaging

All patients require a full Ear, Nose and Throat examination including direct (fibre optic
nasendoscopy) or indirect laryngoscopy (mirror)
If it is safe and with appropriate experience then either an fine needle aspirate (FNA) or core
biopsy should be taken in clinic to aid diagnosis
If this is not possible then an FNA can be carried out under ultrasound guidance
If there is a strong suspicion of malignancy many clinicians will also arrange appropriate
imaging before a tissue diagnosis is made
In summary:
History –> Full ENT examination –> FNA –> Further imaging

Question 34

Differential diagnosis of a neck lump?

Answer 34

Superficial:
Sebaceous cyst
Lipoma
Abscess

Anterior triangle:

-Thyroglossal cyst
-Thyroid swelling
-Dermoid cyst
-Submandibular gland pathology
-Branchial cyst
-Carotid body tumour
-Lymphadenopathy

Posterior triangle:
-Pharyngeal pouch
-Cystic hygroma
-Lymphadenopathy

Within SCM:
Sternocleidomastoid tumor