Surgery: Neck Lumps

Question 1

Anterior, Midline and Posterior Triangle Lumps

What is the presentation of Cervical Rib?

Answer 1

• Hard swelling: mostly asymmpomatic
• Vascular symptoms
• Neurological symptoms

Question 2

Anterior, Midline and Posterior Triangle Lumps

What are the Vascular symptoms of Cervical Rib?

Answer 2

Question 3

Anterior, Midline and Posterior Triangle Lumps

What are the Neurological symptoms of Cervical Rib?

Answer 3

Question 4

Causes of a midline neck lump

Answer 4

Lymph node
Lipoma
Dermoid cyst
Epidermoid cyst
**Enlarged thyroid gland
Thyroid nodule
Thyroglossal cysts
Laryngocele

Question 5

Causes of a neck lump located in the anterior triangle

Answer 5

Lymph node
Lipoma
Epidermoid cyst
**Submandibular gland swelling
Branchial cyst
Carotid artery aneurysm
Carotid body tumour
Laryngocele

Question 6

Causes of a neck lump located in the posterior triangle

Answer 6

Lymph node
Lipoma
Epidermoid cyst
Subclavian artery aneurysm
Pharyngeal pouch
Cystic hygroma
Branchial cyst
Mass in the tail of the parotid gland

Question 7

Cystic Hygroma Picture:

Answer 7

Question 8

Branchial Cyst

Answer 8

Question 9

Thyroglossal Cyst

Answer 9

Question 10

Goitre

Answer 10

Question 11

Neck Lumps Key History Questions

Answer 11

• Duration of onset
• Any recent change in size, number of neck lumps
• Associated symptoms (especially red flag symptoms, discussed below)
• Relevant past medical history – smoking status, alcohol intake, previous head and neck cancers, and known radiation exposure (e.g. previous radiotherapy)

Question 12

Red Flags for a Neck Lump

Answer 12

• Hard, painful and fixed lump
• Associated otalgia, dysphagia, stridor, or hoarse voice
• Unilateral nasal symptoms such as epistaxis, discharge, or congestion
• Unexplained weight loss, night sweats, or fever or rigors
• Cranial nerve palsies

Question 13

Differential Diagnoses

The possible causes of a neck lump can be formulated using a ‘surgical s

Answer 13

Infective

• Reactive lymphadenopathy – increase in size of the cervical lymph nodes in response to infection
• Sialadenitis

Neoplastic

• Lymphoma – a haematological malignancy that commonly causes lymphadenopathy
• Head and Neck Cancer or Salivary Gland Tumour
• Metastatic disease spread
• Skin lump, ranging from benign (e.g. lipoma) to malignant (skin cancer)

Vascular
*Carotid body tumour (see below)

Inflammatory
*Sarcoidosis

Traumatic
*Haematoma

Autoimmune
*Thyroid disease, such as Graves’ disease
Congenital
* Cystic hygroma (see below)
* Thyroglossal cyst (see below)
* Branchial cyst (see below)
* Dermoid cyst – a cystic type teratoma, form along the lines of embryological fusion, can present as midline painless lumps, more common in children and young adults

Question 14

Investigations for a Neck Lump

Answer 14

The first-line investigation for a suspicious neck lump is ultrasound +/- fine needle aspiration (FNA).

Question 15

What is a Cystic Hygroma?

Answer 15

A cystic hygroma (also known as a cystic lymphangioma) is a benign fluid-filled sac caused by a malformation of the lymphatic system. They can be found anywhere on the body, but classically presents in the axilla or posterior triangle of the neck.

Question 16

Presentation of a Cystic Hygroma?

Answer 16

Cystic hygromas are typically noticed and diagnosed before aged two years, presenting as soft painless fluctuant masses that transilluminate. They can be associated with congenital conditions (e.g. Turners syndrome) and can grow large enough to cause airway obstruction or dysphagia.

Question 17

What is a Carotid Body Tumour

Answer 17

Carotid body tumours (also known as a carotid paragangliomas) are benign neuroendocrine tumours that arise from the paraganglion cells of the carotid body. The carotid body is made up of a cluster of neuroendocrine cells, whereby sporadic (or hereditary) mutations lead to the formation of paragangliomas (Fig. 4).

Question 18

How does a Carotid Body Tumour Present?

Answer 18

A carotid body tumour will present as a pulsatile painless neck lump, often with a bruit present on auscultation*. Carotid paragangliomas are slow growing, but can become large enough to compress surrounding cranial nerves, leading to palsies. Rarely, patients can present in cardiac arrhythmia if the carotid sinus is stimulated by compression from the tumour.

Question 19

What is a Thyroglossal Cyst?

Answer 19

A thyroglossal cyst is a congenital fluid filled sac, commonly presenting in younger patients (typically <20yrs) and have equal incidence between men and women.

Embryology of Thyroglossal Cysts
During embryonic development, the thyro

Question 20

How does a Thryoglossal Cyst present?

Answer 20

hyroglossal cysts present as a palpable painless midline mass* (Fig. 5A) that move up with swallowing and protrusion of the tongue. When infected, they can increase in size and become painful.

Question 21

What is a Branchial Cyst?

Answer 21

Branchial cysts are congenital masses which arise in the lateral aspect of the neck, typically anterior to the sternocleidomastoid (SCM).

During the fourth week of development, branchial clefts form ridges know

Question 22

How does a Branchial Cyst Present?

Answer 22

They present as palpable masses anterior to SCM, typically unilateral (Fig. 6). When infected, they can increase in size and become painful. Larger branchial cysts can result in dysphagia, dysphonia, and difficulty breathing.