Swelling in neck Flashcards
Congenital causes for lump in neck?
Brachial cyst
Thyroglossal duct cyst
What is branchial cyst?
Benign, developmental defect of branchial arches
Why are branchial cysts prone to infections?
May have fistula - so infection can manifest.
What may be in immediate PMH in pt presenting w/ branchial cyst?
Respiratory tract infection —> branchial cysts enlarge after a resp infection
Epidemiology of branchial cyst? Who?
Pt is late childhood/early adulthood
Female
Ddx for branchial cyst?
Congential: Thyroglossal duct cyst, Dermoid cyst, Vascular malformation
Inflammatory: Reactive lymphadenopathy, Lymphadenitis
Neoplastic: lymphoma, thyroid tumour, salivary gland tumour
Inv for branchial cyst?
USS
Referral to ENT (if in GP setting)
Fine needle aspiration
Management for branchial cyst?
Conservative
Surgical excision
Abx for any acute infection
How does thyroglossal duct cyst arise?
Thyroid develops from floor of pharynx.
Thyroid is connected to tongue by the thyroglossal duct.
Normally TGD atrophies but sometimes persists = TGDC
Presentation of thyroglossal duct cyst?
Pt <20yrs
Midline lump
Moves upwards on tongue protrusion
Painless usually. Painful if infected
Management of thyroglossal duct cyst?
Surgical excision
Abx if infected
Malignant causes of neck lumps?
Metastatic cancer
Thyroid cancer
Lymphoma
Borders of anterior triangle of neck?
Superiorly – inferior border of the mandible (jawbone).
Laterally – anterior border of the sternocleidomastoid.
Medially – sagittal line down the midline of the neck.
Borders of posterior triangle of neck?
Anterior – posterior border of the sternocleidomastoid.
Posterior – anterior border of the trapezius muscle.
Inferior – middle 1/3 of the clavicle.
Name superficial lymph nodes in neck
Submental
Submandibular
Pre-auricular
Post-auricular
Occipital
Superficial cervical
Posterior cervical
Anterior cervical
Name three deep lymph nodes in the neck
Jugulo-digastric
Jugulo-omohyoid
Supraclavicular
Differentials for cervical lymphadenopathy?
Acute infection - viral infection, infective mononucleosis, toxoplasmosis, infected eczema
Chronic infection - TB, HIV, syphilis
Malignancy - Hodgkin’s and non-Hodgkin’s lymphoma, chronic lymphocytic leukaemia, acute lymphoblastic leukaemia,
secondary malignancy - thyroid, nasopharyngeal, breast, lung, stomach
Other causes - RA, sarcoidosis, phenytoin reaction, Kawasaki’s syndrome
What to ask in Hx for neck lump?
Lump:
◦ Duration
◦ Position, Mobility
◦ Pain, tender
◦ Relation to swallowing
Associated symptoms:
◦ Sore throat/Dysphagia/Odynophagia
◦ Dysphonia/Otalgia/Other neck lumps
◦ Fever, night sweats, TB contact, travel abroad
◦ Smoking, alcohol
What examinations would you do for neck lump?
Clinical ENT examination
—> clinical neck examination - Site, size, shape
—> flexible endoscopy to visualize the nose,
nasopharynx, oropharynx, hypopharynx and larynx
Think - is it in posterior or anterior triangle? Midline or lateral placement? Movement on swallowing or tongue protrusion? Palpation features?
- feel deeper? superficial?
- hard/soft/smooth/irregular?
- fixed or mobile?
- tender? non-tender?
- overlying skin changes? redness etc
What investigations to do for neck lump?
Bloods
◦ FBC, CRP, monospot
FNAC (fine needle aspiration cytology) - Don’t incise or excise neck mass if might be SCC
CXR/USS/CT/MRI
Endoscopy and formal biopsy of primary
What are red flags for neck lump?
Persists 6+ weeks
Fixed, hard, irregular
Rapidly growing in size
Associated with generalised lymphadenopathy
Systemic signs- weight loss, night sweats
Change in voice/hoarseness
Dysphagia/Odynophagia
Risk factors for head and neck cancer?
Smoking
Alcohol misuse
HPV, EBV
Radiation exposure - UV, CT scanners
Immunosuppression
Occupation - acid mists, asbestos, wood dust
FHx
General clinical presentation of head and neck cancers?
Hoarsness/change in voice
Throat pain
Tongue ulcers
Painless neck lump
Sx present for 3+ weeks
If tumour is endocrine in nature - have weight loss, hormonal Sx
Presentation of laryngeal cancer (to refer via 2ww)?
Persistent, unexplained hoarseness
Unexplained lump in neck
Presentation of oral cancer (to refer for 2ww)?
Unexplained ulceration in oral cavity for 3+ weeks
Persistent, unexplained lump in neck
Lump on lip or in oral cavity
Red/red and white patch in oral cavity - erythroplakia/erythroleukoplakia
Presentation of thyroid cancer (to refer for 2ww)?
Unexplained thyroid lump
Causes of a neck lump?
Reactive lymphadenopathy - v v common
Lymphoma
Thyroid swelling
Thyroglossal duct cyst
Pharyngeal pouch
Branchial cyst
Cervical rib
Carotid aneurysm
Presentation of Hodgkin’s lymphoma?
Lymphadenopathy - non-tender, painless, asymmetrical
Systemic Sx - weight loss, pruritus, night sweats, fever
Painful LN after drinking alcohol
LDH raised
Normocytic anaemia, eosinophilia
Name of cell characteristically seen in Hodgkin’s lymphoma?
Reed-Sternberg cell
Staging for Hodgkin’s and non-Hodgkin’s lymphoma?
Ann-Arbor staging
Management for lymphoma?
Watchful waiting
Radiotherapy
Chemotherapy
Flu and pneumococcal vaccine
Investigations for neck lump / suspected lymphoma
Bloods:
* FBC
* ESR
* LDH
* HIV test
* blood film
Procedures
* Excisional node biopsy
Imaging:
* CT CAP
* PET scan for any bone marrow involvement
Presentation of thyroid cancer?
Neck lump
Compressive Sx - swallow problem, feel like being strangled
Voice changes
Types of thyroid cancer?
Papillary adenocarcinoma - most common (80%)
Follicular adenocarcinoma - (10%)
Medullary carcinoma
Anaplastic carcinoma
Investigations for thyroid cancer?
Triple assessment
1. Full Hx + Ex,
2. Imaging - USS
3. Needle biopsy - fine needle aspiration cytology
Management for thyroid cancer?
Thyroidectomy
Radioactive Iodine
Radiotherapy or chemotherapy
Features specific to papillary adenocarcinoma?
Age 30-40
Locally compress trachea
Can met to bone and lungs
Features specific to follicular adenocarcinoma?
Common in areas of low iodine
Women > men
Likely to metastasise into lung and bones (rather than locally invade)
Features specific to medullary thyroid cancer?
Worse prognosis than papillary or follicular
Comes from calcitonin producing C cells- so can present with hypocalcaemia and diarrhoea
Mets to LN - lymphadenopathy
Features specific to anaplastic thyroid cancer?
Age 60-70
V aggressive - pt presents with rapid growing neck lump
Already invaded into trachea and recurrent laryngeal nerve when presents
Survival 8m - v poor.
Autoimmune condition associated with thyroid lymphoma?
Hashimoto’s thyroiditis
Presentation of sialadenitis?
(inflame of salivary glands - usually parotid or sub-mandibular)
Pain
Tenderness
Redness
Localised swelling
- Swelling in neck - if submandibular gland
- Swelling at parotid gland if this is affected
Ddx of sialadenitis?
Reactive lymphadenopathy
Malignant lymphadenopathy
Tumour
Sub-mandibular salivary stone
Management of sialadenitis?
Abx, oral hygiene advice
Encourage salivary flow - e.g. lemon juice
Associated abscess = incision and drainage
Presentation of Ludwig’s angina?
Neck swelling
Dysphagia
Fever
Pathophysiology of Ludwig’s angina?
Progressive cellulitis
Invades floor of mouth and soft tissues of neck
From odontogenic infection (tooth infection)—> spreads into submandibular space
Management of Ludwig’s angina?
Airway obstruction can occur as a result - so this is an emergency!
Need:
- airway management
- IV abx
Presentation of pharyngeal pouch?
Older man
Midline lump
Gurgles on palpation
Dysphagia
Regurgitation
Aspiration
Chronic cough
Halitosis
Inv for pharyngeal pouch?
Barium swallow combined with dynamic video fluoroscopy
Avoiding endoscopy due to risk of perforating the lesion
Management for pharyngeal pouch?
- If the pouch is small and asymptomatic, no treatment is necessary.
- For larger or symptomatic pouches, surgical approaches may be employed such as resection of the diverticulum, or incision of the cricopharyngeus muscle.
Presentation of carotid aneurysm?
Pulsaive lateral neck mass
Does not move on swallowing
How to clinically distinguish between a thyroglossal cyst and thyroid nodule?
Thyroglossal duct cyst moves upwards on tongue protrusion
Thyroid nodule moves upwards on swallowing
Risks of thyroid surgery on pt who is hyperthyroid?
Thyrotoxic storm
and
Higher risk of bleeding
Complications of carrying on thyroid surgery on a euthyroid patient?
Bleeding
Infection
Damage to recurrent laryngeal nerves
Hypothyroidism
Hypoparathyroidism
After thyroidectomy, what blood test would you do?
Symptoms to suggest this blood test being low?
Calcium
Tingling around mouth and fingertips. If v v low = muscle spasms
