3- Throat (Neck lumps) Flashcards
causes of neck lumps in adults
- Normal structures (e.g., bony prominence)
- Skin abscess
- Lymphadenopathy (enlarged lymph nodes)
- Tumour (e.g., squamous cell carcinoma or sarcoma)
- Lipoma
- Goitre (swollen thyroid gland) or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma (a collection of blood after trauma)
- Thyroglossal cysts
- Branchial cysts
causes of neck lumps in children
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
basic anatomy of the neck
There are three descriptions to note the location of a neck lump:
* Anterior triangle
* Posterior triangle
* Midline (vertically along the centre of the neck)
These two triangles are on either side of the sternocleidomastoid muscle.
The borders of the anterior triangle are:
- Mandible forms the superior border
- Midline of the neck forms the medial border
- Sternocleidomastoid forms the lateral border
The borders of the posterior triangle are:
- Clavicle forms the inferior border
- Trapezius forms the posterior border
- Sternocleidomastoid forms the lateral border
differential based on location of lump: midline
- thryoglossal cyst
- thryoid nodule
- goitre
- dermoid cyst
- submental gland pathology
differential based on location of lump: anterior triangle
- reactive lymphadenopathy
- malignant lymphadenopathy
- branchial cyst
- carotid artery aneurys
- carotid body tumour
- submandibular gland pathology
differential based on location of lump: anterior triangle
- reactive lymphadenopathy
- malignant lymphadenopathy
- branchial cyst
- carotid artery aneurys
- carotid body tumour
- submandibular gland pathology
differential based on location of lump: posterior triangle
- reactive lymphadenopathy
- malignant lymphadneoapthy
- cystic hygroma (lymphangioma)
differential based on location of lump: anywhere
- lipoma
- sebaceous cyst
- haemangioma
- skin malignancy
neck lump red flags
In the context of a neck lump, the ‘Red flag’ features raise the suspicion of an underlying head and neck malignancy.
- Hard and fixed lump
- Associated otalgia, dysphagia, stridor, or hoarse voice
- Epistaxis or unilateral nasal congestion
- Unexplained weight loss, night sweats, or fever or rigors
- Cranial nerve palsies
- In children, red flag symptoms also include the presence of a supraclavicular mass, lumps larger than 2cm, and a previous history of malignancy.
neck lump history
- General information about the symptoms (e.g., when the lump first appeared and how quickly it has grown)
- Features that suggest or exclude a particular diagnosis (e.g., night sweats indicating lymphoma)
- Risk factors for that condition (e.g., family history, age and smoking status)
- General fitness for further investigations and treatment (e.g., co-morbidities and medications such as anticoagulants)
two week wait if
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
Examination
When examining a neck lump, the things to establish are:
* Location (anterior triangle, posterior triangle or midline)
* Size
* Shape (oval, round or irregular)
* Consistency (hard, soft or rubbery)
* Mobile or tethered to the skin or underlying tissues
* Skin changes (erythema, tethering or ulceration)
* Warmth (e.g., infection)
* Tenderness (e.g., infection)
* Pulsatile (e.g., carotid body tumours)
* Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
* Transilluminates with light (e.g., cystic hygroma – usually in young children)
A general examination can be used to look for signs of the underlying cause, such as:
* Ear, nose and throat infections (e.g., reactive lymph nodes)
* Weight loss (e.g., malignancy or hyperthyroidism)
* Skin pallor and bruising (e.g., leukaemia)
* Focal chest sounds (e.g., lung cancer)
* Clubbing (e.g., lung cancer)
* Hepatosplenomegaly (e.g., leukaemia)
investigations: blood tests
Blood tests may be helpful depending on the suspected cause of the neck lumps. Not everyone with a neck lump will require blood tests. The choice of test will depend on the suspected cause:
* FBC and blood film for leukaemia and infection
* HIV test
* Monospot test or EBV antibodies for infectious mononucleosis
* Thyroid function tests for goitre or thyroid nodules
* Antinuclear antibodies for systemic lupus erythematosus
* Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
investigations: imaging
- Ultrasound is often the first-line investigation for neck lumps
- CT or MRI scans
- Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)
investigations: biopsy
may be required to gain a tissue sample (histology) to establish the exact cause. This may be with:
* Fine needle aspiration cytology – aspirating cells from the lump using a needle
* Core biopsy – taking a sample of tissue with a thicker needle
* Incision biopsy – cutting out a tissue sample with a scalpel
* Removal of the lump – the entire lump can be removed and examined
Lymphadenopathy
- Enlarged lymph nodes
carotid body tumour background
- Carotid body is a structure located just above the carotid bifurcation
- Contains glomus cells -> chemoreceptors that detect the bloods oxygen, CO2 and pH
- Groups of glomus cells are called paraganglia
- Carotid body tumours are formed by excessive growth of the glomus cells therefore they are called paragangliomas
- Most are benign
thryoglossal cyst
Background
The thyroglossal duct is an epithelialised tract which connects the thyroid gland to the foramen cecum of the tongue. If it fails to regress, the duct can give rise to cysts or fistulae.
Pathophysiology
- During fetal development, the thyroid gland starts at the base of the tongue.
- From here, it gradually travels down the neck to the final position in front of the trachea, beneath the larynx.
- It leaves a track behind called the thyroglossal duct, which then disappears.
- When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst.
- This is called a thyroglossal cyst.
Why are they a problem?
A thyroglossal cyst results from a build-up of secretions within the duct. It typically presents as a midline lump in the anterior neck, and characteristically rises on tongue protrusion. If left untreated, this cyst can become infected, and form a cutaneous fistula – discharging out onto the skin of the anterior neck.
thyroglossal cyst management
Thyroglossal cysts and fistulae are usually treated with complete excision. Recurrence is quoted at approximately 2.5%.
branchial cyst
Branchial cyst
- Congenital abnormality that arises when the **second branchial cleft **fails to form properly during fetal development
- Leaves a space surrounded by epithelial tissue in the lateral aspect of the neck that can fill with fluid
- This fluid-filled lump is called a branchial cyst
presentation of branchial cyst
Presentation
- Round
- Soft
- Cystic swellings between the angle of the jaw and Sternocleidomastoid muscle in the anterior triangle of the neck
- Present after the age of 10 years
Causes: Malignant thryoid nodules
Thyroid cancers e.g. follicular adenocarcinoma, papillary adeno, medullary carc, anaplastic carcinoma
