4. Neck Lump

Question 1

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

Answer 1

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

Question 2

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

Answer 2

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

Question 3

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

Answer 3

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?

Question 4

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

Answer 4

< 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

Question 5

How does the size of the lump change in malignancy?

Answer 5

Very slow growing

Except for anaplastic tumours, which grow rapidly

Question 6

Which types of neck lumps are painful?

Answer 6

Acute infective lymphadenitis

Infected branchial cyst

Question 7

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

Answer 7

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

Question 8

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

Answer 8

Malaise
Fever
Rigors

Question 9

What are the B symptoms of lymphoma?

Answer 9

Fever
Night sweats
Weight loss

Question 10

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

Answer 10

Dysphonia
Stridor
Stertor
Breathing difficulty 
Dysphagia
Odynophagia
Globus
Cough 
Haemoptysis 
Otalgia

Question 11

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

Answer 11

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

Question 12

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

Answer 12

Previous cancer 
Family history 
Previous radiotherapy to the neck
Smoking 
Alcohol

Question 13

List some types of superficial neck lumps.

Answer 13

Epidermal cyst
Dermoid cyst
Abscess
Lipoma

Question 14

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

Answer 14

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

Question 15

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

Answer 15

Cervical rib
Lymphatic malformation
Pharyngeal pouch
Subclavian aneurysm
Lymphadenopathy

Question 16

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

Answer 16

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

Question 17

Which types of lumps tend to be tender and warm?

Answer 17

Infected or inflammatory lumps

Question 18

List the diseases that are associated with hard neck lumps

Answer 18

Malignant lymph nodes

Question 19

List the diseases that are associated with rubbery neck lumps

Answer 19

Chronic inflammatory lymph nodes (e.g. tuberculosis)

Question 20

List the diseases that are associated with fluctuant neck lumps

Answer 20

Branchial cyst
Pharyngeal pouch
Laryngocoele 
Epidermal cyst
Dermoid cyst

Question 21

Which types of neck lump may be pulsatile?

Answer 21

Subclavian and carotid artery aneurysms

Carotid body tumours

Question 22

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

Answer 22

Most lymph nodes are relatively mobile

Malignant lymph nodes appear tethered to surrounding structures

Question 23

What else should you examine if infectious lymphadenopathy is suspected?

Answer 23

Throat (mainly tonsils)

All lymph nodes in the head and neck

Question 24

What else should you examine if malignant lymphadenopathy is suspected?

Answer 24

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

Question 25

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

Answer 25

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

Question 26

What method is used to diagnose the cause of lymphadenopathy?

Answer 26

Fine needle aspiration

Question 27

List the thyroid differential diagnosis of midline neck lumps.

Answer 27

``` Physiological goitre Multinodular goitre Graves’ disease Hashimoto’s thyroiditis Thyroglossal cyst Thyroid cyst Solitary adenoma ```

Question 28

List the non-thyroid differential diagnosis of midline neck lumps.

Answer 28

Lipoma Dermoid cyst Epidermal cyst

Question 29

What is the thyroglossal duct?

Answer 29

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

Question 30

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

Answer 30

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

Question 31

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

Answer 31

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

Question 32

Which type of thyroid cancer grows rapidly?

Answer 32

Anaplastic cancer

Question 33

Which midline neck lumps are painful?

Answer 33

Subacute thyroiditis Infected thyroglossal cyst Acute haemorrhagic cyst

Question 34

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

Answer 34

Malignant until proven otherwise

Question 35

List some signs and symptoms of hyperthyroidism.

Answer 35

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

Question 36

List some signs and symptoms of hypothyroidism.

Answer 36

``` Weight gain Fatigue Constipation Cold intolerance Bradycardia Slow, deep voice Slow reflexes ```

Question 37

List some signs and symptoms of hypothyroidism.

Answer 37

``` Weight gain Fatigue Constipation Cold intolerance Bradycardia Slow, deep voice Slow reflexes ```

Question 38

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

Answer 38

Stridor Dyspnoea Dysphagia

Question 39

What does a change in voice suggest?

Answer 39

Malignant invasion of the recurrent laryngeal nerve

Question 40

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

Answer 40

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

Question 41

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

Answer 41

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

Question 42

Which types of midline neck lump moves on swallowing

Answer 42

Thyroid lump

Question 43

Which types of midline neck lump moves on tongue protrusion

Answer 43

Thyroglossal cyst

Question 44

Which types of midline neck lump is tethered to neighbouring muscle or skin

Answer 44

Malignant | Riedel’s thyroiditis

Question 45

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

Answer 45

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

Question 46

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

Answer 46

Malignancy

Question 47

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

Answer 47

Thyroglossal cyst Epidermal cyst Dermoid cyst Thyroid cyst

Question 48

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

Answer 48

Multinodular goitre

Question 49

What sign may be elicited in patients with retrosternal goitres?

Answer 49

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

Question 50

Describe how TSH levels may indicate hypo- and hyperthyroidism.

Answer 50

Hypothyroidism – HIGH TSH | Hyperthyroidism – LOW TSH

Question 51

What might an elevated serum calcitonin suggest?

Answer 51

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)

Question 52

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

Answer 52

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

Question 53

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

Answer 53

Radionuclide scanning with Technetium-99 or Iodine-123

Question 54

Outline the treatment of follicular thyroid lesions.

Answer 54

``` Surgery T3 replacement Iodine-131 ablation T4 suppression Follow-up ```

Question 55

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

Answer 55

Chemodectoma

Question 56

Describe the mobility and character of a chemodectoma.

Answer 56

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

Question 57

What are the characteristic features of glandular fever?

Answer 57

Fever Sore throat Lymphadenopathy

Question 58

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

Answer 58

Acute CMV | Toxoplasmosis

Question 59

List some investigations used to diagnose glandular fever.

Answer 59

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

Question 60

Describe the typical presentation of a branchial cyst.

Answer 60

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

Question 61

How are epidermal cysts formed?

Answer 61

They are formed due to blockage of the sebaceous glands

Question 62

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

Answer 62

Smoking

Question 63

Describe some treatments used for Graves’ disease.

Answer 63

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

Question 64

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

Answer 64

Agranulocytosis