Lateral Neck Lumps

Question 1

Differential diagnoses for a lateral neck lump

Answer 1

Artery - carotid artery/subclavian artery aneurysm, carotid body tumour
Nerves - neurofibroma, schwannoma
Lymphatics - lymphatic malformation
Lymph nodes - infective, neoplastic, granulomatous
Salivary glands - infective, autoimmune, neoplasm
Larynx - laryngocele
Pharynx - pharyngeal pouch
Brachial arch remnant - branchial cyst/sinus/fistula
Skin/superficial SC - lipoma, cyst, abscess
Muscle/cartilage/bone - sarcomas,

Question 2

What are the most common causes of lateral neck lumps in children

Answer 2

75% are benign
Congenital and inflammatory most common e.g. brachial cleft cysts, lymphatic malformations and lymphadenitis
Any malignancy is usually a lymphoma or sarcoma

Question 3

What are the most common causes of lateral neck lumps in adults

Answer 3

75% are malignant
80% are metastases, rest lymphomas
In the absence of infection, a lateral neck mass is lymphadenopathy due to metastatic carcinoma until proven otherwise

Question 4

What questions should be asked about the lump

Answer 4

How long as the lump been there
Has the lump gotten bigger, smaller or stayed the same size
Is the lump painful
Are they any other lumps?

Question 5

What is a lump that has been there for less than a few weeks most likely to be, and what action should be taken if it is more than a few weeks

Answer 5

Infective or inflammatory lymphadenopathy

Must exclude malignancy

Question 6

What is a lump that has been there for years with little change most likely to be

Answer 6

Most likely benign

Question 7

What does a lump that progressively grows in size suggest

Answer 7

Malignancy until proven otherwise

Question 8

Which neck lumps are classically painful

Answer 8

Acute infective lymphadenitis

Question 9

What does presence of other lumps suggest

Answer 9

Represents either a systemic disease (HIV, EBV -> infectious mononucleosis) or disseminated malignancy e.g. lymphoma

Question 10

Which symptoms are suggestive of infection

Answer 10

Malaise
Fever
Rigors
Symptoms of the local infection e.g. coryzal, dental abscess pain

Can also present in lymphoma, so time course is useful (acute history favours infection)

Question 11

Which symptoms are suggestive of head and neck cancer

Answer 11

Not usually associated with weight loss or malaise
Dysphonia
Stridor 
Stertor 
Breathing difficulty 
Dysphagia 
Odynophagia
Globus 
Cough/haemoptysis
Otalgia
UNilateral hearing loss 
Nasal discharge 
Epistaxis, lumps or ulcers on the head or face

Question 12

What aspects of a history may make an infective process more likely

Answer 12

Recent infection (upper resp?)
History of contact with someone infected
Recent trauma, insect bites, animal bites, scratches

Question 13

What aspects of a history may make a malignant process more likely

Answer 13

Current or previous cancer
Family history of cancer
PReviously had radiotherapy to the neck
Ever been a smoker and/or high alcohol intake

Question 14

What specifically do you want to know about the location of a lateral neck lump

Answer 14

is it superficial or deep
In the anterior or posterior triangle of the neck
What is its relationship to muscle

Question 15

Give examples of superficial lateral neck lumps

Answer 15

Lipomas, abscesses, epidermal cysts, dermoid cysts

Question 16

What lumps will you find in the anterior triangle of the neck (lateral)

Answer 16

Branchial cysts/sinus/fistula 
Carotid body tumour (chemodectoma)
Carotid artery aneurysms 
Salivary 
Laryngocele
Lymphadenopathy

Question 17

What lumps will be found in the posterior triangle of the neck

Answer 17

Lymphatic malformation
Cervical rib
Pharyngeal pouch 
Subclavian aneurysm 
Lymphadenopathy

Question 18

What other features should be asked about the lateral lump

Answer 18

Is it tender/warm
Solid or fluctuant
Is it pulsatile
Is it mobile

Question 19

Which lateral lumps may be tender

Answer 19

Infected or inflammatory masses

Also at-risk patients-group in TB adenitis

Question 20

What can lumps be classically divided into in terms of consistency

Answer 20

Hard - malignant
Rubbery - chronic inflammatory lymph node e.g. TB
Soft - acute inflammatory lymph nodes
Fluctuant - branchial cysts, cystic hygromas, pharyngeal pouches, laryngoceles

Question 21

Which lateral neck lumps are pulsatile

Answer 21

Subclavian or carotid aneurysms

Carotid body tumour are often pulsatile

Question 22

Which lateral neck lumps may not be mobile

Answer 22

Malignant lymph nodes may be tethered to adjacent structures (TB nodes may appear matted together)

Question 23

What else should be examined if infectious lymphadenopathy is suspected

Answer 23

Examine the throat, paying particular attention to the tonsils
Examine all lymph nodes of the head and neck

Question 24

What else should be examined if malignant lymphadenopathy is suspected

Answer 24

Examine the scalp, face, ears, mouth and nose - potential SCC or melanoma
Otalgia in the absence of any pathology is suggestive of malignancy
Examine the breasts and the lungs
Consider palpating for hepatosplenomegaly if lymphoma or chronic lymphocytic leukaemia is supsected
Full abdominal exam if Virchow’s palpable
Endoscopy

Question 25

What else should be examined if there is parotid swelling

Answer 25

Examine the integrity of the facial nerve (palsy may occur from malignant tumour)
Examine the oral cavity for displacement of the soft palate by a tumour involving the deep love of the parotid

Question 26

What investigations can be done for a suspected for a lymphadenopathy

Answer 26

Ultrasound - size, shape, echogenicity, vascularity
Fine needle aspiration - for cytological diagnosis, may be USS guided
Core biopsy needed to confirm

Question 27

Female with swelling (2x2) the right upper anterior triangle, not painful, not attached to SCM, firm, non-tender, transmitted pulse. The lump moves from side to side but not up and down

Answer 27

Carotid Body tumour (chemodectoma)

Located at the carotid bifurcation

Question 28

What investigations should be done for carotid body tumours

Answer 28

Imaging to determine location - duplex USS, angiography, CT/MRI

Question 29

Females with sore throat, headache, fever and fatigue. No cough or coryzal symptoms. Febrile on exam, enlarged tonsils and multiple palpable lumps in her neck. 5 are firm and tender, all SC and in the posterior triangle. Relatively mobile and are not warm or pulsatile. There is splenomegaly

Answer 29

Cervical lymphadenitis due to glandular fever caused by EBV

Question 30

What does EBV infection (glandular fever) present with

Answer 30

Cervical lymphadenitis
Tonsilar enlargement 
Sore throat
Splenomegaly 
Fever

Question 31

What differentiates the symptoms of EBV and toxoplasmosis and acute cytomegalovirus (CMV)

Answer 31

All will present with splenomegaly and lymphadenopathy, but only EMV accounts for sore throat and swollen tonsils

Question 32

What investigations should be done for suspected glandular fever due to EBV

Answer 32

FBC (leucocytosis and lymphocytosis)
Heterophil antibody tests (Paul-Bunnell/monospot test)
Blood film (atypical lymphocytes)

Question 33

What is the treatment for glandular fever due to EBV

Answer 33

Do not give amoxicillin as it will cause a rash

No specific management, just avoid contact sports due to risk of damage to the spleen.

Question 34

Single palpable lesion in the left anterior triangle, anterior to the SCM. Does not move on swallowing or tongue movement. Smooth, non-tender fluctuant and non-pulsatile. Gradually increasing in size over weeks.

Answer 34

Branchial Cyst

Congenital epithelial cyst that presented due to RTI

Question 35

Lump in the left anterior triangle which has smooth regular borders and is fluctuant. Non-tender and cannot moved separately from the skin, but mobile over deep tissues. Does not change position on swallow. No punctum overlying the lump. 2-month history

Answer 35

Epidermal cyst

Could be dermoid cyst, but due to punctum more likely to be epidermal

Question 36

Where will a dermoid cyst be found

Answer 36

Formed at embryological lines of fusion (midline) or following trauma in the neck

Question 37

A patient presents with intermittent swelling of the parotid gland. What question is important to ask?

Answer 37

Whether the painful swelling is connected to eating

Typical of sialothiasis - salivary gland calculi

Question 38

What lump is associated with Turner’s syndrome

Answer 38

Cystic Hygroma’s

Question 39

What lump is associated with Sjrogens syndrome

Answer 39

Non-Hodgkins lymphoma