ENT Case 2 - Neck Lumps Flashcards
What questions should you ask in a neck lump history?
SOCRATES:
- Changes in size
- Associated features: pain, redness, discharge
- Lumps elsewhere
- Preceding symptoms - particularly coryzal, tonsillitis, pharyngitis
- Recent travel - particularly where TB is endemic
- Contact with TB patients
- Occupation eg. petrochemical wood industry
- Animals - cat scratch
- Radiation exposure
- HIV status
- Dental problems
What are the red flag symptoms in a neck lump history?
- Weight loss
- Fevers
- Night sweats
- Persistent sore throat
- Hoarseness
- Dysphagia
- Odynophagia
What investigations might you do for a neck lump?
1st line:
- CT
- US
- FNAC - fine needle aspiration cytology
2nd line:
- MRI
- Excision biopsy (should be avoided in some pathologies eg. excision of a metastatic lymph node has a detrimental effect on outcome)
What differentials might be considered for a neck lump?
Congenital:
- Dermoids - derived from stem cells, midline, common above hyoid, contain calcium + fat
- Thyroglossal cyst - anterior triangle, below hyoid, derived from remnants of thyroglossal duct
- Haemangioma - benign vascular tumour, red/blue lesion
- Cystic hygroma / lymphangioma - lymphatic malformation consisting of 1 or more cysts
Infectious:
- Lymphadenopathy - bacterial (e.g. strep or staph), viral (e.g. EBV or cytomegalovirus), TB
- Abscess
Inflammatory:
- Sarcoidosis
- Kawasaki disease - rare vasculitits seen in children
- Castleman’s syndrome
Neoplastic - benign:
- Lipoma
- Sebaceous cyst
Neoplastic - malignant:
- Metastatic SCC
- Lymphoma
Vascular:
- Carotid body tumour
- Carotid artery aneurysm
Thyroid:
- Nodule
- Goitre
- Thyroiditis
Name 4 risk factors for squamous cell carcinoma (SCC) of the head and neck?
- Smoking (up to 16 fold)
- Alcohol (up to 5 fold)
- Human papilloma virus (HPV) - responsible for head/neck Ca in younger pts i.e.e 20-40s
- Epstein Barr virus has been implicat in nasopharyngeal Ca
- Betel nut chewing - chewed commonly in the Indian subcontinent, parts of Asia and around the Pacific (carcinogenic)
Outline the 3 basic steps of head and neck cancer management
- Panendoscopy - examination of upper aerodigestive tract (pharynx, larynx, upper trachea, and oesophagus) under anaesthetic
- Use: to identify the primary site + to biopsy for histological diagnosis
- 5-10% of cases, no primary is identified
- CT skull base to diaphragm - assess the extent of the primary tumour and any regional or distant mets
- MDT meeting
What questions would you ask in a history on hoarseness?
Red flag screen:
- Weight loss
- Night sweats
- Fever
Specific:
- Dysphagia - of liquids / solids?
- Odynophagia (pain on swallowing)
- Heartburn / indigestion - GORD can cause inflammation of the larync and dysphonia
- Postnasal drip - can cause dysphonia through excessive through clearing
Systemic:
- Noticed any lumps in neck or elsewhere?
- Tiredness / fatigue
- Nausea
- SoB
What is included in the NICE guideline for urgent referral due to concern of head and neck cancer?
- Hoarseness > 6 weeks
- Oral swellings > 3 weeks
- Dysphagia > 3 weeks
- Unilateral nasal obstruction (particularly when associated with purulent discharge)
- Unresolving neck masses > 3 weeks
- Cranial neuropathies
- Orbital masses
What are some symptoms associated with a thyroid lump that make you concerned about malignancy?
- Thyroid nodules in a child
- A rapidly enlarging painless thyroid mass
- Stridor
- Enlarged cervical lymph nodes
- Unexplained hoarseness
What is the most common site of head and neck squamous carcinoma in adults?
- Hypopharynx
- Larynx
- External auditory canal
- Nasopharynx
- Oral cavity
Oral cavity.
- Oral cavity carcinoma –> commonest type of mucosal carcinoma
- Most often a SCC but can also be lymphoma / salivary glad tumour / melanoma
