Neck lump

Question 1

Thyroid swellings - causes

Answer 1

Goitre
Benign nodules
Malignant nodules

Question 2

Cervical lymphadenopathy - causes

Answer 2

Infection - IM, CMV, reactive nodes, etc.
Inflammation - JIA, Kawasaki, Sarcoid, etc.
Malignant - lymphoma, leukaemia, metastases

Question 3

Developmental abnormalities (congenital)

Answer 3

• Thyroglossal cysts (midline, moves on swallowing AND tongue protrusion)
• Branchial cysts (lateral)

Question 4

Lump under mandible - DDx?

Answer 4

Lymph node

Salivary gland swelling

Question 5

Lump anterior to the tragus - DDx?

Answer 5

Parotid swelling - parotitis, parotid tumour

Question 6

Differentials for neck lump.

a) Reactive nodes (more common if < 40)
b) Malignant nodes (more common if > 40)
c) Cutaneous/subcutaneous

Answer 6

a) - Viral (viral URTI, EBV, CMV, HIV, HSV)
- Bacterial (strep, staph, syphilis, TB)
- Other (toxoplasma, cat scratch, fungal)
- Inflammation (sarcoid, JIA, Kawasaki)

(note: reactive nodes should NOT last > 6 weeks)
b) Malignancy: leukaemia, lymphoma, metastases
c) Sebaceous cyst, abscess, pustule, lipoma

Question 7

Investigations for a neck lump.

a) Bedside
b) Bloods
c) Imaging
d) Special tests

Answer 7

a) ?Throat swab.
b) FBC and ESR (malignancy), TFTs, viral serology (eg. Monospot, CMV, HIV)
c) USS usually first line, ?CXR/CT, ?Radionucleotide scanning (thyroid)
d) US-guided fine-needle aspiration biopsy.

Question 8

Neck lumps: 2-week wait

a) May be to ENT, haematology, respiratory, etc.
b) Any neck mass persisting longer than how long warrants referral?
c) Urgent referral to hospital should be considered when?

Answer 8

a) - Weight loss
- Hoarseness, dysphagia, or dyspnoea for > 3/52
- Haemoptysis
- B symptoms (weight loss, night sweats, fever
- Other haematological symptoms: SOB, bleeding, etc.
- Unexplained persistent enlarged lymph node
- There are suspicious clinical features.
- Diagnosis is unclear.

b) 6 weeks
c) Stridor, or signs of SVC obstruction.

Question 9

Neck lump: history

a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx

Answer 9

a) - Site
- Onset
- Character
- Timing - duration, intermittent or constant, changing? (eg. enlarging, evolving)
- Exacerbating factors - eating, swallowing, speech, tender to touch, etc.

b) - Infective symptoms - fever, cough, cold, etc.
- Sinister symptoms - weight loss, anorexia, night sweats, unexplained bruising/bleeding, SOB
- Thyroid symptoms

c) - Previous malignancy
- Thyroid disease

d) - ?angio-oedema
- response to NSAIDs?

e) - Thyroid disease

f) - Smoking, alcohol
- Occupational risks
- Travel history

Question 10

Neck lump: examination

a) Important features of any lump - inspection (5), palpation (5), auscultation (1)
b) For neck lumps - what special tests are there?
c) Should also examine…?
d) Further assessment

Answer 10

a) Inspection.
- Site - anterior, posterior triangle, etc.
- Size - use tape measure, or distal phalanx of index finger (~ 2.5 cm) for reference
- Shape - round, irregular, etc.
- Colour - erythematous or same as surrounding skin
- Contour - appearance of overlying skin

Palpation.

• Tenderness
• Temperature
• Tethering - freely mobile, or tethered to overlying skin or underlying muscle?
• Consistency - hard (forehead), firm (tip of nose), soft (lips)
• Pulsatility - suggests aneurysm

Auscultation.
- Bruit - suggests aneurysm

b) - Moves with tongue protrusion (?thyroglossal cyst)
- Moves with swallowing (?thyroid swelling/thyroglossal cyst)
- ?transillumination - suggests cystic swelling

c) - Regional lymph nodes
- ENT
- Chest
- General examination for other lesions, organomegaly, systemic illness (eg. jaundice, anaemia, bruising), etc.

d) - Imaging - eg. USS
- Biopsy