neck lumps

Question 1

describe the location and divisions of the anterior triangle

Answer 1

• anterior to and including SCM
• split into digastric, carotid, muscular triangles

Question 2

describe the location of the posterior triangle

Answer 2

• posterior to SCM
• anterior to trapezius
• superior to middle third of clavicle

Question 3

describe the different levels of the neck

Answer 3

• I = submandibular and submental region
• II = upper SCM region
• III = middle SCM region
• IV = lower SCM region
• V = posterior triangle
• VI = anterior neck in front

Question 4

what things should be covered when taking history of a neck lump? (up to 8)

Answer 4

• onset
• changes
• recurrence
• other lumps
• associated features (weight loss, fever, nausea, pain with alcohol)
• foreign travel
• pets
• social history

Question 5

what needs to be included in the examination of a lump itself? (12)

Answer 5

• site, size, shape, surface
• temperature, tenderness, transillumination, texture
• colour
• margin
• pulsation
• mobile/fixed

Question 6

give the causes of cervical lymphadenopathy (4)

Answer 6

• infective (local or general, bacterial, viral, etc)
• neoplastic (local metastases, general)
• drugs (eg phenytoin)
• sarcoidosis

Question 7

give some bacterial causes of cervical lymphadenopathy (~4)

Answer 7

• local = dental, tonsil, face, scalp infections
• TB
• syphilis
• cat scratch disease

Question 8

give some viral causes of cervical lymphadenopathy (~4)

Answer 8

• herpetic stomatitis (HSV)
• infectious mononucleosis (EBV)
• HIV infection
• childhood fevers, mumps, etc

Question 9

give examples of primary and secondary neoplasms which may cause cervical lymphadenopathy

Answer 9

• primary = Hodgkin’s lymphoma, NHL, leukaemia
• secondary = SC/BC carcinoma, malignant melanoma, gastric and abdominal metastases

Question 10

describe branchial cleft cysts (what, important differential, presentation, types)

Answer 10

• congenital epithelial cysts on lateral neck (in youth)
• must always exclude metastasis if >45yo
• small, painless, fluctuant mass often on anterior border of SCM +/- fistula (between levels III/IV)
• first arch = preauricular opening
• second arch = just below preauricular area
• third arch = levels III/IV, may open into larynx (finger sucking-indrawing sign)

Question 11

which is the most common type of branchial cleft cyst?

Answer 11

second branchial cleft cyst (95%, 10-40yo)

Question 12

give the groups of head and neck lymph nodes (~10)

Answer 12

• pre and post auricular
• parotid
• occipital
• tonsillar/jugulodigastric
• submental
• submandibular/submaxillary
• superficial cervical
• internal jugular/deep cervical chain
• supraclavicular/transverse cervical
• posterior cervical chain/spinal accessory

Question 13

give some causes of dysphagia (up to 10)

Answer 13

neuromuscular:
- old age
- bulbar or pseudobulbar palsy
- motor neurone disease
- stroke
- constriction of cricopharyngeus muscle
obstructive:
- foreign body
- carcinoma of pharynx, post-cricoid or oesophagus
- oesophagitis
- invasion by carcinoma of lung
- achalasia of cardia

Question 14

give some differentials for a superficial lump of the neck at any site (3)

Answer 14

• skin abscess
• lipoma
• dermoid cyst

Question 15

give some differentials for midline-specific neck lumps (4)

Answer 15

• thyroid swelling = goitre, neoplasms
• thyroglossal duct cysts and persistent tracts
• submental lymph nodes
• sublingual dermoid cyst

Question 16

what are the 3 types of malignant neoplasm of the thyroid and which has the worst prognosis?

Answer 16

• papillary carcinoma
• medullary carcinoma
• follicular carcinoma = worst

Question 17

what may cause diffuse enlargement of the thyroid? (2)

Answer 17

• iodine deficiency
• autoimmune thyroiditis

Question 18

how to tell the difference between a thyroid swelling and thyroglossal swelling?

Answer 18

• thyroid swelling moves on swallowing (also usually women)
• thyroglossal duct cyst moves on swallowing and tongue protrusion

Question 19

give some differentials for an anterior neck triangle lump (5)

Answer 19

• lymphadenopathy
• submandibular gland
• tail of parotid gland swelling
• branchial and lymphoepithelial cysts
• thyroid lobe swellings

Question 20

give some differentials for a posterior neck triangle lump (2/3)

Answer 20

• lymphadenopathy
• carotid body tumour
• Virchow’s node (left supraclavicular, Troisier’s sign)

Question 21

what is TINCAMBEDO?

Answer 21

surgical sieve acronym:
Trauma
Infectious, inflammation, iatrogenic
Neoplastic
Congenital and developmental
Autoimmune
Metabolic
Bone, bowel, brain
Endocrine
Degenerative
Other

Question 22

what is the first line imaging modality for soft tissue lumps?

Answer 22

ultrasound

Question 23

pros and cons of MRI

Answer 23

+:
- soft tissues in a wide area
- identifies the composition of a lump
-:
- no metals
- enclosed space
- must lie still
- expensive and time-consuming
- contrast (bad for renal disease)

Question 24

how many DPTs is equivalent to a medical CT scan?

Answer 24

200

Question 25

what are PET scans used for? (3)

Answer 25

• cancer detection and staging
• treatment monitoring
• checking for cancer recurrence

Question 26

what is a sestamibi scan? (3)

Answer 26

• technetium 99 injection
• locates parathyroid glands to aid surgical removal
• used with ultrasound (missed 15%)

Question 27

give some investigations you may do regarding a neck lump (up to 9)

Answer 27

• bloods - FBP (leukaemia, anaemia, glandular fever)
• CXR (Hodgkin’s, sarcoidosis)
• serology (glandular fever, toxoplasmosis, HIV)
• ACE and calcium levels (sarcoidosis)
• Mantoux test (latent TB)
• FNA (neoplasms, TB)
• ultrasound
• thyroid function tests (thyroid tumour)
• nodal biopsy (last resort, cultured)

Question 28

give an example of a parasitic infection which may cause cervical lymphadenopathy

Answer 28

toxoplasmosis