Throat - NECK LUMPS

Question 1

Describe the boudaries of the anterior triangle

Answer 1

Superiorly: Mandible

Posteriorly: SCM

Anteriorly: Midline of the neck

Question 2

Contents of anteior triangle

Answer 2

ECA, CN 9/10/12, Submandibular + Submental nodes

Question 3

Boundaries of posterior triangle

Question 4

Contents of posterior triangle

Answer 4

CN II, cervical nerve plexus, EJV, accessory nerve

Question 5

Investigation of choice for neck lumps?

Answer 5

First choice investigation for neck lumps= FNA + Cytology (+/- USS)

Question 6

What is the differential diagnosis for midline neck masses?

Answer 6

Submental reactive lymphadenopathy

Plunging ranula

Thyroglossal cyst

Thyroid mass (goitre)

Pharyngeal pouch

Dermoid cysts

Question 7

What are thyroglossal cysts?

Answer 7

Congenital cystic remnant of the thyroglossal tract (runs from foramen caecum to thyroid gland)

Question 8

Presentation of thyroglossal cyst

Answer 8

Smooth fluctuant painless lump MOVES UP on tongue protrusion (NOTE: thyroid lumps do not move on protrusion)

May become infected and therefore become tender

Question 9

Management of thyroglossal cyst

Answer 9

Surgical excision although chance of recurrence

Question 10

Differential of thyroid mass

Answer 10

Single (solitary) nodule- 10% malignant

• Cyst
• Adenoma (benign)
• Malignancy
• Prominent nodule in multinodular goitre

Goitre

• Smooth non-toxic goitre- endemic
• Smooth toxic goitre- graves, De Quervain’s
• Multinodular colloid goitre- most common
• Toxic multinodular goitre

ASK YOURSELF: is thyroid smooth or nodular? Is the pateint euthyroid, thryotoxic or hypothyroid?

Question 11

What are dermoid cysts

Answer 11

Congenital defects in fusion of the midline of the skin - Contains tissue and cells normally present in skin layers including hair follicles, sebaceous (skin oil) + sweat glands

The gland and tissue secrete their normal substances and therefore closing cyst to grow

Question 12

If an u20 year old presented with a midline swelling what is it likely to be?

Answer 12

Dermoid cysts, doesnt move up on tongue protrusion/swallowing

Question 13

What is the differential diagnosis for lateral neck masses?

Answer 13

Reactive lymphadenopathy Lymphoma Salivary gland enlargement Branchial cyst Cystic hygroma Carotid aneurysm Thyroid mass Cervical rib

Question 14

Differentials anterior triangle lumps

Answer 14

LN’s

Branchial Cyst

Laryngoceles

Carotid artery aneurysm

Carotid Body Tumour

Parotid Tumour

Question 15

What is a branchial cyst?

Answer 15

Congenital non-disappearance of the second bronchial cleft in embryonic development

Question 16

Describe presentation and investigations of branchial cysts

Answer 16

Smooth non-tender, fluctuant swelling in anterior triangle Cyst may enlarge following URTI

FNA- creamy fluid (CHOLESTEROL CRYSTALS)

Question 17

Management branchial cyst

Answer 17

Surgical - excision

Question 18

What are laryngoceles

Answer 18

Uncommon cause of anterior triangle lumps

Painless and may worse on blowing

May be associated with laryngeal cancer

Question 19

Describe carotid artery aneurysm

Answer 19

Localised pulsating and laterally expansile

Question 20

What is a carotid body tumour (chemodectoma)

Answer 20

Tumour of carotid body chemoreceptors arising in the carotid bifurcation

Question 21

Describe presentation of chemodectoma

Answer 21

Firm/occasionally soft + PULSATILE + non tender

Can be moved side to side but not up and down

Pressure on tumour may cause dizziness and syncope by stimulating vagal tone via carotid sinus

Suspected in any mass, just anterior to the upper 1/3rd of SCM

V rare - would be surgically excised

Question 22

Differentials posterior triangle lump

Answer 22

Cystic Higroma

Pancoast Tumour

Cervical Ribs

Pharyngeal Pouch

Question 23

What is a cystic higroma

Answer 23

Congenital benign proliferation of lymph vessels that is found in posterior triangle - derived from jugular lymph sac

Presentation:

• Present at birth
• Multi-cystic swelling that is fleshy + compressible (+ contains clear fluid)
• Characteristically: transluminate brightly

Question 24

Cause of pancoats tumour

Answer 24

Apical lung cancer:

• Invades sympathetic plexus (ipsilateral Horner’s)
• +/- Brachial plexus (Arm pain)
• Recurrent laryngeal nerve (hoarse voice/bovine cough)

Question 25

Differential submandibular triangle lumps

Answer 25

Duct calculus Parotiditis Pleomorphic Adenoma

Question 26

Causes of enlarged salivary glands

Answer 26

Acute viral infection (mumps)- bilateral acute swelling Acute bacterial infection (parotiditis) Calculi + distal infection (submandibular) Sjogrens syndrome -Chronic bilateral symptoms, dry eyes + mouth +/- Sjogrens Tumours

Question 27

Causes of parotiditis

Answer 27

Aetiology- infection, stone, tumour, viral (mumps) Pathology- inflammation of parotid gland Presentation- one or bilateral

Question 28

Whats the 80% rule in salivary gland tumours?

Answer 28

80% are in parotid 80% are pleomorphic adenomas 80% are in superficial lobe

Question 29

Presentation of pleomorphic adenoma

Answer 29

Middle age and grows slowly, hard and PAINLESS

Question 31

What is the most common cause of neck swelling?

Answer 31

Reactive lymphadenopathy

Question 32

What is the mnemonic for remembering the causes of lymphadenopathy?

Answer 32

Mnemonic: HODGKINS DISEASE H aematological: Hodgkins lymphoma, NHL, Leukaemia O ncological: metastases D ermatopathic lymphadenitis G aucher's disease K awasaki disease I nfections: TB, glandular fever, Syphilis N iemann Pick disease S erum sickness - reaction to proteins in antiserum derived from a non-human animal source D rug reaction (phenytoin) I mmunological (RA) S arcoidosis E ndocrinological (Hyperthyroidism) A ngioimmunoplastic lymphadenopathy S LE E osinophilic granulomatosis

Question 33

What are the features of a neck lump that would make you suspect lymphoma?

Answer 33

Rubbery, painless lymphadenopathy Some report lump becomes painful when drinking alcohol Associated with nights sweats and splenomegaly

Question 34

What are the features of a neck lump that would make you suspect a thyroid swelling?

Answer 34

Moves upwards when patient swallows Symptoms of hypo- or hyper-thyroidism

Question 36

What are the features of a neck lump that would make you suspect a thyroglossal cyst?

Answer 36

Usually midline, between isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of tongue May be painful if infected More common in patients under 20

Question 37

What are the features of a neck lump that would make you suspect a pharyngeal pouch?

Answer 37

Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration, chronic cough and halitosis (bad breath) More common in older men

Question 38

What is a pharyngeal pouch?

Answer 38

A pharyngeal pouch is a posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men

Question 39

What are the features of a neck lump that would make you suspect a cystic hygroma?

Answer 39

Typically found in left posterior triangle of the neck Most are evident at birth, around 90% present before 2 years of age

Question 40

What is a cystic hygroma?

Answer 40

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side

Question 41

What are the features of a neck lump that would make you suspect a branchial cyst?

Answer 41

Oval, mobile cystic mass Develops between sternocleidomastoid muscle and pharynx Usually present in early adulthood

Question 42

What is a branchial cyst?

Answer 42

A congenital epithelial cyst that arises on the lateral part of the neck due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) in embryonic development.

Question 43

What are the features of a neck lump that would make you suspect a cervical rib?

Answer 43

Hard, non mobile Situated above first rib

Question 44

What is a cervical rib?

Answer 44

Extra rib which arises from the seventh cervical vertebra. Sometimes known as "neck ribs", their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.6% (1 in 150 people) to 0.8% of the population. People may have a cervical rib on the right, left or both sides.

Question 45

Which group more commonly develop a cervical rib?

Answer 45

Females

Question 46

What is the main complications of a cervical rib?

Answer 46

Thoracic outlet syndrome: either compression of the brachial plexus or compression of the subclavian artery.

Question 47

What are the clinical features of thoracic outlet syndrome?

Answer 47

Compression of the brachial plexus may be identified by weakness of the muscles around the muscles in the hand, near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson's sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.