NECK LUMPS

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QUESTIONS 1

The mother of a 2-year old becomes concerned after she notices a lump in his neck. On examination, the child is well, there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates. The most likely diagnosis is:

A. Dermoid cyst

B. Branhial cyst

C. Thyroglossal cyst

D. Cystic hygroma

E. Ranula

QUESTION 2

A 61-year old lady presents with a neck lump. The mass is below the sternocleimastoid muscle. Although the swelling is painless, she is profoundly embarrassed by halitosis. The most likely diagnosis is:

A. Goitre

B. Reactive lymphadenopathy

C. Lymphoma

D. Pharyngeal pouch

E. Cervical rib

QUESTION 3

A 31- year old man presents with recurrent infection and abscesses in the neck. On examination, you notice a midline defect with an overlying scab. The swelling moves upwards on tongue protrusion. The defect is most likely due to:

A. Dermoid cyst

B. Branhial cyst

C. Thyroglossal cyst

D. Cystic hygroma

E. Ranula

QUESTION 4

A 80-year old complains of neck swelling after a recent cold, which has not resolved. On direct questioning, he has experienced night sweats and has noticed some pain in the lumps when he drinks wine with his meals. Examination reveals multiple, painless swelling in the neck of a ‘rubbery’ consistency. His symptoms are most likely due to:

A. Goitre

B. Reactive lymphadenopathy

C. Lymphoma

D. Pharyngeal pouch

E. Cervical rib

QUESTION 5

A fit 19-year old man notices a neck swelling whilst he is shaving. On examination, there is a smooth, round and mobile lump not tethered to underlying structures. Fluid aspirated from the swelling contains cholesterol crystals. The most likely cause of the swelling is:

A. Dermoid cyst

B. Branhial cyst

C. Thyroglossal cyst

D. Cystic hygroma

E. Ranula

1. Reactive lymphadenopathy

2. Lymphoma

3. Dermoid cyst

Midline lumps:

4. Thyroid swelling

5. Thyroglossal cyst

6. Pharyngeal pouch

Lateral lumps:

6. Cystic hygroma

7. Branchial cyst

8. Cervical rib

9. Carotid aneursym

SESSION OVERVIEW

A COMMON COMPLIANT…

• You will see a lot of neck lumps, whether you work in GP pr hospital.

• Affects all age groups.

• Comes in all shape, sizes and consistencies.

• Painful vs. painless.

• Can occur in isolation, or accompany other systemic or local symptoms.

• A common presentation of head and neck malignancy, beyond the scope of this presentation.

ANATOMY: TRIANGLES OF THE THE NECK

ANATOMY: LEVELS OF THE NECK

• I: Submental/submandibular triangles.

• II: To hyoid bone

• III: To omohyoid muscle

• IV: To clavicle

• V: Posterior triangle

• VI: Midline

• I and V sometimes sub-divided into a + b.

1. REACTIVE LYMPHADENOPATHY

• By far the most common cause of neck swellings.

• Affects all age groups.

• Tender to touch.

• History of local infection or generalised viral illness.

• Should resolve spontaneously.

• No specific treatment required.

2. LYMPHOMA

• Manifestation of a systemic malignancy.

• Rubbery, painless lymphadenopathy.

• Pain on drinking alcohol, uncommon symptom.

• May be associated with night sweats, weight loss and splenomegaly.

3. DERMOID CYST

• Can occur anywhere in the body.

• Cystic teratoma.

• Contains developmentally mature and well-differentiated tissue: clumps of hair, pockets of sebum, bone, teeth, eyes, cartilage and/or thyroid tissue.

• Almost always benign.

• Management: Complete surgical removal without spillage of contents.

4. THYROID SWELLING

• Most likely due to hyperthyroidism or hypothyroidism.

• Thyroid disease F > M.

• Typically young female patients.

• Midline swelling.

• Moves upwards on swallowing.

• Accompanied by thyroid symptoms: Heat intolerance, palpitations, diarrhoea, fine tremor, proptosis etc.

• FNA may be useful to rule-out more sinister pathology

• Manage underlying thyroid disorder.

5. THYROGLOSSAL CYST

• Fibrous cyst due to persistence of the thyroglossal duct.

• More common in patients <20 years age.

• Location: Midline, usually between hyoid bone and thyroid isthmus.

• Movement: Upwards with tongue protusion.

• May be painful if infected.

6. PHARYNGEAL POUCH

• Posteromedial herniation between thyropharyngeus and cricophayrgeus muscles.

• Most common in older men.

• Not usually seen, can be perforated during an OGD.

• Can present as a large midline lump in neck.

• Gurgles on palpation.

• Trapped food debris causes halithosis.

• Symptoms: Dysphagia, regurgitation, aspiration, halithosis, chornic cough.

7. CYSTIC HYGROMA

• Congential lymphatic lesion (lymphangioma).

• Typically found in neck.

• Classically on left side.

• Most evident at birth.

• 90% present by age 2 years.

• Management: Surgery

8. BRANCHIAL CYST

• Failure of obliteration of 2nd branchial cleft in embryonic development.

• Oval, mobile, cystic mass developing between SCM and pharynx.

• Usually presents in teenage years and early adulthood.

• Management: Conservative (no treatment) or surgical excision.

• Management:

9. CERVICAL RIB

• Extension of costo-cartilage on 7th cervical vertebra.

• Prevalence: 1 in 500 (0.2% population).

• More common in adult females.

• 10% develop thoracic outlet syndrome.

• Also compression of brachial plexus and subclavian artery.

• Abson’s sign: Loss of radial pulse on arm abduction and external rotation.

10. CAROTID ANEURSYM

• Pathological dilatation of carotid artery.

• Secondary to atherosclerotic disease.

• Puslatile lateral neck mass, doesn’t move on swallowing.

• May hear a bruit.

• Rare, incidence increases with age.

• Other isk factors: Trauma, HTN, endocarditis.

• Management dependent on size: Conservative vs. surgical repair

INVESTIGATIONS

• Blood tests• FBC• U&Es, CRP• Thyroid function tests

• Imaging:• USS• CT• MRI

• Biopsy:• Fine needle aspiration (FNA)• Excision biopsy

• Look – Listen – Feel• Site• Size• Shape• Surface (Smooth or

Nodular?)• Mobility (Tethered?)• Consistency• Colour• Tenderness• Transillumination

• Consider sex and age group of patient.

• Timing

• Pain

• Movement

• Associated symptoms

SUMMARY: TIPS FOR PHYSICAL EXAMINATION

REVIEW: QUESTION 1The mother of a 2-year old becomes concerned after she notices a

lump in his neck. On examination, the child is well, there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates. The most likely diagnosis is:

A. Dermoid cyst

B. Branhial cyst

C. Thyroglossal cyst

D. Cystic hygroma

E. Ranula

Correct answer: D

REVIEW: QUESTION 2

A 61-year old lady presents with a neck lump. The mass is below the sternocleimastoid muscle. Although the swelling is painless, she is profoundly embarrassed by halitosis. The most likely diagnosis is:

A. Goitre

B. Reactive lymphadenopathy

C. Lymphoma

D. Pharyngeal pouch

E. Cervical rib

Correct answer: D

REVIEW: QUESTION 3

A 31- year old man presents with recurrent infection and abscesses in the neck. On examination, you notice a midline defect with an overlying scab. The swelling moves upwards on tongue protrusion. The defect is most likely due to:

A. Dermoid cyst

B. Branhial cyst

C. Thyroglossal cyst

D. Cystic hygroma

E. Ranula

Correct answer: C

REVIEW: QUESTION 4

A 80-year old complains of neck swellings after a recent cold, which has not resolved. On direct questioning, he has experienced night sweats and has noticed some pain in the lumps when he drinks wine with his meals. Examination reveals multiple, painless swelling in the neck of a ‘rubbery’ consistency. His symptoms are most likely due to:

A. Goitre

B. Reactive lymphadenopathy

C. Lymphoma

D. Pharyngeal pouch

E. Cervical ribCorrect answer: C

REVIEW: QUESTION 5

A fit 19-year old man notices a neck swelling whilst he is shaving. On examination, there is a smooth, round and mobile lump, not tethered to underlying structures. Fluid aspirated from the swelling contains cholesterol crystals. The most likely cause of the swelling is:

A. Dermoid cyst

B. Branhial cyst

C. Thyroglossal cyst

D. Cystic hygroma

E. Ranula

Correct answer: B

‘ To be a successful surgeon, you need the eyes of a hawk, the heart of a lion and the hands of a lady…’

Sir Lancelot Spratt, Doctor in the House