Neck Lumps

 

• Differential diagnosis

  By location

  Anywhere:

  • Lipoma
  • Sebaceous (epidermoid) cyst. May have central punctum.

  Midline:

  • Thyroid: goitre, colloid nodule, adenoma, cancer, cyst.
  • Thyroglossal cyst.
  • Dermoid cyst. Rubbery and feels attached to underlying bone.

  Anterior triangle, bordered by the midline, anterior SCM, and lower mandible:

  • Lymph node.
  • Branchial cyst.
  • Parotid tumour.
  • Carotid body tumour or carotid artery aneurysm (pulsatile).

  Submandibular triangle sits within the anterior triangle:

  • Lymph node.
  • Salivary: stone, tumour, sialadenitis.

  Posterior triangle, bordered by the posterior SCM, anterior trapezius, and clavicle:

  • Cystic hygroma: a congenital lymphangioma, usually on left.

  Lymphadenopathy

  >1 lump almost invariably means lymph nodes.

  Groups:

  • Submental under mid-chin.
  • Submandibular along jaw.
  • Preauricular in front of ears.
  • Cervical along anterior sternocleidomastoid.
  • Supraclavicular above clavicle (Virchow's): point to GI disease, not head and neck.
  • Posterior in the posterior triangle.
  • Postauricular behind ear.
  • Occipital over occiput.

  Causes:

  • Infection: EBV, TB, HIV.
  • Inflammation: autoimmune disease.
  • Infiltration: lymphoma, mets (GI, lung, head and neck).

  If lymphadenopathy is found, check for hepato- and splenomegaly, which may be found in lymphoma.

• Benign neck lumps

  Cystic hygroma

  • Congenital cyst in posterior triangle of neck.
  • Arises from jugular lymph sac, hence a 'lymphangioma'.
  • Treat with surgical resection or sclerosing agent.

  Branchial cyst

  • Remnant of 2nd branchial cleft. ⅓ down anterior SCM.
  • Epithelial-lined, containing 'glary fluid' of cholesterol crystals.
  • Removal may be difficult due to proximity to jugular and carotid vessels.
  • Typically presents in early adulthood.

  Thyroglossal cysts

  • Remnant of thyroid tissue during its embryological migration from the foramen caecum of the posterior tongue.
  • Midline lump that moves with tongue protrusion.
  • Typically presents in early adulthood or childhood.
  • Can lead to infection or fistula formation, so surgical removal is recommended.

• Red flags

  New neck lumps that are suspicious for cancer:

  • Lumps in older patients (>40 years old).
  • Lumps in smokers.
  • Painless lumps.
  • Rubbery lumps: ?lymphoma.

• Investigations

  Lump imaging:

  • US is usually 1st line.
  • Digital subtraction angiography (more accurate) or doppler US for carotid body tumours or aneurysms. Don't try and aspirate these!
  • CT or MRI.

  Tissue sampling:

  • Fine needle aspiration (FNA), usually done during US.
  • Firm lumps may also need incisional biopsy (part removed) or excision biopsy (e.g. lymphoma).
  • Lumps within the pharynx or larynx can be biopsied through endoscopy.

  Other investigations are guide by the clinical picture:

  • Imaging for cancer primary or mets: CXR, CT, PET-CT (do pre-biopsy as post-biopsy it will be metabolically active).
  • FBC, U&E.
  • TFT
  • Consider LDH (lymphoma).

• Neck and thyroid examination

  Inspection

  Have patient sat in chair with neck exposed and space behind the chair.

  General appearance:

  • Hyperthyroidism: slim, nervous, agitated, sweaty, flushed.
  • Hypothyroidism: obese, slow, lethargic.
  • Speech problems may suggest recurrent laryngeal nerve compression.

  Hyperthyroid hands:

  • Thyroid acropachy (clubbing and bony growths), palmar erythema.
  • Hot, clammy.
  • Pulse: ↑HR, AF.
  • Fine tremor: hold hands out to check. Place piece of paper on hands to make clearer.

  Hypothyroid hands:

  • Dupuytren's contracture.

  Neck lumps:

  • Look from front and sides.
  • Swallow sip of water → thyroid and thyroglossal cysts move with swallow.
  • Tongue protrusion → if lump moves, thyroglossal cyst.

  Hypothyroid face:

  • Puffy, pallor, dry, flaky skin, balding.
  • Xanthelasma, corneal arcus.

  Thyroid eye disease can be seen in hyper or hypothyroidism, or even euthyroid patients. Start by standing in front, to look for:

  • Exophthalmos or lid retraction: both appear as sclera visible above the iris.
  • Lid lag: delayed movement of eyelid as patient follows finger from high to low.
  • Diplopia: may be experienced by patient as they follow your finger making an H shape.
  • Rare signs: ophthalmoplegia (diffuse eye muscle weakness), exposure keratitis with chronic disease.
  • Then stand behind to look for exophthalmos – anterior protrusion of the eye – manifest as visible sclera. Proptosis is basically synonymous, though some use exophthalmos for endocrine causes and proptosis for non-endocrine.

  Palpation

  Still standing behind, feel for lumps:

  • Place middle 3 fingers of either hand on the mandible below the chin.
  • Start with the anterior tringle, moving along mandible, down anterior SCM, then check sternal notch. At bottom of neck, stabilise trachea with one hand, and palpate the other side for paratracheal nodes, then switch sides. Then move back up midline, and arrive back where you started. The thyroid is in the inferior midline, and is not usually palpable.
  • Then pre-auricular, post-auricular, and occipital nodes.
  • Posterior tringle: start at mastoid, then down posterior SCM, feel in the supraclavicular nodes, then move back up anterior trapezius. Arrive back where you started.
  • Swallow test: feel as they swallow from a glass of water.

  Describing a lump, S4T4ABC:

  • Site
  • Size
  • Shape
  • Skin changes
  • Temperature
  • Texture: rough or smooth.
  • Tenderness
  • Transillumination
  • Attachment to skin or underlying tissue.
  • Bruits
  • Consistency: soft, firm, or hard. Check for fluctuance (fluid-filled), by placing fingers on 2 points, and pressing one to see if the other lifts.

  Move round to front of neck:

  • Palpate trachea to see if deviated by lump.
  • Percuss sternum for retrosternal extension of goitre
  • Auscultate for thyroid bruit: sign of increased blood flow in Graves.

  Limbs

  Finish by examining the limbs:

  • Pretibial myxoedema: brown swelling above the lateral malleoli seen in Graves.
  • Proximal muscle wasting and weakness in hypothyroidism. Have them stand from chair with arms crossed to opposite shoulder.
  • Reflexes: slow relaxation (hypothyroid) or brisk (hyperthyroid).