Neck Lump

History

• Ask about the site, onset, growth/change; timescale
• Ask about associated symptoms; in particular-
  • Pain
  • ENT symptoms
    • Dysphagia/Odynophagia
    • Hoarseness
    • Soar throat; ear ache
  • Constitutional symptoms
    • Fatigue/lethargy/malaise
    • Night sweats
    • Weight loss
  • Other systemic symptoms that might be suggestive of malignancy
    • e.g. shortness of breath; itching; bruising/bleeding; bone/joint pain
  • Symptoms suggestive of thyroid cause
    • Underactive
      • Weight gain, dry skin/hair, cold sensitivity, tiredness, myalgia, depression
    • Overactive
      • Hyperactivity, anxiety, weight loss, sweating/heat sensitivity, diarrhoea, tiredness, insomnia
• Ask about concurrent/recent illnesses or recent trauma (anywhere)
• Ask about PMHx and drugs, including radiotherapy/radiation exposure
• Ask about FHx (particularly of endocrine tumours)
• Ask about Social History
  • Smoking, alcohol
  • Travel

Examination

• NB If you suspect hypo-/hyperthyroidism associated with the mass (and, in fact, for most other causes)
  • Look at the hands- sweating, temperature, look for tremor (paper balance test); acropatchy nails (similar to clubbing); onycholysis; palmar erythema
  • Feel the pulse
• Inspect the neck and surrounding area for obvious swellings, scars, pulsations
  • For central masses, inspect the mass with the tongue protruded (movement suggests thyroglossal cyst)
    • Also assess the mass on swallowing (suggests thyroid masses)
• Palpate from behind
  • Lymph nodes
    • Submental; submandibular; pre-auricular; anterior cervical; supraclavicular; posterior cervical; post-auricular; occipital (Z shape roughly)
    • 
  • Thyroid gland
    • Both lobes and isthmus
• NB Whilst from behind- look superiorly for protrusion of the eyes (exophthalmos)
• Auscultate the neck/thyroid

NB Other structures e.g. ear, oral cavity etc may also want to be examined

Describing neck lumps: Size (height, width, depth); Location; Shape (well-defined?); consistency (smooth, rubbery e.g. lymphoma), hard, nodular, irregular); Fluctuant/fluid filled (is it trans-illuminable); Pulsatility; Temperature; Overlying skin changes (erythema; ulceration; puctum); Relation to underlying/overlying tissue (tethered?; mobile?); Auscultation status

Causes

• Superficial Lumps
  • Sebaceous cyst; lipoma; abscess; dermoid cyst
• Lymph Nodes
• Anterior Triangle
  • Lymph nodes most common (coming from mouth, throat, thyroid, skin of head/neck)
  • Consider also metastasis; infection (including TB).  If it doesn’t move, consider branchial cyst; cystic hygroma; carotid aneurysm; tumours (including lymphoma); laryngocele; parotid gland swellings
• Posterior Triangle
  • Again, lymph nodes- look also for hepato-/splenomegaly
  • Cervical rib
  • Pharyngeal pouch
  • Cystic hygroma
  • Branchial cyst
• Midline mass
  • Thyroid swellings (including thyroglossal cyst)
  • Laryngeal swelling
  • Chondroma of thyroid cartilage
  • Dermoid cyst
• Supraclavicular
  • Virchows node (malignancy)

Investigations

• Solitary nodules
  • Can be malignant/benign; secreting/non-secreting; solid/cystic; hot/cold (on iodine scan)
    • Hot or cold nodules can be malignant- therefore- investigation of choice is fine needle aspirate.
• Multinodular goitre
  • Most commonly associated with euthyroid (asymptomatic) state but can be hyperthyroid or hypothyroid.  They are almost never malignant, so USS can be used to confirm diagnosis and TFTs used to guide treatment
• Painful swellings under the jaw (submandibular) or at the jaw angle (parotid) are usually indicative of salivary gland stones.  Sialogram can be used to investigate.  Large stones in the gland may require surgery, whilst smaller ones in the duct can be passed manually.
• Cervical lymphadenopathy
  • Depends on associated symptoms
    • If hoarse voice/dysphagia then nasopharygoscopy
    • If SOB, CXR/CT
    • If malaise, night sweats- Biopsy/FNA