Approach to a Neck Lump

Approach to a Neck Lump 2018-01-30T16:37:04+00:00

Differential diagnosis

  • Congenital
    • Brachial cleft cyst (anterior to sternocleidomastoid, just inferior to angle of mandible)
    • Thyroglossal cyst (anterior neck in the midline)
    • Laryngocoele
  • Lymphadenopathy
    • Reactive lymphadenopathy secondary to viral infection
    • Viral lymphadenopathy (EBV, CMV, HIV)
    • Neoplastic
      • Primary head and neck cancer
      • Lung carcinoma
      • Breast carcinoma
      • Lymphoma
    • Inflammatory
      • Sarcoidosis
      • Kikuchi disease
  • Thyroid masses
    • Benign thyroid nodule / adenoma
    • Multinodular goitre
    • Diffuse goitre
    • Thyroiditis
    • Thyroid carcinoma
  • Neoplastic
    • Sub-mandibular salivary gland neoplasm
    • Paraganglioma (benign tumour arising from parasympathetic paraganglia), usually from carotid body
    • Schwannoma of vagus nerve or sympathetic chain
    • Lipomas

History

  • Lump
    • How did you first notice it?
    • Where is it?
    • Is it painful?
    • Have you had a fever recently?
    • Has it been growing?
    • Is it just one lump, or are there others?
    • Have you noticed any skin changes over the lump?
    • Have you ever noticed any discharge from it?
    • Have you ever noticed a wheezing sound when you breathe in?
    • Do you feel short of breath?
    • Has your voice changed?
    • Do you feel like your face is swollen?
    • How is it affecting you?
  • Lymphadenopathy
    • Have you had a fever recently?
    • Have you noticed any rashes?
    • Do you have a sore throat or cough?
    • Are you sexually active?
    • How many partners do you have?
    • Do you use contraception?
    • Do you ever find that you are sweating an unusual amount at night?
    • Have you lost any weight?
    • Have you ever coughed up blood?
    • Do you smoke?
    • Have you noticed any lumps anywhere else in your body?
  • Thyroid masses
    • Do you feel unusually hot or cold?
    • Have you noticed any tremor?
    • Do you ever get a feeling that your heart is beating too fast?
    • Do you feel anxious?
    • Have you ever had double vision?
    • Do you have any diarrhoea or constipation?
    • Have you noticed any change in your periods?
    • Do you feel that your voice has changed?
    • Do you feel that the texture of your hair has changed?
    • Do you have any difficulty in getting up from a sitting position?
  • General malignancy screening
    • Have you lost any weight?
    • Do you feel like you are unable to eat?
    • Do you feel tired?
    • Has this affected your swallowing?

Examination

  • General
    • Nutritional status
    • Eyes – divergent gaze / proptosis
    • Facies – coarse (hypothyroidism) or flushed (venous obstruction)
    • Tremor (hyperthyroidism)
    • Clubbing / pseudoclubbing
    • Pre-tibial myxedema
  • Pulse: rate and rhythm (thyroid status
  • Eyes
    • Exophthalmos
    • Lid lag
    • Complex ophthalmoplegia
  • Neck
    • Mass
      • Anterior or in the cervical chains?
      • Tethered to overlying skin / underlying tissue?
      • Texture – smooth or craggy or rubbery
      • Tender / non-tender
      • Does it move with tongue protrusion?
      • Does it move with swallowing?
      • Is there an overlying bruit?
      • Does it pulsate?
    • Tracheal deviation
    • Cervical lymph nodes
  • Cardiovascular
    • Displaced apex beat
    • Peripheral oedema
    • Raised jugular venous pulsation
    • Pulmonary oedema
  • Pemberton’s sign
  • Proximal myopathy

Investigations

  • Full blood count: anaemia, evidence of lymphoproliferative disease
  • Peripheral blood film to look for abnormal lymphoid cells
  • Thyroid function tests if thyroid mass
  • Consider thyroid antibodies to look for Graves’ or Hashimoto’s
  • HIV test if patient consents
  • Fine needle aspiration of lymph node for cytology
  • Consider excision biopsy if histology needed
  • Chest radiograph to look for mediastinal lymphadenopathy, thoracic masses, TB
  • Ultrasound scan of the neck and thyroid gland
  • Consider computed tomography scan of the neck and thorax

Management

  • Patient education
  • Treat underlying cause
    • Thyroid
      • Hypothyroidism: thyroid hormone replacement
      • Hyperthyroidism: carbimazole (neutropaenic advise) + propranolol
        • Referral to ophthalmology if Graves’ eye disease present
      • Thyroiditis: will resolve spontaneously
    • Lymphadenopathy
      • HIV test, consider HAART if positive
      • EBV: self-resolving
      • Lymphoma: refer to Haematology
      • Malignancy: refer to medical oncology

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This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.