Approach to a Neck Lump

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