Definition
A neck lump is any congenital or acquired mass arising in the
anterior or posterior triangles of the neck between the clavicles
inferiorly and the mandible and base of the skull superiorly.
KEY POINTS
• Thyroid swellings move upwards (with the trachea) on
swallowing.
• Most abnormalities of the neck are visible as swellings.
• Ventral lumps attached to the hyoid bone, such as thyroglossal
cysts, move upwards with both swallowing and protrusion of the
tongue.
• Multiple lumps are almost always lymph nodes.
• Don’t forget a full head and neck examination, including the oral cavity,
in all cases of lymphadenopathy.
Differential diagnosis
• 50% of neck lumps are thyroid in origin.
• 40% of neck lumps are caused by malignancy (80% metastatic
usually from primary lesion above the clavicle; 20% primary
neoplasms: lymphomas, salivary gland tumours).
• 10% of neck lumps are inflammatory or congenital in origin.
Thyroid
• Goitre, cyst, neoplasm.
Neoplasm
• Metastatic carcinoma.
• Primary lymphoma.
• Salivary gland tumour.
• Sternocleidomastoid tumour.
• Carotid body tumour.
Inflammatory
• Acute infective adenopathy.
• Collar stud abscess.
• Cystic hygroma.
• Branchial cyst.
• Parotitis.
Congenital
• Thyroglossal duct cyst.
• Dermoid cyst.
• Torticollis.
Vascular
• Subclavian aneurysm.
• Subclavian ectasia.
Important diagnostic features
Children
Congenital and inflammatory lesions are common.
• Cystic hygroma: in infants, base of the neck, brilliant transillumination,
‘come and go’.
• Thyroglossal or dermoid cyst: midline, discrete, elevates with
tongue protrusion.
• Torticollis: rock-hard mass, more prominent with head flexed,
associated with fixed rotation (a fibrous mass in the sternocleidomastoid
muscle).
• Branchial cyst: anterior to the upper third of the sternocleidomastoid.
• Viral/bacterial adenitis: usually affects jugular nodes, multiple,
tender masses.
• Neoplasms are unusual in children (lymphoma most common).
Young adults
Inflammatory neck masses and thyroid malignancy are common.
• Viral (e.g. infectious mononucleosis) or bacterial (tonsillitis/
pharyngitis) adenitis.
• Papillary thyroid cancer: isolated, non-tender, thyroid mass,
possible lymphadenopathy.
Over-40s
Neck lumps are malignant until proven otherwise.
• Metastatic lymphadenopathy: multiple, rock-hard, nontender,
tendency to be fixed.
• 75% in primary head and neck (thyroid, nasopharynx, tonsils,
larynx, pharynx), 25% from infraclavicular primary (stomach,
pancreas, lung).
• Primary lymphadenopathy (thyroid, lymphoma): fleshy, matted,
rubbery, large size.
• Primary neoplasm (thyroid, salivary tumour): firm, nontender,
fixed to tissue of origin.
KEY INVESTIGATIONS
• U/S scan:
Solid/cystic.
• FNAC:
Colloid nodule
Follicular neoplasm
Papillary carcinoma
Anaplastic carcinoma.
All patients–FBC
?Thyroid
• Full examination:
Fundoscopy
Auroscopy
Nasopharyngoscopy
Laryngoscopy
Bronchoscopy
Gastroscopy.
• FNAC:
?Lymphoma/carcinoma.
• Biopsy:
?Lymphoma cell type.
• CXR
• CT scan:
Source of carcinoma.
LAD
• U/S scan.
• FNAC.
Primary tumours
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