Neck Lumps

History & Examination

c.white.1@warwick.ac.uk
Differential Diagnoses
Midline Anterior triangle Posterior triangle
Lymph nodes
Lipomas
Sebaceous cysts
Dermoid tumours
Thyroid gland Salivary gland swelling Subclavian artery
Thyroid nodule Branchial cyst aneurysm
Thyroglossal cysts Carotid aneurysm Pharyngeal pouch
Carotid body tumour Cystic hygroma
Laryngocele
Neck Lump 1
A 36 year old male has a smooth round,
firm 3x3cm lump on the back of his neck.
It has a central punctum and is mobile in
relation to deep tissues. Its doesn’t
transilluminate
EPIDERMOID (SEBACEOUS CYST)
• Caused by proliferation of epidermal
cells within the dermis. Occurs in
response to injury originating from the
follicular infundibulum.
• The filling is liquid or semi-solid.

• Abx if infected
Reasons for removal may include:
• Unsightly
• interferes with ADLs e.g. catches comb
• becomes infected.
 Neck Lump 2
A 52 year old glass blower presents to your surgery
with an uncomfortable neck lump and hoarse voice.
On examination you note that the lump is painless
reducible and has little palpable content.
Laryngocele: Dilation of the laryngeal ventricular
saccule (where vocal cord secretions come from).
Thin walled, air-filled lesions.
Presentation (depends on size and extension)
• Sore throat
• Dysphagia
• Stridor
• Airway obstruction
Risk factors
Excessive cough, woodwind/brass/glass blowing,
obstructing lesion e.g. tumour obstructing the
laryngeal ventricle
Infection = pyolaryngocele
Treatment: Excision or laryngoscope (laser)
 Neck Lump 3
A small for gestational age 6 month year
old girl, year old is brought to the GP
surgery. Her parents have noted a swelling
in her neck.
On examination she is small, has a webbed
neck and a lump posterior to
sternocleinomastoid. The lump is fluctuant
and transilluminates ‘brilliantly’
Cystic Hygromas are caused by failure of
normal lymphatic formation. They should
prompt a search for chromosomal
abnormalities (50-75% will have such an
abnormality, Turner’s being the most
common). They can occur anywhere but
have a predilection for the left posterior
triangle of the neck.
Treatment options:
Conservative, self resolution is uncommon
Sclerotherapy e.g. Bleomycin
Surgical excision
 Turner’s syndrome (45 XO)
Chromosomal disorder in females.
Complete or partial absence of the
second sex chromosome.
Approximately 1 in 2000 live-births.

*aka Webbed neck

 Neck Lump 4
The 29 year old male patient pictured right
presents to your practice. He has a firm,
round, midline neck mass.
It moves when you ask the patient to take
a sip of water. It also moves up when the
patient sticks out their tongue.
Thyroglossal duct cyst
How do these cysts form?
A cystic remnant of the tract that the
thyroid cells take during early foetal
development from the foramen caecum
(base of the tongue) to their postnatal
position in the middle to lower neck.
Normally the remnants obliterate. Most
commonly found at or below the level of
the hyoid bone. Cells secrete mucus.
Most common congenital cysts of the neck.
2/3rd diagnosed before 30.
 Sistrunk procedure

(This reduces recurrence from 70% to 2-4%!)

Thyroid scans and thyroid function studies are

ordered preoperatively; this is important to
demonstrate that normally functioning thyroid
tissue is in its usual area.
Neck Lump 5
A 60 year old male presents with a very ??2WW???
slow growing lump in the right posterior
triangle of the neck.
On examination it has a soft, a somewhat
fluctuant feel; is lobulated; and there is
free mobility of overlying skin. You notice
that it tends to slip away from your fingers
as you palpate it. It doesn’t
transilluminate.
Lipoma
Treatment options include:
Observations
Surgical excisoin
Liposuction
Lipolysis
What features of a neck lump/presentation
indicate malignancy?
• Presence of risk factors
• Age >45
• Smoking
• Alcohol
• GORD
• Nitrosamines (rubber workers)
• Other abrasive / toxic chemical exposure
• Fast growing lump
• Hard / nodular / irregular
• Immobile / tethering to underlying structures
• Overlying skin changes/itchy skin
• Red flags (weight loss, night sweats)
• Compression of structures (hoarse, stridor, neuro)
• Changes in the oral cavity
 Neck Lump 6
The patient pictured (right)
presents with a slow growing,
hard, lobulated, immobile,
pulsatile mass.
Where does the carotid usually
bifurcate?
~C3/4 at the level of the hyoid
bone
Treatment
Surgical resection
Radiotherapy
 Neck Lump 7
A 18 year old girl presents following a recent
URTI. She has noticed that an old lump on her
neck has become sore and has been enlarging
slowly.
On examination the lump lies on the anterior
border of sternocleidomastoid. It doesn’t
transilluminate
Branchial Cyst
3rd and 4th Arches covered by the 2nd should
involute around week 7. If they fail to do so
the entrapped remnant forms and epithelium
lined cyst
Treatment
Antibiotics for infections
Surgical excision (warn
patient that it may recur)
*if the sinus fails to close
completely it can be
discharging
 Neck Lump 8
An 81 year old patient presents with a lump in
the posterior triangle of the neck. The patient
is a resident at a dementia-specialty care home
and is not able to give a full history.
Her carers report that she has been finding it
hard to swallow food recently and has been
being sick - mainly undigested food. Also you
notice that the patient has severe hallitosis.

You send her for a contrast swallow test. These

images are reported. What do they show?

Pharyngeal Diverticulum

Treatment
Observation
Excision
Suture / staple sealed
 Neck Lump 9
• The lady (pictured) comes to your surgery
with lump, just posterior to the maxillary
teeth.
• It appeared a long time ago but has started
rapidly evolving
You note that she has facial droop & weakness
on the same side as the lesion. This includes
her forehead.
Parotid tumour
80% of salivary gland tumours are parotid,
80% are benign, with 80% being benign
pleomorphic adenomas, and much of the • Diagnostic evaluation
remainder Warthin's tumour. • Plain x-rays may be used to exclude calculi
• Sialography may be used to delineate
In this case, there appears to be involvement
of the facial nerve, which is a feature of ductal anatomy
malignancy, and is found with malignant • FNAC is used in most cases
parotid tumours. • Superficial parotidectomy may be either
Rx: benign =Resection diagnostic of therapeutic depending upon
the nature of the lesion
Malignant = Radical or extended • CT/MRI if staging required
Parotidectomy
 What else…..
• Review Tunstall’s neck anatomy lectures for malignant
neck lumps
• Review thyroid pathology, presentation and lab result
interpretation ?next week
• For the Lymphadenopathy presentation fill the
following gaps:
• Infection
• Toxoplasmosis (cat scratch) – Played in litter
• Ebstein-Barr Virus (infectious mononucleosis – glandular fever)
• Mumps (epidemic parotitis) – No MMR
• Lymphoma (just briefly !low yield!)
• Hodgkins
• Non-hodgkins