Examination of the Neck

History of a Neck Lump

• Duration

• First symptom

• Other symptoms

• Progression

• Persistence

• Multiplicity

• Cause

History of a Neck Lump: Duration

• “When did you first notice the lump?”

• Be precise with dates

• Be aware that the lump may have been present months before the patient first noticed it

History of a Neck Lump: First Symptom

• “What made you first notice the lump?”

• Incidental

- The patient felt it while washing

- Someone else noticed it

• Symptomatic

- The patient noticed it when they felt a painful area

History of a Neck Lump: Other Symptoms

• “Does the lump cause any problems?”

• May be:

- Painful

- Disfiguring

- Interfere with function e.g. swallowing

History of a Neck Lump: Progression

• “Has the lump changed since it was first noticed?”

• It may have:

Changed in size
The time frame for change
- Rapidly enlarging
- Fluctuating in size (congenital cyst)
Become more painful

History of a Neck Lump: Persistence

• “Does the lump ever disappear?”

• Only a few conditions disappear and reappear

e.g. Salivary gland obstruction

• Less likely to be malignant

History of a Neck Lump: Multiplicity

• “Have you ever had a lump like this before?”

• “Do you have any other lumps elsewhere?”

• There may be a link between the neck lump and other lumps

Recurrence of a lump
Systemic causes of lymphadenopathy e.g. Lymphoma, Sarcoidosis

History of a Neck Lump: Cause

• “What do you think caused this lump?”

• The lump may have occurred after an event, injury or illness

History of a Neck Lump: Other important information to elicit

• Age

<16 – The majority are either inflammatory or congenital
16 to 40 – Inflammatory or congenital causes are still most common but malignant causes start to increase
>40 – Should be considered neoplastic, and potentially malignant, until proven otherwise (especially if the patient smokes and/or drinks)

• History of Head & Neck Cancer

• History of skin cancer of the face and scalp

• History of immunosuppression

• Weight loss/night sweats/fever

• Contact with relatives with infectious disease/pets & animals/occupational exposures/recent foreign travel

Red Flags for Malignancy

• Lump present for > 2-3 weeks duration

• Patient > 40 years old

• Tobacco and alcohol use

• Previous history of malignancy (head and neck, skin, lymphoma)

• Immunocompromised (renal transplant)

• Unexplained weight loss

• Other head and neck symptoms

Change in voice/hoarseness
Blood in saliva
Dysphagia/odynophagia
Otalgia
Nasal congestion

Examination of a Neck Lump

• Site

• Size

• Shape

• Consistency

• Tenderness

• Mobility

• Temperature

• Overlying skin

• Fluctuance

Examination of a Neck Lump (ICE)

• Clean hands before examination

• Introduce yourself

• Consent

• Explain what you are going to do

• Obtain verbal consent

• Expose

• Should be able to see everything above clavicles

• Unbutton shirts and remove scarves etc.

Examination of a Neck Lump

• Inspection from the front

• Ask the patient to swallow a sip of water

Watch for any movement of the midline lump

• Palpate from behind in a systematic fashion

• Systematically palpate all levels of the neck

• Remember to examine preauricular and postauricular areas

• Examine oral cavity and oropharynx

• Bimanual palpation of submandibular gland

the

• Examine the skin of the face and scalp

Description of a Neck Lump: SITE

• Description of anatomical location

• Neck level

• Think of underlying anatomical structures

Midline – thyroid
Pre-auricular – parotid
Lateral neck – lymph node

Description of a Neck Lump: SIZE

• Measure with a ruler

Length
Width

• Use common objects/food

Golf ball
Pea

Description of a Neck Lump: SHAPE

• Round

• Oval

• Pear shaped

• Kidney shaped

Description of a Neck Lump: SURFACE

• Smooth

• Irregular

Description of a Neck Lump: EDGE

• Discrete

• Diffuse

Description of a Neck Lump: CONSISTENCY

• Rock hard: Bone

• Firm: Hard but not as hard as bone

• Rubbery: Slightly squashable – rubber ball

• Spongy: Squashable – some resilience

• Soft: Squashable – no resilience

Description of a Neck Lump: MOBILITY

• Relationship between the lump and surrounding structures

• Move independently

• Fixed

Description of a Neck Lump: TEMPERATURE

• Hot or normal temperature

• Assess by feeling a lump with the dorsum of the hand (back of the hand)

• Hot - inflammatory process

Description of a Neck Lump: TENDERNESS

• Ask the patient if the lump is tender before palpating

• If so be gentle!

• Look at the patient’s face while palpating to assess the severity of tenderness

Description of a Neck Lump: OVERLYING SKIN

• Look at colour

• Look for breaks in skin/ulceration

• Puckering

• Orange peel skin (peau d’orange)

Description of a Neck Lump: FLUCTUANCE

• Fluid filled/cystic

• Compression to one point causes expansion elsewhere

RED FLAGS

• Size > 1cm

• Round or irregular

• Firm

• Fixed

• Normal temperature

• Non-tender

• Overlying skin ulcerated (fungating)

Differential Diagnosis

Surgical Sieve

• Congenital

• Acquired

• Vascular

• Inflammatory or Infective

• Traumatic

• Autoimmune

• Metabolic

• Idiopathic

• Neoplastic

Primary
Metastatic

• Degenerative

• Environmental

VITAMIN C, D, E

Congenital

Thyroglossal Duct Cyst

• Most common congenital neck mass - 70%

• >50% before age 20yrs

• 75% midline

• 65% infra-hyoid

• Fluctuant

• Painless unless it becomes infected

• Moves when patient protrudes tongue (fixed to hyoid bone)

Branchial Cyst

• Remnant of branchial cleft (usually 2nd)

• Stratified squamous epithelium with lymphoid tissue

• Smooth, fluctuant mass level 2. Anterior to SCM

• Present post-URTI in an older child/young adult

• Painless fluctuant swelling

• Remember > 40 yrs = Malignant until proven otherwise

Haemangioma

• Most common paediatric tumour

• 0.5 % H&N tumours

• Proliferate/involute

• Haemangiomas usually resolve

• Complicated lesions may require treatment

• Propanolol

• (90% by 9 years)

• CT/MRI

Lymphatic Malformations

• “Cystic Hygroma”/“Lymphangioma”

• Present neonate (90% by 2yrs)

• Painless, fluctuant

• Cystic Hygroma usually found at the base of the posterior triangle

• No regression

• Require Rx.

Sclerosing agents
Resection

Acquired

Surgical Sieve

• Congenital

• Acquired

Vascular
- Carotid Body Tumour
- Carotid Aneurysm
Inflammatory or Infective
- Bacterial
- Viral
- Protozoal
- Thyroid
Traumatic
Autoimmune
- Thyroid
Metabolic
- Thyroid
Neoplastic
- Primary
  - Thyroid
  - Lymphoma
  - Salivary
- Metastatic
  - Skin
  - Oral/Oropharyngeal
  - Salivary
  - Thyroid
  - Distant
Degenerative
Idiopathic