Makindo Medical Notes

Neck lumps are a classic surgical and medical exam topic. They can arise from congenital, inflammatory, or neoplastic causes. 👉 Think in terms of position, pathology, movement, and consistency. A systematic approach with history, examination, and investigations is essential to avoid missing sinister causes like lymphoma or thyroid cancer.

📍 Neck Lumps by Position

• Midline
  • Thyroid goitre (moves on swallowing)
  • Thyroid nodule / cancer
  • Thyroglossal cyst (moves on tongue protrusion 👅)
  • Dermoid cyst (does not move)
• Anterior Triangle
  • Lymphadenopathy (reactive, TB, lymphoma, metastasis)
  • Submandibular gland swelling (stone, tumour)
  • Branchial cyst (young adults, lateral, fluctuant)
  • Carotid body tumour (pulsatile, splaying of vessels)
  • Carotid artery aneurysm (expansile pulsation)
  • Laryngocele (swelling ± hoarseness, enlarges with cough)
  • Pharyngeal pouch (elderly, regurgitation of food, gurgling lump)
• Posterior Triangle
  • Lymphadenopathy (infection, TB, lymphoma, metastasis)
  • Cystic hygroma (paediatric, congenital, transilluminates)
  • Cervical rib (palpable bony structure, may cause thoracic outlet syndrome)
  • Subclavian aneurysm (pulsatile mass, bruit)
• Parotid Region
  • Parotid gland tumour (painless, slow-growing, facial nerve involvement = malignant)
  • Sialolithiasis (stone causing pain on eating)
  • Parotitis (painful swelling, often infective e.g. mumps, bacterial)

📋 History & Examination

• Onset & Duration: Acute (infection, abscess) vs chronic (cancer, cyst).
• Pain: Painful lumps = infection/inflammation; painless = tumour until proven otherwise.
• Systemic features: B symptoms (fever, night sweats, weight loss) → lymphoma.
• Movement:
  • With swallow ➝ thyroid lesions
  • With tongue protrusion ➝ thyroglossal cyst
  • Pulsatile/expansile ➝ vascular lesion
• Examination: Site, size, shape, surface, consistency, mobility, transillumination, overlying skin changes.

🔬 Investigations

• 🧪 Bloods: FBC, ESR/CRP, thyroid function, EBV/monospot if viral.
• 🖼️ Imaging: Ultrasound ± FNAC (first-line for most neck lumps); CT/MRI if deep or malignant suspicion.
• 🧬 Biopsy: FNAC for diagnosis (except suspected lymphoma → excisional biopsy preferred).

🛠️ Management

• Infective causes: Antibiotics, drainage if abscess.
• Congenital cysts (thyroglossal, branchial, dermoid): Surgical excision (e.g. Sistrunk’s for thyroglossal cyst).
• Neoplastic:
  • Benign ➝ surgical excision if symptomatic.
  • Malignant ➝ MDT approach: surgery ± radiotherapy/chemotherapy.
• Vascular: Vascular surgery review ± embolisation/resection.

🧾 Key Pathologies

Pathology	Typical Features	Diagnosis	Management
Thyroglossal Cyst 👅	Midline, moves with tongue out/swallow, children/young adults.	USS ± FNAC	Sistrunk’s operation (cyst + central hyoid excision)
Branchial Cyst 💧	Lateral, anterior to SCM, young adults, fluctuant ± infected.	USS ± FNAC	Surgical excision
Cystic Hygroma 🌟	Congenital, posterior triangle, transilluminates, soft, children.	USS/MRI	Surgical excision or sclerotherapy
Carotid Body Tumour ⚡	At bifurcation, mobile laterally but not vertically, pulsatile.	CT/MRI angiography	Surgical resection ± embolisation
Lymphadenopathy 🧬	Tender = infection, rubbery = lymphoma, hard = metastasis.	USS + FNAC, bloods, CXR (TB/lymphoma), biopsy if unclear.	Treat cause (antibiotics, TB treatment, oncology referral).
Parotid Tumour 🦠	Painless, slow-growing, firm. Facial nerve palsy = malignant.	USS + FNAC	Superficial/total parotidectomy ± radiotherapy

💡 Clinical Pearls

• 👉 Painless lump = malignancy until proven otherwise.
• 👉 Midline vs lateral + movement on swallow/tongue protrusion helps localise origin.
• 👉 Always assess for systemic signs (weight loss, fever, night sweats, hepatosplenomegaly).
• 👉 FNAC is first-line for most neck lumps but avoid excision biopsy unless lymphoma suspected.

Cases — Neck Lumps

• Case 1 — Thyroid Nodule (Endocrine): A 35-year-old woman presents with a painless anterior neck lump noticed 3 months ago. Exam: firm, mobile thyroid nodule that moves with swallowing. Thyroid function tests are normal. Diagnosis: Solitary thyroid nodule (most benign, but malignancy must be excluded). Management: Ultrasound ± fine needle aspiration (FNA); thyroid MDT if suspicious.
• Case 2 — Branchial Cleft Cyst (Congenital): A 20-year-old man has a soft, fluctuant swelling on the left side of his neck, just anterior to the sternocleidomastoid. It enlarges intermittently after upper respiratory tract infections. Diagnosis: Branchial cleft cyst. Management: Ultrasound to confirm cystic nature; surgical excision if recurrent or symptomatic.
• Case 3 — Lymphoma (Malignant): A 28-year-old man presents with a progressively enlarging, firm, non-tender cervical lymph node. He also has night sweats, fever, and weight loss. Diagnosis: Lymphadenopathy due to Hodgkin lymphoma. Management: Excisional lymph node biopsy (not FNA); staging with CT/PET; chemotherapy (ABVD regimen).
• Case 4 — Reactive Lymphadenitis (Infective): A 10-year-old boy presents with a tender, enlarged right anterior cervical lymph node following a sore throat. Exam: erythematous pharynx, fever. Diagnosis: Reactive cervical lymphadenitis secondary to streptococcal pharyngitis. Management: Oral antibiotics (penicillin or amoxicillin), analgesia, reassurance; usually resolves in 1–2 weeks.

Teaching Commentary 🧾

Neck lumps can be grouped into 4 key categories: 1. Congenital (thyroglossal cyst, branchial cyst), 2. Inflammatory/infective (reactive lymphadenitis, abscess), 3. Neoplastic (lymphoma, thyroid cancer, metastatic SCC), 4. Miscellaneous (vascular malformations, dermoid cysts). Key exam point: ask if the lump moves with swallowing (thyroid) or with tongue protrusion (thyroglossal cyst). Ultrasound is first-line for most, with FNA or biopsy depending on suspicion.