Neck Lump 3

Take a history from this 24 year old student with a neck lump just below the angle of mandible, anterior to the sternocleidomastoid. It became infected 3 weeks ago and he required antibiotics.


History

  • Onset

  • Duration

  • Location

  • Predisposing events – trauma, recent URTI, tonsillitis/quinsy

  • Associated symptoms – pain, pulsation, change in size, movement on swallowing, gurgling on swallowing, dry mouth, dry eyes

  • B-symptoms – weight loss, malaise, anorexia, night sweats

  • Red flags – odynophagia, referred otalgia, dyspnoea, dysphonia, haemoptysis, haematemesis, epistaxis, headaches, nasal obstruction, glue ear, skin lesions

  • Past Medical History – respiratory disease, thyroid disease, HIV, tuberculosis systems review

  • Drug History – General drug Hx, need for recurrent Abx

  • Social History – smoking, alcohol, occupation, foreign travel, pets

  • Family History – Family history of cancer 

  • Systems review

  • Elicit the patient’s ideas, concerns and expectations 


Conclusion

  • Summarise consultation

  • Thank patient

  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Benign

Congenital

  • Branchial cyst

  • Dermoid cyst

  • Thyroglossal cyst

  • Ranula

  • Cystic hygroma

Acquired

  • Pharyngeal pouch

  • Laryngocoele

  • Sebaceous cyst

Neoplastic

  • Benign

    • Benign salivary neoplasm – pleomorphic adenoma, Warthin’s tumour

    • Benign thyroid – colloid cyst, follicular adenoma

    • Lipoma

    • Schwannoma

    • Carotid body tumour

  • Malignant

    • Primary – e.g. lymphoma

    • Secondary metastasis e.g. SCC, melanoma

    • Thyroid

    • Salivary gland

    • Lung

Infective

  • Viral lymphadenopathy

  • Glandular fever

  • Toxoplasmosis

  • HIV

  • Tuberculosis

  • Cat scratch disease

Autoimmune

  • Hypothyroidism

  • Inflammatory arthritis

  • Sarcoidosis

Inflammatory

  • Sialadenitis

*Table not exhaustive


Management


You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations. 

In general, neck lumps are initially investigated with an ultrasound ± fine needle aspiration for cytology. Further imaging may be requested depending on your presumed diagnosis. Tests for full blood count, inflammatory markers and thyroid function may be indicated in the first instance. 

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