Examine the neck. Lumps in the neck. - thyroglossal cyst - pharyngeal pouch

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1 Lumps in the neck Midline - goitre - thyroglossal cyst - pharyngeal pouch Examine the neck Lateral - lymph node - sebaceous cyst / lipoma - cystic hygroma/ branchial cyst - vascular: aneurysm, tumour - nerve: neurofibroma Thyroid : inspect From in front From the side Ask patient to sip water, hold it, then swallow Goitre moves up on swallowing Stick out tongue: thyroglossal cyst moves up (linked to foramen caecum: back of tongue) Thyroid: palpation From in front From behind: swallow again Dimensions:?diffusely enlarged?single nodule?size Edge: can you get below? Surface:?smooth? nodular Consistency: soft, firm, hard Local structures Palpate for cervical nodes (from behind) Look over top of head for proptosis Check for tracheal deviation Percuss clavicles and upper sternum Finally, auscultate Ask to check thyroid status Graves disease Goitre Eye signs Thyrotoxicosis Dr R Clarke 1

2 Indications for surgery Patient choice Failure of medical treatment Poor compliance with medication Intolerance of medication (eg rashes) Large goitre Complications of surgery Bleeding (laryngeal or tracheal compression) Thyroid crisis (fast atrial fibrillation/ pulmonary oedema) Hypoparathyroidism- hypocalcaemia Damage to recurrent laryngeal nerve Late hypothyroidism Recurrent hyperthyroidism Hashimoto s Goitre Hypothyroidism Positive microsomal antibodies The thyroid: view from the front Oesophagus External carotid a Superior thyroid a Recurrent laryngeal nerve Trachea Inferior thyroid a Subclavian a Dr R Clarke 2

3 Vagus n. Internal jugular v Carotid a Transverse section through the neck Parathyroid Thyroid Recurrent laryngeal nerve Pre-tracheal fascia Commonest large goitre Multinodular goitre Patient usually euthyroid Rarely can go thyrotoxic (toxic multinodular goitre or Plummer s syndrome) Indications for surgery include cosmetic, patient choice and compression of local structures (change in voice or stridor) Question stop! What are the causes of lymphadenopathy? Dr R Clarke 3

4 Cervical lymph nodes: horizontal ring Submental Submandibular Pre-auricular Post-auricular Occipital Cervical lymph nodes: vertical chain Supraclavicular (eg Virchow s node, Troissier s sign) Posterior triangle Deep cervical Cervical lymph nodes: check Face and scalp for source of sepsis etc Mouth, especially coffin corner of tongue plus throat and ears I would ask for full ENT assessment, to include oropharynx and larynx Check axillary, inguinal, epitrochlear (antecubital) nodes Ask to check breasts and abdomen Other neck lumps Where: which triangle Red: skin colour, ulceration etc DESC + lamp Local structures: tense st-mastoid by asking patient to push chin against your hand Check for lymphadenopathy Causes of cervical nodes- local Acute infection eg tonsillitis, otitis externa Chronic infection eg cold abscess of TB Neoplastic: local spread from head and neck, lung, breast, abdomen Causes of cervical nodes- generalized Acute infection eg acute mononucleosis Chronic infection eg TB, syphilis, HIV Neoplasms: primary and secondary carcinoma Hodgkin, non-hodgkin, CLL Sarcoid Amyloid Dr R Clarke 4

5 Cystic hygroma Rare except in examinations! Cavernous lymphangioma Derived from jugular lymph sac (embryological precursor of thoracic duct) Noted at birth or early childhood Multiloculated cystic mass Usually in posterior triangle Brilliant transillumination Branchial cyst Develops from pharyngeal pouch remnants Usually develops in teens or young adults Lateral structure, appearing from behind upper st-mastoid at level of hyoid bone Distinct regular edge Smooth surface Usually transilluminates Three cysts in the neck Branchial cyst Cystic hygroma Thyroglossal cyst Dr R Clarke 5

6 Carotid aneurysm Localized, pulsating and laterally expansile Differential from tortuous carotid (common in elderly) and from Carotid body tumour Carotid body tumour Slowly enlarging lobulated mass High in neck in carotid triangle Arises at bifurcation Hard, solid, non-transilluminable Transmits carotid pulsation but not expansile Lipoma Subcutaneous Soft Mobile, not attached to skin Fluctuant Anywhere but palms, soles and scalp Epidermoid (sebaceous) cyst Smooth, round Attached to skin at punctum Mobile over deep tissues Fluctuant All sites except palms and soles Neurofibroma Solitary or generalized Check for axillary freckling Plus café au lait spots Associated with acoustic neuroma (check facial nerve, corneal reflex and hearing) Salivary glands Where: parotid or submandibular Check inside mouth: parotid duct by 2nd upper molar; submandibular duct under tongue on either side of frenulum Bimanual palpation of submandibular distinguishes it from lymph node Check VII if suspect parotid swelling Dr R Clarke 6

7 Enlarged salivary gland Acute viral infection eg mumps Acute bacterial infection eg staph secondary to dehydration, diabetes, malnutrition, dry mouth of phenothiazines, alcoholism, pancreatitis Calculi + distal infection Sicca syndrome and Sjogrens eg with rheumatoid arthritis Tumours Parotid & submandibular glands parotid Stenson s duct tonsillar lymph node sterno-mastoid submandibular gland Parotid tumour Submandibular tumours very rare Mixed parotid tumour commonest Suspect malignancy if pain, fixation, VII etc The main points Goitre is the commonest short case If obvious Graves, say so and ask for clarification: examiners like dialogue! If not, just examine the neck and say you would go on to assess thyroid status Goitre Multinodular goitre: usually euthyroid; gland may be large; firm consistency; surface may feel smooth or nodular; commonest goitre UK Simple goitre, colloid goitre, non-toxic goitre - same but smaller and smoother Graves- smooth, soft goitre +/- bruit Hypothyroidism- usually no goitre Hashimoto s- hypo with firm goitre, usually small/ medium size Dr R Clarke 7