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Lumps in the neck are relatively common and although the majority are benign in nature they can sometimes be the first signs of more sinister pathology such as malignancy. It is therefore essential that you are able to competently perform neck lump examination. This guide demonstrates how to examine a patient with a neck lump in your OSCE, visit our thyroid status examination guide for instructions on how to perform a detailed thyroid gland assessment.

Check out the neck lump examination mark scheme here.

 


Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain examination

Gain consent

Appropriately position and adequately expose the neck to the clavicles


General inspection

Voice – weak/hoarse?

Note any dyspnoea or stridor

Identify any scars on the neck – previous surgery (e.g. thyroidectomy) / radiotherapy

Observe for any obvious masses in the neck

Inspect from the front and both sides

 

If a mid-line lump is present:

  • Ask the patient to take a sip of water, hold it in their mouth and swallow the water on command – thyroid masses and thyroglossal cysts will rise
  • Ask patient to protrude tongue – thyroglossal cyst will rise /and thyroid masses will not

 

Look for systemic signs that may relate to neck pathology:

  • Cachexia – malignancy
  • Exophthalmos / proptosis – Graves’ disease

If there is a mid-line lump/scar or systemic signs suggestive of thyroid disease, ask the examiner if a full thyroid status examination should be performed.

  • Neck Lump Examination
    Gain adequate exposure

Palpation

Lymph nodes

Note: Sometimes asking the patient to slightly tilt their head forward can help to relax the neck muscles.

Lymph nodes can become enlarged for a number of reasonsinfection/malignancy

Lymph nodes are usually smooth, rubbery, with some mobility.

An enlarged, hard, irregular lymph node would be suggestive of malignancy.

 

Palpate the lymph nodes:

  • Supraclavicular – left sided enlarged lymph node – Virchow’s node 
  • Anterior cervical chain
  • Posterior cervical chain
  • Sub-mental
  • Sub-mandibular
  • Occipital
  • Pre-auricular
  • Post-auricular
  • Parotid

Note: You do not need to follow this specific routine but be clear in your own mind so that you cover all regions of the neck.

 

Thyroid gland

Palpation of the thyroid gland may not be expected in an OSCE with a neck lump that is not related to the thyroid. However, to perform a thorough examination of the neck, this should ideally be included as part of the assessment.

1. Place the three middle fingers of each hand along the midline of the neck below the chin

2. Locate the upper edge of the thyroid cartilage (“Adam’s apple”)

3. Move inferiorly until you reach the cricoid cartilage/ring

4. The first two rings of the trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area

5. Palpate the thyroid isthmus using the pads of your fingers

6. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus

7. Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass)

8. Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it will rise during tongue protrusion)

9. If a thyroid mass is present, feel above and below it. Assess retrosternal extension by percussion on the sternum and assess vascularity by auscultation.

Note: A normal thyroid will be impalpable

  • Thyroid palpation
    Palpate thyroid cartilage

Submandibular gland

The submandibular glands can be bilaterally palpated inferior and posterior to the body of the mandible.

Move inwards from the inferior border of the mandible near its angle with the patient’s head tilted forwards.

Submandibular gland swellings are usually singular (whereas lymph node swelling often involves multiple nodes).

Salivary duct calculi are relatively common and may be felt as a firm mass within the gland.

Assessing a neck lump

Size – width / height / depth

Location – can help narrow the differential – anterior triangle / posterior triangle / mid-line

Shape – well defined?

Consistency – smooth / rubbery / hard / nodular / irregular

Fluctuance – if fluctuant, this suggests it is a fluid-filled lesion – cyst

Trans-illumination – suggests mass is fluid-filled – e.g. cystic hygroma

Pulsatility – suggests vascular origin – e.g. carotid body tumour/aneurysm

Temperature – increased warmth may suggest inflammatory / infective cause

Overlying skin changes – erythema / ulceration / punctum

Relation to underlying/overlying tissue – tethering/mobility (ask to turn head)

Auscultation – to assess for bruits – e.g. carotid artery aneurysm

  • Neck lump examination
    Assess size & location of mass

To complete the examination

Thank patient

Wash hands

Summarise findings

 

Suggest further assessment and investigations


Differential diagnosis of a neck lump

Red flags

The following features are red flags that should raise your suspicion of malignancy in the context of a neck lump:

  • Hard, fixed mass
  • Patient is over 35 years old
  • Presence of mucosal lesion in the head or neck
  • A history of persistent hoarseness or dysphagia
  • Trismus
  • Ear pain (referred from tongue base)

 

Differential diagnosis

The location of the lump within the neck can sometimes be useful in narrowing the differential diagnosis. However, it should be noted that this is not an absolute rule, with further investigations required to confirm a particular diagnosis.

Mid-line

Lymph nodes – often multiple, may suggest infection or malignancy

Lipoma – painless/smooth mass

Dermoid cyst – cysts formed along the lines of embryological fusion, painless swellings that do not move with tongue protrusion (more common in children and young adults).

Sebaceous cyst

Thyroid gland – located below thyroid cartilage

Thyroid nodule – can be single or multiple – adenomas/cysts/malignancy

Thyroglossal cysts – painless/smooth /cystic – rises on tongue protrusion

Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing

 

Anterior trianglearea of the neck anterior to sternocleidomastoid 

Lymph nodes

Lipoma – painless/smooth mass

Sebaceous cyst

Salivary gland swelling – doesn’t move on swallowing

Branchial cyst –  present from birth – noticed in early adulthood when it manifests as an infected neck lump

Carotid artery aneurysm – pulsatile mass  – bruit present on auscultation

Carotid body tumour – transmits pulsation – can be moved side to side but not up and down (due to carotid sheath)

Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing

 

Posterior trianglearea of the neck posterior to sternocleidomastoid 

Lymph nodes – often multiple – can be rubbery or hard depending on aetiology

Lipoma – painless/smooth mass

Sebaceous cyst

Subclavian artery aneurysm – pulsatile mass

Pharyngeal pouch – may present as a reducible mass

Cystic hygroma – most commonly on left side – fluctuant mass – transilluminates

Branchial cyst

Tail of parotid mass – could be a pleomorphic adenoma or malignancy

Note: Lymph nodes in any of any of these regions can also be caused by lymphoma and tuberculosis, so a comprehensive history is key to provide a clinical context for your findings. 


REVIEWED BY

Mr Ben Cosway – ENT Registrar (ST4)

Mr Krishan Ramdoo ENT Registrar (ST6)


 

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