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 (e.g. 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 your hands

Introduce yourself

Confirm the patient’s details (i.e. name and date of birth)

Explain the examination

Gain consent

Appropriately position and adequately expose the neck to the clavicles


General inspection

Listen to the patient’s voice for abnormalities (e.g. hoarse voice)

Note any dyspnoea or stridor

 

Identify any scars on the neck:

  • Previous surgery (e.g. thyroidectomy)
  • Radiotherapy-related scarring

 

Observe for any obvious masses in the neck 

 

 

If a mid-line lump is present:

  • Ask the patient to take a sip of water, hold it in their mouth and then swallow it whilst you observe the movement of the lump. Thyroid masses and thyroglossal cysts will typically rise when the water is swallowed.
  • Ask the patient to protrude their tongue, whilst you observe the mass. A thyroglossal cyst will rise and a thyroid mass will not.
  • Further imaging (e.g. ultrasound) would be required to confirm the aetiology of a mid-line neck lump.

 

Look for systemic signs that may relate to neck pathology:

  • Cachexia may suggest underlying malignancy
  • Exophthalmos/proptosis may suggest a diagnosis of Graves’ disease

 

If there is a mid-line lump 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

  • Lymph nodes can become enlarged for a number of reasons, including infection and malignancy.
  • Lymph nodes are usually smooth and rubbery, with a degree of mobility.
  • An enlarged, hard, irregular lymph node is suggestive of malignancy.

 

Palpate the lymph nodes

Palpate each of the following groups of lymph nodes:

  • Supraclavicular
  • Anterior cervical chain
  • Posterior cervical chain
  • Sub-mental
  • Sub-mandibular
  • Occipital
  • Pre-auricular
  • Post-auricular
  • Parotid

Asking the patient to tilt their head slightly forward can help to relax the neck muscles.

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. It is important to note that a normal thyroid gland is typically impalpable.

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 (often referred to as the “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 the 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.

  • Thyroid palpation
    Palpate thyroid cartilage

Submandibular gland

  • Each submandibular gland can be 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 forward.
  • 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

When assessing any neck lump, you should consider each of the following characteristics:

  • Size – width / height / depth
  • Location – anterior triangle / posterior triangle / mid-line
  • Shape
  • Consistency – smooth / rubbery / hard / nodular / irregular
  • Fluctuance – if fluctuant, this suggests it is a fluid-filled lesion (i.e. cyst)
  • Trans-illumination – suggests mass is fluid-filled (i.e. cystic hygroma)
  • Pulsatility – suggests vascular origin (i.e. carotid body tumour/aneurysm)
  • Temperature – increased warmth may suggest an inflammatory or infective cause
  • Overlying skin changes – erythema / ulceration / punctum
  • Relation to underlying/overlying tissue – tethering/mobility (ask the patient to turn their head)
  • Auscultation – to assess for bruits (i.e. carotid artery aneurysm)
  • Neck lump examination
    Assess size & location of mass

To complete the examination

Thank the patient

Wash your hands

Summarise your 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
  • The 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 – typically have an associated punctum
  • Thyroid gland – located below the thyroid cartilage
  • Thyroid nodule – can be single or multiple – adenomas/cysts/malignancy
  • Thyroglossal cysts – painless/smooth /cysticrises on tongue protrusion
  • Laryngocele – reducible tense massmass returns on sneezing or nose blowing

 

Anterior triangle

The anterior triangle refers to the area of the neck anterior to the sternocleidomastoid muscle:

  • 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 massmass returns on sneezing or nose blowing

 

Posterior triangle

The posterior triangle refers to the area of the neck posterior to the sternocleidomastoid muscle:

  • 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 the left side – fluctuant mass – transilluminates
  • Branchial cyst
  • Mass in the tail of the parotid gland – could be a pleomorphic adenoma or malignancy

 

Note: Lymph nodes in 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 (ST5)

 

Mr Krishan Ramdoo

ENT Registrar (ST6)


 

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