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11/13/24, 7\:06 PM Guide | Neck lump examination

Neck lump examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Ask the patient to sit on a chair for the assessment.
Adequately expose the patient’s neck to the clavicles.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Inspect the patient, looking for clinical signs suggestive of underlying pathology\:
Scars\: may indicate previous neck surgery (e.g. thyroidectomy, lymph node biopsy/excision, radiotherapy related scarring).
Cachexia\: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly
associated with underlying malignancy.
Hoarse voice\: caused by compression of the larynx due to thyroid gland enlargement (e.g. thyroid malignancy).
Dyspnoea or stridor\: may indicate compression of the upper respiratory tract by a neck mass.
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Behaviour\: anxiety and hyperactivity are associated with hyperthyroidism (due to sympathetic overactivity). Hypothyroidism
is more likely to be associated with low mood.
Clothing\: may be inappropriate for the current temperature. Patients with hyperthyroidism su
whilst patients with hypothyroidism experience cold intolerance.
Exophthalmos\: bulging of the eye anteriorly out of the orbit associated with Graves' disease.

Neck lump inspection

Ask the patient to point out the neck lump's location if relevant.
Inspect the neck lump from the front and side, noting its location (e.g. anterior triangle, posterior triangle, midline).

Midline neck lump

If a midline mass is identi
di
Swallowing
Ask the patient to swallow some water and observe the movement of the mass\:
Thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing.
Lymph nodes will typically move very little with swallowing.
An invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue.
Tongue protrusion
Ask the patient to protrude their tongue\:
Thyroglossal cysts will move upwards noticeably during tongue protrusion.
Thyroid gland masses and lymph nodes will not move during tongue protrusion.
Further assessment
If you identify a midline neck lump or systemic signs indicative of thyroid disease, ask the examiner if a full thyroid status
examination should be performed.
Inspect the neck
Anterior and posterior triangles of the neck
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The boundaries of the anterior triangle of the neck are\:
Superior\: the inferior border of the mandible.
Medial\: the midline of the neck.
Lateral\: the anterior border of the sternocleidomastoid.
The boundaries of the posterior triangle of the neck are\:
Anterior\: the posterior margin of the sternocleidomastoid muscle.
Posterior\: the anterior margin of the trapezius muscle.
Inferior\: the middle one-third of the clavicle.
Anterior triangle of the neck [6]

Assessing a neck lump

Palpate the neck lump assessing the following\:
Site\: assess the lump's location in relation to other anatomical structures (e.g. anterior triangle, posterior triangle, midline).
Size\: assess the size of the lump.
Shape\: assess the lump's borders to determine if they feel regular or irregular.
Consistency\: determine if the lump feels soft (e.g. cyst), hard (e.g. malignancy) or rubbery (e.g. lymph node).
Mobility\: assess if the lump feels mobile or is tethered to other local structures. Asking the patient to turn their head as you
palpate the mass can reveal if it is tethered to the underlying muscle (e.g. malignant tumour).
Fluctuance\: hold the lump by its sides and then apply pressure to the centre of the mass with another

Temperature\: increased warmth may suggest an in
Overlying skin changes\: note any overlying skin changes such as erythema (e.g. in
punctum (a pore in the epidermis indicative of an underlying epidermoid cyst).
Pulsatility\: suggests vascular origin (e.g. carotid body tumour, aneurysm).
Tenderness\: may indicate infective and/or in
Other characteristics of the lump may include\:
Transillumination\: apply a light source to the lump, if it is illuminated it suggests the lump is
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Vascular bruit\: auscultate the lump to listen for a bruit suggestive of vascular aetiology (e.g. carotid artery aneurysm).
Assess size, shape, location & pulsatility of the lump
Branchial cyst vs cystic hygroma
A branchial cyst arises from embryological remnants of the second branchial cleft in the neck. It typically presents in
young adults when an upper respiratory tract infection causes it to increase in size. The solitary smooth cyst is most often
located in the anterior triangle. It is usually painless but may be painful during acute infection. A conservative approach to
management may be taken if the cyst is small or alternatively surgical excision can be performed.
A cystic hygroma is a congenital lymphatic lesion which is typically identi
arise anywhere but typically develops in the left posterior triangle of the neck. Cystic hygromas are benign but can be
dis
reaccumulation of lymphatic

Assessing lymph nodes

Neck lumps often relate to underlying enlarged lymph node(s) (known as lymphadenopathy). Lymphadenopathy is a clinical
feature of several di
Performing a thorough clinical assessment of all relevant lymph node groups is therefore essential.
It is important to examine for lymphadenopathy in a systematic manner. There are several chains that can be easily palpated on
clinical examination.
For any palpable lymph node, it’s important to assess the following characteristics to help narrow the di
Site\: assess the lymph node’s location in relation to other anatomical structures.
Size\: assess the size of the lymph node.
Shape\: assess the lymph node’s borders to determine if they feel regular or irregular.
Consistency\: determine if the lymph node feels soft, hard or rubbery.
Tenderness\: note if the lymph node is tender on palpation.
Mobility\: assess if the lymph node feels mobile or is tethered to other local structures.
Overlying skin changes\: note any overlying skin changes such as erythema.
Interpretation of lymph node
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Benign lymph nodes\: typically less than 1cm, smooth, rounded, non-tender and mobile.
Reactive lymph nodes\: typically smooth, rounded, tender, mobile and associated with infective symptoms (e.g. fever).
Lymphadenopathy associated with haematological malignancy\: widespread enlarged rubbery lymph nodes.
Lymphadenopathy associated with metastatic cancer\: regional lymphadenopathy in lymph node groups draining the
a

Palpation of cervical lymph nodes

1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to
relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap.
2. Inspect for any evidence of lymphadenopathy or irregularity of the neck.
3. Stand behind the patient and use both hands to start palpating the neck.
4. Use the pads of the second, third and fourth
the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size,
consistency and mobility of lymph nodes.
5. Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but
a systematic approach will ensure no areas are missed\:
Submental
Submandibular
Tonsillar
Parotid
Pre-auricular
Post-auricular
Super
Deep cervical
Posterior cervical
Occipital
Supraclavicular
Take caution when examining the anterior cervical chain that you do not compromise cerebral blood
compression). It may be best to examine one side at a time here.
A common mistake is a “piano-playing” or “spider’s legs” technique with the
the pads of the second, third and fourth
Example of a logical systematic examination of the lymph nodes
1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (submandibular), turn
upwards at the angle of the mandible (tonsillar and parotid lymph nodes) and feel anterior (preauricular lymph nodes) and
posterior to the ears (posterior auricular lymph nodes).
2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up
behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process.
3. Palpate over the occipital protuberance (occipital lymph nodes).
4. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior
border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).
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Lymph node locations

Assessing the thyroid gland

Assessment 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 be included as part of the assessment.

Palpation of the thyroid gland

Palpate each of the thyroid's lobes and the isthmus\:
1. Stand behind the patient and ask them to tilt their chin slightly downwards to relax the muscles of the neck to aid palpation
of the thyroid gland.
2. Place the three middle
3. Locate the upper edge of the thyroid cartilage ("Adam's apple") with your
4. Move your
cricoid cartilage and the thyroid isthmus overlies this area.
5. Palpate the thyroid isthmus using the pads of your
6. Palpate each lobe of the thyroid in turn by moving your
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 (if a mass represents a thyroglossal cyst, you will feel it rise during tongue
protrusion).
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Palpate the thyroid cartilage

Characteristics of the thyroid gland

When palpating the thyroid gland, assess the following characteristics\:
Size\: note if the thyroid gland feels enlarged.
Symmetry\: assess for any evidence of asymmetry between the thyroid lobes (unilateral enlargement may be caused by a
thyroid nodule or malignancy).
Consistency\: assess the consistency of the thyroid gland tissue, noting any irregularities (e.g. a widespread irregular
consistency would be suggestive of a multinodular goitre).
Masses\: note if there are any distinct palpable masses within the thyroid gland's tissue (e.g. solitary thyroid nodule or thyroid
malignancy).
Palpable thrill\: assess for evidence of a palpable thrill caused by increased vascularity of the thyroid gland due to
hyperthyroidism (suggestive of Graves' disease).
Thyroglossal cyst
Thyroglossal cysts are the most common congenital abnormality of the neck and arise as a result of the persistence of
the thyroglossal duct. The thyroglossal duct is the tract by which the thyroid gland descends during embryological
development to its
thyroglossal cysts rise during tongue protrusion.

Assessing the submandibular gland

Assessment of the submandibular gland may be expected if the neck lump is located in the submandibular region.

Palpating the 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. To assess the gland thoroughly, you
should perform bimanual palpation with one gloved
externally underneath the mandible.
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Submandibular gland swellings are usually singular, whereas lymphadenopathy typically involves multiple nodes). Salivary
duct calculi are relatively common and may be felt as a
See our guide to oral cavity examination for more details.
Palapte the submandibular gland

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 3 2- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
"
t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t . T h e r e
" I n s p e c t i o n o f t h e n e c k w a s u n r e m a r k a b l e , b u t p a l p a t i o n r e v e a l e d a 1 x 2 c m m a s s i n t h e l e f t p o s t e r i o r t r i a n g l e. T h e
m a s s w a s m i l d l y t e n d e r o n p a l p a t i o n w i t h o v e r l y i n g e r y t h e m a a n d a v i s i b l e p u n c t u m. T h e m a s s w a s s m o o t h a n d r o u n d
i n s h a p e . T h e r e w a s n o e v i d e n c e o f t e t h e r i n g t o t h e u n d e r l y i n g t i s s u e , h o w e v e r , t h e l e s i o n d i d a p p e a r t o b e t e t h e r e d t o
t h e e p i d e r m i s . T h e r e w a s a l s o n o p a l p a b l e l y m p h a d e n o p a t h y i n t h e c e r v i c a l r e g i o n .
"
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Thyroid status examination and thyroid function tests (TSH, T3, T4)\: if a midline lump is present.
Examination of the lymphoreticular system\: if lymphoma or leukaemia is suspected.
Examination of oral cavity, oropharynx and nasal cavity\: to exclude a mucosal lesion.
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Routine blood tests such as FBC, U&Es, CRP\: useful if considering infection or malignancy.
Ultrasound scan and other imaging (e.g. CT/MRI)\: to determine aetiology.
Fine needle aspiration\: to allow histological diagnosis.
Early referral to ENT\: if there is suspicion of malignancy.

Di

The location of the lump within the neck can sometimes be useful in narrowing the di
combined with other clinical
Causes of a midline neck lump
Lymph node\: often multiple and associated with underlying infection or malignancy.
Lipoma\: a solitary painless, rubbery, smooth mass.
Dermoid cyst\: formed along the lines of embryological fusion. Dermoid cysts present as painless swellings that do not move
with tongue protrusion (more common in children and young adults).
Epidermoid cyst\: a solitary painless mass (can be painful with overlying erythema if ruptured/infected) that has an
associated punctum in the epidermis overlying the lesion. They are tethered to the epidermis and contain keratin.
Enlarged thyroid gland\: typically located below the thyroid cartilage (see our thyroid examination guide for more details).
Thyroid nodule\: may be single or multiple and represent adenomas, cysts or malignancy.
Thyroglossal cysts\: a painless, smooth
Laryngocele\: a reducible tense mass that can increase in size during sneezing or nose blowing.
Causes of a neck lump located in the anterior triangle
The anterior triangle refers to the area of the neck anterior to the sternocleidomastoid muscle\:
Lymph node\: often multiple and associated with underlying infection or malignancy.
Lipoma\: a solitary painless, rubbery, smooth mass.
Epidermoid cyst\: a solitary painless mass (can be painful with overlying erythema if ruptured/infected) that has an
associated punctum in the epidermis overlying the lesion. They are tethered to the epidermis and contain keratin.
Submandibular gland swelling\: typically located medial to the angle of the mandible and may be caused by a salivary
gland stone (sialolithiasis) and/or infection of the gland (sialoadenitis).
Branchial cyst\: present from birth and typically noticed in early adulthood when it becomes swollen due to infection.
Carotid artery aneurysm\: a pulsatile mass with an audible bruit on auscultation.
Carotid body tumour\: pulsatile and can be moved side to side but not up and down (due to the carotid sheath).
Laryngocele\: a reducible tense mass which increases in size during sneezing or nose blowing.
Causes of a neck lump located in the posterior triangle
The posterior triangle refers to the area of the neck posterior to the sternocleidomastoid muscle\:
Lymph node\: often multiple and associated with underlying infection or malignancy.
Lipoma\: a solitary painless, rubbery, smooth mass.
Epidermoid cyst\: a solitary painless mass (can be painful with overlying erythema if ruptured/infected) that has an
associated punctum in the epidermis overlying the lesion. They are tethered to the epidermis and contain keratin.
Subclavian artery aneurysm\: a pulsatile mass with an audible bruit on auscultation.
Pharyngeal pouch\: a reducible mass.
Cystic hygroma\: a
Branchial cyst\: present from birth and typically noticed in early adulthood when it becomes swollen due to infection.
Mass in the tail of the parotid gland\: typically associated with pleomorphic adenoma or primary parotid malignancy.

Reviewers

Mr Ben Cosway
Senior ENT Registrar
Mr Krishan Ramdoo
Senior ENT Registrar
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