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Neck lump

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Infective Causes

  • Reactive Lymphadenopathy: Commonly due to infections such as viral upper respiratory infections, tonsillitis, or dental infections; presents with tender, mobile lymph nodes.
  • Tuberculous Lymphadenitis (Scrofula): Chronic, non-tender lymphadenopathy, often matted and associated with systemic symptoms such as night sweats and weight loss.
  • Infectious Mononucleosis: Caused by Epstein-Barr virus; presents with generalized lymphadenopathy, fever, sore throat, and fatigue.
  • Cat Scratch Disease: Bartonella henselae infection causing regional lymphadenopathy following a scratch or bite from a cat.

Neoplastic Causes

  • Lymphoma: Painless, rubbery lymphadenopathy; may be associated with systemic ‘B symptoms’ such as fever, night sweats, and weight loss.
  • Metastatic Carcinoma: Firm, non-tender lymph nodes; commonly from primary sites such as head and neck cancers, lung, or breast cancer.
  • Thyroid Cancer: Thyroid nodule with or without cervical lymphadenopathy; may be associated with dysphagia, hoarseness, or rapid growth.
  • Salivary Gland Tumors: Parotid or submandibular gland masses, may be benign (pleomorphic adenoma) or malignant (mucoepidermoid carcinoma).
  • Lipoma: Soft, mobile, benign fatty tumor; typically painless and slow-growing.

Congenital and Developmental Causes

  • Thyroglossal Duct Cyst: Midline neck lump that moves with swallowing or tongue protrusion; typically presents in children or young adults.
  • Branchial Cleft Cyst: Lateral neck mass, often presenting in late childhood or early adulthood; may become infected and present with swelling and tenderness.
  • Dermoid Cyst: Congenital, often midline mass; typically painless and slow-growing.
  • Cystic Hygroma: Congenital lymphatic malformation, often in the posterior triangle of the neck; presents as a soft, compressible, and transilluminable mass.

Endocrine Causes

  • Goiter: Diffuse or nodular enlargement of the thyroid gland; may be associated with hyperthyroidism, hypothyroidism, or euthyroid state.
  • Thyroid Nodule: Can be benign (colloid nodule, cyst) or malignant; solitary nodules are more concerning than multinodular goiters.
  • Parathyroid Adenoma: Typically presents with hypercalcemia symptoms such as bone pain, kidney stones, and abdominal pain; palpable in some cases.
  • Thyroiditis: Inflammatory condition of the thyroid, can cause a tender thyroid gland; may be associated with viral infection (De Quervain’s thyroiditis) or autoimmune disease (Hashimoto’s thyroiditis).

Key Points in History 🥼

Symptomatology

  • Onset and Duration: Rapid onset suggests infection or hemorrhage into a cyst, whereas a slow-growing mass is more likely neoplastic or congenital.
  • Pain and Tenderness: Painful lumps are often infective, whereas painless lumps may suggest malignancy or a benign growth.
  • Associated Symptoms: Systemic symptoms such as fever, night sweats, weight loss, or dysphagia may suggest malignancy, infection, or significant endocrine dysfunction.
  • Changes in Size: Rapid changes in size, particularly in the context of infection or hemorrhage, may require urgent evaluation.
  • Voice Changes: Hoarseness or voice changes may suggest involvement of the recurrent laryngeal nerve, particularly in thyroid or metastatic disease.

Background

  • Past Medical History: Important to note history of malignancy, thyroid disease, or previous infections.
  • Drug History: Review use of medications such as antithyroid drugs, anticoagulants, or immunosuppressants.
  • Family History: Consider family history of thyroid disease, malignancies, or congenital neck lumps.
  • Social History: Assess for smoking, alcohol use, occupational exposures, or high-risk behaviors such as intravenous drug use.
  • Recent Infections: History of recent upper respiratory infections, dental infections, or skin infections can point towards reactive lymphadenopathy or abscess formation.

Possible Investigations 🌡️

Laboratory Tests

  • Full Blood Count: To assess for infection, anemia, or hematologic malignancy.
  • Thyroid Function Tests: Assess for hyperthyroidism or hypothyroidism in the context of a thyroid lump.
  • ESR and CRP: Elevated in inflammatory or infective causes.
  • Calcium Levels: Elevated in hyperparathyroidism or bone metastases.
  • Viral Serology: Consider EBV, CMV, or HIV testing in cases of lymphadenopathy with systemic symptoms.
  • Fine Needle Aspiration (FNA): Key diagnostic test for cytology in suspected neoplastic causes; helps to distinguish between benign and malignant lesions.

Imaging and Specialist Tests

  • Ultrasound: First-line imaging for neck lumps; useful for assessing the nature of the lump (solid vs cystic), its vascularity, and involvement of surrounding structures.
  • CT/MRI Scan: Indicated if malignancy is suspected or if there is concern about deep tissue involvement; provides detailed anatomical information.
  • Radioisotope Scan: Useful in the assessment of thyroid nodules; helps differentiate between hyperfunctioning (‘hot’) and hypofunctioning (‘cold’) nodules.
  • PET Scan: Consider in cases of suspected metastatic disease or lymphoma; provides metabolic information about the lump.
  • Biopsy: Excisional or core biopsy may be required if FNA is inconclusive or if lymphoma or other malignancies are strongly suspected.

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Endocrine & metabolic