This document discusses the examination and evaluation of lumps in the neck and on the skin. It provides guidance on how to describe lumps and outlines the broad categories of neck lumps including lymph nodes, salivary glands, thyroid, vascular structures and more. It lists relevant investigations and treatments for different types of lumps. Common benign and malignant skin lesions are discussed. Surgical procedures for removing various lumps are also summarized.

1. Revision: Lumpsof neck and skin
Christiane Riedinger, September 2014

2. Lumps and bumps cover three broad areas: skin
lumps / dermatology, lymph nodes and neck lumps /
thyroid
Also see examination manual for neck, lump and skin
examination, especially in the appendices!

3. Introduction

4. How to describe a lump
● she cuts the fish 3x + PER
○ site, size, surface
○ colour, contour, consistency, compressibility/fluctuance
○ tenderness, temperature, transillumination
○ fluid-filled, fixed/mobility/depth (tethering vs. fixation), fields (lymphatic drainage)
○ pulsatile (e.g. aneurysm)
○ expansile
○ reducible/relation to skin, muscle, other structures (hernia/breast lesion)
● The way they fit better for presentation
The patient has a XXcm (SIZE), XX (COLOUR), XX (NON/TENDER) lump in the XX (SITE). Upon palpation, it
has a XX in CONSISTENCY with a XX SURFACE and XX CONTOUR. It has a XX TEMPERATURE compared
to the surrounding skin and is NON/PULSATILE/EXPANSILE. The lump is FIXED/MOBILE and seems to be
connected to XX (RELATION). Judging from the site, the lump drains to XX NODES and palpation in this area
suggests NO/LYMPHADENOPATHY.

5. Investigations
● FBC - lymphocytes to rule out lymphoma, AOCD
● TFTs - thyroid abnormalities, +/- thyroid autoantibodies
● LFTs - liver mets?
● U&Es - Ca2+ of malignancy
● If suspect medullary carcinoma: electrophoresis for calcitonin amyloidosis; somatostatin, 5-HT,
VIP levels, red gene => if present prophylactic thyroidectomy.
● CRP/ESR - inflammation, lymphoma?
● Thyroid US with US-guidd FNA of lump (FHY1-5 classification?)
FNA is 1st line Ix for a thyroid lump! FNA cannot distinguish between follicular adenoma and
carcinoma)
● Thyroid radioisotope scan (radioiodine) to identify hot nodules
● Transnasal laryngoscopy to check vocal cords
● (Hemithyroidectomy if in doubt for histological analysis)
● Sialogram
● MRI/CT endoscopy
● Arteriography of carotid bifurcation
● PET
● Node: Always FNA NOT excision biopsy as usually not curative on its own if node

6. Lumps in the Neck
For more Info, see Consultation Manual

7. Overview of Neck Lumps
● Structural classification. Can also arrange by location (see examination manual)
● Lymph nodes Infectious lymphadenitis: (non-specific, mono, syphilis, toxo, TB
cervical adenitis (+/- HIV)***), originating from skin, tonsils
Lymphoma, leukaemia, 2* of head, neck, chest or abdo tumour
Sarcoidosis
● Salivary glands Sialadenitis (e.g. parotitis), sialolithiasis, adenoma/carcinoma
● Thyroid Single vs multiple nodules vs diffuse swelling
Cyst vs tumour
● Dental abscess
● Vascular Carotid artery aneurysm
Carotid chemodectoma/carotid glomus tumour/paraganglioma
Note link to syndromes: MEN II, VHL, NFI
Cystic hygroma (congenital lymphangioma)
● Embryological Thyroglossal cyst/sinus, branchial cyst, pharyngeal pouch
● Skin Sebacious cyst, dermoid cyst, lipoma
● Musculoskeletal Cervical rib

8. 1* neoplasms => cervical nodes
● Scalp and upper face => post.triangle
● Nasal cavity and nasopharynx => post. triangle
● Tongue and floor of mouth => submental
● Lips
● Tonsils and oropharynx => upper neck
● Submandibular glands
● Laryngopharynx and larynx => middle neck
● Thyroid => lower neck, post. triangle
● Upper Oe
● Upper limbs and chest wall
● Breast
● Lungs
● Stomach and viscera

9. Pharyngeal Pouch / Zenker’s Div.
● Pulsion diverticulum of the pharynx through a gap between the upper
horizontal fibres of cricopharyngeus and lowermost oblique fibres of inf.
constrictor.
○ Unsupported area = Killian’s dehiscence that can bulge out over
time, esp. if cricopharyngeus does not relax appropriately during
swallowing => occurs in old age usually
● Symptoms: halitosis, recurrent sore throats, regurgitation, dysphagia
● Complication: aspiration
● May cause swelling behind sternocleidomastoid that gurgles upon
compression and changes in size / disappears at times
● Treatment:
○ Endoscopic stapling
○ Excision +/- cricopharyngeal myotomy

10. Neck Lumps and their Treatments
Branchial cyst Ant. of Stclm. sup. Excision (close to in. jugular vein and carotid a)
Branchial sinus Hole ant of stclm inf. Excision
Cystic hygroma* Base of L post. tri. Excision but recurrence possible
Dermoid cyst Sites of embr. fusion Excision, if possible in one piece,
recurrence pos.
Pharyngeal pouch Endoscopic stapling, excision and
cricopharyngeal myotomy
Carotid body tumour Carotid triangles Excision (after exclusion of phaeo)
Multinodular colloid goitre Thyroidectomy if symptomatic
Subtotal/hemi: to protect parathyroid glands and
recurrent laryngeal nerves
Thyroid cyst Aspiration
Lingual thyroid Excision: removal of central portion of the hyoid
bone followed by dissection.
Thyroglossal fistula after infection of lingual thyroid or inadequate surgical removal
Surgical Rx for hyperparathyroidism Exploration and ID of all four parathyroids

11. Neck Lumps and their Treatments ctnd.
Parotid Superficial and deep portions separated by space in which VII runs.
=> Cannot remove in one go otherwise facial palsy.
Superficial parotidectomy via long vertical incision in front of ear
Deep parotidectomy is much more likely to damage facial nerve
Acute parotitis Lump + severe pain from capsule extension, viral or bacterial
May be post-op complication in patient with poor salivary flow!
Treat with AB? Excise abscess?
Salivary calculi Submandibular most likely (plan X-ray or sialogram = contrast in
salivary duct
Salivary neoplasms Pleomorphic/mixed salivary adenoma, adenolymphoma/Warthin’s
tumour, adenoid cystic carcinoma = malignant +/- facial nerve palsy
Treatment by excision or palliative.
Carotid tumour Dissection of tumour +/- graft replacement of the artery
Conservative or local radiotherapy in elderly

12. Sternocleidomastoid “Tumour”
● In newborn, swelling in middle ⅓ of SCM caused by birth trauma
● Ischaemic contracture of a segment of the SCM
● Child’s head turned away from lesion but tilted towards the swelling =
Torticollis
● Torticollis may disappear or become permanent if muscle fibroses
● DD: Torticollis can also be caused by a squint (attempt to correct it)
● In adults: can be caused by muscular spasm

13. Thyroid Lumps
● Embryology: thyroid descends from floor of pharynx. Foramen caecum on
tongue is remnant of thyroglossal duct

14. Different Thyroid Carcinomas
● Combine with path summary from last year
● Papillary
○ Good prognosis even if spread to local lymph nodes
○ Subtotal thyroidectomy, may be followed by completion thyroidectomy after histological analysis
○ Radioiodine treatment for metastases (better post-op so that thyroid does not accumulate the substance)
● Follicular
○ Still good prognosis but poorer in older patients
○ Blood-borne spread (unusual for carcinoma, usually lymphoid)
○ Subtotal thyroidectomy, may be followed by completion thyroidectomy after histological analysis
○ Radioiodine treatment for metastases (better post-op so that thyroid does not accumulate the substance)
● Anaplastic
○ Highly aggressive, worst prognosis
○ Palliative care, if surgical then tracheostomy and external beam radiotherapy
● Medullary (from C-cells, calcitonin producing)
○ MEN1, red gene
○ Total thyroidectomy
● Lymphoma
○ HL and HNL
○ Chemo

15. DD of Skin Lumps
● Always consider in skin
○ Superficial lumps
○ Sebaceous cyst Central punctum, fluctuant, soft, round
○ Lipoma Soft, mobile, painless, smooth, demarcate, in layer
where you would expect fat, may be fixed to muscle,
especially near scapula, may be fluctuant if fat liquid
in
warm skin.
Familial: Dercum’s disease, multiple lipomas
○ Abscess Pain, swelling, erythema
○ Dermoid cyst At sites of embryological fusion, e.g.near eyebrow of
child, under tongue, at midline.
○ Lymph node Firm, mobile, can be tender

16. DD of Skin Lumpsctnd.
● Benign
○ Keloid scars Raised thickened scars that send extensions into
normal skin. Surgical excision if often unsatisfactory.
Steroid therapy, radiotherapy and topical retinoic acid
show moderate response. Some individuals and skin
areas are more prone: Young adults, dark skin, upper
half of body
○ Lipoma
○ Neurofibroma Benign nerve tumours, many in neurofibromatosis I
Small, firm, smooth and not fixed to the skin
○ Sebaceous cyst
○ Carbuncle Coalescence or multiple sebaceous cysts that become
infected, esp. on back of diabetic patients
Surgical excision

17. DD of Skin Lumpsctnd.
● Benign ctnd.
○ Hidratenitis suppurativaCluster of abscesses due to infection of apocrine
glands,
or cysts. Treat with drainage.
○ Papillomas Warts, keratin horns, basal cell warts, pedunculated
papillomas
○ Vascular malformations
■ Cherry angiomas (Campbell de Morgan spots)
Red, domeshaped spots that increase with age. No Rx
■ Port wine stains Mode common on face and scalp, deep red.
If in ophthalmic area potential ass. with Sturge-Weber
Syndrome (meningeal angioma)
■ Strawberry naevi (capillary angioma)
Raised purplish nodules or plaques in early life. Rarely
caused by dermal ischaemia

18. DD of Skin Lumpsctnd.
● Benign lesions ctnd.
○ Vascular malformations ctnd.
■ Cavernous haemangioma
Soft, compressible, mauvish-blue swellings that vary
Surgical excision or sclerosants.
■ Venous lakes Bluish saccular dilatations of the lip in the elderly
■ Glomus tumours Painful benign cuboidal lesion on the fingertips
■ Pyogenic granulomas
Rapidly growing red, domed papules with glazed or
eroded surface, often on fingers and toes. May resolve
spontaneously

19. DD of Skin Lumpsctnd.
● Pigmented lesions
○ Benign naevi/pigmented mole
<16 normal, multiple in dysplastic naevus syndrome
Flat, pigmented, can be slightly irregular.
I.e. mole that does not display the ABCDE of melanoma
Features of mature benign naevus: raised and seizing
to produce pigment. Atypical if associated stromal rxn?
○ Malignant melanoma ABCDE of melanoma
○ Basal cell carcinoma COMMON low grade malignancies, 90% on face above
level of ears and mouth. Raised, pearly pink papule with
fine telangiectasia. Later + ulceration “rodent ulcer”.
Surgical excision, cryotherapy, radiotherapy
○ Squamous cell carcinomaMay arise in pre-existing lesions such as leg ulcers
(Marjolin’s ulcers). Excision +/- radiotherapy to nodes

20. DD of Skin Lumpsctnd.
● Pigmented lesions ctnd.
○ Bowen’s disease Intraepidermal squamous carcinoma in situ
Head and neck of men and lower limbs and cheeks of
women
Single or multiple slowly growing well-defined brownish
plaques, raised and scaly. Can be on mucous membranes
Erythroplasia of Queyrat if on glans penis
Surgical excision with 4mm margin, topical antineoplastic
drugs, radiotherapy, photodynamic therapy
○ Kaposi sarcoma HIV association. HHV-8 infection.
Nodular red, purple, brown or black plaques.
Single or multiple in skin, mucosa, GI or resp. tracts.
Can grow slow or rapidly. Treat underlying cause.

21. ABC of Melanoma
● Asymmetrical shape
● Border irregularity
● Colour irregularity
● Diameter >7 mm
● Evolution of lesion (e.g. change in size and/or shape)
● Symptoms, e.g. bleeding, itching

22. Surgical Procedures
● “Lumpectomy”
● Total excision biopsy, e.g. for suspicious mole +/- sentinel lymph node
biopsy
○ Margins of melanoma excision: 1cm if 1mm and impalpable, 2-3cm if
thicker and palpable (>1.5mm). Margin determins local recurrence, not
survival.
● Surgical drainage of abscess
● Partial/subtotal thyroidectomy If done for histological purposes, may be
followed by completion thyroidectomy if lesion >1cm and malignant
● Hemithyroidectomy
● Total thyroidectomy
● Superficial/deep parotidectomy

23. Complications of Thyroid Surgery
● Acute haemorrhage +/- airway obstruction, <1%
○ Contact anaesthetist for potential intubation
○ Removal of clips and surgical evacuation of haematoma
○ Wound exploration in theatre
● Damage to recurrent laryngeal nerve
○ Near larynx or inf. thyroid artery
○ Hoarseness if unilateral
○ Airway obstruction req. tracheostomy if bilateral
● Damage to the parathyroid glands
○ Hypocalcaemia => tetany
○ Chvostek and Trousseau’s sign
● Hypothyroidism