Neck Lump
A neck lump is an abnormal swelling in the neck that may arise from enlarged lymph nodes, thyroid pathology, salivary gland disease, congenital cysts, or neoplastic processes, requiring systematic evaluation to exclude malignancy.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Reactive lymphadenopathy | Recent URTI, tender, mobile node, young patient | 「最近有冇傷風感冒喉嚨痛？」(Recent URTI?) |
| Multinodular goitre (MNG) | Midline, moves with swallowing, multiple nodules palpable, long history | 「吞口水個腫塊會唔會郁？」(Moves with swallowing?) | |
| Thyroid nodule (solitary) | Anterior midline, firm, moves with swallowing | 檢查：Firm, solitary, moves with swallowing | |
| Serious Not To Miss | Lymphoma (HL / NHL) | Painless, rubbery, rapidly enlarging node ± B-symptoms [5] | 「有冇發燒、夜汗、消瘦？」 |
| Thyroid carcinoma | Hard, fixed, ± hoarseness, cervical LN [3] | 「有冇聲沙？」+ 檢查：Hard fixed nodule | |
| NPC with cervical node metastasis | Posterior triangle node, epistaxis, nasal obstruction, conductive hearing loss — very common in HK/Southern Chinese [1] | 「有冇鼻塞、流鼻血、耳仔塞住聽唔到？」 | |
| Metastatic node (other H&N / GI primary) | Hard, fixed, supraclavicular (Lt = Virchow's) [1] | 「有冇胃痛、吞嘢困難、大便習慣改變？」 | |
| Pitfalls | Thyroglossal duct cyst | Midline, elevates with tongue protrusion, young patient [4] | 「伸脷出嚟個腫塊郁唔郁？」(Tongue tug test) |
| Branchial cyst | Anterior to SCM, young adult, smooth and fluctuant [1] | 檢查：Anterior to upper 1/3 SCM, transilluminant | |
| TB lymphadenitis (cold abscess) | Painless, matted nodes, ± collar-stud abscess, contact Hx [7] | 「身邊有冇人有肺癆？」(TB contact?) | |
| Salivary gland tumour | Parotid/submandibular region, firm, slow-growing | 「個腫塊係咪喺耳仔前面或者下巴底？」 | |
| Masquerades | Goitre from thyroiditis (Hashimoto's / subacute) | Diffuse, ± hypo/hyperthyroid symptoms, ± pain (subacute) | 「有冇怕凍、便秘、成日攰？」(Hypothyroid Sx) |
| Drug-induced lymphadenopathy | Phenytoin, carbamazepine | 「食緊咩藥？」 | |
| Cancer anxiety / health anxiety | Triggered by relative's diagnosis, media exposure | 「你最擔心嘅係咩呢？有冇屋企人最近病咗？」 | |
| Psychosocial stress | Work/family stress presenting as health concern | 「最近有冇咩嘢壓力大？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好，我係今日嘅醫生，點稱呼你？」「今日有咩嘢唔舒服想睇吓？」 | Friendly opening → interpersonal marks. Open question lets patient tell their story. |
| 0:30–1:30 | HPI: lump characterisation | 「個頸嘅腫塊幾時發現㗎？」「大咗定細咗？」「有冇痛？」「喺頸嘅邊個位置？」「有冇紅腫或者流膿？」 | Core symptom analysis (onset, duration, size change, pain, location, skin changes). |
| 1:30–2:30 | Red flags & associated symptoms | 「有冇聲沙？吞嘢困唔困難？」「有冇消瘦？出夜汗？發燒？」「有冇手震、心跳快、怕熱？」「有冇咳嗽、痰中帶血？」 | B-symptoms (lymphoma), thyroid symptoms, compressive symptoms, NPC/lung red flags. |
| 2:30–3:30 | PMHx, drug, FHx, social, occupation | 「你以前有冇乜嘢大病或者做過手術？」「食緊咩藥？有冇藥物敏感？」「屋企人有冇甲狀腺問題或者癌症？」「你做邊行㗎？有冇煙酒習慣？」 | Radiation exposure (NPC), smoking/alcohol (H&N SCC), FHx thyroid CA. |
| 3:30–4:30 | ICE (hidden agenda) | 「你自己覺得個腫塊係咩嚟㗎？」(Ideas)「你最擔心嘅係咩呢？」(Concerns)「你今日嚟想我哋幫你做啲咩呢？」(Expectations) | Directly tested on Case Report Form. The hidden concern is often cancer worry → must elicit. |
| 4:30–5:15 | Summarise & signpost | 「等我總結返你嘅情況：你發現頸有個腫塊大概（X週），冇痛，冇其他唔舒服。你最擔心會唔會係癌症。我講得啱唔啱？」 | Demonstrates active listening; marks for summarising and checking understanding. |
| 5:15–6:00 | Explain plan, safety-net, close | 「我建議幫你做個詳細檢查同安排超聲波，如果有需要可能會轉介專科。如果個腫塊突然大咗好多、有出血、呼吸困難，就要即刻返嚟急症室。」「你有冇其他想問嘅嘢？」 | Safe management close + safety net → prevents losing marks. Courteous ending. |
Uncovering the hidden agenda: The patient may present with "neck lump" but the real reason for consultation (RFC) is often fear of cancer or worry triggered by a family member's diagnosis. Always ask 「你最擔心嘅係咩呢？」 early — this is the RFC, not the lump itself.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did you first notice the lump? | 「個腫塊幾時開始有㗎？」 | Acute = infection/reactive; weeks-months = neoplasm; years = benign/congenital [1] | Acute → reactive lymphadenitis; Chronic → thyroid nodule, lymphoma |
| Size change | Has it been getting bigger? How fast? | 「有冇越嚟越大？大得快唔快？」 | Rapid growth → malignancy (anaplastic thyroid CA, lymphoma); slow → benign [1][2] | Rapid → lymphoma, anaplastic CA; Slow → MNG, benign cyst |
| Location | Where exactly on the neck? | 「喺頸前面、側面定後面？」 | Midline → thyroid, thyroglossal cyst; Lateral → LN, branchial cyst; Supraclavicular → GI malignancy mets [1] | Midline anterior → thyroid; Lateral → branchial cyst/LN; Supraclavicular → Virchow's node |
| Pain | Is it painful? | 「有冇痛？」 | Pain → infection, haemorrhage into cyst, subacute thyroiditis [3] | Tender → abscess, thyroiditis; Painless → neoplasm |
| Swallowing movement | Does it move when you swallow? | 「吞口水嘅時候個腫塊會唔會郁？」 | Moves with swallowing → thyroid origin [4] | Thyroid nodule, MNG, thyroglossal cyst |
| Tongue protrusion | Does it move when you stick out your tongue? | 「伸脷嘅時候會唔會郁？」 | Moves with tongue protrusion → thyroglossal duct cyst [3][4] | Thyroglossal cyst |
| B-symptoms | Any fever, night sweats, weight loss? | 「有冇發燒？夜晚出好多汗？體重有冇輕咗？」 | B-symptoms → lymphoma [5] | Hodgkin/NHL |
| Thyroid symptoms | Palpitations, tremor, heat intolerance, weight change? | 「有冇心跳快、手震、怕熱、體重變化？」 | Hyper-/hypothyroid symptoms help classify thyroid lump [3] | Graves' (diffuse goitre + thyrotoxic), Hashimoto's |
| Compressive symptoms | Difficulty breathing, swallowing, or voice change? | 「有冇呼吸困難、吞嘢困難、聲沙？」 | Dyspnoea/dysphagia/dysphonia → compression or invasion by malignancy [1][3] | Thyroid CA, lymphoma, retrosternal goitre |
| Ear/nose symptoms | Any blood-stained nasal discharge, blocked ear, hearing loss? | 「有冇鼻塞、流鼻血、耳仔塞住？」 | NPC commonly presents as neck node in HK [1] | NPC with cervical node metastasis |
| Smoking/alcohol | Do you smoke or drink? | 「你有冇食煙飲酒嘅習慣？」 | Smoking + alcohol → H&N squamous cell carcinoma [6] | Laryngeal CA, oropharyngeal CA, NPC |
| Radiation history | Any previous radiation to head/neck? | 「以前有冇做過頭頸嘅電療？」 | Radiation exposure ↑ risk papillary thyroid CA [3] | Papillary thyroid carcinoma |
| Family history | Any family history of thyroid disease or cancer? | 「屋企人有冇甲狀腺問題或者癌症？」 | FHx thyroid CA: ~20% medullary CA (MEN II), ~5% papillary CA [3] | Medullary thyroid CA / MEN2 |
| Drug history | Taking any medications? Allergies? | 「食緊咩藥？有冇藥物敏感？」 | Phenytoin → lymphadenopathy; lithium → goitre | Drug-induced |
| Occupation | What is your job? | 「你做邊行㗎？」 | Woodworking → sinonasal CA; radiation workers | Occupational exposure |
| Functional impact | Does it affect your daily life, work, or sleep? | 「對你日常生活、返工有冇影響？」 | Marks for biopsychosocial assessment | Social/functional problem for CRF |
| Psychological | Are you worried or stressed about this? | 「你有冇因為呢個嘢好擔心或者瞓唔著？」 | Identifies anxiety/cancer phobia | Psychological problem for CRF |
Case Report Form Answer Builder
Neck lump for [duration], noticed incidentally / by patient / by family.
Key points to capture:
- Duration and onset (sudden vs gradual)
- Location (midline / lateral / posterior triangle / supraclavicular)
- Size change (stable, growing, fluctuating)
- Pain or tenderness
- Associated symptoms: B-symptoms, thyroid symptoms, compressive symptoms, ENT symptoms
- Risk factors: smoking, alcohol, radiation, family history
- Impact on function
| Likely RFC | Phrasing |
|---|---|
| Worried the lump might be cancer | "Patient is concerned about the possibility of malignancy" |
| Lump is getting bigger | "Enlarging neck lump causing cosmetic / functional concern" |
| Prompted by family/friend | "Family member encouraged consultation after noticing lump" |
| Compressive symptoms | "Difficulty swallowing / breathing prompted consultation" |
Pick the ONE that matches what the patient says in response to 「你今日嚟最主要想解決咩問題？」
| Component | Likely Content | Example Wording for CRF |
|---|---|---|
| Ideas | "Patient thinks it may be a thyroid problem / enlarged gland / tumour" | "Patient suspects the lump may be related to thyroid disease" |
| Concerns | "Worried it could be cancer" (most common hidden concern) | "Patient is worried the lump could be malignant, especially as a family member had cancer" |
| Expectations | "Wants investigation (blood test, scan) / specialist referral / reassurance" | "Patient expects imaging and specialist referral to rule out cancer" |
For the FM station, the most likely diagnosis depends on the stem:
- Young patient + midline + moves with swallowing → Thyroid nodule or Thyroglossal cyst
- Middle-aged + anterior triangle + painless, rubbery → Reactive lymphadenopathy or Lymphoma
- Older patient + lateral neck + hard, fixed → Metastatic lymph node (? NPC, H&N SCC)
- Midline + multinodular + long Hx → Multinodular goitre
Minimum supporting evidence: location, consistency, mobility, movement with swallowing, duration, associated symptoms.
| DDx | Key Discriminator |
|---|---|
| Reactive lymphadenopathy | Recent infection, tender, mobile, soft, <2cm, resolves in weeks |
| Thyroid nodule / MNG | Midline, moves with swallowing, ± thyroid dysfunction |
| Lymphoma | Painless, rubbery, rapidly growing, ± B-symptoms |
| NPC metastatic node | Posterior triangle, Southern Chinese, epistaxis, serous otitis media |
| Thyroglossal cyst | Midline, moves with tongue protrusion, young patient |
| Branchial cyst | Lateral, anterior to SCM, young adult, fluctuant |
Pick three that contrast with your most likely diagnosis.
| Domain | Problem |
|---|---|
| Biological | Neck lump requiring investigation to exclude malignancy |
| Psychological | Anxiety about possible cancer / sleep disturbance due to worry |
| Social | Impact on work (e.g. time off for investigations) / cosmetic concern affecting social interaction |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Thyroid nodule / MNG | Mass moves upward with swallowing [4] | Ask patient to hold water in mouth, palpate lump, ask to swallow → observe/feel upward movement | Thyroid is attached to pretracheal fascia → moves with laryngeal elevation during swallowing; other neck lumps do not |
| Thyroglossal cyst | Mass elevates on tongue protrusion (tongue tug test) [4] | Place fingers on lump, ask patient to protrude tongue → feel upward movement | Cyst attached to thyroglossal duct remnant connected to foramen caecum |
| Reactive lymphadenopathy | Tender, mobile, soft lymph node <2cm | Palpate — mobile in all directions, soft, mildly tender | Reactive nodes are not fixed, not hard, and tender due to active inflammation |
| Lymphoma | Firm/rubbery, non-tender, fixed or matted lymph nodes [5] | Palpate — rubbery, painless, may be matted (multiple nodes adherent) | Neoplastic infiltration makes nodes firm/rubbery and non-tender |
| NPC metastatic node | Hard, fixed, non-tender posterior triangle lymph node | Palpate posterior triangle — hard, immobile node | NPC commonly metastasises to posterior triangle; hard and fixed suggests malignant infiltration |
| Thyroid carcinoma | Hard, irregular, fixed thyroid nodule ± cervical lymphadenopathy (level VI) [3] | Palpate thyroid — hard and fixed to surrounding structures; palpate level VI nodes | Fixation and hardness indicate invasion through capsule; level VI is first site of metastasis |
Top Traps That Lose Marks
- Forgetting to ask about movement with swallowing — this single test distinguishes thyroid from non-thyroid neck lumps. Always ask.
- Missing NPC — in a Hong Kong / Southern Chinese patient with a lateral neck node, NPC must be considered. Ask about epistaxis, nasal obstruction, unilateral hearing loss.
- Not asking B-symptoms — fever, night sweats, weight loss are the key discriminators for lymphoma.
- Neglecting ICE — especially the concern about cancer. This is heavily weighted on the CRF.
- Writing "lump" as the RFC — the RFC is usually the worry (e.g. fear of cancer), not the lump itself.
- Forgetting tongue protrusion test for midline lump — misses thyroglossal cyst.
- Not asking about compressive symptoms (dysphagia, dyspnoea, dysphonia) — these are red flags for malignancy and retrosternal extension.
Must-Not-Miss Red Flags → Urgent Referral:
- Hard, fixed, rapidly growing node
- B-symptoms (fever, night sweats, >10% weight loss in 6 months) [5]
- Hoarseness / stridor / dysphagia suggesting invasion
- Supraclavicular node (? visceral malignancy)
- Posterior triangle node in Southern Chinese (? NPC) [1]
- Thyroid nodule with hard consistency, fixation, cervical LN
Safety-net line (for closing):
「如果個腫塊突然大咗好多、有出血、呼吸困難或者吞嘢困難，要即刻返嚟急症室。」
High Yield Summary
What to ASK: Movement with swallowing, tongue protrusion (midline lumps), B-symptoms, thyroid symptoms, compressive symptoms (dysphagia/dyspnoea/dysphonia), NPC symptoms (epistaxis, ear blockage), smoking/alcohol, FHx thyroid CA, radiation Hx, and ICE (especially cancer worry).
What to WRITE on CRF: Location + movement with swallowing as key exam finding; RFC = patient's concern (usually fear of cancer), not just "neck lump"; ICE with specific cancer worry; biopsychosocial must include anxiety; physical sign = moves with swallowing (thyroid) or hard/fixed/rubbery node (malignancy).
What NOT to MISS: NPC in HK patient (posterior triangle node), lymphoma (painless rubbery + B-symptoms), thyroid CA (hard fixed + hoarse voice), and always perform the swallowing test and tongue protrusion test (if midline).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 218. I have a swelling in the neck Neck mass (Notes).pdf [2] Lecture slides: Clinical Demonstration_Head & Neck.pdf [3] Senior notes: Ryan Ho Endocrine.pdf (Section 1.2, Thyroid examination and Hx) [4] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (Neck examination, p.122) [5] Senior notes: Maksim Medicine Notes.pdf (Lymphoma, p.178); Adrian Lui Pediatrics Notes.pdf (NHL, p.427) [6] Lecture slides: GC 219. Infections and tumours in pharynx and oral cavity.pdf [7] Senior notes: Gen Clerk Anaes + Microbiology Summary.pdf (TB lymphadenitis, p.33)
Nausea / Vomiting
Nausea is the unpleasant sensation of an urge to vomit, while vomiting is the forceful expulsion of gastric contents through the mouth, both mediated by the brainstem vomiting center in response to various peripheral or central stimuli.
Neck Pain / Stiffness
Neck pain or stiffness is discomfort or restricted range of motion in the cervical spine region, commonly caused by muscular strain, degenerative disc disease, or cervical spondylosis, but requiring urgent evaluation when associated with meningeal signs or neurological deficits.