GC218 I Have A Swelling In The Neck Neck Mass (notes)
A neck mass is an abnormal lump or swelling in the neck that may arise from congenital, inflammatory/infectious, or neoplastic causes involving structures such as lymph nodes, thyroid, salivary glands, or developmental remnants.
I Have a Swelling in the Neck: Neck Mass
Lecture Map
A neck mass is a clinical crossroads — it can be the first presentation of anything from a harmless congenital cyst in a child to an aggressive metastatic carcinoma in an elderly patient. The entire lecture by Prof. William I. Wei (ENT, Head & Neck Surgery) is built on one core principle: systematic clinical assessment (age, duration, location, physical characteristics) narrows the differential rapidly, and the correct sequence of investigations prevents diagnostic disasters (e.g., doing an excisional biopsy of a metastatic node before finding the primary tumour). [1]
- Understand the anatomy and aetiology of neck swelling [2]
- Differentiate benign from malignant neck masses clinically
- Understand the investigation approach — FNAC, endoscopy, imaging
- Understand indications and complications of thyroidectomy
- Know the lymph node distribution in the neck and drainage paths [3]
This topic is tested repeatedly in Fourth Summative MCQs (especially EMQ "Head and Neck Tumour" stems), SAQs (neck mass differentials, thyroid investigations, complications of thyroidectomy), and Minicases (full clinical vignettes from history → exam → Ix → Mx → complications). It integrates with GC 177 (thyroid nodule), GC 217 (salivary gland), GC 215 (NPC), and GC 219 (pharynx/oral cavity tumours).
Core Concepts and Mechanisms
The neck is packed with structures from different embryological origins — each anatomical compartment has its own roster of pathologies. The fascial planes of the neck (investing layer, pretracheal, prevertebral) create compartments that limit the spread of disease and determine which structures a mass is likely to arise from. This is why location is the single most useful physical finding for narrowing the differential.
"Lesions occurring in young patients are probably congenital while those in old patients are likely to be malignant." [1]
This is because congenital lesions (cystic hygroma, branchial cyst, thyroglossal cyst) are remnants of embryological structures that failed to involute — they are present from birth but may not become clinically apparent until childhood or young adulthood when they enlarge (often after an upper respiratory infection). In contrast, malignant neck masses (metastatic lymph nodes, primary thyroid cancer) accumulate enough mutations to become clinically detectable over decades of life.
"Benign lesions grow slowly while malignant lesions increase in size rapidly." [1]
Benign tumours are well-differentiated, have low mitotic rates, and respect tissue boundaries. Malignant tumours have high proliferative indices, recruit blood supply aggressively (angiogenesis), and invade surrounding structures — hence rapid enlargement.
Slide-by-Slide High-Yield Content
"Swellings in the neck may be benign or malignant and in the latter case, primary or secondary." [1]
| Category | Examples | Key Feature |
|---|---|---|
| Congenital | Cystic hygroma, branchial cyst, thyroglossal cyst, dermoid cyst | Young patient, slow growth, characteristic location |
| Inflammatory/Infective | Reactive lymphadenopathy, TB lymphadenitis, abscess | Tender, associated systemic symptoms |
| Benign neoplasm | Pleomorphic adenoma, lipoma, neurofibroma, carotid body tumour | Slow growth, well-defined |
| Malignant — primary | Thyroid cancer, lymphoma, salivary gland malignancy | Arises from neck structures |
| Malignant — secondary (metastatic) | Metastatic lymph nodes from NPC, larynx, oropharynx, GI tract | Most common malignant neck mass in adults |
Physical Characteristics of the Mass [1]
| Feature | What It Tells You | Example |
|---|---|---|
| Location | Points to origin (see below) | Supraclavicular → GI malignancy |
| Size | Large masses more likely neoplastic | > 1.5 cm lymph node is suspicious |
| Consistency | Rubbery = lymphoma; Hard = carcinoma; Soft = lipoma/cyst | "Rubbery in consistency and occurs in a young patient → lymphoma should be suspected" [1] |
| Mobility | Fixed = malignant infiltration; Mobile = benign | Fixed to skin or deep structures = advanced cancer |
| Transillumination | Brilliantly transilluminant = fluid-filled cystic lesion | "A cystic hygroma transilluminates brilliantly" [1] |
| Pulsation | Vascular origin | "A carotid body tumour is pulsatile" [1] |
| Tenderness | Inflammatory/infective | Acute lymphadenitis, infected branchial cyst |
3. Location-Based Differential Diagnosis
"Supraclavicular fossa mass may be secondary deposits from primary malignancies in the gastrointestinal tract. Sometimes patients with a small primary papillary cancer of the thyroid may also present with lower neck lymph nodes metastasis." [1]
Why? The thoracic duct drains into the left subclavian vein at its junction with the left internal jugular vein. Lymphatics from the abdomen, pelvis, and lower body converge here → metastases from GI, lung, and gynaecological malignancies preferentially seed the left supraclavicular fossa (Virchow's node / Troisier's sign). Right supraclavicular nodes can receive drainage from the lung and mediastinum.
"Midline neck mass in the lower neck probably arises from the thyroid gland while in the upper neck; thyroglossal cyst is the likely diagnosis." [1]
| Location | Likely Diagnosis |
|---|---|
| Upper midline | Thyroglossal cyst (moves with swallowing AND tongue protrusion) |
| Lower midline | Thyroid mass (moves with swallowing only) |
| Other midline | Dermoid cyst, ranula (sublingual), submental lymph node |
Why does thyroid move with swallowing? The thyroid is enclosed in the pretracheal fascia, which is anchored to the trachea via Berry's ligament. When you swallow, the larynx and trachea elevate → the thyroid is pulled upward with them. [5][6]
Why does thyroglossal cyst move with tongue protrusion? The thyroglossal duct runs from the foramen caecum of the tongue to the thyroid gland, passing through or near the hyoid bone. Even when the duct obliterates, a cyst arising from its remnant remains tethered to the foramen caecum. Protruding the tongue pulls on the foramen caecum → pulls the cyst upward (positive tongue tug test). [5][7]
"Lateral neck mass is more frequently seen than midline mass. Lesions in the upper neck may be salivary glands related. While swellings under the cover of sternomastoid muscle are likely to be lymph nodes." [1]
| Location | Differential |
|---|---|
| Upper lateral (Level I–II) | Submandibular gland tumour/stone, branchial cyst, metastatic LN |
| Mid-lateral (Level II–IV, under SCM) | Lymph nodes (reactive, TB, metastatic, lymphoma) |
| Lower lateral (Level V) | NPC metastasis (in southern Chinese), cystic hygroma |
| Anterior triangle | Carotid body tumour, branchial cyst, laryngocele |
| Posterior triangle | Schwannoma, cystic hygroma, cervical rib |
Understanding levels is essential for correlating the location of an enlarged node with the likely primary tumour:
| Level | Location | Common Primary Sites |
|---|---|---|
| I | Submental & submandibular | Oral cavity, lip |
| II | Upper jugular (skull base to hyoid) | NPC, oropharynx, oral cavity, salivary gland |
| III | Mid-jugular (hyoid to cricoid) | Larynx, hypopharynx, thyroid |
| IV | Lower jugular (cricoid to clavicle) | Thyroid, oesophagus, lung apex |
| V | Posterior triangle | NPC (especially in southern Chinese), scalp |
| VI | Anterior compartment | Thyroid, larynx (subglottic) |
5. Specific Congenital Neck Masses
- Congenital malformation of lymphatic channels
- Usually presents in infancy/childhood
- Located in posterior triangle
- Transilluminates brilliantly [1] — because it's a thin-walled, fluid-filled cyst
- Treatment: Surgical excision at appropriate age [1]; injection sclerotherapy is an alternative in selected cases
- Arises from remnants of 2nd branchial arch/cleft
- Typically presents as a lateral neck mass anterior to the upper third of SCM (Level II)
- Young adult, smooth, non-tender, fluctuant
- Can become infected → abscess → branchial fistula
- Treatment: Surgical excision [1]
- Failure of thyroglossal tract to obliterate → cystic expansion of remnant [7]
- 60% located at thyrohyoid membrane level [7]
- Tongue tug test positive — pathognomonic [5][7]
- Moves with swallowing (attached to hyoid → pretracheal fascia)
- Association: thyroid ectopia (mostly lingual thyroid) → must confirm normal thyroid gland exists before surgery (otherwise removing the cyst/duct might remove the only functioning thyroid tissue) [7]
- Complications: abscess, fistula, malignant transformation (papillary carcinoma — rare) [7]
- Treatment: Sistrunk operation — remove cyst + entire tract + body of hyoid bone up to foramen caecum to prevent recurrence [7]
"Congenital lesion in general should be removed surgically at the appropriate age. These include cystic hygroma, branchial cyst or thyroglossal cyst. Otherwise these lesions may increase in size leading to functional disturbances later." [1]
6. Lymph Node Pathology
"Lymph node should be investigated first rather than excised. Fine needle aspiration generally gives a clue to the aetiology of the enlarged lymph node." [1]
Why? If you excise a metastatic lymph node without first finding the primary tumour, you:
- Lose the architecture needed for staging
- May seed tumour cells in the wound
- Compromise the subsequent surgical field (scarring, fibrosis)
- Miss the primary cancer, which continues to grow
"When a metastatic cervical lymph node is suspected, endoscopic examination and/or even examination under anaesthesia should be carried out. Every effort should be spent to locate the primary tumour." [1]
The sequence is:
- FNAC of the node first
- If FNAC shows squamous cell carcinoma → think head & neck primary (NPC, oropharynx, larynx, hypopharynx)
- Endoscopic examination of the upper aerodigestive tract (nasopharyngoscopy, laryngoscopy, oesophagoscopy) is mandatory [1]
- Biopsy any suspicious mucosal lesion
- If no primary found → random biopsies of likely sites (especially nasopharynx in southern Chinese)
- Imaging (CT/MRI) to assess extent
High Yield — NPC in Southern Chinese
"In southern Chinese, when fine needle aspiration showed undifferentiated squamous cell carcinoma, one of the differential diagnoses is lymph node metastasis from nasopharyngeal carcinoma. EBV DNA in blood should be checked. If it is elevated, endoscopic examination and random biopsies of the nasopharynx are indicated." [1]
This is a classic HKU exam scenario because NPC is endemic in Hong Kong/Southern China. The link is EBV (Epstein-Barr virus). Undifferentiated carcinoma of the nasopharynx (WHO Type III) is strongly EBV-associated. Plasma EBV DNA serves as both a diagnostic marker and a tumour burden marker.
"Excisional biopsy of the lymph node is only done as a last resort or when the diagnosis of lymphoma is suspected." [1]
Why lymphoma needs excision? Lymphoma diagnosis requires assessment of the architectural pattern of the node (follicular vs. diffuse), immunohistochemistry, flow cytometry, and sometimes molecular studies — all of which require an intact node, not just scattered cells from an FNA. FNAC can suggest lymphoma but cannot subtype it reliably.
| Feature | Lymphoma | Metastatic Carcinoma |
|---|---|---|
| Age | Younger (but Hodgkin's bimodal: 20s and 60s+) | Older |
| Consistency | Rubbery [1] | Hard, stony |
| Mobility | Usually mobile | May be fixed |
| Tenderness | Usually non-tender | Usually non-tender |
| Other findings | B symptoms, hepatosplenomegaly | Primary tumour symptoms (hoarseness, dysphagia, etc.) |
| Investigation | Excisional biopsy for architecture | FNAC → find primary |
"Fine needle aspiration cytology is useful in the diagnosis of neck swelling. This should be done for most neck masses and the associated morbidity is low." [1]
| Investigation | When/Why | Key Points |
|---|---|---|
| FNAC | First-line for most neck masses | Low morbidity, can distinguish benign/malignant, guides further workup [1] |
| Endoscopy | Suspected metastatic node | "Essential part of evaluation" — nasopharyngoscopy, laryngoscopy, etc. [1] |
| CT scan | Extent of disease, surgical planning | Shows size, invasion, retrosternal extension |
| MRI | Soft tissue detail, salivary/neurogenic tumours | Better for perineural spread, parapharyngeal space |
| Angiography / MR angiography | Carotid body tumour suspected [1] | Demonstrates tumour vascularity and relationship to carotid bifurcation |
| Ultrasound | Thyroid masses, superficial lymph nodes | First-line for thyroid, characterises solid vs. cystic |
| EBV DNA | Southern Chinese with undifferentiated SCC in neck node | Elevated → suspect NPC → nasopharyngeal biopsies [1] |
"We are seeing an increasing number of patients with carcinoma of tonsil and tongue base presenting with metastatic neck lymph node. Fine needle aspiration (FNA) is done whenever the diagnosis is suspected." [1]
This reflects the global trend of HPV-related oropharyngeal squamous cell carcinoma (HPV-16). These patients are often younger, non-smokers, and present with a cystic-appearing level II neck node before the primary tumour is noticed. The prognosis is generally better than HPV-negative oropharyngeal cancer.
"Treatment depends on the nature of the neck mass." [1]
| Nature | Treatment |
|---|---|
| Congenital | Surgical excision at appropriate age [1] |
| Infective LN | Appropriate antibiotics including anti-tuberculous chemotherapy [1] |
| Metastatic LN | Treat the primary (surgery ± RT ± chemo) + neck dissection if indicated |
| Lymphoma | Chemotherapy ± radiotherapy (depending on type and stage) |
| Thyroid mass | See thyroid nodule management (GC 177) |
| Carotid body tumour | Surgical excision (risk of carotid injury) |
Clinical Approach: History, Examination, Investigations
| Question | Rationale |
|---|---|
| Age | Young → congenital; Old → malignant |
| Duration | Weeks → inflammatory; Months, slowly → benign neoplasm; Rapidly growing → malignant |
| Pain/tenderness | Suggests inflammation/infection; pain in malignancy suggests nerve involvement |
| Change in size | Fluctuating → reactive/inflammatory; Progressive → neoplasm |
| Associated symptoms | Hoarseness → laryngeal involvement/RLN palsy; Dysphagia → oesophageal/pharyngeal; Weight loss → malignancy; Night sweats/fever → lymphoma/TB; Epistaxis/nasal obstruction → NPC; Haemoptysis → lung/laryngeal Ca |
| Smoking/alcohol | Risk factors for SCC of head & neck |
| PMH | Previous malignancy, previous radiation |
| FHx | Thyroid cancer (MEN syndromes), familial NPC |
| Exposure | TB contact, HIV |
Systematic approach:
- Inspect: Location (midline vs. lateral, level), size, skin changes, scars
- Swallowing test: Ask patient to take a sip of water and swallow → mass moves up = thyroid or thyroglossal cyst [5][6]
- Tongue protrusion: Place finger above mass → ask patient to protrude tongue → mass moves up = thyroglossal cyst [5][6]
- Palpate: Size, shape, consistency (soft/firm/hard/rubbery), tenderness, mobility, fixation, fluctuance
- Transillumination: Brilliant transillumination → cystic hygroma [1]
- Pulsation/thrill/bruit: Carotid body tumour, carotid aneurysm [1]
- Other neck masses: Check all cervical levels bilaterally
- Examine related structures: Oral cavity, oropharynx, thyroid, salivary glands
- Systemic: Hepatosplenomegaly (lymphoma), other lymph node groups, skin lesions
Exam Trap — Signs Suggesting Malignant Thyroid Mass
Students often forget the clinical signs that distinguish a malignant from benign thyroid nodule. Examiners love asking this (tested in 2019 Minicase Q4):
- Hard consistency (not firm or soft)
- Fixed to skin or underlying structures (trachea, strap muscles)
- Hoarseness (recurrent laryngeal nerve invasion)
- Cervical lymphadenopathy (metastasis)
- Rapid growth
- Stridor / dysphagia (invasion)
Integration with Related Lectures
A thyroid mass presenting as a neck swelling connects directly to the thyroid nodule lecture:
- USG is first-line imaging for thyroid masses
- FNAC guided by USG is the key diagnostic step (Bethesda classification)
- Thyroid function tests to exclude hyper/hypothyroidism
- CT if retrosternal extension or invasion suspected
- Indications for thyroidectomy: 4C — Cancer, Compression, Cosmetic, unControlled thyrotoxicosis [7]
Upper lateral neck mass may arise from the submandibular gland:
- Pleomorphic adenoma — most common salivary gland tumour, slow-growing, firm, mobile (tested in 2021 and 2025 EMQ) [8]
- Mucoepidermoid carcinoma — most common malignant salivary gland tumour
- Level V lymph node in southern Chinese → think NPC [1]
- EBV DNA is the screening/diagnostic test
- Undifferentiated SCC on FNAC + elevated EBV DNA → nasopharyngeal biopsies
- Deep neck space infection → presents with sore throat, fever, neck swelling
- If crepitus present → necrotizing fasciitis / gas-forming infection
- Ludwig's angina → submandibular/sublingual space infection from dental origin
- Management: IV antibiotics + surgical drainage + airway management [9]
From GC 218, Case 2, and supporting notes — this is consistently examined in minicases. [6][7]
| Timing | Complication | Mechanism | Management |
|---|---|---|---|
| Immediate | Reactionary haemorrhage → neck haematoma | Bleeding from thyroid bed within 24h → venous compression → laryngeal oedema → airway compromise | Remove all stitches at bedside immediately → evacuate haematoma → protect airway → return to OT for haemostasis [6][7] |
| Early | Recurrent laryngeal nerve injury | Traction or transection during dissection | Unilateral: hoarseness → medialization; Bilateral: stridor → re-intubation ± tracheostomy [6] |
| Early | Hypocalcaemia | Damage to parathyroid glands or their blood supply (inferior thyroid artery) | Monitor serum Ca, supplement IV calcium gluconate → oral calcium + calcitriol [6] |
| Early | Superior laryngeal nerve injury | Damage to external branch during ligation of superior thyroid vessels | Weak voice, cannot sing high pitch [6] |
| Late | Hypothyroidism | Removal of functioning thyroid tissue | Lifelong thyroxine replacement |
| Late | Hypoparathyroidism | Permanent parathyroid damage (1-4%) | Lifelong calcium + vitamin D |
| Rare | Tracheomalacia | Degeneration of cartilage after removal of long-standing large goitre | May need tracheostomy support |
Bedside Emergency — Post-Thyroidectomy Neck Haematoma
This is a life-threatening emergency. The venous compression causes laryngeal oedema which can completely obstruct the airway within minutes. The FIRST action is to open all wound stitches at the bedside — do NOT wait to go to the operating theatre. This is tested repeatedly in SAQs and minicases.
Exam Intelligence
-
EMQ "Head and Neck Tumour" — appears in 2021, 2022, 2025 Fourth Summative MCQs with almost identical stems:
- 40-year-old lady, central neck mass, moves with swallowing → Papillary thyroid carcinoma [8][10][11]
- 60-year-old man, right upper neck mass, slowly growing over 5 years → Pleomorphic adenoma [8][10][11]
- 50-year-old man, NPC, FNAC of level V node → Undifferentiated carcinoma [8][10][11]
- 70-year-old lady, 8mm ulcer at lower eyelid → Basal cell carcinoma [8][10][11]
-
"What moves with swallowing?" → Thyroid mass or thyroglossal cyst (both move with swallowing because both are connected to pretracheal fascia). Thyroglossal cyst ALSO moves with tongue protrusion.
-
"Young patient, rubbery node" → Lymphoma. Don't be tricked into choosing reactive lymphadenopathy — the keyword "rubbery" is the discriminator.
-
"Southern Chinese, undifferentiated SCC in neck node" → NPC until proven otherwise. Check EBV DNA.
-
"Cannot get below the mass" → retrosternal extension (tested in 2022 Minicase Case 2) [12]
-
Sequence trap: Students who say "excise the lymph node" for a suspected metastatic node lose marks. The correct answer is FNAC first → endoscopy → find primary → then treat. Excisional biopsy is only for lymphoma or as a last resort. [1]
| Scenario | Correct Answer | Common Trap | Discriminator |
|---|---|---|---|
| Central neck mass, moves with swallowing, diffuse, tachycardia, tremor | Graves' disease | Thyroid cancer | Diffuse + hyperthyroid symptoms [13] |
| Central neck mass, moves with swallowing, 40F | Papillary thyroid carcinoma (in EMQ context) | Thyroglossal cyst | No mention of tongue tug test; age favours thyroid Ca |
| Upper midline, tongue tug +ve | Thyroglossal cyst | Dermoid cyst | Tongue tug test is pathognomonic [14] |
| Acute thyroid swelling in 2 days after coughing | Thyroid haemorrhagic cyst | Subacute thyroiditis | Acute onset in 2 days + preceded by coughing → haemorrhage into pre-existing cyst [14] |
Past Paper Questions
Section 1 Q1: "Name five tissues/organs and one differential diagnosis within each tissue/organ for the neck swelling."
- Answer: (1) Thyroid — multinodular goitre; (2) Lymph node — metastatic carcinoma; (3) Salivary gland — pleomorphic adenoma; (4) Congenital — branchial cyst; (5) Vascular — carotid body tumour. (Also acceptable: skin — lipoma/sebaceous cyst; nerve — schwannoma)
Section 2 Q2: "What is the most likely origin?" → Thyroid (mass moves with swallowing). "List four possible pathologies" → Multinodular goitre, thyroid adenoma, thyroid carcinoma, thyroid cyst.
Section 2 Q4: "List four clinical signs that may suggest a malignant cause" → Hard consistency, fixation to skin/deep structures, cervical lymphadenopathy, hoarseness of voice.
Stem: "20-year-old woman, central neck swelling for 6 months, diffuse swelling moves with swallowing, tachycardia, resting tremor. Most likely diagnosis?"
- Answer: B. Graves' disease
- Discriminator: Diffuse (not nodular), young female, hyperthyroid signs (tachycardia, tremor). Thyroglossal cyst would not cause hyperthyroid signs. Follicular carcinoma is unlikely in 20-year-old presenting with diffuse swelling.
Q7: "60-year-old man, right upper neck mass growing in past 5 years, no other symptoms" → G. Pleomorphic adenoma (slow growth, no symptoms, upper neck = salivary gland region)
Q8: "50-year-old man, newly diagnosed NPC, FNAC of right level V neck mass" → J. Undifferentiated carcinoma (NPC is WHO Type III undifferentiated carcinoma)
Q9: "40-year-old lady, central neck mass that moves with swallowing" → F. Papillary thyroid carcinoma (most common thyroid malignancy, central neck, moves with swallowing)
Q14: "65-year-old man, chronic smoker and drinker, hoarseness, right neck mass, infrequent haemoptysis for 2 months" → J. Squamous cell carcinoma (of larynx — classic triad of smoking + hoarseness + neck mass)
Q15: "30-year-old woman, right upper neck mass for 3 years, slowly increasing, no other symptoms" → I. Pleomorphic adenoma
Section 2: 80-year-old lady, enlarging neck swelling, difficulty breathing 6 months. Multinodular swelling, anterior lower neck, moves with swallowing. Cannot get below mass on right. Trachea deviated to left.
- "Name the organ" → Thyroid
- "Two physical signs of significant mass effect" → Tracheal deviation; cannot get below the mass (retrosternal extension)
- "Four important investigations" → TFTs, USG thyroid, FNAC, CT neck/thorax (for retrosternal extension)
- "One benign diagnosis" → Multinodular goitre
Q4: "2 cm upper neck mass at midline, tongue tug test positive" → H. Thyroglossal cyst
Q5: "Diffuse goitre, proptosis, irregular pulse" → B. Graves' disease
Q6: "3 cm right neck hard mass, moves with swallowing, multiple enlarged right lateral neck lymph nodes, paroxysmal headache/palpitations/sweating, raised CEA and Calcitonin" → D. Medullary thyroid carcinoma (calcitonin is the tumour marker, paroxysmal symptoms suggest associated phaeochromocytoma in MEN2)
Q7: "Acute onset 4 cm left thyroid swelling in 2 days, preceded by coughing" → J. Thyroid haemorrhagic cyst
Q8: "Small goitre, raised TSH, raised anti-TPO antibodies" → C. Hashimoto thyroiditis
Stem: "18-year-old lady, central neck swelling for 6 months, feels hot easily, disturbed menstrual cycle, diffusely enlarged central neck, moves with swallowing. Most likely diagnosis?"
- Answer: C. Thyroid nodule hyperplasia (Note: despite hyperthyroid symptoms, the answer choices given suggest this — likely interpreted as thyroid hyperplasia/Graves' in the exam context. In reality, the clinical picture fits Graves' disease.)
Stem: "65-year-old man, 4-day sore throat, painful neck swelling, fever 39°C, swollen floor of mouth, right painful neck swelling."
- (a) Most likely diagnosis → Deep neck space infection / Ludwig's angina
- (b) Most common infective origin → Dental infection (odontogenic)
- (c) Investigation → CT neck with contrast
- (d) Crepitus of right neck → Necrotizing fasciitis / gas gangrene
- (e) Management → IV antibiotics, surgical drainage/debridement, airway protection (intubation/tracheostomy if needed), IV fluids/resuscitation
Stem: "40-year-old woman, acute onset 3 cm right thyroid swelling within 2 days, tracheal deviation to left, difficulty swallowing."
- (a) Three DDx → Thyroid haemorrhagic cyst, subacute thyroiditis, thyroid carcinoma with haemorrhage
- (b) Two investigations → USG thyroid, FNAC
- (c) One treatment option → Aspiration of cyst / thyroid lobectomy
- (d) One complication → Recurrent laryngeal nerve injury / hypocalcaemia / haematoma
Q21-25: Almost identical to 2021 EMQ (see above). Same stems repeated:
- Q22: 60M, right upper neck mass, 5 years → Pleomorphic adenoma
- Q23: 50M, NPC, FNAC level V → Undifferentiated carcinoma
- Q24: 40F, central neck mass, moves with swallowing → Papillary thyroid carcinoma
Stem: "80-year-old man, cheek mass 3 months, painless, 4 cm ulcer with irregular edges, dirty wound base, telangiectasia, palpable 2 cm right upper neck mass."
- (a) Most likely diagnosis → Squamous cell carcinoma of the cheek (could also consider BCC but irregular edges + dirty base + neck mass favours SCC)
- (b) Two investigations for pathology → Incisional biopsy of cheek lesion, FNAC of neck mass
- (c) Investigation for treatment planning → CT/MRI head and neck (staging)
- (d) Best treatment → Wide local excision of cheek tumour + neck dissection ± adjuvant radiotherapy
High Yield Summary
The approach to a neck mass is fundamentally about three questions:
-
Where is it? — Midline upper (thyroglossal cyst), midline lower (thyroid), lateral under SCM (lymph node), supraclavicular (metastatic from below clavicle), upper lateral (salivary gland).
-
Who has it? — Young → congenital; Old → malignant; Rubbery node in young → lymphoma; Southern Chinese with undifferentiated SCC → NPC.
-
What should you do? — FNAC first for most masses. If metastatic node suspected, MANDATORY endoscopic examination of upper aerodigestive tract. Do NOT do excisional biopsy unless lymphoma suspected or as last resort. Congenital lesions → surgical excision. Infective nodes → antibiotics/anti-TB. Always check EBV DNA in southern Chinese with undifferentiated SCC in a neck node.
Key exam stems that recur: EMQ "Head and Neck Tumour" with 5 identical stems (2021, 2025); Minicase with thyroid mass workup and post-thyroidectomy complications (2019, 2022); MCQ on Graves' vs thyroid cancer vs thyroglossal cyst (2020, 2023, 2024).
Active Recall - Lecture Notes
[1] Lecture slides: GC 218. I have a swelling in the neck Neck mass (Notes).pdf [2] Lecture slides: Case 2 - Neck swelling.pdf (Learning Objectives) [3] Lecture slides: Interactive Tutorial Questions 1 - 4.pdf [4] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1595, Localization table) [5] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p.121, Neck examination) [6] Senior notes: Ryan Ho Endocrine.pdf (p.7, p.22, Thyroid examination and thyroidectomy complications) [7] Senior notes: Maksim Surgery Notes.pdf (p.193-197, Thyroglossal cysts, Thyroidectomy) [8] Past papers: 2021 Fourth Summative Assessment MCQ.pdf (p.38, EMQ Head and Neck Tumour Q6-10) [9] Past papers: 2024 Fourth Summative SAQ.pdf (p.4, Q3) [10] Past papers: 2025 Fourth Summative MCQ.pdf (p.43, EMQ Head and Neck Tumour Q21-25) [11] Past papers: 2025 Fourth Summative MCQ.pdf (p.43) [12] Past papers: 2022 Fourth Summative Minicase.pdf (p.9-12, Case 2) [13] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (p.23, Q58) [14] Past papers: 2023 Fourth Summative MCQ.pdf (p.38, EMQ Thyroid Examination Q4-8) [15] Past papers: 2019 Fourth Summative Mini Case.pdf (p.8-12, Case 2) [16] Past papers: 2022 Fourth Summative MCQ.pdf (p.38, EMQ Head and Neck Surgery Q11-15) [17] Past papers: 2024 Fourth Summative MCQ.pdf (p.22, Q59) [18] Past papers: 2024 Fourth Summative SAQ.pdf (p.10, Q9) [19] Past papers: 2025 Fourth Summative SAQ.pdf (p.7, Q5)
GC218 I Have A Swelling In The Neck Neck Mass
A neck mass is an abnormal lump or swelling in the neck that may arise from enlarged lymph nodes, thyroid pathology, salivary gland disorders, congenital cysts, or neoplastic processes requiring systematic evaluation based on patient age, location, and duration.
GC219 Infections And Tumours In Pharynx And Oral Cavity
Infections and tumors of the pharynx and oral cavity encompass a spectrum of inflammatory, infectious, and neoplastic conditions—including pharyngitis, tonsillar abscess, oral candidiasis, and squamous cell carcinoma—that affect the mucosal surfaces of the mouth and throat.