Neck Swellings — Viva

Q1: Clinical examination (2 min)

"A patient has a midline neck swelling. How do you examine it?"

• Does it move on swallowing? (Offer water - thyroid and thyroglossal cyst move up)
• Does it move on tongue protrusion? (Only thyroglossal cyst - tract to foramen caecum)
• Consistency: soft (cystic), firm (thyroid nodule), hard (cancer)
• Position: midline (thyroid/thyroglossal/dermoid) vs lateral (branchial/node/salivary)
• Palpate cervical lymph nodes (levels I-VI)

Q2: Thyroglossal cyst (2 min)

"Describe the Sistrunk procedure."

• Excise the cyst, entire thyroglossal tract, and central portion of hyoid bone
• Why central hyoid? The tract passes THROUGH the hyoid
• Reduces recurrence from 50% (simple excision) to under 5%
• Pre-op: confirm normal thyroid (avoid removing ectopic thyroid tissue)

Q3: Adult over 40 with neck lump (3 min)

"A 55-year-old has a hard, fixed, painless lateral neck lump. What do you do?"

• MALIGNANCY until proven otherwise
• Ultrasound + FNA
• Do NOT trial antibiotics or observe
• If metastatic SCC: PANENDOSCOPY with biopsies (tonsil, base of tongue, piriform fossa, nasopharynx)
• If primary found: treat according to site
• If primary not found: neck dissection + radiotherapy

Q4: Special neck swellings (2 min)

"Name three neck swellings that require special precautions."

• Carotid body tumour: pulsatile, DO NOT BIOPSY (catastrophic bleeding). CT angiogram (lyre sign). Vascular surgery.
• Lymphoma: needs EXCISION BIOPSY (not FNA) for architecture. Never incision biopsy (seeding).
• Cystic hygroma: children, transilluminates. Sclerotherapy or surgery. Recurs.