History of a Neck Lump and Assessment of Thyroid Status

Personal History
Age - the risk of malignancy increases with age.
Ethnic Origin - Asian patients with enlarged neck nodes have a higher
incidence of metastatic nasopharyngeal cancer or tuberculosis.
Occupation - occupational exposure to asbestos, nickel and wood
dust are associated with an increased risk of head and neck cancers.
History of the lump
• Site - 1 or 2+, Localised or generalised (is it an isolated lump or
is the entire neck swollen?)
• Shape
• Size
• Consistency – hard, soft, cystic, nodular?
• Is it painful? SOCRATES- Suggests acute inflammation or
infection
• Onset:
When was the lump first noticed?
- A rapid onset painful swelling suggests an inflammatory
lymphadenopathy.
- A slowly progressive, non-painful lump suggests malignancy.
• Duration:
- Inflammatory lumps settle once the primary infection is
treated.
- A neck lump which is persistent (> 6 weeks) with or without
associated symptoms needs referral to an ENT surgeon.
• Any growth or changes to the lump? And the timescale of this.
• Fluctuance? Does the lump come and go?
• Surroundings – any skin rashes or disclouration?
• Fixation - to underlying structures is more suggestive of
carcinoma.
• Does the lump move with:
- Swallowing (thyroid mass/thyroglossal cyst)
- Tongue protrusion? (thyroglossal cyst)
• Any previous lumps?
Associated Symptoms:
Consider other features in the history that may suggest a cause:
 Symptoms of hyperthyroidism
- Weight loss
- Increased or decreased appetite
- Irritability
- Weakness and fatigue
- Diarrhoea ± Steatorrhoea
- Sweating
- Tremor
- Mental illness: may range from anxiety to psychosis
- Heat intolerance
- Loss of libido
- Oligomenorrhoea or amenorrhoea
 Symptoms of hypothyroidism
- Tiredness, lethargy, intolerance to cold
- Dry skin and hair loss
- Slowing of intellectual activity, e.g. poor memory and difficulty
concentrating
- Constipation
- Decreased appetite with weight gain
- Deep hoarse voice
- Menorrhagia and later oligo- or amenorrhoea
- Impaired hearing due to fluid in middle ear
- Reduced libido
 Symptoms of hypercalcaemia (suggestive of
Hyperparathyroidism)
‘Stones (renal calculi), moans (psychological symptoms –
depression, mild cognitive impairment and confusion), groans
(constipation), bones (boney pain).’
Other symptoms can include: anorexia and nausea, vomiting,
lethargy, muscle weakness, pancreatitis, polyuria, polydipsia,
dyspepsia, abdominal pain and arrythmias.
 Symptoms suggestive of an infectious or inflammatory
cause:
• Recent history of illness
Infections of the ear, nose, throat, scalp and teeth commonly
cause lymphadenopathy in the neck. Enquire about symptoms
of:
fever and rigors, sore throat, cough, ear ache, rash, tooth
infections.
• Recent travel, insect bites, exposure to pets or other animals
or contact history of infectious disease
 History suggestive of a traumatic cause — may indicate
haematoma or in time have caused fibrosis.
 Symptoms suggestive of malignancy:
• Local malignancy:
- Anorexia and weight loss
- Dysphonia
- Dysphagia
- Odynophagia
- Dyspnoea
- Persistent hoarseness
- Otalgia
Especially unilateral symptoms.
• Haematological malignancy:
- Fatigue
- Night sweats
- Fever
- Weight loss
- Pruritus
- Breathlessness
- Bruising or bleeding
- Recurrent infections
- Bone pain, alcohol-induced pain, or abdominal pain
- lymphadenopathy at sites other than the neck
Systems Review
Past Medical History
Ask about previous cancers of the skin, lip, oral cavity and other
mucosal sites.
Drug History and Allergies
Family History
• Family history of an endocrine tumour — may be suggestive of
multiple endocrine neoplasia (MEN) syndrome.
Social History:
Factors that increase the risk of malignancy:
• Smoking
• Heavy alcohol consumption
• Previous radiation to the neck