Endgames Case Report

Neck lump in a young woman

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d26 (Published 09 February 2011) Cite this as: BMJ 2011;342:d26
  1. D Burrage, foundation year 1,
  2. F U Hassan, nuclear medicine registrar,
  3. S Clarke, nuclear medicine physician
  1. 1Nuclear Medicine Department, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
  1. Correspondence to: D Burrage d.burrage{at}doctors.org.uk

A 27 year old woman presented to her general practitioner with an increase in the size of a longstanding lump in her neck. She had first noticed it four years ago, as a small right sided lump, but in recent months it had increased in size to cause obvious asymmetry. Over the past few years she has also experienced flushing when drinking alcohol and loose stools. Her only medical history was tonsillectomy and adenoidectomy as a child. She had no family history of endocrinopathy or sudden death. On examination, she had a single well defined lump in the right anterior triangle, extending down to her clavicle. She was clinically euthyroid and thyroid function tests were unremarkable.

Questions

  • 1 Name five criteria that should prompt urgent outpatient referral for a neck lump.

  • 2 What is the differential diagnosis in a young woman with these symptoms?

  • 3 What is the diagnostic investigation of choice?

  • 4 What other investigations might add to the clinical picture?

  • 5 What rare diagnosis is suggested by this clinical picture?

Answers

1 Name five criteria that should prompt urgent outpatient referral for a neck lump

Short answer

Local symptoms such as voice changes, a nodule in a child, cervical lymphadenopathy, rapid enlargement, or stridor should prompt urgent referral.

Long answer

Urgent referral (under two weeks) to a local ear, nose, and throat or endocrine surgeon should be prompted by any of the following:

  • Unexplained hoarseness or voice changes associated with goitre

  • Thyroid nodule in a child

  • Cervical lymphadenopathy associated with a thyroid lump (usually deep cervical or supraclavicular region)

  • A rapidly enlarging painless thyroid mass over a period of weeks (a rare presentation of thyroid cancer and usually associated with anaplastic thyroid cancer or thyroid lymphoma)

  • Stridor associated with a thyroid lump (same day referral).1 …

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