Neck Swellings

Meet the patient

A 45-year-old man notices a painless lump just to the right of his midline while shaving one morning. It has been there six weeks, is growing slowly, and does not hurt. He is otherwise well — no fever, no weight loss, no hoarseness — and his GP gave him two weeks of antibiotics. The lump is unchanged.[1]

Two questions decide his next move, and they decide every neck lump you will ever clerk: where does it sit, and what does it do when he swallows and sticks his tongue out? Hold those two questions and the whole topic falls into place. The third, which decides his urgency, is his age: at 45, that lump is cancer until you prove it is not.[1]

The triangles of the neck — where it sits narrows what it is

You cannot diagnose a neck swelling without the triangles, because the position of a lump narrows the differential more sharply than any single bedside feature. The sternocleidomastoid is the great landmark — feel it tense when the patient turns the head against your hand — and it splits the neck into the anterior triangle (where thyroid, thyroglossal, branchial, and carotid body lesions live) and the posterior triangle (where cystic hygroma and supraclavicular nodes live).[1]

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The carotid sheath runs deep to SCM through the anterior triangle and carries, lateral to medial, the internal jugular vein, the vagus nerve, and the common then internal carotid artery — the mnemonic is VA-N within the sheath: Vein lateral, Artery medial, Nerve sandwiched between. The carotid bifurcation — the seat of the carotid body tumour — sits at the upper border of the thyroid cartilage around C3 to C4. The thyroid gland lies draped across the second to fourth tracheal rings, which is exactly why a thyroid swelling rises with swallowing.[1]

The two signs that crack the midline lump

Two bedside manoeuvres separate the three midline swellings, and one of them is pathognomonic. Give the patient a sip of water and watch the lump, then ask them to push the tongue out (tell them not to open the mouth wide, or the movement is lost).[1]

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Red-flag symptoms that escalate a lump toward malignancy: hoarseness (recurrent laryngeal nerve involvement — thyroid or laryngeal cancer until proven otherwise), dysphagia or odynophagia, weight loss, night sweats, fever (lymphoma, TB), haemoptysis or epistaxis (a head and neck primary), otalgia (referred pain from tongue base or larynx via the tympanic branch of the glossopharyngeal nerve), and a rapidly enlarging mass with stridor (anaplastic thyroid carcinoma — an airway emergency).[1]

The over-40 rule — malignancy until proven, ultrasound plus FNA not antibiotics

This is the single sentence the AAO-HNS guideline is built on, and the one every final-prof candidate must reproduce. In an adult over 40, a new neck lump is malignancy until proven otherwise, because malignant neoplasms far exceed any benign aetiology in that group and an asymptomatic mass may be the only sign of a head and neck cancer, lymphoma, thyroid, or salivary malignancy.[1]

In children and young adults the picture inverts: neck lumps are most often benign — reactive lymphadenopathy from a viral or bacterial upper respiratory infection, then the developmental cysts (thyroglossal duct cyst is the commonest congenital neck mass, prevalence about 7 per cent) and branchial cysts that declare themselves in the second to fourth decade.[3][4]

The AAO-HNS rule is operational, not abstract. An adult at increased malignancy risk — a mass present for more than 2 weeks without fluctuation, OR fixity, firmness, size over 1.5 cm, or skin ulceration — gets ultrasound plus fine-needle aspiration, not a trial of antibiotics and not observation.[1]

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The classic trap: antibiotics for an adult neck lump. The AAO-HNS guideline explicitly recommends against routine antibiotics for a neck mass without signs of bacterial infection — you have lost diagnostic time and the cancer keeps growing. The correct reflex is ultrasound plus FNA on the same visit.[1]

Midline, lateral, or pulsatile — the three face-offs

The first branch point is midline versus lateral, then cystic versus solid versus vascular within each. Three small face-offs, with a one-line discriminator beneath each, carry most of the examination marks on this topic.[1]

Discriminator line: midline plus swallowing equals thyroid; midline plus swallowing AND tongue equals thyroglossal; lateral in a young adult at the anterior border of SCM equals branchial; pulsatile equals carotid body until imaging says otherwise.[1]

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The two face-off tables below are the highest-yield examination content on this topic — three or more discriminators per entity is what earns marks.[1]

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The can't-miss diagnoses are metastatic cervical lymphadenopathy (a hard node may be the only sign of a small head and neck primary), lymphoma (excision biopsy for architecture), anaplastic thyroid carcinoma (airway emergency), and cystic metastasis masquerading as a branchial cyst in an adult. The classic mimics to keep in the back of your mind are a tortuous carotid in the elderly (no further workup, but commonly over-investigated), a cervical rib (hard supraclavicular mass with thoracic outlet features), and an ectopic thyroid presenting as a thyroglossal cyst — image before you excise, or removal causes permanent hypothyroidism.[3]

The investigation ladder — SAFE

The ladder depends on whether the lump is cystic or solid, midline or lateral, child or adult — but the entry point for every neck swelling is the same: ultrasound first, then FNA. The AAO-HNS guideline is unambiguous that adults at increased malignancy risk get ultrasound plus FNA, not antibiotics.[1]

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Ultrasound neck (high-frequency linear probe) splits cystic from solid, scores a thyroid nodule with TI-RADS, reads lymph node morphology (hilum preserved, shape, cortical thickness, Doppler vascularity), and guides the needle. It is operator-dependent but cheap, radiation-free, and the agreed first test for every neck swelling.[1][2]

Fine-needle aspiration cytology (FNA) is for the thyroid nodule, the suspicious node, and the salivary gland mass — a 23 to 25 G needle with or without suction, with negligible complications and seeding essentially unheard of except for some salivary tumours. Thyroid cytology is reported by the Bethesda system in six categories — I non-diagnostic, II benign, III atypia of undetermined significance (AUS/FLUS), IV follicular neoplasm or suspicious, V suspicious for malignancy, VI malignant — each carrying an escalating risk of malignancy from under 1 per cent to over 95 per cent.[2]

The rest of the ladder: thyroid function tests (a suppressed TSH argues for a benign autonomous nodule; a normal or raised TSH does not exclude cancer; calcitonin if medullary carcinoma is suspected, and to screen for MEN2); contrast CT or MRI of neck and chest for staging once a malignant diagnosis is established, with MRI preferred for salivary detail and CT for nodal staging and bone; CT or MR angiogram for any pulsatile or vascular lesion and NEVER biopsy one; PET-CT for staging head and neck SCC, lymphoma, and an unknown primary with a metastatic node; and panendoscopy under anaesthesia — direct laryngoscopy, oesophagoscopy, nasopharyngoscopy with directed biopsies of tonsil, base of tongue, piriform fossa, and nasopharynx — when a metastatic SCC node is found and the primary is occult on imaging.[1]

Excision biopsy is for the inconclusive FNA or the suspected lymphoma, because nodal architecture is essential for subtyping (Hodgkin Reed-Sternberg cells, follicular architecture in follicular lymphoma). The TB workup adds FNA for AFB stain, culture (gold standard, takes weeks), and GeneXpert MTB/RIF (rapid PCR), with HIV testing whenever TB or lymphoma is on the cards; when lymphoma is the working diagnosis, add FBC, LDH, ESR, CRP, EBV serology, peripheral film, and serum angiotensin-converting enzyme for sarcoid.[1]

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The bedside round — a fixed sequence and the named signs

A focused neck examination is a high-yield OSCE station, and it follows a fixed sequence every time.[1]

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Named signs and manoeuvres earn viva marks. The dual movement sign (swallowing plus tongue protrusion) is pathognomonic for a thyroglossal cyst. Transillumination of a soft posterior-triangle mass in an infant clinches cystic hygroma. Horner syndrome with a neck mass means a tumour on the cervical sympathetic chain. Recurrent laryngeal nerve palsy (hoarse, breathy voice, bovine cough) with a thyroid mass is malignancy until proven otherwise. Boyd sign (gurgling on compression of a pharyngeal pouch) is rarely elicited but a known stem. And a plea from the marking sheet: Stemmer sign (inability to pinch a skin fold at the base of the second toe) is for lymphoedema, not the neck — do not volunteer it.[1]

Three neck-swellings emergencies — airway, Ludwig, and the biopsy-induced bleed

Most neck swellings are elective, but three presentations are time-critical and a final-prof candidate is expected to name them cold.[1]

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The recurring trainee error in this group is reaching for antibiotics in an adult at increased malignancy risk. The AAO-HNS guideline recommends against routine antibiotics for a neck mass without signs of bacterial infection — the correct move is ultrasound plus FNA on the same visit.[1]

Thyroglossal duct cyst — Sistrunk is cyst plus tract plus central hyoid

A thyroglossal duct cyst moves on swallowing AND on tongue protrusion, and the operation that cures it is the Sistrunk — excise the cyst, the whole tract, and the central portion of the hyoid bone. It is the commonest congenital neck mass, and the dual-movement sign is its pathognomonic clue.[3]

The embryology is the whole story. During development the thyroid descends from the foramen caecum at the tongue base along the thyroglossal duct, passing through (or curling behind and in front of) the hyoid bone to reach its pre-tracheal home. The duct should obliterate; if a remnant persists, a cyst forms anywhere along that tract — about 80 per cent infrahyoid, 15 per cent suprahyoid, 5 per cent intralingual. Because the tract runs through the hyoid and tethers to the tongue base, the cyst rises both on swallowing (the larynx lifts) and on tongue protrusion (the tract is pulled up).[3]

Etymology for viva gold: thyroglossal is thyroid plus glossa — the Greek for tongue — because the duct runs from thyroid to tongue. Sistrunk is the surgeon's name: Walter Sistrunk described the operation at the Mayo Clinic in 1920, and it is the reason recurrence drops from about 50 per cent with simple excision to under 5 per cent.[3]

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The classic trap: excising an ectopic thyroid mislabelled as a thyroglossal cyst. The patient leaves with no thyroid gland at all and a lifetime of levothyroxine that a single pre-operative ultrasound would have prevented.[3]

Branchial cyst — young adult; over 40 it is cystic metastasis until proven

A branchial cyst sits at the junction of the upper and middle thirds of the anterior border of SCM in a young adult, and in anyone over 40 the same cystic lateral mass is a cystic metastasis until proven otherwise. It arises from remnants of the second branchial cleft (about 95 per cent of branchial lesions), classically deep to SCM, with a tract that runs between the external and internal carotid arteries to the tonsillar fossa — surgical anatomy that matters when you excise a fistula.[4]

It typically declares itself in the second to fourth decade, often after an upper respiratory infection that fills the dormant cyst with clear or milky, cholesterol-rich fluid. Surgical excision of the entire cyst and any tract, via a transverse cervical incision along skin creases, is the treatment; avoid rupture, because spillage seeds infection and recurrence.[4]

The classic trap: labelling a cystic lateral neck mass in an adult as a branchial cyst. HPV-positive oropharyngeal SCC metastasises to level II as a cystic mass and is dangerously easy to misread as branchial — the AAO-HNS guideline is explicit that a cystic neck mass in an adult must never be assumed benign. FNA with p16 or HPV testing, imaging, and panendoscopy come BEFORE excision, because excising a cystic metastasis compromises the subsequent neck dissection planes.[1]

Thyroid nodule — TI-RADS on ultrasound, Bethesda on FNA

A solitary thyroid nodule is risk-stratified on two scores: TI-RADS on the ultrasound and Bethesda on the FNA. Most nodules are benign (colloid nodules, cysts, follicular adenomas); roughly 5 to 15 per cent of those that reach FNA are malignant, with papillary carcinoma predominating at about 80 per cent, follicular 10 per cent, medullary 2 to 4 per cent, and anaplastic 1 to 2 per cent.[2]

Malignancy risk rises with a history of neck irradiation, a family history of thyroid cancer, age under 20 or over 60, male sex, and a nodule that is hard, fixed, rapidly growing, or accompanied by cervical adenopathy. Bethesda II (benign) nodules are observed with serial ultrasound; Bethesda III or IV trigger repeat FNA, molecular testing (Afirma, Thyroseq), or diagnostic lobectomy; Bethesda V or VI mandate surgery — lobectomy or total thyroidectomy by size, bilaterality, and histology.[2]

For confirmed cancer, papillary and follicular (differentiated) carcinoma is treated with total thyroidectomy (plus prophylactic central neck dissection for tumours over 4 cm or clinically involved nodes), adjuvant radioactive iodine for intermediate and high-risk disease, and TSH suppression with levothyroxine titrated to risk. Medullary carcinoma needs total thyroidectomy plus central and lateral neck dissection (it does not take up radioiodine; calcitonin is the marker) — and you MUST screen for MEN2 and exclude a pheochromocytoma first to avoid an anaesthetic hypertensive crisis. Anaplastic carcinoma carries near-uniform mortality; treatment is palliative, with airway security the immediate priority.[2]

Cervical lymphadenopathy — reactive, TB, lymphoma, metastatic

Lymph nodes enlarge by one of four mechanisms, and the consistency on palpation points to which. Reactive hyperplasia (viral or bacterial infection) gives soft, mobile, tender nodes that resolve over 2 to 4 weeks. Granulomatous inflammation (TB, atypical mycobacteria, sarcoid) gives matted, often non-tender nodes with caseating granulomas on histology; TB favours the posterior triangle and level V.[1]

Lymphoma (Hodgkin or non-Hodgkin) gives firm, rubbery, painless nodes that grow slowly and may matt together; nodal architecture on excision biopsy is essential for subtyping. Metastatic carcinoma gives hard, fixed, irregular nodes — classically from head and neck SCC, thyroid, or skin (scalp, melanoma); a hard supraclavicular node (Virchow node, Troisier sign) drains the abdomen via the thoracic duct and is gastric cancer until excluded.[1]

The classic trap: incision biopsy of a node that turns out to be lymphoma. Incising distorts the architecture you need for subtyping and seeds the tract; excision biopsy is mandatory. Reactive nodes are observed for 2 to 4 weeks and then re-evaluated; tuberculous nodes (scrofula) get the WHO revised regimen — 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol, then 4 months of isoniazid and rifampicin (2HRZE/4HR), all once daily and oral — with excision biopsy reserved for nodes that fail to resolve, are unsightly, or stay undiagnosed after FNA and GeneXpert. Metastatic SCC sends you hunting for the primary by panendoscopy (biopsying tonsil, base of tongue, piriform fossa, nasopharynx) and PET-CT if it stays occult; treatment is then site and stage driven — early oral cavity SCC is surgical resection plus neck dissection, while oropharynx, hypopharynx, larynx, and nasopharynx are chemoradiotherapy-led, with HPV-positive oropharyngeal disease carrying the better prognosis.[1]

Salivary gland tumour — the 80 per cent rule and the facial nerve

Roughly 80 per cent of parotid tumours are benign, and roughly 80 per cent of those benign tumours are pleomorphic adenomas — that is the 80 per cent rule of the parotid. Warthin tumour (papillary cystadenoma lymphomatosum) is next: bilateral in 10 per cent, a smoker, slow-growing at the tail of the parotid.[1]

Because a pleomorphic adenoma carries about a 5 per cent lifetime risk of malignant transformation, the treatment is superficial parotidectomy with facial nerve preservation — the nerve runs through the gland and is the keystone of safe parotid surgery. The malignant parotid tumours are mucoepidermoid carcinoma (the commonest malignancy), adenoid cystic carcinoma (notorious for perineural spread along the facial nerve — pain and skip lesions along the nerve with a long indolent course), and carcinoma ex-pleomorphic adenoma (transformation of a long-standing adenoma). Malignant disease may need total parotidectomy, possible facial nerve sacrifice, neck dissection, and adjuvant radiotherapy. Submandibular gland tumours are roughly 50 per cent malignant and are treated by gland excision with level I dissection.[1]

Carotid body tumour — pulsatile, do NOT biopsy, the lyre sign, Shamblin

A carotid body tumour is a neuroendocrine tumour of the carotid body chemoreceptor at the bifurcation — it is pulsatile, it moves horizontally but not vertically, and you NEVER put a needle in it. It is highly vascular and splays the internal and external carotid arteries into the lyre sign on imaging. Most are sporadic; about 10 per cent are familial (SDHB, SDHD germline mutations) and roughly 5 to 10 per cent are bilateral, and the vast majority are benign though local invasion can make resection hazardous.[1]

The classic trap: biopsying a carotid body tumour. The needle causes catastrophic bleeding. Diagnose with CT angiogram or MR angiogram, which shows the vascular mass splaying the carotids, and grade difficulty with the Shamblin classification — type I small and easily dissected, type II adherent and partially surrounding the carotids, type III deeply adherent and surrounding them (may need vessel resection and graft). Treatment is surgical resection by a vascular or head-and-neck surgeon with adequate exposure (pre-operative embolisation may reduce bleeding for large tumours); radiotherapy is the alternative for the elderly, the surgically unfit, or residual and recurrent disease. Screen for multiple paragangliomata and SDHx mutations in familial or bilateral disease.[1]

Cystic hygroma — infants, posterior triangle, brilliantly transilluminant

A cystic hygroma is a congenital malformation of the jugular lymphatics — multiloculated cystic spaces in the posterior triangle, present at birth or in early infancy, and the commonest transilluminating neck mass in a neonate. It is best managed by a multidisciplinary vascular anomalies team: sclerotherapy (picibanil or OK-432, doxycycline, or bleomycin) is first-line for macrocystic lesions, with surgical excision reserved for microcystic disease, residual masses, or compression of the airway and great vessels. Airway compromise at delivery may need the EXIT procedure (ex-utero intrapartum treatment).[1]

Complications and pitfalls

Of the disease — airway compromise from a large goitre, anaplastic thyroid carcinoma, retrosternal extension, or retropharyngeal abscess; infection of a developmental cyst (branchial, thyroglossal) with pain, cellulitis, and abscess; fistula formation after a branchial cyst is incised and drained; malignant transformation (papillary carcinoma within a long-standing thyroglossal cyst in about 1 per cent, carcinoma ex-pleomorphic adenoma in a long-standing parotid adenoma); and nerve involvement — recurrent laryngeal nerve (hoarseness) in thyroid cancer, facial nerve in malignant parotid tumour, hypoglossal nerve in carotid body tumour, and the sympathetic chain with Horner syndrome.[1]

Of surgery — recurrence from incomplete excision, most often a thyroglossal cyst done without Sistrunk (50 per cent recurrence, under 5 per cent with Sistrunk) or a branchial cyst with a residual tract; recurrent laryngeal nerve injury at thyroidectomy (hoarseness, aspiration; bilateral injury obstructs the airway and needs a tracheostomy, so intra-operative nerve monitoring is increasingly used); facial nerve injury at parotidectomy (transient neuropraxia common, permanent injury rare with meticulous dissection); hypocalcaemia after total thyroidectomy from parathyroid devascularisation (check corrected calcium on day one); hypothyroidism after thyroidectomy or after removal of an ectopic thyroid misdiagnosed as a thyroglossal cyst; cervical chain nerve injury in neck dissection (spinal accessory nerve and shoulder droop, hypoglossal and tongue palsy, vagus and voice, phrenic and diaphragm); stroke after carotid body resection from carotid injury or embolism; and hypertrophic or keloid scarring, especially in darker skin types, so plan incisions along skin creases.[3]

The classic pitfalls to name in a viva: biopsying a carotid body tumour (catastrophic bleeding — diagnose with imaging, never a needle); antibiotics for an adult over 40 with a neck lump (you have lost diagnostic time); incision biopsy of a node that turns out to be lymphoma (distorts architecture, seeds the tract — excision biopsy is mandatory); mistaking a cystic metastasis from HPV-positive oropharyngeal SCC for a branchial cyst in an adult; removing an ectopic thyroid mislabelled as thyroglossal cyst (permanent hypothyroidism); and not screening for MEN2 or pheochromocytoma before thyroidectomy for medullary carcinoma (anaesthetic hypertensive crisis).[1]

Special populations

Children. The dominant causes are developmental cysts (thyroglossal, branchial, cystic hygroma) and reactive lymphadenopathy; malignancy is rare but lymphoma is the main worry, and a node over 2 cm, supraclavicular, hard or fixed, growing, or persisting beyond 4 to 6 weeks is a red flag. Ultrasound is first-line with a lower threshold for observation in clearly reactive nodes, and excision biopsy if persistent or suspicious. Cystic hygroma may compromise the airway at delivery and need the EXIT procedure.[3]

Elderly. Risk of malignancy rises with each decade; anaplastic thyroid carcinoma, salivary malignancy, and metastatic SCC dominate, a hard fixed node is metastatic until proven, and comorbidities make the surgical decision harder — weigh fitness for surgery against the natural history of the disease.[1]

Pregnant patients. Physiological thyroid enlargement is common, but a new nodule still warrants ultrasound (no radiation) and FNA, which is safe in pregnancy. Definitive surgery for cancer, if indicated, is generally deferred to the second trimester or post-partum unless the tumour is aggressive (anaplastic). Radioactive iodine is absolutely contraindicated in pregnancy and breastfeeding.[2]

Immunocompromised (HIV, post-transplant). Lymphoma and atypical infection (mycobacterium avium, cryptococcus, Kaposi sarcoma) rise up the differential; test for HIV whenever TB or lymphoma is suspected, and remember EBV-driven post-transplant lymphoproliferative disorder can present as a neck mass. Anticoagulated patients can still have FNA (haematoma risk small but real; warfarin or a DOAC may be continued for thyroid FNA per local policy), but stop anticoagulation before any surgical biopsy or excision and bridge as appropriate.[1]

Prognosis and disposition

Benign developmental cysts do excellently after complete excision — under 5 per cent recurrence for thyroglossal after Sistrunk, under 3 per cent for branchial. Thyroid nodules are over 90 per cent benign, and differentiated thyroid cancer has an excellent prognosis (5-year survival over 98 per cent for localised papillary disease in patients under 55); medullary carcinoma runs 40 to 90 per cent 5-year survival by stage, while anaplastic carcinoma is among the most aggressive human cancers with median survival under 6 months.[3][2]

A metastatic cervical node's prognosis turns on primary site, nodal stage (N1 versus N3), extra-nodal extension, and HPV status — HPV-positive oropharyngeal SCC carries about 80 to 90 per cent 5-year survival against 40 to 60 per cent for HPV-negative disease. Lymphoma is subtype and stage driven: Hodgkin about 85 to 90 per cent 5-year survival, diffuse large B-cell non-Hodgkin about 60 to 70 per cent, follicular indolent with 10-year survival common. A carotid body tumour is benign in over 90 per cent, and surgical morbidity (cranial nerve injury, stroke) is the main determinant of outcome, rising with Shamblin grade.[1]

Disposition. Any unexplained neck mass at increased malignancy risk is referred urgently (the UK 2-week-wait suspected cancer pathway, or equivalent) to a head-and-neck or surgical team with ultrasound plus FNA on the same visit. Confirmed malignancy goes to a head-and-neck MDT (surgery, oncology, radiation oncology, pathology, radiology, specialist nursing); benign developmental cysts are managed electively by a surgical team, with paediatric ENT input for children.[1]

The mantra, the mnemonic, and the viva gold

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The mantra: midline swallowing is thyroid; midline swallowing-plus-tongue is thyroglossal; over 40 a new lump is cancer until proven.[1]

Etymology for viva gold: thyroglossal is thyroid plus glossa, the Greek for tongue — the duct runs from thyroid to tongue. Branchial is from the Greek branchia, gills — the embryo literally carries gill clefts that become cysts. Carotid is from the Greek karos, heavy sleep — the ancients thought pressing the carotid induced sleep. Sistrunk is the surgeon's name, not the procedure's mechanism; and the lyre sign is the splayed carotids shaped like the stringed instrument.[3]

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Ward-round test — three stems, thirty seconds each

Stem 1 — the 45-year-old from the top of the topic (answer)

The 45-year-old with a six-week painless right-of-midline lump that did not respond to two weeks of antibiotics. What are your next two moves, and why? Model: At 45 this is malignancy until proven — the AAO-HNS rule. The two moves are ultrasound of the neck and fine-needle aspiration, on the same visit, NOT more antibiotics and not observation. The ultrasound reads cystic versus solid, scores a thyroid nodule with TI-RADS, and reads node morphology; the FNA reports thyroid cytology by Bethesda or samples a node. If the lump moves on swallowing it is thyroid in origin, and Bethesda V or VI sends him to surgery; if he has hoarseness with a thyroid nodule it is papillary carcinoma until proven.[1]

Stem 2 — the midline lump that moves on tongue protrusion (answer)

A 22-year-old presents with a painless fluctuant midline neck lump that rises when she swallows AND when she sticks her tongue out. Name the diagnosis, the operation, and the single pre-operative check that prevents a lifelong error. Model: This is a thyroglossal duct cyst — the dual movement (swallowing plus tongue protrusion) is pathognomonic, because the tract runs through the hyoid to the foramen caecum. The operation is the Sistrunk procedure — excision of the cyst, the entire tract, and the central portion of the hyoid bone — which drops recurrence from about 50 per cent with simple excision to under 5 per cent. The pre-operative check is ultrasound (with TFTs) to confirm a normal thyroid in the normal position, so that an ectopic thyroid — the patient's only functioning thyroid tissue — is not excised by mistake and cause permanent hypothyroidism.[3]

Stem 3 — the pulsatile lateral mass in a 50-year-old (answer)

A 50-year-old has a firm, pulsatile mass at the carotid bifurcation that moves horizontally but not vertically, with a bruit on auscultation. The registrar wants to book an FNA. What do you do, and what does the imaging show? Model: This is a carotid body tumour (paraganglioma) — and the one rule is do NOT biopsy it; an FNA here risks catastrophic bleeding. Order a CT angiogram or MR angiogram, which shows the highly vascular mass splaying the internal and external carotid arteries into the lyre sign, and grade the difficulty of resection with the Shamblin classification (I small and easily dissected, II adherent and partially surrounding, III surrounding and possibly needing vessel resection). Treatment is surgical resection by a vascular or head-and-neck surgeon, with radiotherapy for the elderly, the surgically unfit, or residual disease — and screen for SDHx mutations and multiple paragangliomata if familial or bilateral.[1]

References

1. [1]Pynnonen MA, Gillespie MB, Roman B, Rosenfeld RM, et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Otolaryngol Head Neck Surg, 2017.PMID 28891406
2. [2]Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer Thyroid, 2016.PMID 26462967
3. [3]Amos J, Sutton AE, Shermetaro C. Thyroglossal Duct Cyst 2026.PMID 30085599
4. [4]Holt AC, Lofgren DH, Hohman MH, Shermetaro C. Branchial Cleft Anomalies 2026.PMID 29763089