A neck swelling with difficulty swallowing in a 54-year-old: a case to work up

Why a neck swelling with pressure symptoms matters

Most neck swellings in the front of the neck are thyroid, and most thyroid swellings are benign. The work-up has two jobs: decide whether the gland is working normally, and decide whether the swelling could be cancer or is pressing on the windpipe, gullet or the nerve to the voice box.

What to ask in the history

• How long the swelling has been there, and whether it is growing, and how fast
• Pain or tenderness
• Pressure symptoms: difficulty swallowing, breathlessness, noisy breathing, change in voice
• Symptoms of an overactive thyroid (weight loss, heat intolerance, palpitations, tremor) or an underactive one (weight gain, cold intolerance, constipation, tiredness)
• Weight loss, fevers or night sweats
• Radiation to the neck in the past; family history of thyroid disease or thyroid cancer
• Where she lives and her diet (iodine), medicines

Red flags

• Rapid growth
• A hard, irregular or fixed swelling
• Hoarseness or a change in voice
• Stridor or breathlessness
• Enlarged lymph nodes in the neck
• Weight loss or night sweats
• Past radiation to the neck

What to examine

• Inspect from the front: does it move up on swallowing? On sticking the tongue out?
• Palpate from behind: size, surface (smooth, nodular), consistency, tenderness
• Whether you can get below it (retrosternal extension), and tracheal position
• Cervical lymph nodes
• Thyroid status: pulse, tremor, skin, reflexes, eye signs
• Pemberton's sign if retrosternal extension is suspected

First investigations

• TSH, with free T4 if TSH is abnormal
• Ultrasound of the neck
• Fine needle aspiration cytology (FNAC) of a suspicious nodule
• Laryngoscopy to look at the vocal cords when the voice has changed
• CT of the neck and chest if retrosternal extension or tracheal compression is suspected
• Thyroid antibodies

Differential diagnosis of a neck swelling with pressure symptoms

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• A normal TSH says the gland is working normally. It says nothing about whether a nodule is benign.
• Not examining the vocal cords when the voice has changed.
• Forgetting tuberculosis as a cause of neck lumps in India.