Neck lumps (branchial & thyroglossal cysts)

Overview

A practical framework for the neck lump, anchored on the two classic congenital cysts: a THYROGLOSSAL cyst (midline, moves up with tongue protrusion/swallowing) and a BRANCHIAL cyst (lateral, anterior to sternocleidomastoid). The overriding rule: a persistent neck lump in an adult is malignancy/metastasis until proven otherwise.

Recognise

• Thyroglossal cyst: MIDLINE, moves UP on tongue protrusion and swallowing (attached to the hyoid/tongue base), young patients
• Branchial cyst: smooth lump at the ANTERIOR border of sternocleidomastoid (upper third), young adults, may get infected
• Reactive lymph node: tender, mobile, resolves; the location and behaviour place the lump in a differential

Differentials & how to tell them apart

Investigations

Ultrasound + FNA is the key initial work-up of a neck lump. Thyroglossal/branchial cysts are confirmed on imaging; a suspicious lump → 2-week-wait ENT, endoscopy, and look for a primary.

Management

Ultrasound + FNA to characterise; excise congenital cysts; 2-week-wait if suspicious

1. 1Characterise the lump by location/behaviour and ultrasound + FNA. Congenital cysts (midline thyroglossal — moves on tongue protrusion; lateral branchial) → surgical excision.Gate: In an ADULT, a persistent neck lump is metastatic head-and-neck cancer or lymphoma until proven otherwise → ultrasound + FNA and 2-week-wait ENT, rather than assuming a benign cyst — congenital cysts are the young-patient diagnosis
2. 2Thyroglossal cyst → Sistrunk procedure; branchial cyst → excision; malignant/lymphomatous nodes → oncology MDT after finding the primary.

Monitor & prognosis

Histology/cytology; recurrence after excision; cancer surveillance if malignant.

Excellent for congenital cysts; depends on diagnosis if malignant.