We conclude that patients presenting with level 5 lymphadenopathy should be investigated with heightened clinical vigilance. Our results suggest that up to 80 % will harbour clinically significant pathology requiring further medical treatment, three quarters of which will be malignancy. We report an observational study of histological outcomes of level 5 lymph node biopsies from a regional histopathology department across 5 years. 184 subjects were identified as having a biopsy of a lymph node from the level 5 region within the study period. One hundred and fifty six cases (84.8 %) had clinically significant pathology on final histology requiring further medical treatment. Lymphoma accounted for the highest number of cases (n = 72, 39.1 %), followed by metastatic carcinoma (n = 65, 35.3 %) and granulomatous change (n = 17, 9.2 %). Gender and laterality were not shown to be independent predictors of pathology significance (p [ 0.05).

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Pulsatile tinnitus is a rare symptom, yet it may herald life-threatening pathology in the absence of other symptoms or signs. Pulsatile tinnitus tends to imply a vascular cause, but metastatic disease also can present in this way. Clinicians should therefore adopt a specific diagnostic algorithm for pulsatile tinnitus and always consider the possibility of metastatic disease. A history of malignant disease and new cranial nerve palsies should raise clinical suspicion for skull base metastases. We describe the case of a 63-year-old woman presenting with unilateral subjective pulsatile tinnitus and a middle ear mass visible on otoscopy. Her background included the diagnosis of idiopathic unilateral vagal and hypoglossal nerve palsies 4 years previously, with normal magnetic resonance imaging (MRI). Repeat MRI and computed tomography imaging were consistent with metastatic breast carcinoma. This case raises important questions about imaging protocols and the role of serial scanning in patients at high risk of metastatic disease.