Lumps in the neck are common and the cause is usually benign. However, the lump may be the presentation of more serious disease, e.g. malignancy or chronic infection and so a thorough assessment and diagnosis are essential. If there is any doubt as to the cause, then the patient should be reviewed and/or referred for specialist assessment. Patients over the age of 40 are more likely to have a neoplastic cause. Inflammatory, congenital and traumatic causes are more common in younger patients but neoplasm should still be borne in mind.¹

Assessment²

• Lumps of less than three weeks' duration are most likely due to a self-limiting infection and do not require further investigation but keep under close weekly or fortnightly review. Consider referral if persisting for longer than four weeks.
• Examination should be carried out with the patient sitting on a chair; carefully examine the whole of the scalp, the back of the neck and behind and within the ears.
• Establish how deep the lump is: is it intradermal (suggesting sebaceous cyst with a central punctum, or a lipoma)?
• Is the lump in the midline and does it move on swallowing and/or on protruding the tongue?
• Palpate the lymph nodes of the head and neck: are they tender, fibrous, hard or rubbery, fixed or mobile? For submandibular lumps, examine the mouth and salivary glands, looking for oral malignancies or sources of infection, e.g. abscesses:
• If parotid disease is suspected, identify the orifice of parotid duct and palpate with the patient's head tilted backwards.
• Examine the patient's tongue and floor of mouth, with their tongue first protruding and then elevated inside the mouth.
• Bimanually, palpate lumps in the floor of the mouth, submandibular area and cheeks.
• For lumps in the parotid region, test, assess and record the integrity of the facial nerve.

Neck lumps in children³

• Take a full history (e.g. recent tonsillitis, skin lesion).
• Arrange referral if the cause of swelling is uncertain, especially if swelling is persistent.

Differential diagnosis^4,5,6

• Superficial lumps, e.g. sebaceous cyst, lipoma, abscess, dermoid cyst.
• Lymph nodes.
• Anterior triangle:
  • Lymph nodes are most common so check the areas which they serve (mouth, throat, thyroid, skin of head and neck).
    Midline:
    • Thyroglossal cyst: (moves on protruding tongue and swallowing; commonly in patients aged under 20 years). Develops from remnant of thyroglossal duct. Cysts are fluid/mucus-filled. Usually painless but may enlarge and become painful if infected.
    • Thyroid swelling: moves on swallowing (but not tongue protrusion). Beware the development of lymphoma in patients with previous Hashimoto's thyroiditis. See related separate article Thyroid Lumps.
    • Dermoid cyst - epithelium-lined cyst which may contain other skin components, e.g. hair, sebaceous or sweat glands. Commonly appears during the first year of life.
  • Submandibular: most likely to be lymph node but may indicate cancer if older, particularly if the node feels firm and is non-tender. Consider tuberculosis (TB), other infections, salivary calculus or tumour.
  • If it doesn't move with swallowing, consider salivary gland swelling, branchial cyst, cystic hygroma, carotid aneurysm, carotid body tumour, sternomastoid tumour (in babies following birth trauma; head is turned away from swelling and tilted towards the lesion) or laryngocele (painless anterior triangle lumps made worse by blowing).
• Posterior triangle lump(s) (i.e. behind sternomastoid, front of trapezius and above clavicle):
  • Multiple lumps are likely to be lymph nodes (TB, glandular fever, HIV, lymphoma or metastases); always look for any generalised lymphadenopathy, hepatomegaly and splenomegaly. Consider metastases from nasopharyngeal carcinoma (more common in older patients of Chinese origin).
  • Cervical rib.
  • Subclavian artery aneurysm.
  • Pharyngeal pouch.
  • Cystic hygroma. Large cystic hygromas present at birth and may be huge and disfiguring. In older children, smaller lesions can present as a painless lump just below the angle of the mandible, soft, fluctuant and transilluminable. Surgical excision may be difficult, as they may extend to deeper neck tissues.
  • Branchial cysts: rare, usually present in late teens with a solitary painless swelling on the side of the neck, which varies in size and may be painful and red in some patients. It forms when the second branchial cleft fails to disappear in utero. Discharging sinuses and fistulae may occur. Aspiration may be pus-like and can be rich in cholesterol crystals. The lump itself is soft and fluctuant and may transilluminate.

Investigation

• All suspicious lumps require an ENT examination before biopsy (refer to ENT to try to find the primary source).
• Investigations of persistent lumps may involve fine-needle aspirate⁷ or excision biopsy, CXR and ultrasound/MRI/CT scanning. One study found that ultrasound was significantly better than CT scanning in screening for malignant cervical lymph nodes.⁸
• Send samples for culture.
• Lymphoma will require further staging investigations.⁹

Document references

1. Rosenberg TL, Brown JJ, Jefferson GD; Evaluating the adult patient with a neck mass. Med Clin North Am. 2010 Sep;94(5):1017-29. [abstract]
2. Schwetschenau E, Kelley DJ; The adult neck mass. Am Fam Physician. 2002 Sep 1;66(5):831-8. [abstract]
3. Gow K; Lymph Node Disorders, Medscape, Mar 2010
4. Turkyilmaz Z, Karabulut R, Bayazit YA, et al; Congenital neck masses in children and their embryologic and clinical features. B-ENT. 2008;4(1):7-18. [abstract]
5. Kanwar VS et al; Lymphadenopathy, Medscape, Mar 2010
6. Smith JC et al; Neck, Cysts, Medscape, Aug 2009
7. O'Donnell ME, Salem A, Badger SA, et al; Fine needle aspiration at a Regional Head and Neck Clinic: a clinically Cytopathology. 2009 Apr;20(2):81-6. Epub 2008 Jan 31. [abstract]
8. Hohlweg-Majert B, Metzger MC, Voss PJ, et al; Preoperative cervical lymph node size evaluation in patients with malignant J Cancer Res Clin Oncol. 2009 Jun;135(6):753-9. Epub 2008 Oct 2. [abstract]
9. Smith OD, Ellis PD, Bearcroft PW, et al; Management of neck lumps--a triage model. Ann R Coll Surg Engl. 2000 Jul;82(4):223-6.; Ann R Coll Surg Engl. 2000 Jul;82(4):223-6. [abstract]

Internet and further reading

• Essential Surgery 3rd edition. Burkitt HG and Quick CRG. Churchill Livingstone 2002
• Kinirons M, Ellis H; French's Index of Differential Diagnosis. 14th edition; 2005
• Turkington JR, Paterson A, Sweeney LE, et al; Neck masses in children. Br J Radiol. 2005 Jan;78(925):75-85. [abstract]

Acknowledgements