Neck Lumps and Bumps

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.

• Lumps of less than 3 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 persists for longer than 4 weeks.
• Examine patient sitting down on a chair, examining carefully the whole of the scalp, the back of the neck and behind and within the ears.
• How deep is the lump: 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 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 suspected identify orifice of parotid duct and palpate with head tilted backwards.
• Examine tongue and floor of mouth with tongue first protruding and then elevated inside the mouth.
• Bimanually palpate lumps in floor of mouth, submandibular area and cheeks.
• For lumps in the parotid region test, assess and record the integrity of the facial nerve.

Neck lumps in children

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

• 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 article Thyroid Lumps.
    • Dermoid cyst - epithelium lined cyst which may contain other skin components eg hair, sebaceous or sweat glands. Commonly appears during 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, other infections, salivary calculus or tumour.
  • If 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 laryngocoele (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 (commoner 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 painless lump just below angle of mandible, soft, fluctuant and transilluminable. Surgical excision may be difficult as they may extend to deeper neck tissues.
  • Brachial cysts: rare, usually present in late teens with solitary painless swelling on side of 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.

• All suspicious lumps require an ENT examination before biopsy (refer to ENT to try and find primary).
• Investigations of persistent lumps may involve fine needle aspirate or excision biopsy, chest x-ray and ultrasound/MRI/CT.
• Send samples for culture.
• Lymphoma will require further staging investigations.¹