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).
• 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).
  • Thyroglossal cyst: (moves on protruding tongue; particularly in patients aged under 20 years).
  • Thyroid swelling: moves on swallowing.
  • 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.
  • Cervical rib.
  • Subclavian artery aneurysm.
  • Pharyngeal pouch.
  • Cystic hygroma.

Isolated Lymph Node Enlargement

May be due to:

• Local disease within its field of drainage e.g. tonsillitis, dental abscess, or malignant oropharyngeal tumour.
• Tumours from the head and neck usually metastasise to nodes in the submandibular region and upper part of the anterior triangle.
• Tumours of chest and abdomen usually metastasise to lower part of posterior triangle, especially Virchow's node lying on the left side deeply in the angle between the sternomastoid and clavicle.
• Metastatic neck nodes: 30% come from head and neck, 30% from the lung, 30% from an "occult" primary, and 10% from distant primary (e.g. prostate, kidney).
• Systemic lymphadenopathy, e.g. glandular fever, HIV or lymphoma.
• Non-Hodgkin's lymphoma or Hodgkin's disease commonly presents in this way and may be the only symptom.
• Cervical TB: scrofula is now rare in this country but may be seen in recent immigrants. Cervical nodes become enlarged and matted together. In advanced cases may form cold abscesses that can drain on to the neck and scar.

Congenital Cysts and Sinuses

Several different types of cystic lesions of congenital origin can be found in the head and neck and some may have external sinus openings. All are uncommon, and surgical excision is the usual treatment.

• Thyroglossal cyst: common midline cyst in the thyroid's migration path (between back of tongue and thyroid), which moves up on protruding the tongue in the tract.
• Midline dermoid cyst: teratoid cyst appearing in midline of neck usually during first year of life.
• Brachial cysts: rare, usually present in late teens with painless swelling on side of neck which varies in size and may be painful and red in some patients. Lump is soft and fluctuant and usually transilluminates.
• Brachial sinuses and fistula: presents as discharging sinus at lower end of the anterior border of the sternomastoid muscle.
• Cystic hygromas: 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.

• 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