neck lumps – a guide to asssessment and...

Neck lumps are a common presentation in gen-eral practice. They are usually first noticed by thepatient, although occasionally they are detected onroutine physical examination.

A comprehensive history and clinical examina-tion with appropriate investigations is importantto determine if the lump is benign or malignant.When in doubt or if clinical assessment suggestsa tumour, prompt referral to a head and neck sur-geon is important to clarify the diagnosis. For -tunately, neck lumps in children nearly alwaysrepresent benign reactive lymph nodes, which can be diagnosed on clinical exami nation alone.However, children with persistent suspicious necklumps should be referred to a paediatric surgeon.As a general rule, a persistent lateral neck lumpin an adult should always be assumed to be malig-nant until proven otherwise.

This article describes the thorough assessmentof a patient with a neck lump and when a patientshould be referred to a specialist.

AssessmentWhat to ask in the historyComprehensive history taking and physical exami-nation are critical in the evaluation of a patient witha neck mass (Table 1).

Children and younger adults presenting with a neck lump of short duration usually have a history suggestive of a preceding infective focus.Examples of such infections are tonsillitis, dentalinfection, mumps and glandular fever (especiallyin teenagers); less common infections include toxoplasmosis, cat scratch disease, tuberculosisand HIV infection.

Adults presenting with a neck lump shouldalways be questioned about their risk factors for head and neck cancer (tobacco smoking, exces-sive alcohol intake and past history of upperaerodigestive tract malignancy). Associated upperaerodigestive tract symptoms such as dysphagia,hoarseness and throat pain, referred otalgia, weightloss and haemoptysis are all possible symptoms

26 MedicineToday � April 2010, Volume 11, Number 4

MedicineToday PEER REVIEWED ARTICLE POINTS: 2 CPD/2 PDP

CHRIS HOBBS BSc, MB BS, MD, FRCS, DLO

RON BOVA MB BS, MS, FRACS

Dr Hobbs is an ENT Fellow and

Dr Bova is an ENT–Head and

Neck Surgeon at St Vincent’s

Hospital, Sydney, NSW.

Neck lumpsA guide to assessment and

managementA wide variety of pathology can present with a neck lump. The two most important

investigations that a GP can arrange prior to referral of a patient with a suspicious neck

lump are a neck soft tissue CT scan and a fine needle aspiration biopsy.

• Neck lumps can be categorised as congenital/developmental, inflammatory or neoplastic

in origin.

• A persistent lateral neck lump in an adult should be considered malignant until proven

otherwise.

• A history of smoking, excessive alcohol consumption or previous head and neck or skin

cancer should raise suspicion.

• A thorough examination of the head and neck (including skin) is essential.

• The most important investigations in a patient with a suspicious neck lump are a neck

soft tissue CT scan with contrast and a fine needle aspiration biopsy.

IN S

UM

MARY

Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2010. Copyright for illustrations as stated.

MedicineToday � April 2010, Volume 11, Number 4 27

Figures 1a and b.

Anatomical divisions of

the neck and sites of

common pathology.

a (left). Lateral neck.

b (right). Midline neck.

of a head and neck mucosal malignancy. Elderly patients, especially those with sun-

damaged skin, should also be questioned aboutprevious facial cutaneous cancers. These cancerscan metastasise to parotid and cervical lymphnodes sometimes months or years following resec-tion of what may have appeared to be a small trivial skin cancer.

Adults with lymphoma can present with a necklump and may experience systemic symptoms suchas fever, malaise, night sweats or weight loss.

What to look for in the examinationThe neck is a complex area that requires a sys -tematic approach to examination. Variations in neck size, thickness and prominence of normalstructures can all make neck examination chal-lenging. Normal structures such as the thyroid,cricoid cartilage, hyoid bone and upper cervicalvertebrae can easily be confused with a deep neckmass.

It is common to feel small (subcentimetre diameter) mobile rubbery lymph nodes in chil-dren and young patients with thin necks. Thesenodes are most commonly found in the posteriortriangle and anterior to the upper third of the ster -nocleidomastoid muscle (jugulodigastric nodes).

Posterior auricular Enlarged lymphnodes

PreauricularEnlarged lymph nodes,parotid lumps

Upper cervicalEnlarged lymph nodes,parotid tail lumps,branchial cysts

SubmentalThyroglossal cysts,plunging ranulas,enlarged lymphnodes

SubmandibularEnlargedsubmandibulargland, enlargedlymph nodes

Mid cervicalEnlarged lymph nodes,carotid artery aneurysm

Lower cervicalEnlarged lymphnodes, thyroid lumps

Thyroid lumps

Thyroglossalcysts

Posterior triangle

Anteriortriangle

Enlarged submentallymph nodes

Posterior cervicalEnlarged lymphnodes

ILLUSTRATIONS © CHRIS WIKOFF, 2010

Table 1. Assessment of a neck lump

• Take a full history – including duration, change

in size of lump, dysphagia, hoarseness,

referred pain (e.g. otalgia), fever, night sweats

and weight loss

• Check risk factors – including smoking,

alcohol consumption, upper aerodigestive

tract malignancy and sun exposure

• Examine the seated patient – inspect the neck

from the front and palpate it from behind. Is

the lump a midline or lateral neck lump, is it

soft or hard, is it mobile or fixed?

• Complete the head and neck examination –

the remainder of the neck, the thyroid, oral

cavity, oropharynx, nose and ears, and the

skin of the scalp and the back of the neck

• Examine the facial nerve for lumps in the

parotid region

• Suspicious neck lumps should be investigated

with CT scan and fine needle aspiration biopsy

• Thyroid lumps should be investigated with an

ultrasound and thyroid function tests

• Consider referral of all suspicious neck lumps

to a head and neck surgeon


© copyright

© copyright


Neck lumps

continued

Similarly, in elderly patients the sub man -di bular glands often descend and arepalpable as symmetrical soft masses inthe submandibular region.

Determining if a neck lump is in themidline or lateral neck is the first step.Lateral neck lumps can further be dividedinto anterior or posterior triangle necklumps. Figures 1a and b illustrate theanatomical triangles and common necklumps found in these locations.

A firm or hard lump should raise alarm bells for metastatic malignancy.Exami nation of the tongue, floor of themouth, oropharynx and buccal mucosacan easily be performed with a tonguedepressor, gloved finger and a bright light.Exa mi nation of the scalp and facial skin for

possible squamous cell carcinoma (SCC)or melanoma is performed, as well as pal-pation of the parotid and thyroid gland.ENT, head and neck surgeons can com-prehensively evaluate the nasal cavity andupper aerodigestive tract by transnasalendoscopy. This is carried out under topi-cal spray anaesthetic in the office.

If lymphoma is suspected, examina-tion of the axillary and inguinal nodesshould be performed, and also a com-plete abdominal examination looking for hepatosplenomegaly.

What investigations to orderThe two most important investigationsthat a GP can arrange prior to referral of apatient with a neck lump are a neck CT

scan and a fine needle aspiration biopsy(FNAB).

Soft tissue CT scanA neck soft tissue CT scan with contrastprovides superior anatomical definitionof any neck lump while also imaging the remainder of the neck tissues. If thereare metastatic nodes, this procedure mayalso facilitate localisation of the primarytumour.

UltrasoundUltrasound is the imaging modality ofchoice for thyroid masses. It is useful fordifferentiating cystic from solid lateralneck masses, but of less utility for assess-ing malignant lumps.

FNABFNAB is the most accurate diagnostic toolfor investigating neck lumps. It can be per-formed in most radiology centres (underultrasound guidance), in major pathologycentres (usually in the teaching hospitalsetting) or by surgeons in their rooms.Although the accuracy of FNAB is high(approximately 90%), false negatives dooccur and hence a suspicious neck massshould always be referred for comprehen-sive evaluation. For example, an FNAB ofa cystic nodal metastasis may reveal degen-erate benign-looking squamous debrisfrom the central fluid component whilemissing the solid peripheral tumour rimof the lymph node.

Blood testsBlood tests are occasionally helpful. Lym-phocytosis on full blood count in additionto viral serology may help diagnose a systemic viral illness (e.g. Monospot test for Epstein Barr virus, toxoplasmaserology and HIV serology). Thyroid func-tion tests are routine when investigating thyroid lumps.

ClassificationNeck lumps are classified into congenital/developmental lumps, inflammatory/

Table 2. Classification of neck lumps

Congenital/developmental• Cystic hygromas (lymphangiomas)

• Vascular malformation

• Branchial cyst

• Thyroglossal cyst

• Dermoid cyst

• Plunging ranula

Inflammatory• Lymphadenopathy

– nonspecific lymphadenitis in babies

and children

– viral, e.g. glandular fever

(Epstein Barr virus infection),

toxoplasmosis

– bacterial, e.g. tonsillitis, odontogenic

infections

– other, e.g. tuberculosis, brucellosis,

cat scratch disease

• Salivary gland inflammation

– ductal obstruction without infection

(due to calculi or strictures)

– bacterial, e.g. staphylococcal

infection

– viral, e.g. mumps

Neoplastic Benign

• Thyroid – colloid nodule, follicular

adenoma, simple cyst

• Salivary gland – pleomorphic adenoma,

Wharthin’s tumour, monomorphic

adenoma

• Neurovascular

– nerve schwannoma, neurofibroma

– vascular malformation

• Connective tissue tumours – lipoma,

fibroma, etc.

Malignant

• Lymphadenopathy

– primary: lymphoma

– secondary: SCC (mucosa or skin),

melanoma, adenocarcinoma (in

upper neck, from salivary gland; in

supraclavicular fossa, from stomach)

• Thyroid – papillary, follicular, medullary

and anaplastic carcinomas

• Salivary gland

– primary: mucoepidermoid, acinic

cell, adenoid cystic, adenocarcinoma

– secondary: cutaneous SCC,

cutaneous melanomaABBREVIATION: SCC = squamous cell carcinoma.


infective lumps and neoplastic lumps, as described below and summarised inTable 2.

Congenital/developmental lumps – midlineThyroglossal cysts Thyroglossal cysts arise from remnants ofthe thyroglossal duct (a developmentaltract of tissue that originates from thetongue base and descends into the lowerneck forming the thyroid gland, and whichusually involutes in utero) and usually present as painless cystic swellings in theregion of the hyoid (Figure 2). The cystsoccasionally get infected and may pre-sent as inflammatory swellings. They can occur in any age group, but are mostcommon in young adults (50% presentbefore age 20 years). Classically they moveupwards on tongue protrusion.

Excision is recommended for all cyststo confirm the diagnosis and to preventfuture infections.

Dermoid cysts Dermoid cysts are inclusion cysts that occuralong lines of fusion (e.g. nose, palate orunder the tongue). Occasionally, however,they can result from implantation throughtrauma, either accidental or iatrogenic following surgery.

Surgical removal is indicated in mostcases. When the cysts occur in or aroundthe nose or eyes, prior CT or MRI scanningis essential to exclude deeper con nectionsthrough the calvarium that may contain ameningocoele or encephalocoele.

Congenital/developmental lumps – lateralCystic hygromas (lymphangiomas)Cystic hygromas are lymphatic hamar-tomas rather than true cysts and present as soft, fluctuant and transilluminablemasses just under the skin. Nearly all pre -sent by the age of 2 to 3 years, with 60%occurring in the head and neck region(usually in the posterior triangle) andmost presenting at birth. They are often

multiloculated and typically painless. Ultrasound is useful to confirm the

diagnosis and CT scanning is essential ifsurgery is contemplated.

Branchial cysts Branchial cysts usually present as smooth,fluctuant masses in the lateral neck, typi-cally just anterior to the upper sternoclei-domastoid, in young adults (Figure 3).They frequently become infected follow-ing an upper respiratory tract infection.Most arise from embryonic remnants ofthe second branchial cleft and may have asmall sinus tract into tonsillar fossa.

CT and FNAB are important to con-firm the diagnosis and to help excludemalignancy. All branchial cysts should besurgically removed.

Plunging ranulas Ranulas are pseudocysts formed by mucousextravasations from the sublingual glandand typically present as cystic swellings in the floor of the mouth. Occasionally,the mucous ruptures through the floor of mouth musculature and presents assoft neck lumps in the submandibular triangle (plunging ranulas).

They are treated by transoral excisionof the sub lingual gland, which results indrain age of the ranula. Surgery is curative.

Inflammatory/infective lumpsLymphadenopathy (nonspecificlymphadenitis) Small palpable cervical nodes are verycommon in children and young adultsand are most common in the jugulo di -gastric region. Such lymphadenopathy can persist for several months and isassociated with very few systemic symp-toms. It is usually related to an initialnonspecific and self-limiting viral upperrespiratory tract infection. If persistentnodes are biopsied to exclude othercauses, the histology reveals reactivehyperplasia.

Acute lymphadenitis Acute lymphadenitis can be bacterial (e.g.Staphylococcus aureus infection, group Astreptococcal infection) or viral (e.g. infec-tious mononucleosis, mumps) in origin.In bacterial infection, the source is usuallytonsillar or dental, with tender nodes typically found in the submandibular orjugulodigastric region.

Mycobacterial lymphadenitis Mycobacterial lymphadenitis should besuspected if an acute lymphadenitis ismore indolent in its course, with only mild tenderness and a partial response toanti biotics. Infection with nontuberculous


Neck lumps

continued

Figure 2. Thyroglossal cyst. CT scan,

sagittal view, showing a thyroglossal cyst

extending inferiorly from just below the

hyoid in a 21-year-old man.

Figure 3. Branchial cyst presenting as a

mass in the upper neck anterior to the

sternocleidomastoid muscle in a 26-year-old

woman.


myco bacteria (atypical mycobacteria) most commonly affects children under the age of 5 years. Patients are normallywell, with a nontender neck mass and no systemic symptoms, although occa-sionally a discharging sinus will be pre-sent. The usual pathogen is an atypicalmyco bacterium such as Mycobacteriumavium-intracellulare.

Tuberculosis is more common in adultsthan children and should be considered ifthe nodes are bilateral or in the supraclav-icular region, and are associated with respiratory symptoms. Other rare granu-lomatous causes of adenopathy includecat scratch disease and actinomycosis.

HIV infection Cervical lymphadenopathy is very com-mon in patients with HIV infection. Lym-phadenopathy syndrome is a mild form of HIV disease that represents one of the initial stages of the infection. Patients canremain stable for months to years, with little in the way of symptoms. This diagno-sis should be considered in any adult withpersistent generalised lymphadenopathyand the relevant risk factors.

Acute sialadenitis Acute infection of the salivary glands can be bacterial or viral in origin. Bacterialsialadenitis occurs more frequently in the parotid glands, is more common in the elderly and is associated with reduced

salivary flow from dehydration or anti-cholinergic medication.

Treatment is with broad-spectrum anti -biotics covering S. aureus, the most com-mon pathogen causing infection of thesalivary glands, in addition to supportivemeasures (rehy dration, analgesics andgland massage to encourage salivary flow). Appropriate antibiotics include

flucloxacillin, cephalexin and clindamycin.Surgical drainage may be required if anabscess develops.

Viral sialadenitis is most commonlydue to the mumps virus, which typicallyaffects the parotid glands bilaterally. Themumps virus most often affects children,with peak incidence at ages 4 to 6 years.Other causes include coxsackievirus,cytomegalovirus and HIV.

Sialolithiasis Sialolithiasis refers to the presence of calculi in the parotid or submandibularducts. Patients present with swelling of the affected gland associated with eating or drinking (Figure 4). Initially, the swelling gradually resolves after the patient stops eating; however, withrepeated enlargement and inflammation,a permanently swollen gland can result(chronic obstructive sialadenitis).

In the acute noninflammatory stage,expulsion or direct removal of the cal -culus from the duct is often all that isrequired. In chronic sialolithiasis orchronic obstructive sialadenitis, salivarygland resection is often necessary.

Autoimmune sialadenitisSjögren’s syndrome, an auto immune disorder, presents with enlarged parotidglands associated with dry eyes and drymouth. An autoimmune screen showsraised antinuclear antibodies (anti-Ro and anti-La).

Diagnosis is usually based on historyand autoimmune serology. How ever,biopsy of a lower lip minor salivary glandis diagnostic (minor salivary glands aretiny submucosal glands that occurthrough out the oral cavity and upperaerodigestive tract).

SialadenosisSialadenosis refers to a non-neoplastic,noninflammatory asymptomatic swellingof the salivary glands. It is usually due to a systemic illness such as endocrine disease (e.g. diabetes, hypothyroidismand Cushing’s syndrome), a metabolicdisorder (e.g. obesity and cirrhosis),nutritional problems (e.g. vitamin defi-ciency and bulimia) or drug-inducedsialomegaly.

Thyroiditis The most common inflammatory goitre is Hashimoto’s thyroiditis. In this auto -immune condition, autoantibodies againstthyroid peroxidase are produced, result-ing in lymphocytic infiltration of the thyroid and eventually a goitre, which istypically firm and rubbery. Managementby an endo crinologist is usually necessarybecause of the initial hyperthyroidism andsubsequent hypothyroidism. Occasion-ally surgery is required for obstructivesymptoms.

Other inflammatory conditions of the thyroid include Riedel’s thyroiditis andDe Quervain’s thyroiditis.


Neck lumps

continued

Figure 4. Sialolithiasis. An enlarged sub -

mandibular gland resulting from calculus

obstruction of the submandibular duct.


Neoplastic lumps – benignA lower central neck lump in an adult islikely to originate from the thyroid gland.However, any structure in the neck canproduce a benign growth – these includediverse tumours such as lipomas, fibromas,haemangiomas and neuromas. Those thatare present in the skin or subcutaneous tissue (e.g. lipomas) are normally obviouson examination.

Thyroid nodules Thyroid nodules are palpable in 5% of the population and approximately 95%are benign. They include hyperplasic or colloid nodules found in multinodulargoitre, cysts and follicular adenomas.When thyroid nodules are detected, thechallenge facing the GP is to distinguishthose patients who have malignancy andtherefore require referral for surgicalmanagement from patients who havebenign nodules and can be followed upnon-operatively.

All patients with suspicious or domi-nant nodules should have thyroid func-tion tests and neck ultrasound, and FNABof the nodules.

Red flags that should alert the GP tothe possibility of a thyroid nodule beingmalignant include:

• male gender

• extremes of age (younger than 20 yearsor older than 65 years)

• exposure to ionising radiation,especially during childhood

• family history of thyroid cancer

• large solitary nodules

• hard nodules or with fixation toadjacent neck tissues

• symptoms of local invasion (neck pain,hoarseness or dysphagia)

• nodules that grow rapidly over weeksor months

• thyroid nodules associated withenlarged cervical neck nodes. Patients with suspicious or sympto-

matic thyroid nodules should be referredto a surgeon once appropriate investiga-tions have been arranged. Patients with

abnormal thyroid function tests and thy-roid nodules should be referred to anendocrinologist for further evaluation.

Salivary gland tumoursThe most common benign salivarytumour is a pleomorphic adenoma. Otherbenign tumours include Warthin’stumour, oncocytoma and monomorphicadenoma. Most salivary gland tumours(80%) occur in the parotid gland (Fig-ure 5). They less commonly originate inthe submandibular gland or minor sali-vary glands. They generally present asslow growing asymptomatic masses andfeel well-circumscribed and firm.

Treatment is surgical excision of theaffected gland in all cases except elderlypatients or those who are unfit for gen-eral anaesthesia.

Neural tumours Neurofibromas and schwannomas canarise from any nerve in the neck, mostcommonly from the vagus or sympatheticchain, and present as well-circumscribedfirm masses. Because of their neural origin,FNAB is often very painful.

Surgical resection often results in palsyof the affected nerve and hence observa-tion of small asymptomatic benign neural

tumours may be appropriate in selectedpatients.

Carotid body tumoursCarotid body tumours are rare benigntumours of the carotid body neural plexus.They usually present as a painless pulsatilemass at the level of the carotid bifurcation,and typically can be moved side to side butnot vertically.

The tumours are extremely vascular,and are diagnosed using a combination of CT scan, MRI, magnetic resonanceangiography and carotid doppler scan-ning. Following comprehensive assess-ment, surgery is usually performed by ahead and neck surgeon and a vascularsurgeon.

Neoplastic lumps – malignantSquamous cell carcinoma SCC is the most common cause of amalignant neck lump. Metastatic SCCmost commonly arises from the mucosaof the upper aerodigestive tract (oral cav-ity, nasopharynx, oropharynx and laryn-gopharynx). Cutaneous malignancies(SCC and melanoma) may also metasta-sise to the parotid gland or lateral cervicallymph nodes, sometimes years after theprimary tumour was excised.


Figure 6. Left-sided supraclavicular

lympha denopathy (Virchow’s node or

Troisier’s sign) in a patient with gastric

adenocarcinoma.

Figure 5. A parotid mass in an elderly man

who six months ago had a small cutaneous

squamous cell carcinoma (SCC) excised

from his left forehead. The parotid mass

turned out to be a metastatic SCC from his

previous skin cancer.


Nasopharyngeal carcinoma (NPC)should always be considered in adult Asianpatients presenting with a neck lumpbecause this is one of the most commoncancers in southern China and HongKong.

LymphomaLymphoma can present with a solitaryneck node but more commonly multiplelymph nodes are involved. The nodes aretypically ‘rubbery’ in consistency. Associ-ated symptoms include night sweats,lethargy and weight loss. Lymphoma is themost common cause of a malignant necklump in children and should therefore,despite being rare, be considered in thedifferential diagnosis of any progressive orpersistent childhood lymphadenopathy.

FNAB and CT scan are indicated, withreferral to a haematologist if cytology issuggestive of lymphoma.

Adenocarcinoma Metastatic adenocarcinoma to the uppercervical lymph nodes may originate fromthe salivary glands or sinonasal cavity.Metastatic adenocarcinoma in the lowerneck may arise from a site below the clavicles (e.g. lung, oesophagus or stom-ach). Virchow’s node (also referred to asTroisier’s sign) refers to metastatic adeno-carcinoma occurring in the left supraclav-icular fossa and usually arising from thestomach (Figure 6).

Thyroid cancerThyroid cancer appears to be increasingin incidence in Western countries. Themost common thyroid cancers are thewell-differentiated types papillary carci-noma (75%) and follicular carcinoma(15%), which have a more favourableprognosis than medullary carcinoma andundifferentiated types such as anaplasticcarcinoma.

Most thyroid cancers present clinicallywith a palpable thyroid nodule, which isoften asymptomatic. About half of thyroidcancers are initially noticed by the patient,

whereas the remainder are detected duringroutine physical examination, by chanceon imaging studies often for unrelatedmedical conditions or during surgery forbenign thyroid disease. Occasionally thy-roid cancer can present with a metastaticneck node, and the diagnosis is confirmedon FNAB.

When thyroid cancer is suspected ordemonstrated on FNAB, prompt referralto a thyroid surgeon is warranted. Totalthyroidectomy and adjuvant iodineablation therapy is indicated for mostpatients diagnosed with thyroid cancer.

Salivary gland malignancySalivary gland cancers include muco -epidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, adeno-carcinoma and metastatic cutaneous SCC.The most common malignant parotidlump in Australia is metastatic cutaneousSCC, reflecting the very high incidence offacial cutaneous cancers in this country.Symptoms and signs that suggest malig-nancy include pain, rapid growth, a hardmass, fixity to the skin or mandible andfacial nerve palsy.

FNAB and CT/MRI scanning areessential to assess the extent of disease andto plan surgery. High-grade salivary gland

malignancy often requires neck dissectionand postoperative radiotherapy.

ConclusionA wide variety of pathology can presentwith a neck lump. To determine whetherthe lump is benign or malignant, a com-prehensive history and clinical examina-tion are essential. If there is any doubt as to the diagnosis or if clinical assessmentsuggests a tumour, then prompt referralto a head and neck surgeon is importantto clarify the diagnosis and plan furthertreatment. The two most important inves-tigations that a GP can arrange prior toreferral are a neck soft tissue CT scan withcontrast and FNAB. MT


Neck lumps

continued

Further reading

Online CPD Journal Program

Lymphoma is a rare cause of neck lumps inchildren. True or false?

Review your knowledge of this topic andearn CPD/PDP points by taking part inMedicine Today’s Online CPD Journal Program.

Log on to www.medicinetoday.com.au/cpd

Bova R. A guide to salivary gland disorders.

Medicine Today 2006; 7(2): 44-48.

Bova R. Head and neck cancer: a guide to

diagnosis and an overview of management.

Medicine Today 2005; 6(4): 54-61.

Gleeson M, Herbert A, Richards A. Management

of lateral neck masses in adults. BMJ 2000; 320:

1521-1524.

COMPETING INTERESTS: None.


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