Neck lumps are a relatively common presentation, particularly in primary care and exams. Being able to identify and manage the different causes is helpful.
Basic Anatomy
There are three descriptions to note the location of a neck lump:
- Anterior triangle
- Posterior triangle
- Midline (vertically along the centre of the neck)
These two triangles are on either side of the sternocleidomastoid muscle.
The borders of the anterior triangle are:
- Mandible forms the superior border
- Midline of the neck forms the medial border
- Sternocleidomastoid forms the lateral border
The borders of the posterior triangle are:
- Clavicle forms the inferior border
- Trapezius forms the posterior border
- Sternocleidomastoid forms the lateral border
Differential Diagnosis
In adults
- Normal structures (e.g., bony prominence)
- Skin abscess
- Lymphadenopathy (enlarged lymph nodes)
- Tumour (e.g., squamous cell carcinoma or sarcoma)
- Lipoma
- Goitre (swollen thyroid gland) or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma (a collection of blood after trauma)
- Thyroglossal cysts
- Branchial cysts
Neck lumps in young children may also be caused by:
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
TOM TIP: It is not uncommon for patients to present worried about a normal bony prominence in the neck. Common areas of concern are the hyoid bone, mastoid process and transverse processes of C1.
History
The purpose of taking a history is to gain:
- General information about the symptoms (e.g., when the lump first appeared and how quickly it has grown)
- Features that suggest or exclude a particular diagnosis (e.g., night sweats indicating lymphoma)
- Risk factors for that condition (e.g., family history, age and smoking status)
- General fitness for further investigations and treatment (e.g., co-morbidities and medications such as anticoagulants)
Examination
When examining a neck lump, the things to establish are:
- Location (anterior triangle, posterior triangle or midline)
- Size
- Shape (oval, round or irregular)
- Consistency (hard, soft or rubbery)
- Mobile or tethered to the skin or underlying tissues
- Skin changes (erythema, tethering or ulceration)
- Warmth (e.g., infection)
- Tenderness (e.g., infection)
- Pulsatile (e.g., carotid body tumours)
- Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
- Transilluminates with light (e.g., cystic hygroma – usually in young children)
A general examination can be used to look for signs of the underlying cause, such as:
- Ear, nose and throat infections (e.g., reactive lymph nodes)
- Weight loss (e.g., malignancy or hyperthyroidism)
- Skin pallor and bruising (e.g., leukaemia)
- Focal chest sounds (e.g., lung cancer)
- Clubbing (e.g., lung cancer)
- Hepatosplenomegaly (e.g., leukaemia)
Neck Lump Red-Flag Referral Criteria
The NICE guidelines on suspected cancer (updated January 2021) suggest a referral for two week wait referral for:
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
TOM TIP: Patients presenting to primary care with symptoms and signs that are suspicious of cancer require either urgent direct-access investigations or a two week wait referral. The NICE guidelines on “suspected cancer: recognition and referral” set out their recommendations by either the site or the symptom, making it really easy to quickly look up the referral criteria. There is also a section for non-specific symptoms, such as unexplained weight loss, appetite loss and deep vein thrombosis.
Investigations
Blood tests may be helpful depending on the suspected cause of the neck lumps. Not everyone with a neck lump will require blood tests. The choice of test will depend on the suspected cause:
- FBC and blood film for leukaemia and infection
- HIV test
- Monospot test or EBV antibodies for infectious mononucleosis
- Thyroid function tests for goitre or thyroid nodules
- Antinuclear antibodies for systemic lupus erythematosus
- Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
Imaging may involve:
- Ultrasound is often the first-line investigation for neck lumps
- CT or MRI scans
- Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)
Biopsy may be required to gain a tissue sample (histology) to establish the exact cause. This may be with:
- Fine needle aspiration cytology – aspirating cells from the lump using a needle
- Core biopsy – taking a sample of tissue with a thicker needle
- Incision biopsy – cutting out a tissue sample with a scalpel
- Removal of the lump – the entire lump can be removed and examined
Lymphadenopathy
Lymphadenopathy refers to enlarged lymph nodes. There are a long list of causes of enlarged lymph nodes, which can be generally grouped into:
- Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis)
- Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis)
- Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis)
- Malignancy (e.g., lymphoma, leukaemia or metastasis)
Enlarged supraclavicular nodes are the most concerning for malignancy of the cervical lymph nodes. They may be caused by malignancy in the chest or abdomen and require further investigation.
Features that suggest malignancy are:
- Unexplained (e.g., not associated with an infection)
- Persistently enlarged (particularly over 3cm in diameter)
- Abnormal shape (normally oval shaped where the length is more than double the width)
- Hard or “rubbery”
- Non-tender
- Tethered or fixed to the skin or underlying tissues
- Associated symptoms, such as night sweats, weight loss, fatigue or fevers
Infectious Mononucleosis
Infectious mononucleosis is a cause of lymphadenopathy. It is caused by infection with the Epstein Barr virus (EBV) and most often affects teenagers and young adults. It is found in the saliva of infected individuals and may be spread by kissing or sharing cups, toothbrushes and other equipment that transmits saliva.
It presents with
- Fever
- Sore throat
- Fatigue
- Lymphadenopathy
Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.
The first-line investigation is the Monospot test. It is also possible to test for IgM (acute infection) and IgG (immunity) to the Epstein Barr virus.
Management is supportive. Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).
Lymphoma
Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy).
There are two categories of lymphoma: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Hodgkin’s lymphoma is a specific disease and non-Hodgkins lymphoma encompasses all the other lymphomas. Hodgkin’s lymphoma is the most likely specific type of lymphoma to appear in your exams.
Overall, 1 in 5 lymphomas are Hodgkin’s lymphoma. It is caused by proliferation of lymphocytes. There is a bimodal age distribution with peaks around aged 20 and 75 years.
Lymphadenopathy is the key presenting symptom. The enlarged lymph node or nodes might be in the neck, axilla (armpit) or inguinal (groin) region. They are characteristically non-tender and feel “rubbery”. Some patients will experience pain in the lymph nodes when they drink alcohol.
B symptoms are the systemic symptoms of lymphoma:
- Fever
- Weight loss
- Night sweats
The Reed-Sternberg cell is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma.
The Ann Arbor staging system is used for both Hodgkins and non-Hodgkins lymphoma.
Leukaemia
Leukaemia is the name for cancer of a particular line of the stem cells in the bone marrow. This causes the unregulated production of certain types of blood cells. They can be classified depending on how rapidly they progress (chronic is slow and acute is fast) and the cell line that is affected (myeloid or lymphoid) to make four main types:
- Acute myeloid leukaemia
- Acute lymphoblastic leukaemia
- Chronic myeloid leukaemia
- Chronic lymphocytic leukaemia
The presentation of leukaemia is quite non-specific. If leukaemia appears on your list of differentials then get an urgent full blood count. Some typical features are:
- Fatigue
- Fever
- Pallor due to anaemia
- Petechiae and abnormal bruising due to thrombocytopenia
- Abnormal bleeding
- Lymphadenopathy
- Hepatosplenomegaly
Thyroid Pathology
A goitre refers to generalised swelling of the thyroid gland. A goitre can be caused by:
- Graves disease (hyperthyroidism)
- Toxic multinodular goitre (hyperthyroidism)
- Hashimoto’s thyroiditis (hypothyroidism)
- Iodine deficiency
- Lithium
Individual lumps can occur in the thyroid due to:
- Benign hyperplastic nodules
- Thyroid cysts
- Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
- Thyroid cancer (papillary or follicular)
- Parathyroid tumour
Salivary Gland Pathology
The three salivary gland locations are the:
- Parotid glands
- Submandibular glands
- Sublingual glands
These can enlarge for three main reasons:
- Stones blocking the drainage of the glands through the ducts (sialolithiasis)
- Infection
- Tumours (benign or malignant)
Carotid Body Tumours
The carotid body is a structure located just above the carotid bifurcation (where the common carotid splits into the internal and external carotids). It contains glomus cells, which are chemoreceptors that detect the blood’s oxygen, carbon dioxide, and pH. Groups of these glomus cells are called paraganglia.
Carotid body tumours are formed by excessive growth of the glomus cells. They are also called paragangliomas. Most are benign. They present with a slow-growing lump that is:
- In the upper anterior triangle of the neck (near the angle of the mandible)
- Painless
- Pulsatile
- Associated with a bruit on auscultation
- Mobile side-to-side but not up and down
Carotid body tumours may compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves. Pressure on the sympathetic nerves may result in Horner syndrome, with a triad of:
- Ptosis
- Miosis
- Anhidrosis (loss of sweating)
A characteristic finding on imaging investigations is splaying (separating) of the internal and external carotid arteries (lyre sign).
They are mostly treated with surgical removal.
Lipoma
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue.
On examination, lipomas are typically:
- Soft
- Painless
- Mobile
- Do not cause skin changes
They are typically treated conservatively with reassurance (after excluding other pathology). Alternatively, they can be surgically removed.
Thyroglossal Cyst
During fetal development, the thyroid gland starts at the base of the tongue. From here, it gradually travels down the neck to the final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears. When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst. This is called a thyroglossal cyst.
Ectopic thyroid tissue is a key differential diagnosis, as this commonly occurs at a similar location.
Thyroglossal cysts occur in the midline of the neck. They are:
- Mobile
- Non-tender
- Soft
- Fluctuant
Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue.
Ultrasound or CT scan can confirm the diagnosis.
Thyroglossal cysts are usually surgically removed to provide confirmation of the diagnosis on histology and prevent infections. The cyst can reoccur after surgery unless the entire thyroglossal duct is removed.
The main complication is infection of the cyst, causing a hot, tender and painful lump.
TOM TIP: Remember the key feature of thyroglossal cysts moving with movement of the tongue. This is a unique fact that examiners like to use to test your knowledge. Look out for a thyroglossal cyst as a differential of a neck lump in your MCQ exam. If you come across a midline neck lump in a child in your OSCEs, ask them to stick their tongue out and look for the lump moving upwards.
Branchial Cyst
A branchial cyst is a congenital abnormality that arises when the second branchial cleft fails to form properly during fetal development. This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This space can fill with fluid. This fluid-filled lump is called a branchial cyst. Branchial cysts arising from the first, third and fourth branchial clefts are possible, although they are much rarer.
Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.
Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected.
Management of a branchial cyst is either:
- Conservative, without any active intervention, where it is not causing problems
- Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems
TOM TIP: Branchial cysts may appear in exams as a differential of neck lumps in teenagers or as part of a neck examination in an OSCE. Remembering the key features will help you differentiate them in your exams. They are just anterior to the sternocleidomastoid muscle, round, soft and non-tender. They might ask you where it was most likely to originate, and the answer would be the second branchial cleft.
Last updated July 2021