Neck lump

What should I ask about?

• Ask about the site of the lump, including its onset, growth, and changes (and the timescale of these), and any pain.
• Check for red flag symptoms that are suggestive of:
• Local malignancy (for example weight loss, difficulty swallowing or painful swallowing, persistent hoarseness, earache, or sore throat — particularly when unilateral).
• Haematological malignancy:
• Fatigue.
• Drenching night sweats.
• Fever.
• Weight loss.
• Generalized itching.
• Breathlessness.
• Bruising or bleeding.
• Recurrent infections.
• Bone pain, alcohol-induced pain, or abdominal pain.
• Lumps (lymphadenopathy) at sites other than the neck (for example the axillae).
• Consider other features in the history suggesting a cause:
• Combination of symptoms indicative of an upper respiratory tract infection causing lymphadenopathy — fever, cough, and sore throat.
• Recent travel, insect bites, or exposure to pets or other animals — suggestive of an inflammatory or infectious cause of neck mass.
• Smoking, heavy alcohol use, or previous radiation to the neck — increase the risk of malignancy.
• Trauma — may indicate haematoma, or if time has elapsed since the traumatic incident, fibrosis.
• Family history of an endocrine tumour — may be suggestive of multiple endocrine neoplasia (MEN) type 2 (thyroid, adrenal, and parathyroid disease).

What should I look for on examination?

• Look for signs of stridor or superior vena cava compression (swelling of the face and/or neck with fixed elevation of jugular venous pressure).
• Examine the neck.
• Look at the neck to identify visible masses and pulsation.
• Standing behind the person, palpate the different areas of the neck.
• Anterior triangle (borders: midline, anterior border of sternocleidomastoid muscle, and the body of the mandible).
• Posterior triangle (borders: posterior border of sternocleidomastoid muscle, trapezius, and the clavicle).
• Midline.
• If a neck lump is identified:
• Assess its size and mobility (whether it is fixed to underlying structures).
• Assess whether it is subcutaneous or part of the skin.
• Determine the characteristics of the lump, for example whether it is compressible (such as a branchial cyst) or pulsatile (suggesting a vascular cause).
• Ask the person to swallow and assess whether the lump moves (thyroid lumps and thyroglossal cysts move upwards on swallowing).
• Ask the person to protrude their tongue (thyroglossal cysts move superiorly).
• If it is a thyroid lump, determine whether it is nodular or diffuse.
• Also examine:
• The skin of the head and neck — for malignant or premalignant lesions (for example actinic keratoses).
• The ears — for infection (such as otitis externa).
• The nose — for malignancy.
• The tonsils and pharynx — infection may cause lymphadenopathy.
• The oral mucosa and tongue — for occult malignancy in the oral cavity (dentures may have to be removed). Use a tongue depressor to examine the lateral borders of the tongue.
• Specific areas where a suspected lymph node metastasis (a firm lump) may have originated.
• In general, if the suspected lymph node metastasis is in the upper or mid neck, the primary is likely to be a head and neck tumour (including thyroid).
• Lateral lymph nodes may be enlarged because of metastasis from squamous cell cancer of mouth, pharynx, and upper oesophagus.
• If the suspected lymph node metastasis is in the lower neck (supraclavicular lymph nodes), the primary may be from the thyroid, pyriform sinuses, upper oesophagus, or from below the clavicle (for example breast, lung, or intra-abdominal malignancy). An enlarged lymph node in the left supraclavicular fossa may indicate gastric cancer (Virchow lymph node).
• The abdomen for hepatosplenomegaly, and the axillae and groins for lymphadenopathy (if haematological malignancy is suspected).

What investigations should I request?

• If there are features of head and neck malignancy, do not delay referral by undertaking investigations in primary care.
• If glandular fever is suspected (typically fatigue, fever, lymphadenopathy, and sore throat in people younger than 40 years of age), consider a Monospot test during the second week of illness.
• If the person has unexplained lymphadenopathy, request a full blood count and blood film, and erythrocyte sedimentation rate, plasma viscosity, or C-reactive protein 
• If the person has unexplained cervical and/or supraclavicular lymphadenopathy or any of the following unexplained symptoms and signs for more than 3 weeks, urgently refer for chest radiography (the result should be available within 5 days):
• Chest and/or shoulder pain.
• Dyspnoea.
• Weight loss.
• Chest signs.
• Hoarseness.
• Finger clubbing.
• Cough, with or without any of the above.
• Features suggestive of metastasis from lung cancer (for example in the brain, bone, liver, or skin).
• If the person has a suspected thyroid lump and does not require immediate admission to hospital:
• Refer to a centre with a multidisciplinary thyroid team if possible.
• Consider doing thyroid function tests, but do not allow this to delay referral, particularly if the person has urgent referral criteria.
• Do not request further investigations, such as ultrasonography or isotope scanning, in primary care.

Basis for recommendation

Suspected malignancy

• The recommendation that investigations for suspected head and neck malignancy should be done in secondary care is extrapolated from guidelines on referral for suspected head and neck cancer from the National Institute for Health and Clinical Excellence. These state that, with the exception of persistent hoarseness, investigations for head and neck cancer in primary care are not recommended as they can delay referral [NICE, 2005a].

Glandular fever

• Monospot test (heterophile antibodies) — heterophile antibodies are present in approximately 90% of people older than 12 years of age who have glandular fever, and can be detected by the Monospot test [Johannsen et al, 2005].
• Blood should be taken in the second or third week of the illness, because false negatives are common if taken earlier. False-negative rates may be 25% in week 1 of the infection, decreasing to approximately 5% in week 3 [Ebell, 2004;Smellie et al, 2007].

Lymphadenopathy of unknown cause

• The recommendation on which investigations to request when infection has been excluded and the cause of the lymphadenopathy is unknown is based on referral guidelines for suspected haematological cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a].

Cervical or supraclavicular lymphadenopathy with chest signs

• The recommendation on referring for chest radiography when the person has unexplained cervical or supraclavicular lymphadenopathy for more than 3 weeks is based on a referral guideline for suspected lung cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a].

Thyroid lumps

• CKS identified conflicting recommendations based on expert opinion in referral guidelines for suspected cancer from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005a] and guidelines on the management of thyroid cancer from the British Thyroid Association (BTA) [BTA, 2007].
• NICE recommends only requesting thyroid function tests in primary care for people with a thyroid swelling without stridor or features requiring urgent referral.
• However, the BTA has subsequently recommended that, for people with a thyroid lump who do not need to be immediately admitted to hospital, thyroid function tests should be requested by the primary healthcare professional and the results included with the referral letter.
• CKS acknowledges that it may be beneficial to do thyroid function tests in primary care, because the results can guide to whom to make a referral and may be useful to the specialist. However, rapid access to secondary care is important when cancer is suspected, and requesting tests should not delay referral.
• NICE and the BTA do not recommend requesting other investigations (such as ultrasonography or isotope scanning) in primary care. This is on the basis of findings from non-randomized clinical trials and expert opinion that this is likely to cause unnecessarily delay in diagnosing cancer [NICE, 2005a; BTA, 2007].

How should I make a diagnosis?

• Use the findings from the history and examination to guide diagnosis. The position of the lump should help narrow down the list of likely causes.
• Midline — thyroid swellings (isthmus), thyroglossal cyst, laryngeal swellings, submental lymph nodes, dermoid cysts.
• Lateral (anterior triangle) — thyroid swellings (lobe), pharyngeal pouch, submandibular gland swelling, branchial cyst, lymph nodes, parotid swelling.
• Lateral (posterior triangle) — lymph nodes, carotid artery aneurysm, carotid body tumour, cervical rib.
• Age can also help to determine the likely cause of a neck lump.
• Children are most likely to have reactive lymphadenopathy of cervical nodes. Single masses are often due to a congenital cause or to inflammation. Malignancy is rare, with lymphomas, thyroid cancer, and soft tissue sarcomas being most likely.
• Adults — young adults will usually have an inflammatory, developmental, or congenital cause; malignancy is less common. The likelihood of malignancy increases with age, particularly in people 40 years of age or older.