A lump in the neck

Essentials

When assessing the aetiology, take into account possible symptoms of infection, the patient’s age and the location of the lump.
After acute infection, the lymph nodes in the neck often are bilaterally enlarged. This article deals with situations where the lump has not receded in 2 to 4 weeks or is not clearly associated with other local infection.
Also normal lymph nodes (< 1 cm) are often palpable. Even slightly lager symmetrically palpable lymph nodes at the mandibular angles are common and rarely require further investigations.

Infectious aetiology is common (reactive enlargement of the lymph nodes), see (Enlarged lymph nodes and other neck lumps in children).
Consider, among others, EBV infection (mononucleosis) and in unilateral, prolonged lymph node enlargement especially toxoplasma and tularaemia.
Symmetrically large lymph nodes at the mandibular angles are frequently encountered and do not usually warrant further investigations.
Cervical cysts often appear in adolescence or young adulthood, usually anterior to the sternocleidomastoid muscle (lateral cervical cyst) or at the hyoid bone (medial cervical cyst).
Lymphatic malformations are quite rare, and are felt as soft and dough-like changes. They also usually appear in adolescence or young adulthood; in rare cases, they may detected in a newborn.
Tumours are rare; malignant tumours more common than benign ones.

Inflammatory changes are similar to children and adolescents, but the proportion of tumours is higher.
Cervical cysts often do not appear before early adulthood.
The majority of tumours in the salivary and thyroid glands (Enlarged or nodular thyroid gland) are benign. The diagnosis is confirmed by surgery; imaging studies and cytology may provide hints.
The most common malignant tumours are lymphomas, followed in frequency by cancers of the thyroid or salivary glands, and occasionally, metastases of an epidermoid carcinoma of the head and neck.

A lump in the neck must always be suspected malignant; a considerable proportion of lumps located outside the region of the thyroid or salivary glands are malignant.
The most common malignancies are metastases from epidermoid (squamous cell) carcinomas, and lymphomas. An epidermoid carcinoma usually originates from the mucous membranes of the head and neck.
Other common malignancies in this region are carcinomas of the thyroid or salivary glands.
A lump in the supraclavicular fossa is usually a metastasis from a cancer in some other location.

All clearly abnormal lumps are referred for further investigations.
If the lumps are consistent with enlarged lymph nodes and they have appeared in association with an infection in the throat, they may be followed up for one month without further investigations.
In children and adolescents, lumps less than 2 cm in diameter may be followed up until they are clearly reduced in size or have disappeared.
The location of a lump or an enlarged lymph node has an essential role when considering the probability of different diagnostic options.

Palpation of the neck and face (including bimanual palpation of the floor of the mouth)
Otorhinolaryngological examination
If the patient has multiple local lumps, examine other lymph node regions (supraclavicular fossae, armpits, groins, and spleen).

Ultrasonography + fine-needle biopsy
- Fine needle biopsy is only suggestive; false negative results are common (patient may have cancer although the finding on fine needle biopsy would be benign).
- A patient with a clinically suspicious finding must be referred for further investigations despite the result of the fine needle biopsy.
Do not perform open biopsy or simple lumpectomy, because a more extensive operation is often indicated already in the primary phase.
Other imaging studies are performed as needed first after the examination by a specialist.