A neck lump is the commonest presentation of any surgical disease arising from the neck. The commonest cause of a lump in the neck is lymphadenopathy which may be due to a simple self limiting infection or a highly malignant cancer. Accurate history and examination are vital to identify the most likely cause of the lump and to decide who needs further investigation.
The neck is divided into two triangles – the anterior triangle and the posterior triangle. The anterior triangle has an:
Anterior boundary: Formed by the median line of the neck.
Posterior booundary: Formed by the anterior boundary of the SCM.
Superior boundary: Formed by the inferior border of the mandible.
The posterior triangle is bound by the posterior edge of the sternocleidomastoid muscle, the clavicle and the anterior edge of the trapezius muscle.
Explain, Consent, Expose
LOOK from the front and the sides for symmetry, any visible lumps or change in contour of the neck and any skin changes.
FEEL from behind the patient. Palpate the midline, the anterior triangle, the posterior triangle and the lymph node areas for any swellings.
DESCRIBE any swellings felt:
- Surface (Smooth or Nodular?)
- Mobility (Tethered?)
If the swelling is in the midline – ask the patient to swallow and stick out their tongue to examine for a thyroid swelling or a thyroglossal cyst respectively.
THINKING GOITRE??? Percuss for retrosternal extension; Auscultate for bruit; Pemberton's test of superior vena cava obstruction.
EXTRAS: Look in the oral cavity and at the throat and ears; check for tracheal position.
Causes of a neck lump
If the neck lump has been present for less than 3 weeks and is in the distribution of the lymph node groups it is most likely to be benignself limiting lymphadenopathy secondary to infection, commonly tonsillitis or pharyngitis.
Although most commonly the lymphadenopathy will be infective, it is important to consider invasive lymphadenopathy due to primary or secondary malignancy. There are features of the lymphadenopathy itself which help distinguish the two, but it is also important to enquire about the constitutional symptoms mentioned above which could alert you towards a potentially malignant cause.
Infective vs Invasive lymphadenopathy
A lump related to the skin is most likely to be a sebaceous cyst or a lipoma.
Lumps in the midline
If a swelling or lump is felt in the midline of the neck it is important to ascertain if it is related to the thyroid gland or not. The isthmus of the thyroid gland overlies the trachea just below the cricoid cartilage and the lobes form a butterfly shape around the trachea.
Below if an algorithm to determine the likely pathology causing a swelling in the midline of the neck:
A goitre is an enlarged thyroid gland. The enlargement may be diffuse or multi-nodular, or the gland could contain a solitary nodule. Thyroid status should be examined if a thyroid swelling is felt to determine the gland’s activity and to aid diagnosis. Diffuse goitres occur in Grave’s disease; a very hard consistency suggests malignant change within the gland; tenderness suggests thyroiditis.
Lumps in the anterior triangle
- Salivary gland pathology (stone, tumour, infection)
- Branchial cyst
- Parotid gland swelling (mumps, parotiditis, tumour, stones, autoimmune)
- Carotid body tumour/ Carotid aneurysm
Lumps in the posterior triangle
- Cervical rib
- Pharyngeal pouch
- Cystic hygroma (usually on the left)
If there are features of head or neck malignancy do not hesitate in referral to secondary care.
For unexplained lymphadenopathy:
- FBC, ESR, CRP
- Chest X-Ray
- Fine needle aspiration
For a thyroid swelling:
- Ultrasound scan
- Isotope scanning
For other neck lumps:
- Ultrasound scan can show consistency
- Fine needle aspiration
Browse’s introduction to the signs and symptoms of surgical disease. 4th Edition.
Macleod’s clinical examination. 12th Edition
Oxford handbook of clinical medicine. 7th Edition.