NECK LUMP

an approach to diagnosis
Gatot Sugiharto, MD, Internist
Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma University
Surabaya
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An approach involves an understanding of 2
basic factors that in combination will allow a
diagnosis to be made.
Anatomy major structures of the neck and
lymph nodes
Pathophysiology that may arise in the above
structures
Introduction
Introduction
There are many causes of lumps in the neck.
The most frequently : enlarged lymph nodes,
(bacterial or viral infections), cancer (malignancy),
or other rare causes
Neck lumps in children and adults should be
checked immediately.
In children, most neck lumps are caused by
treatable infections.
As adults age, the likelihood of the lump being a
cancer increases

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ANATOMICAL STRUCTURES OF THE
NECK
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Major structures
Located largely in the anterior & posterior
triangles.
The anterior borders : inferior border of the
mandible, the sternocleidomastoid muscle and
the midline.
The posterior borders : sternocleidomastoid
muscle, the trapezius muscle and the clavicle.
The major structures
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Anterior triangles : hyoid bone, thyroid cartilage
(the Adams apple), cricothyroid membrane,
cricoid cartilage and trachea.
The isthmus of the thyroid gland : may be
palpated over the first 2 tracheal rings and its right
and left lobes lie over the cricoid and thyroid
cartilages laterally.
A normal thyroid gland (not easily palpable)
The carotid bulb
The parotid gland (not prominent on palpation)
The submandibular salivary glands (often
palpable in thin individuals)


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Lymph node levels of the neck
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Lymphadenopathy
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Inflammatory diseases usually resolves within
4 - 6 weeks, if persists > 6 weeks requires
further evaluation.
Other conditions that required further
evaluation :
>1.5 cm in diameter, firm, rubbery lymph nodes,
matted lymph nodes and nodes that are fixed or
have decreased mobility.
HISTORY
(1)
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A careful history can provide important clues to the
diagnosis
Duration of symptoms is one of the most important :
Inflammatory : usually acute in onset and resolve within several weeks.
Neoplasm : chronic process
Cervical lymphadenitis (most common cause of neck
mass) associated with upper respiratory tract infections
A history of coughs, fever, sore throat, recent travel,
dental problems, and insect bites should be sought.
Congenital neck masses : often present for an extended
duration, but not always, since birth. (branchial cysts in
young adults) .
HISTORY
(2)

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Rapid enlargement of lymph nodes :
May occur following an URI
Malignant/metastatic neck masses, as in cervical lymph nodes
Common origin : squamous cell carcinoma, > 80% are associated
with tobacco and alcohol.
Further features of malignancy : voice change, odynophagia,
dysphagia, haemoptysis and previous radiation, especially with thyroid
tumours.
Additional important features : oral lesions, recent trauma, referred ear
pain, muffled or decreased hearing and constitutional symptoms (e.g.
night sweats, anorexia, weight loss), unilateral nasal discharge or
epistaxis, family history of cancer and previous tumours.
EXAMINATION
(1)
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Examination should include the mass itself, the rest of the neck, the
skin of the head and neck and the ENT system (ears, oral cavity,
nasal cavity, nasopharynx, oropharynx, hypopharynx and the larynx).
In cases that is difficult to examine, patients should be referred to
specialist
The first question :
A lymph node or part of another neck structure ?
The size, consistency, tenderness and mobility of the mass
Acute inflammatory : tend to be soft, tender and mobile.
Chronic inflammatory : often non-tender and rubbery and either mobile or matted.
Congenital masses : usually soft, mobile and non-tender unless infected.
Vascular masses : may be pulsatile or have a bruit.
Malignant masses : may be hard, non tender and fixed
EXAMINATION
(1)

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The scalp and skin of the head and neck should be examined
for primary cutaneous tumours.
Recent bite marks/scratches : cat scratch disease.
The ear : serous otitis media associated with a
nasopharyngeal carcinoma or a fistula in the external auditory
canal associated with some branchial cleft abnormalities.
Cranial nerve examination is also necessary.
Nasal examination : a unilateral nasal mass or discharge
suspicious of a neoplasm.
The mucosa of the oral cavity/oropharynx , the lateral border
of the tongue, floor of mouth, soft palate/tonsil complex
majority of oral cancers arise from these areas.
Palpate the base of the tongue to exclude occult lesions.
EXAMINATION
(1)

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Tonsil :
A unilateral, asymmetrically enlarged tonsil may
suggest a neoplasm.
Pushed across towards the midline by a
parapharyngeal mass
Dentition : dental infection cause of cervical
lymphadenitis
The major structures and lymph node levels
(assisted by bimanual palpation)
A mass with swallowing movement : suggests a
lesion in the thyroid gland or a thyroglossal cyst

A midline neck mass, thyroglossal
cyst
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PATHOLOGY/AETIOLOGY/
DIFFERENTIAL DIAGNOSIS
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Is the mass single or multiple?
Is it in the anterior or posterior triangle?
Does it move with swallowing?
Is it solid, cystic or pulsatile?
Is it midline or lateral?
It is preferable to use a combination of an
anatomical and pathological approach in
diagnosis, always being guided by the history
and examination
Infectious/inflammatory vs neoplastic vs
congenital
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The most important distinction to make in an
adult is between an infectious/ inflammatory vs
a neoplastic cause.
In a child or young adult maintain a high index
of suspicion of a congenital cause.

Infectious/inflammatory masses
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Cervical lymphadenitis : most common in children and adolescents.
Viral and bacterial pharyngitis : acutely swollen and tender lymph nodes,
which usually return to normal within several weeks. The most common
organism is group A beta-haemolytic streptococcus.
Cervical adenitis : infectious mononucleosis (posterior triangle) of the neck
(level V), may persist for 4 6 weeks. (similar with CMV infection)
Mycobacterial infections : chronic, usually but not always, accompanied by
pulmonary pathology.
Generalised lymphadenopathy including cervical nodes : early stages of
HIV infection.
Salivary gland inflammation : acute sialadenitis caused by a calculus
obstructing the duct, tender, inflamed, swollen gland.
Acute parotitis due to mumps.
Chronic sialadenitis
Thyroiditis
Infective & inflammatory
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The most common cause is inflammatory/infective lymphadenopathy,
a result of self-limited bacterial or viral infection (resolves within
weeks)
Aetiologies:
Bacterial streptococcal and staphylococcal infections; mycobacterial infections,
tuberculosis and atypical mycobacteria; lymphadenitis secondary to dental infection
and tonsillitis;5 unusual disorders, cat-scratch disease, actinomyces, tularaemia
Viral Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus
(HSV), other viruses causing URTIs, HIV
Parasitic toxoplasmosis,
Fungal coccidiomycosis
Sialadenitis (parotid, submandibular and sublingual) due to
obstruction, e.g. calculus, or infections, e.g. mumps
Thyroiditis.
Other inflammatory conditions (e.g. sarcoidosis) and neck abscesses
are also common causes of neck masses.
Neoplastic masses
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Can arise from any of the tissues
Benign :
Lipoma : the most common
Parotid gland neoplasms, pleomorphic adenomas, neurinoma and
schwannoma.
Benign submandibular salivary gland neoplasms
Thyroid nodules
Malignant :
Malignant primary tumours : from the thyroid gland, salivary gland
and lymphoid tissue.
Metastatic neck masses : from squamous cell carcinoma of the
upper aerodigestive tract.
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Other masses
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Congenital masses : Branchial cleft cysts and fistulas,
thyroglossal duct cysts, dermoid cysts, lymphangiomas (cystic
hygromas) congenital torticollis, teratomas and thymic tumor
Vascular masses : paragangliomas and vascular
malformations (haemangioma, AV malformation, aneurysm)
Traumatic masses: haematoma, false aneurysm, AV fistula.
Thyroid gland masses : multinodular/difus goitre, colloid
goitre, thyroiditis,
Salivary gland masses : prominence with ageing,
sialadenitissialadenitis, sialolithiasis, salivary cysts (HIV) and
Sjgrens syndrome
Parapharyngeal masses : a high neck mass and a medially
displaced tonsil.
Cystic hygroma
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A lateral neck mass, branchial
cyst
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Algoritm
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INVESTIGATION
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Investigation is tailored to the clinical impression
In children, incisional or excisional biopsy is preferred to fine-needle
aspiration.
All thyroid and salivary gland masses need investigation as does
any mass persistent beyond 4 - 6 weeks
Blood investigations : often exclude metabolic and any other
uncommon causes of neck masses.
CT scanning : the best imaging technique for evaluating a neck
mass
Fine-needle aspiration : a simple office procedure that is safe and is
the optimal initial method for obtaining tissue samples for diagnostic
Incisional/excisional biopsy : rarely needed for diagnosis in adults,
but it is often necessary for the classification of lymphoma
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INDICATIONS FOR REFERRAL
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If the mass does not resolve within 2 - 3 weeks
following an antibiotic
Malignant tumour suspected
Mass is rapidly enlarging with or without
inflammation
Mass is in the thyroid gland
Mass is in the parotid gland
Fixed Mass
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