Head and Neck A7


Investigating a neck lump

Asymmetric neck mass in an adult must be considered malignant until proven otherwise. When you encounter a neck lump in the clinic, you must ask yourself two questions:

  1. Is the lump malignant?
  2. What is the lump?

Head and neck malignancy risk factors include:

  • Age
  • Smoking & Alcohol history
  • Chinese ethnicity (nasopharyngeal) 
  • EBV (nasopharyngeal) and HPV (oropharyngeal) infection
  • Betel nut

Location of the neck lump provides an important clue for what the lump could be:

  • Anywhere in the neck:
    • Lymph node
    • Lipoma
    • Sebaceous cyst
  • Anterior triangle:
    • Branchial cyst
    • Paraganglioma
    • Salivary gland pathology (obstruction, infection, neoplastic)
    • Thyroid pathology (neoplastic, goitre)
  • Posterior triangle:
    • Cystic hygroma
    • Supraclavicular lymphadenopathy (breast, GI, lung)
  • Midline:
    • Thyroglossal cyst

ENT surgeons use a concept of a neck level to further divide the neck into specific regions.

Red flag symptoms for head and neck cancer include:

  • Hoarse voice
  • Dysphagia
  • Odynophagia
  • Pain in the mouth or throat
  • Haemoptysis
  • Blocked nose
  • Epistaxis
  • Facial pain
  • Unilateral otalgia
  • Unilateral hearing loss
  • Systemic symptoms such as weight loss, loss of appetite, or malaise

The lump size, consistency and mobility provide clues to what the lump could be:

  • Hard and fixed: likely squamous cell carcinoma
  • Soft and rubbery: lymphoma
  • Warm and tender: infective
  • Pulsatile: vascular tumour (carotid body tumour)

Adults presenting with a neck lump warrant a full ENT examination that consists of ear examination, oral cavity examination, neck examination, and an examination of the nasal cavity, post nasal space and the larynx with a flexible nasoendoscope.

When to consider referral:

  • Cervical lymphadenopathy >2 cm persisting for a period of >6 weeks with no obvious infective cause
  • Progressively worsening lymphadenopathy without any cause
  • Cervical lymphadenopathy with red flag symptoms for head and neck cancer

Ultrasound is the imaging modality of choice for a neck lump. During examination, if the lump looks suspicious, an ultrasound guided biopsy (either fine needle aspiration or a core biopsy) can be performed to obtain a tissue sample for analysis.

Correct Answer: