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:
- Is the lump malignant?
- What is the lump?
Head and neck malignancy risk factors include:
- 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
- Sebaceous cyst
- Anterior triangle:
- Branchial cyst
- Salivary gland pathology (obstruction, infection, neoplastic)
- Thyroid pathology (neoplastic, goitre)
- Posterior triangle:
- Cystic hygroma
- Supraclavicular lymphadenopathy (breast, GI, lung)
- 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
- Pain in the mouth or throat
- Blocked nose
- 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.