Neck Lump

Causes

• Inflammatory / Infectious

  • Reactive lymphadenopathy (viral, bacterial)

  • Abscess (e.g. bacterial lymphadenitis)

• Congenital / Developmental

  • Thyroglossal duct cyst (midline, may move with tongue protrusion)

  • Branchial cleft cyst (usually lateral)

  • Cystic hygroma (lymphangioma) in children

• Benign Tumours

  • Lipoma (soft, mobile)

  • Salivary gland adenomas (pleomorphic adenoma, Warthin’s tumour)

  • Dermoid cyst

• Malignant Tumours

  • Lymphoma (Hodgkin’s/non-Hodgkin’s)

  • Metastases from squamous cell carcinoma (oropharynx, nasopharynx, larynx), GI tract, or lung

  • Thyroid carcinoma (papillary, follicular, medullary)

  • Salivary gland malignancies (mucoepidermoid, acinic cell)

• Thyroid-Related

  • Goitre (multinodular or diffuse)

  • Thyroid nodules (benign or malignant)

Symptoms

• Neck swelling with or without pain, tenderness, or fluctuance

• Possible dysphagia, odynophagia, hoarseness (laryngeal involvement)

• Systemic features such as fever, night sweats, or weight loss (malignancy, lymphoma)

Red Flags

• Persistent lump >2 weeks

• Hoarseness, stridor, or voice changes

• Otalgia (referred pain from oropharyngeal lesions)

• Nasal obstruction or epistaxis (nasopharyngeal lesion)

• Weight loss or systemic “B” symptoms

• Dysphagia or odynophagia

• Rapidly enlarging or firm, fixed mass

• Age >40, smoking or heavy alcohol use, prior head/neck cancer

• Previous skin lesions on head/neck or suspicious pigmented lesions

Investigations

• Ultrasound Neck

  • First-line imaging to determine cystic vs solid nature

  • Guides further procedures (FNAC)

• FNAC (Fine-Needle Aspiration Cytology)

  • Useful for cytological diagnosis of suspicious lymph nodes or thyroid nodules

  • May need core biopsy if cytology is inconclusive

• Additional Imaging

  • CT or MRI to assess anatomical extent if malignancy or deep tissue involvement is suspected

• Blood Tests

  • Thyroid function tests (TSH, free T4) if thyroid origin suspected

  • Inflammatory markers if infection or lymphoma considered

• PET Scan

  • For metastatic disease of unknown primary or staging certain malignancies

Risk Factors for Malignancy

• Smoking and alcohol use

• Age over 40

• Exposure to HPV (especially oropharyngeal SCC)

• Family history of thyroid cancer or hereditary tumour syndromes

• Prior radiation exposure to head/neck region

Management

• Observation

  • For small, benign-appearing lumps with no red flags or normal ultrasound features

• Antibiotics

  • If bacterial lymphadenitis or suspicion of infection (fever, tenderness, erythema)

• Surgical Intervention

  • For suspicious, enlarging, or symptomatic lumps

  • Excision biopsy for definitive histopathological diagnosis if high suspicion of malignancy

  • Removal of benign masses if symptomatic (compression, cosmetic) or at patient request

• Specialist Referral

  • ENT, Head & Neck Surgery, or Oncology evaluation for lumps with concerning features (rapid growth, fixation, associated systemic symptoms)

  • Consider for thyroid nodules suspicious on ultrasound or cytology (Bethesda category)

  • Neck masses that persist >2–4 weeks despite antibiotics or with suspicious ultrasound findings

  • Enlarged salivary gland lumps needing parotidectomy or submandibular gland excision if indicated

Complications

• Local: Compression of airway, oesophagus, neurovascular structures

• Infection: Abscess formation

• Malignant Transformation: Benign lumps (rare) or discovering malignancy on histology

• Metastatic Spread: Especially in SCC or lymphoma if delayed diagnosis

Prognosis

• Depends on the underlying cause

• Benign lesions generally have favourable outcomes once removed or managed

• Malignancy prognosis improves with early detection, timely biopsy, and referral

• Early ENT evaluation is crucial for lumps with red flags to optimise outcomes

Notes:

• Thorough history (duration, progression, associated symptoms) and physical examination (palpate all cervical zones, check for fixation) are essential

• Ultrasound is the initial imaging of choice, guiding cytological assessment with FNAC

• Any suspicious features warrant prompt referral for specialist assessment, especially if lumps persist despite conservative treatment

• Consider a “2-week rule” for referral if significant risk factors or alarm features are present