Neck Lump

Adult Neck Lump.png


Red Flags requiring immediate ENT referral:

  • Respiratory distress / stridor

  • Superior vena cava obstruction

  • Complete dysphagia +/- aspiration


Assessment

History

  • Duration

  • Bilateral or unilateral

  • Pain

  • Skin Change

  • Trigger (recent URTI or trauma)

  • Swallowing (dysphagia)

  • Voice change (hoarseness)

  • Recent treatment

  • Malignancy red flags (Weight loss, night sweats, haemoptysis, referred ear pain)

  • Social history (smoking, alcohol)

Examination

  • Mouth: mouth opening (inability to open mouth is trismus), tonsils (erythematous with exudate - tonsillitis, ulcer - malignancy), posterior pharyngeal  wall (erythematous or swollen – URTI), dentition

  • Ears: Discharge (otorrhoea – otitis externa), bulging injected tympanic membrane (acute otitis media)

  • Neck: movement (inability to move neck is torticollis), lymphadenopathy or masses (size, tenderness, mobility, firmness, smoothness), skin changes

  • Axilla: Examine to exclude widespread lymphadenopathy as seen in systemic illness (eg Lymphoma)

Investigations

  • Generalised lymphadenopathy – Urgent FBC to rule out leukaemia (NICE)

  • 40 Years + supraclavicular or persistent lymphadenopathy - Urgent CXR

 

Differential Diagnosis

Head and Neck Malignancy

Adults with non resolving lymphadenopathy should be suspected to have a head and neck malignancy most commonly an SCC. Therefore a full ENT examination should be performed for any patient with lymphadenopathy. These patients need to be referred to ENT or Maxillofacial teams as a 2 week wait.

Thyroid cancer or nodules can present as a anterior neck lump. These patients need screening thyroid and parathyroid function blood tests and referred as a 2 week wait to a head and neck clinic.

Benign Causes

Cyst, lipoma, reactive lymphadenopathy, haematoma secondary to trauma and thyroglossal duct cyst.

 

Red flags for malignancy

  • Weight loss

  • Night sweats

  • Generalised lymphadenopathy

  • Enlarging mass

  • Supraclavicular mass

  • Hard, irregular, fixed mass

  • History of malignancy

 

Referral Pathways 

Same day

  • Respiratory distress / stridor

  • Superior vena cava obstruction

  • Complete dysphagia +/- aspiration

Cancer-wait referral

  • Adult with non-resolving lymphadenopathy

Routine referral

  • A child with a thyroglossal duct cyst, dermoid, branchial cyst and no red flag symptoms

  

More information

https://cks.nice.org.uk/neck-lump#!scenario:1

https://cks.nice.org.uk/head-and-neck-cancers-recognition-and-referral#!scenario

 

Author: Elliot Heward ENT Registrar North West Deanery