🩺 Neck Lump

Neck lumps are frequently encountered in both primary and secondary care. They may be congenital, inflammatory, or neoplastic. In children and young adults, inflammatory lymphadenopathy is the most common cause, whereas in older adults, the suspicion of malignancy—either primary (lymphoma, thyroid) or metastatic (Head and Neck squamous cell carcinoma)—is significantly higher. Management involves a systematic approach to rule out cancer, often utilizing the 'one-stop' neck lump clinic model for rapid diagnosis via ultrasound and cytology.

Establish the duration and growth rate of the lump. Persistent lumps (>3 weeks) in patients over 40 are suspicious. Ask about 'B' symptoms (fever, night sweats, weight loss) which suggest lymphoma. Inquire about risk factors for Head and Neck squamous cell carcinoma, specifically smoking and alcohol intake. Associated symptoms like dysphagia, hoarseness (recurrent laryngeal nerve involvement), or referred otalgia are significant. In children, focus on infectious triggers (sore throats, dental issues).

Inspect the neck for symmetry and visible masses. Palpate from behind the patient, systematically checking all lymph node levels (I-VI). Note the size, consistency (hard/fixed vs. soft/mobile), and tenderness of the lump. Ask the patient to swallow and to protrude their tongue to observe movement. Perform a full ENT examination including the oropharynx and a scalp check for skin cancers. Palpate the thyroid and look for signs of hyper/hypothyroidism.

Lymphadenopathy (Reactive, Lymphoma, Metastatic), Thyroid nodules/Goitre, Salivary gland tumours (e.g., Parotid), Branchial cyst, Thyroglossal cyst, Carotid body tumour, and Cystic hygroma.

Fixed/hard consistency, size >2cm, persistent for >3 weeks, supraclavicular location, associated hoarseness or dysphagia, and systemic 'B' symptoms (weight loss, sweats).

First-line imaging for most neck lumps is an Ultrasound scan (USS), often combined with Fine Needle Aspiration (FNA) or Core Biopsy if suspicious features are present. Blood tests include FBC, ESR/CRP, TFTs, and Monospot test (if glandular fever suspected). A Chest X-ray may be used to look for primary lung malignancy or sarcoidosis. CT or MRI of the neck/base of skull is usually reserved for staging known malignancies in secondary care.

The 'rule of 80s': in adults, roughly 80% of non-thyroid neck lumps are neoplastic, and of those, 80% are malignant (often metastatic). A midline lump that moves upwards on tongue protrusion is classic for a thyroglossal cyst. A lump lateral to the midline that moves with swallowing is likely thyroid in origin. Supraclavicular nodes (Virchow's node) are highly suggestive of sub-diaphragmatic malignancy.

Mapped to 'Neck Lump' and 'Head and Neck Cancer'. Critical knowledge includes the 2-week wait (2WW) referral criteria for unexplained persistent neck lumps in adults. Understand the anatomy of the anterior and posterior triangles.