a diagnostic guide for general practitioners

neck lumps
a diagnostic guide for
general practitioners
Professor Christopher J O’Brien MS FRACS
The Sydney Head & Neck Cancer Institute
Sydney Cancer Centre
Royal Prince Alfred Hospital
University of Sydney

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introduction
The purpose of this booklet is to provide information to the General Practitioner about
common neck lumps, their clinical features and how they should be investigated.
Lumps and swellings in the neck are seen frequently in general practice and often it is
easy to make a diagnosis based on clinical examination alone. Commonly however,
investigations are required to clarify the diagnosis and, in particular, exclude or confirm
a diagnosis of malignancy. The most important issue is that the possibility of a
malignant diagnosis is not overlooked and that the pathway of diagnosis and referral
of patients with cancer in the neck is appropriate.
Neck lumps in children are common but rarely malignant, frequently representing
reactive lymph node enlargement. In adults on the other hand benign reactive lymph
node enlargement is uncommon and the following rule should apply.
An adult with a lump in the lateral neck
has cancer until proved otherwise.
Adults with lateral neck lumps should be investigated therefore to exclude malignancy
– they should not be subjected to lengthy trials of observation or antibiotic therapy. A
diagnosis can be readily made in the vast majority of cases when the following are
used judiciously:
1. Thorough clinical history
2. Physical examination
3. Fine needle aspiration biopsy (FNAB)
4. CT Scan
When a diagnosis of cancer in the neck is made, the patient
should be referred to a head and neck surgeon or oncologist
who participates in a multi-disciplinary clinic.
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neck lumps: a diagnostic guide for practitioners
lateral neck swellings
History and physical examination are fundamental to making an early and correct
diagnosis. The age of the patient, the length of time the swelling has been present
and its position in the neck are all helpful. Children commonly present with a short
history of tender, enlarged lymph nodes in the jugulodigastric area (tonsillar lymph
node) suggesting an infective process, or multiple small non-tender nodes in the
posterior triangle, suggesting a subclinical viral infection. Cystic swellings are usually
congenital and can be due to lymphangioma (cystic hygroma) or haemangioma.
Localised swellings in the thyroid gland or parotid in children are uncommon but
malignancy needs to be excluded.
Adolescents also often develop acute inflammatory lymphadenopathy, particular in
the jugulodigastric region and this can be bacterial or viral (e.g. glandular fever).
Adolescents can develop lymphoma, particularly Hodgkin’s Disease, and prominent
lymph nodes which are non-tender and progressively enlarging should be treated
with suspicion. Branchial cysts are seen mainly in young adults, presenting in the
jugulodigastric region. They are not developmental but are probably due to epithelial
cell “rests” in a lymph node.
The diagrammatic
representation on
the right
demonstrates the
distribution of the
lymph nodes in
the neck along
with the main
muscular anatomy.
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lateral neck swellings
Multiple small nodes, commonly occurring in the posterior triangle, again tend to be
due to subclinical viral infections.
Clinical evaluation of adults with lateral neck lumps
is aimed at excluding cancer.
Middle-aged adults who smoke and drink are at high risk of having mucosal cancers
of the oral cavity, oropharynx or laryngopharyngeal region. Associated symptoms like
referred ear pain, voice change, dysphagia or weight loss should be sought.
Always ask for a history of a previously treated cancer of the skin, lip, oral cavity and
other mucosal sites.
Asian patients with enlarged neck nodes will frequently have either nasopharyngeal
cancer or tuberculosis.
Elderly patients, especially those with fair skin, may have a history of previous skin cancer
and a lump in the neck, especially in the submandibular region, the upper neck or tail
of parotid that may represent metastatic skin cancer, especially SCC or melanoma.
This 19 year old girl had a two-week history
of a painless swelling in the left
jugulodigastric region. FNAB demonstrated
benign squamous cells, cellular debris and
cholesterol crystals. CT scan demonstrated
a well circumscribed cystic mass, anterior
to the sternomastoid muscle. This is a
typical branchial cyst.
This young woman had a one-week history
of a rapidly enlarging mass in the upper
right neck with localised tenderness. The
CT scan again demonstrates a well-
circumscribed unilocular cyst, with a
smooth wall -branchial cyst.
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neck lumps: a diagnostic guide for practitioners
This young man has a prominent painless lymph node
in the jugulodigastric region. Fine needle aspiration
biopsy indicated a diagnosis of Hodgkin’s Disease.
The 40 year old man (inset) has a lump in an identical
position, also painless and present for months. Fine
needle aspiration biopsy confirmed the diagnosis of
metastatic squamous cell carcinoma from a
tonsil cancer. He was a non smoker.
NOT ALL CYSTIC MASSES IN THE NECK ARE
BENIGN. The man on the right is 60, a heavy smoker
and presents with a hoarse voice and large mass in
the right upper neck. Fine needle aspiration biopsy
showed necrotic debris and the CT scan demonstrates
a unilocular cystic mass. The cyst wall is irregular and
this is metastatic squamous carcinoma, which
has undergone cystic degeneration. The primary
cancer was in the hypopharynx.
This man has nasopharyngeal carcinoma with
multiple metastatic lymph nodes in the posterior
triangle, bounded by the clavicle below,
sternomastoid muscle anteriorly and the trapezius
posteriorly. Nasopharyngeal carcinoma is really the
only mucosal cancer which can spread to the
posterior triangle, without nodes elsewhere in the
neck. Metastatic skin cancer and lymphoma
could also present with this distribution of nodes.
Beware of cystic lateral neck masses in adults.
They may be metastatic SCC with cystic degeneration.
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anterior neck swellings
Lumps in the anterior neck compartment can occur in the submental region (below
the chin) or the upper or lower anterior neck. Lumps in the submental triangle are
usually enlarged lymph nodes and may be reactive or neoplastic.
In young adults Hodgkin’s Disease needs to be excluded while in older adults
metastatic cancer, particularly from cancers of the lip or from an asymptomatic
floor of mouth cancer should be considered.
Swellings around the hyoid bone are most likely to represent a thyroglossal duct
remnant. About 80% of these lie below the level of the hyoid bone and an important
clinical feature is that theyelevate with protrusion of the tongue. Dermoid cysts can
also occur in the midline, anywhere from the chin to the jugular notch. These are
congenital, benign and usually contain thick white paste-like material.
The commonest swellings in the central compartment of the neck involve the thyroid
gland. These are rarely in the midline unless the nodule occupies the isthmus or
pyraminal lobe and so they tend to sit to one side of the midline.
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neck lumps: a diagnostic guide for practitioners
The important clinical feature of a thyroid nodule is that the lump elevates with
swallowing. When there are multiple thyroid lumps (multinodular goitre) the risk of
malignancy is low, about 5%, however the incidence of malignancy is higher in a
solitary thyroid lump, especially when larger than 4cm and in men.
Solitary or dominant thyroid nodules should be investigated
by FNAB and serum TSH. Ultrasound and nuclear scanning
contribute little to excluding malignancy.
The young man on the right had a firm, but not hard
submandibular swelling which had been present for
5 years. The CT scan on the right demonstrates a
midline dermoid cyst. This is a well localised benign
congenital lesion.
This young woman, aged 25, has a well localised
swelling just below the hyoid bone, which elevates on
protrusion of the tongue. The CT scan on the right is
from another patient but demonstrates identical
pathology of a well circumscribed cystic structure lying
anterior to the thyroid cartilage - thyroglossal cyst.
This young woman has a prominent right thyroid
nodule. The appropriate investigations are FNAB and
serum TSH.
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submandibular region
The main anatomical structures in the submandibular triangle are the submandibular
salivary gland and the submandibular lymph nodes, which lie anterior and posterior to
the facial vessels (so called pre-vascular and post-vascular nodes).
These nodes are a common site of reactive enlargement in children and adolescents
but they may also be a site of metastatic disease from cancers of the lip or the
skin of the face and less commonly, oral cavity cancer.
Swellings of the submandibular salivary gland are usually acute, related to eating and
are due most commonly to a stone obstructing the submandibular duct. Painless,
progressive swelling of the submandibular gland raises the possibility of a tumour.
In contrast to parotid tumours, at least 50% of tumours of the submandibular
salivary gland are malignant.
An uncommon submandibular swelling, which frequently poses diagnostic difficulty, is a
plunging ranula. This is due to extravasation of mucoid saliva from a disrupted sublingual
gland in the floor of the mouth. Instead of the mucoid saliva collecting in the floor of
the mouth and causing a swelling under the mucosa (a ranula) the mucous makes its
way into the subcutaneous space in the submandibular region. Removal of the
sublingual gland via the mouth is the curative operation for a plunging ranula.
This boy, aged 14,
presented with a cystic
mass in the left
submandibular region.
Needle biopsy
demonstrated the
presence of mucoid
material and the CT scan
shows a cystic mass lying
anterior to the left
submandibular salivary
gland. This is a typical
plunging ranula and is due
to extravasation of mucoid
saliva from the left
sublingual gland.
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neck lumps: a diagnostic guide for practitioners
The CT scan on the right
demonstrates a pathologically
enlarged lymph node (large arrow)
lying In front of the left submandibular
salivary gland (small arrow). Fine
needle biopsy demonstrated atypical
lymphocytes and the lymph gland
was excised. The diagnosis was
non-Hodgkin’s Lymphoma. The
CT scan on the far right shows a
pathologically enlarged right
submandibular salivary gland (large
arrow) while the submandibular
salivary gland on the left (small
arrow) is of normal size. The mass
on the right was painless and slowly
growing over two years. Needle
biopsy suggested a diagnosis of
pleomorphic adenoma and this
was proven on excision.
This elderly man has a large left
submandibular mass. An SCC of
the cheek was removed a year
earlier. FNAB showed metastatic
SCC and the CT scan demonstrates
a large cystic mass with a septum,
consistent with metastatic cancer.
This 45 year old Asian woman,
recently migrated to Australia,
presented with a supurating mass
in the right submandibular region.
A diagnosis of tuberculosis was
made following culture of tissue from
the mass.
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swellings around the parotid region
In contrast to the submandibular gland, infective and inflammatory swellings of the
parotid gland are not particularly common.
Viral infections (e.g. mumps) and bacterial infections (frequently secondary to salivary
obstruction) can occur and the history usually is of acute pain and swelling. Tumours
tend to have a longer history and are usually painless. Over 85% of primary parotid
tumours are benign, usually pleomorphic adenoma in younger adults and Warthin’s
tumour in older adults. The commonest malignant parotid tumour which we
see in Australia is metastatic skin cancer, either SCC or melanoma.
Excision biopsy of lumps around the parotid region should
not be carried out. If the lump proves to be a parotid
malignancy, inappropriate excision biopsy can lead to great
difficulty in subsequent treatment and predispose to recurrence.
This fair haired man aged 70
previously had a cutaneous SCC
removed from the right side of the
forehead (arrow) and presented
6 months later with a prominent
painless mass in the right
pre-auricular region. This is
metastatic SCC involving a parotid
lymph node. This is the
commonest parotid malignancy
seen in Australia.
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