Lumps in the neck are common and the cause is usually benign.

However, the lump may be

the presentation of more serious disease, eg malignancy or chronic infection and so a
thorough assessment and diagnosis are essential. If there is any doubt as to the cause, then
the patient should be reviewed and/or referred for specialist assessment. Patients over the age
of 40 are more likely to have a neoplastic cause. Inflammatory, congenital and traumatic
causes are more common in younger patients but neoplasm should still be borne in mind

Assessment

[2]

Lumps of less than three weeks' duration are most likely due to a self-limiting infection
and do not require further investigation but keep under close weekly or fortnightly review.
Consider referral if persisting for longer than four weeks.

Examination should be carried out with the patient sitting on a chair; carefully examine
the whole of the scalp, the back of the neck and behind and within the ears.

Establish how deep the lump is: is it intradermal (suggesting sebaceous cyst with a
central punctum, or a lipoma)?

Is the lump in the midline and does it move on swallowing and/or on protruding the
tongue?

Palpate the lymph nodes of the head and neck: are they tender, fibrous, hard or
rubbery, fixed or mobile? For submandibular lumps, examine the mouth and salivary
glands, looking for oral malignancies or sources of infection, eg abscesses:

If parotid disease is suspected, identify the orifice of parotid duct and palpate with the
patient's head tilted backwards.

Examine the patient's tongue and floor of mouth, with their tongue first protruding and
then elevated inside the mouth.

Bimanually, palpate lumps in the floor of the mouth, submandibular area and cheeks.

For lumps in the parotid region, test, assess and record the integrity of the facial nerve.

Neck lumps in children

[3]

Take a full history (eg recent tonsillitis, skin lesion).

Arrange referral if the cause of swelling is uncertain, especially if swelling is persistent.

Differential diagnosis

[4][5][6]

Superficial lumps, eg sebaceous cyst, lipoma, abscess, dermoid cyst.

Lymph nodes.

Anterior triangle:

Lymph nodes are most common so check the areas which they serve (mouth,
throat, thyroid, skin of head and neck).

Submandibular: most likely to be lymph node but may indicate cancer if

older, particularly if the node feels firm and is non-tender.
Consider tuberculosis (TB), other infections, salivary calculus or tumour.

If it doesn't move with swallowing, consider salivary gland

swelling, branchial cyst, cystic hygroma, carotid aneurysm, carotid body
tumour, sternomastoid tumour (in babies following birth trauma; head is turned
away from swelling and tilted towards the lesion) or laryngocele (painless
anterior triangle lumps made worse by blowing).

Posterior triangle lump(s) (ie behind sternomastoid, front of trapezius and above
clavicle):

Multiple lumps are likely to be lymph nodes (TB, glandular fever, HIV,
lymphoma or metastases); always look for any generalised lymphadenopathy,
hepatomegaly and splenomegaly. Consider metastases from nasopharyngeal
carcinoma (more common in older patients of Chinese origin).

Cervical rib.

Subclavian artery aneurysm.

Pharyngeal pouch.

Cystic hygroma. Large cystic hygromas present at birth and may be huge and
disfiguring. In older children, smaller lesions can present as a painless lump just
below the angle of the mandible, soft, fluctuant and transilluminable. Surgical
excision may be difficult, as they may extend to deeper neck tissues.

Branchial cysts: rare, usually present in late teens with a solitary painless
swelling on the side of the neck, which varies in size and may be painful and red in
some patients. It forms when the second branchial cleft fails to disappear in utero.
Discharging sinuses and fistulae may occur. Aspiration may be pus-like and can be
rich in cholesterol crystals. The lump itself is soft and fluctuant and may
transilluminate.