Neck Lumps

What are Neck Lumps?

A neck lump is any congenital or acquired mass arising in the anterior or posterior triangles of the neck between the clavicles inferiorly and the mandible and the base of the skull superiorly.


I have a lump the size of a marble next to my Adam’s apple. What could it be?

The most common cause in the middle of the neck adjacent to the Adam’s apple is a cyst or tumour in your thyroid gland. Most cysts or tumors in the thyroid gland are benign but they need to be investigated. As a rule of thumb any swelling in the thyroid gland greater than a centimeter needs either a needle biopsy to ascertain the nature of the cells in it and/or surgical removal.

Cystic degeneration of the thyroid gland occurs with increasing age, but a lesion the size of a marble should definitively be investigated.


What will happen when I come in the ENT clinic?

If you came to see us we would undertake clinical examination because your thyroid gland are next to the nerves that move your voice box so as a first step it is important to know that your vocal cords are moving normally. Thereafter if it is an isolated lesion, which is to say that there is only one lesion, we would normally proceed to what’s called a fine needle aspirate. This involves sticking a needle in it, sucking out some of the contents and sending it to a pathologist for appropriate investigation.

If there are multiple lymph nodes and/or palpable lymph nodes in your next, the situation is more serious. You would need to proceed to appropriate imaging, be it ultrasound or a CAT-scan, and more likely than not proceed to an operation to remove at least that half of the sinus gland.

We suggest that the more quickly that you get in touch with us, the more quickly your problem can be diagnosed and treated appropriately.


Normal or Abnormal?

Normal & Abnormal Lymph Nodes

It is important to be able to recognize the normal neck masses. The hyoid bone and the thyroid cartilage are palpable normal structures in the neck. The transverse process of the 1st cervical vertebra just below the mastoid process behind the ear are palpable and are normal structures in the neck. The presence of multiply small non-tender mobile lymph nodes, particularly in children, is considered normal.

Age

In the pediatric age group (0-15), a neck lump is likely to be inflammatory or congenital. Lumps are rarely neoplastic.

History

The important information to be gathered while taking history from any patient with a neck lump is:

  1. Onset- the nature of the onset of the lump is vital to establish the pathology of the lump. Rapid onset and painful swelling suggests an inflammatory condition whereas a slowly progressive lump that is not painful suggests a neoplastic legion. Inflammatory swellings of the neck are commonly associated with infections of the ear, nose, throat or scalp.
  2. Duration- inflammatory lumps settle once the primary source of infection is treated. A neck lump that persists for more than 6 weeks with or without associated symptoms needs referral to an ENT Surgeon.
  3. Associated symptoms- it is vital to gather information from the patient that may help suggest a primary Head and Neck malignancy presenting as a metastatic lymph node enlargement. The symptoms and their associations are:
    • Dysphonia or altered voice (indicating the possibility of a cancer of the larynx).
    • Dysphagia or odynophagia (indication a cancer of the pharynx or oesophagus).
    • Shortness of breath or dyspnea (indicating a cancer of the trachea or lungs).
    • Weight loss or cachexia (which is often associated with a visceral malignancy).
  4. Social History- occupational exposure to carcinogens such as asbestos, nickel and wood dust are associated with an increased risk of specific Head and Neck cancers. Smoking remains the single most important risk factor for carcinoma of the upper aerodigestive tract and a detailed history regarding active and passive smoking should be sought. Alcohol consumption is also a known risk co-factor probably acting as a potentiating agent for cancers of the Head and Neck.
  5. Physical examination- at primary case physician level physical examination involves meticulous examination of the neck, looking for certain characteristics of the lump, particularly in the following; Is it a single lump or are there multiple lumps? Is it larger or smaller than 2 cm? Is it fixed or mobile? Is it tender or non tender? Is it associated with surrounding inflammation or not? Has it been growing? How long has it been there?

Remember that 50% of upper aerodigestive tract malignancies occur on the tongue and in the oral cavity so carefully examine the gums, the area behind the teeth (retro molar trigone), the palate and the tongue. If the lump has been there for more than 6 weeks or if it has any of the characteristics discussed above suggesting malignancy, urgent referral to an Ear Nose and Throat Surgeon is indicated.

He/ She will perform, in addition to the examination that you have performed, endoscopic assessment of the upper aerodigestive tract, appropriate imaging which would probably involve either ultrasound or CT scan of the neck, define needle aspiration biopsy and then plan definitive therapy.

Characteristics of CT or MRI scans indicating malignancy include rim enhancement, central necrosis, nodal size of greater than 1 cm and obliteration of tissue planes in the neck.

Remember that open biopsy should be avoided because it can compromise definitive treatment. Fine needle aspiration is safe, rapid, inexpensive and very useful in terms of pre surgical planning and patient counseling. It avoids the need for open biopsy and there is no evidence of it causing tumour seeding in Head and Neck malignancies.

Don’t ignore adult neck lumps especially when the cause is not apparent and when they have been present for more than 6 weeks. History, meticulous examination of the neck and the oral cavity is mandatory. If you are going to organize imaging ultrasound and CT scans are the initial imaging modalities together with ultrasounds-guided fine needle aspirate. In conclusion neck lumps are common, they are usually benign in children.


Neck Lumps in Children

Sebaceous cysts can occur anywhere in the neck in children, they are slowly enlarging and on close examination have punctum. They are entirely benign and if they are unsightly or causing a problem are appropriately managed by surgical excision.

Cystic hygromas are congenital lesions of lymphoid tissue. They tend to occur in infants, often occur at the base of the tongue. They transilluminate quite brilliantly and they often come and go. Large cystic hygromas can cause protrusion of the tongue, salivation or an unsightly neck mass. Treatment depends on the severity of symptoms caused and may involve simple observation, injection with sclerosants, laser therapy or excision.

Thyroglossal cysts are the most common congenital neck mass. 50% of these present before the age of 20 often in the second decade of life, 75% of them are midline structures, the other 25% are near the midline. They are discrete firm lumps that elevate on swallowing or protrusion of the tongue. They are an embryological remnant of the descent of the thyroid gland from the base of the tongue into its position in the neck. Thryroglossal duct cysts are managed by surgical excision. The operation often involves resecting part of the hyoid bone and the tract from the thyroglossal duct cyst to the foramen caecum in the base of the tongue.

Dermoid cysts can occur in the midline and mimic thyroglossal duct cysts. Treatment for dermoids again is surgical excision and histopathological evaluation.

Branchial cysts present as a cystic mass anterior to the sternocleidomastoid muscle, just below the mandible. They may get infected so they may appear as a large inflammatory swelling, which subsides with antibiotics. They represent a persistence of the 2nd branchial cleft. Occasionally they have a small internal tract or sinus into the tonsillar fossa. They are treated by surgical excision.

A ranula is a cystic swelling in the floor of the mouth. It is a mucous extravasation cyst caused by saliva or spit escaping from the sublingual salivary glands. If they extend through the floor of the mouth they are referred to as a plunging ranula and may present as a soft mass adjacent to the midline just under the angle of the jaw. If symptomatic, treatment is surgical.

Viral/bacterial lymphadenitis - remember that small multiple lymph nodes are often palpable in children. Cervical adenitis secondary to acute upper respiratory tract infection, tonsillitis and Epstein Barr virus are usually obvious from taking a history. If these lumps persist, think of chronic inflammatory diseases such as cat scratch fever, sarcoidosis or typical or atypical tuberculosis. Neoplasms are unusual in children and usually lymphomas.

Young adults

Inflammatory masses and thyroid malignancies are the common neck swelling in young adults. Viruses like infectious mononucleosis or bacterial infections like tonsillitis and pharyngitis lead to cervical lymphadenopathy. Remember that papillary thyroid cancer can present as an isolated non-tender thyroid mass or isolated non-tender lymphadenopathy in this age group.

In the over 40’s neck lumps are presumed to be malignant until proven otherwise. These can be primary or secondary tumours and they can be benign or malignant. With regards to the benign primary tumour any structure may be involved. It may be the skin, subcutaneous tissue, fat, nerve, muscle or blood vessels. Examples of common benign primary tumours in the neck are lipomas, fibromas, haemangiomas and neuromas. The other most common group of primary benign tumours in the head and neck are salivary gland tumours. Of the salivary gland tumours the most common tumours are either pleomorphic adenoma or Wharthin’s tumour both of which occur as an isolated lump in the tail of the parotid. Benign thyroid tumours are commonly multinodocular goitre, isolated cysts or adenomas.

Primary malignant tumours can occur in the salivary glands (parotid or submandibular gland), thyroid gland as well as primary lymph node tumours or lymphomas and sarcomas.

Secondary malignancies often present as metastatic lymphadenopathy. Lymph nodes tend to be multiple, rock hard, non-tender and have a tendency to be fixed. The primary tumour can be anywhere in the upper aerodigestive tract or may arise from the skin of the head and neck such as squamous cell carcinomas or melanomas. 75% of the primaries are in the head and neck, that is to say thyroid, nasopharynx, tonsils, larynx, pharynx or skin but remember that 25% of the primaries may be infraclavicular, predominantly stomach, pancreas, lung or kidney.