Find information on medical topics, symptoms, drugs, procedures, news and more, written for the health care professional.

* This is a professional Version *

Neck Mass

by Marvin P. Fried, MD

Patients or their family members may notice a mass on the neck, or one may be discovered during routine examination. A neck mass may be painless or painful depending on the cause. When a neck mass is painless, much time may pass before patients seek medical care.

Etiology

There are many causes of neck mass, including infectious, cancerous, and congenital causes (see Some Causes of Neck Mass).

Some Causes of Neck Mass

Cause

Suggestive Findings

Diagnostic Approach

Infectious disorders

HIV

High-risk groups

Generalized, painless adenopathy

Serologic testing for HIV

Mononucleosis

Multiple, nontender cervical nodes in an adolescent

Usually pharyngitis and marked malaise

Serologic testing for Epstein-Barr virus

Oropharyngeal infection, viral or bacterial (most commonly pharyngitis or URI, sometimes a dental infection)

Frequently URI symptoms, sore throat, or toothache

Acute, rubbery adenopathy with little or no tenderness

Multiple enlarged nodes sometimes present with viral URI

Clinical evaluation

Sometimes throat culture

Primary bacterial lymphadenitis

Acute, isolated, tender adenopathy

Clinical evaluation

TB

High-risk groups

Matted, painless adenopathy, sometimes fluctuant

PPD

Culture

Cancer*

Local primary (eg, oropharyngeal, thyroid, salivary)

Nodes from distant primary (eg, lymphomas, prostate, breast, colon, kidney)

Nodes from local or regional primary (eg, lung, upper GI)

For most common local primary cancers, usually in older patients, typically with significant tobacco use, alcohol consumption, or both; may or may not have visible or palpable primary (eg, in oropharynx)

Cancerous masses likely to be firm or hard and fixed to underlying tissues rather than mobile

Regional or distant metastases with or without local symptoms

see Testing

Typically laryngoscopy, bronchoscopy, and esophagoscopy with biopsy of all suspect areas

CT of the head, neck, and chest and possibly a thyroid scan

Congenital disorders

Branchial cleft cyst

Lateral mass, usually overlying the sternocleidomastoid muscle, often with a sinus or fistula

In children, ultrasonography

In adults, CT

Dermoid or sebaceous cyst

Rubbery and nontender (unless infected)

Thyroglossal duct cyst

Midline, nontender mass

Usually manifests in childhood or adolescence but sometimes not until later

Other disorders

Simple, nontoxic goiter

Nontender diffuse thyroid enlargement

Thyroid function testing

Thyroid scan

Ultrasonography

Subacute thyroiditis

Fever, usually thyroid tenderness and enlargement

Submandibular salivary gland enlargement (eg, due to sialadenitis or stones)

Typically a painless mass just below the mandible laterally

CT and MRI

Biopsy

*Patients suspected of having cancer should undergo a head and neck examination by an otolaryngologist.

The most common causes in younger patients include the following:

  • Reactive adenitis

  • Primary bacterial lymph node infection

  • Systemic infections

Reactive adenitis occurs in response to viral or bacterial infection somewhere in the oropharynx. Some systemic infections (eg, mononucleosis, HIV, TB) cause cervical lymph node enlargement—usually generalized rather than isolated.

Congenital disorders may cause a neck mass, typically longstanding. The most common are thyroglossal duct cysts, branchial cleft cysts, and dermoid or sebaceous cysts.

Cancerous masses are more common among older patients but may occur in younger ones. These masses may represent a local primary tumor or lymph node involvement from a local, regional, or distant primary cancer. About 60% of supraclavicular triangle masses are metastases from distant primary sites. Elsewhere in the neck, 80% of cancerous cervical adenopathy originates in the upper respiratory or alimentary tract. Likely sites of origin are the posterior-lateral border of the tongue and the floor of the mouth followed by the nasopharynx, palatine tonsil, laryngeal surface of the epiglottis, and hypopharynx, including the pyriform sinuses.

The thyroid gland may enlarge in various disorders, including simple nontoxic goiter (see Simple Nontoxic Goiter), subacute thyroiditis (see Subacute Thyroiditis), and, less often, thyroid cancer (see Thyroid Cancers).

A submandibular salivary gland can enlarge if it is blocked by a stone, becomes infected, or develops a cancer.

Evaluation

History

History of present illness should note how long the mass has been present and whether it is painful. Important associated acute symptoms include sore throat, URI symptoms, and toothache.

Review of systems should ask about difficulty swallowing or speaking and symptoms of chronic disease (eg, fever, weight loss, malaise). Regional and distant cancers causing metastases to the neck occasionally cause symptoms in their system of origin (eg, cough in lung cancer, swallowing difficulty in esophageal cancer). Because numerous cancers can metastasize to the neck, a complete review of systems is important to help identify a source.

Past medical history should inquire about known HIV or TB and risk factors for them. Risk factors for cancer are assessed, including consumption of alcohol or use of tobacco (particularly snuff or chewing tobacco), ill-fitting dental appliances, and chronic oral candidiasis. Poor oral hygiene also may be a risk.


Physical examination

The neck mass is palpated to determine consistency (ie, whether soft and fluctuant, rubbery, or hard) and presence and degree of tenderness. Whether the mass is freely mobile or appears fixed to the skin or underlying tissue also needs to be determined.

The scalp, ears, nasal cavities, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx are closely inspected for signs of infection and any other visible lesions. Teeth are percussed to detect the exquisite tenderness of root infection. The base of the tongue, floor of the mouth, and the thyroid and salivary glands are palpated for masses.

The breasts and prostate gland are palpated for masses, and the spleen is palpated for enlargement. Stool is checked for occult blood, suggestive of a GI cancer.

Other lymph nodes are palpated (eg, axillary, inguinal).


Red flags

The following findings are of particular concern:

  • Hard, fixed mass

  • Older patient

  • Presence of oropharyngeal lesions (other than simple pharyngitis or dental infection)

  • A history of persistent hoarseness or dysphagia


Interpretation of findings

Important differentiating factors for a neck mass (see also Some Causes of Neck Mass) include acuity, pain and tenderness, and consistency and mobility.

A new mass (ie, developing over only a few days), particularly after symptoms of a URI or pharyngitis, suggests benign reactive lymphadenopathy. An acute tender mass suggests lymphadenitis or an infected dermoid cyst.

A chronic mass in younger patients suggests a cyst. A non-midline mass in older patients, particularly those with risk factors, should be considered cancer until proven otherwise; a midline mass is likely of thyroid origin (benign or malignant).

Pain, tenderness, or both in the mass suggest inflammation (particularly infectious), whereas a painless mass suggests a cyst or tumor. A hard, fixed, nontender mass suggests cancer, whereas rubbery consistency and mobility suggest otherwise.

Generalized adenopathy and splenomegaly suggest infectious mononucleosis or a lymphoreticular cancer. Generalized adenopathy alone may suggest HIV infection, particularly in those with risk factors.

Red and white mucosal patches (erythroplakia and leukoplakia) in the oropharynx may be malignant lesions responsible for the neck mass.

Difficulty swallowing may be noted with thyroid enlargement or cancer originating in various sites in the neck. Difficulty speaking suggests a cancer involving the larynx or recurrent laryngeal nerve.


Testing

If the nature of the mass is readily apparent (eg, lymphadenopathy caused by recent pharyngitis) or is in a healthy young patient with a recent, tender swelling and no other findings, then no immediate testing is required. However, the patient is reexamined regularly; if the mass fails to resolve, further evaluation is needed.

Most other patients should have a CBC and chest x-ray. Those with findings suggesting specific causes should also have testing for those disorders (see Some Causes of Neck Mass).

If examination reveals an oral or nasopharyngeal lesion that fails to begin resolving within 2 wk, testing may include CT or MRI and fine-needle biopsy of that lesion.

In young patients with no risk factors for head and neck cancer and no other apparent lesions, the neck mass may be biopsied.

Older patients, particularly those with risk factors for cancer, should first undergo further testing to identify the primary site; biopsy of the neck mass may simply reveal undifferentiated squamous cell carcinoma without illuminating the source. Such patients should have direct laryngoscopy, bronchoscopy, and esophagoscopy with biopsy of all suspicious areas. CT of the head, neck, and chest and possibly a thyroid scan are done. If a primary tumor is not found, fine-needle aspiration biopsy of the neck mass should be done, which is preferable to an incisional biopsy because it does not leave a transected mass in the neck. If the neck mass is cancerous and a primary tumor has not been identified, random biopsy of the nasopharynx, palatine tonsils, and base of the tongue should be considered.


Treatment

Treatment is directed at the cause.

Key Points

  • An acute neck mass in younger patients is usually benign.

  • Neck mass in an elderly patient raises concern of cancer.

  • Thorough oropharyngeal examination is important.

Resources In This Article

* This is a professional Version *