Etiology of a Neck Mass
There are many causes of a neck mass, including infectious, cancerous, and congenital causes (see table ). Most neck masses are enlarged lymph nodes.
The most common causes of a neck mass in younger patients include the following:
Primary bacterial lymph node infection
Reactive adenitis occurs in response to viral or bacterial infection somewhere in the oropharynx. Some examples of primary bacterial lymph node infection are cat-scratch disease Cat-Scratch Disease Cat-scratch disease is infection caused by the gram-negative bacterium Bartonella henselae. Symptoms are a local papule and regional lymphadenitis. Diagnosis is clinical and confirmed... read more , toxoplasmosis Toxoplasmosis Toxoplasmosis is infection with Toxoplasma gondii. Symptoms range from none to benign lymphadenopathy, a mononucleosis-like illness, to life-threatening central nervous system (CNS) disease... read more , tubercular lymphadenitis Lymphadenitis Lymphadenitis is an acute infection of one or more lymph nodes. Symptoms include pain, tenderness, and lymph node enlargement. Diagnosis is typically clinical. Treatment is usually empiric.... read more , and actinomycosis Actinomycosis Actinomycosis is a chronic localized or hematogenous anaerobic infection caused by Actinomyces israelii and other species of Actinomyces. Findings are a local abscess with multiple... read more . Some systemic infections (eg, mononucleosis Infectious Mononucleosis Infectious mononucleosis is caused by Epstein-Barr virus (EBV, human herpesvirus type 4) and is characterized by fatigue, fever, pharyngitis, and lymphadenopathy. Fatigue may persist weeks or... read more , HIV Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more , tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more ) cause cervical lymph node enlargement—usually generalized rather than isolated.
Congenital disorders may cause a neck mass, typically long-standing. 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 Simple Nontoxic Goiter Simple nontoxic goiter, which may be diffuse or nodular, is noncancerous hypertrophy of the thyroid gland without hyperthyroidism, hypothyroidism, or inflammation. Except in severe iodine deficiency... read more , subacute thyroiditis Subacute Thyroiditis Subacute thyroiditis is an acute inflammatory disease of the thyroid probably caused by a virus. Symptoms include fever and thyroid tenderness. Initial hyperthyroidism is common, sometimes followed... read more , nodular thyroid disease Approach to the Patient With a Thyroid Nodule Thyroid nodules are benign or malignant growths within the thyroid gland. They are common, increasingly so with increasing age. (See also Overview of Thyroid Function.) The reported incidence... read more , and, less often, thyroid cancer Thyroid Cancers Thyroid cancer can derive from follicular cells or parafollicular C-cells. Most thyroid cancers manifest as asymptomatic nodules. Diagnosis is often by fine-needle aspiration biopsy but may... read more .
A submandibular salivary gland can enlarge if it is blocked by a stone Salivary Stones Stones composed of calcium salts often obstruct salivary glands, causing pain, swelling, and sometimes infection. Diagnosis is made clinically or with CT, ultrasonography, or sialography. Treatment... read more , becomes infected, or develops a cancer Salivary Gland Tumors Most salivary gland tumors are benign and occur in the parotid glands. A painless salivary mass is the most common sign and is evaluated by fine-needle aspiration biopsy. Imaging with CT and... read more .
Evaluation of a Neck Mass
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, upper respiratory infection (URI) symptoms, and toothache.
Review of systems should include asking 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, difficulty swallowing 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 include asking about known HIV or tuberculosis and risk factors for them. Risk factors for cancer are assessed; they include consumption of alcohol, use of tobacco (particularly snuff or chewing tobacco), ill-fitting dental appliances, and chronic oral candidiasis. Poor oral hygiene may also be a risk.
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, a possible finding in gastrointestinal tract cancer.
Other lymph nodes (eg, axillary, inguinal) are palpated.
The following findings in patients with a neck mass are of particular concern:
Hard, fixed mass
A new mass in older patients
Presence of oropharyngeal lesions (other than simple pharyngitis or dental infection)
Interpretation of findings
Important differentiating factors for a neck mass (see table ) 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 Lymphadenopathy Lymphadenopathy is palpable enlargement of ≥ 1 lymph nodes. Diagnosis is clinical. Treatment is of the causative disorder. (See also Overview of the Lymphatic System.) Lymph nodes are present... read more . An acute tender mass suggests lymphadenitis Lymphadenitis Lymphadenitis is an acute infection of one or more lymph nodes. Symptoms include pain, tenderness, and lymph node enlargement. Diagnosis is typically clinical. Treatment is usually empiric.... read more 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 to originate in the thyroid and may be benign or malignant.
Pain, tenderness, or both in the mass suggest inflammation (particularly infectious); a painless mass suggests a cyst or tumor. A hard, fixed, nontender mass suggests cancer; rubbery consistency and mobility suggest a benign cause.
Generalized adenopathy and splenomegaly suggest infectious mononucleosis Infectious Mononucleosis Infectious mononucleosis is caused by Epstein-Barr virus (EBV, human herpesvirus type 4) and is characterized by fatigue, fever, pharyngitis, and lymphadenopathy. Fatigue may persist weeks or... read more or a lymphoreticular cancer. Generalized adenopathy alone may suggest HIV Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more 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 result from thyroid enlargement or cancer originating in various sites in the neck. Difficulty speaking suggests a cancer involving the larynx or recurrent laryngeal nerve.
If the nature of the neck mass is readily apparent (eg, lymphadenopathy caused by recent pharyngitis) or occurs in a healthy young patient with a recent, tender swelling, and no other findings, no immediate testing is required. However, the patient is reexamined regularly; if the mass does not resolve, further evaluation is needed.
Most other patients should have a CBC (complete blood count) and chest x-ray. Those with findings suggesting specific causes should also have testing for those disorders (see table Some Causes of Neck Mass Some Causes of Neck Mass ).
If examination reveals an oral or nasopharyngeal lesion that does not begin resolving within 2 weeks, 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, imaging of the neck mass, possibly followed by biopsy, may be done.
In older patients, particularly those with risk factors for cancer, further testing is needed to identify the primary site; biopsy of the neck mass may simply show undifferentiated squamous cell carcinoma without identifying the source. Such patients require direct laryngoscopy, bronchoscopy, and esophagoscopy with biopsy of all suspect areas. Specimens identified as squamous cell carcinoma should be tested for human papillomavirus (HPV). CT of the head, neck, and chest and possibly a thyroid scan are done. Ultrasonography of the neck is preferred for children to avoid radiation exposure; it may be used in adults if a thyroid mass is suspected. If a primary tumor is not found, fine-needle aspiration biopsy of the neck mass should be done; it 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 of a Neck Mass
Treatment of a neck mass is directed at the cause. In children, infection is the most common cause of neck masses, so for children, a trial of antibiotics is usually done first to see if the mass goes away.
An acute neck mass in younger patients is usually benign.
Consider cancer when a neck mass occurs in older patients, particularly those with risk factors for cancer.
Do a thorough oropharyngeal examination.