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Neck Mass


Marvin P. Fried

, MD, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine

Last review/revision Sep 2021 | Modified Sep 2022
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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 of Neck Mass

There are many causes of a neck mass, including infectious, cancerous, and congenital causes (see table ).


The most common causes of a neck mass in younger patients include the following:

  • Reactive adenitis

  • Primary bacterial lymph node infection

  • Systemic infections

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.

Evaluation of 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 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 tuberculosis 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 gastrointestinal 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 table ) include acuity, pain and tenderness, and consistency and mobility.

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.

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.


If the nature of the neck 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 (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 Some Causes of Neck Mass ).

If examination reveals an oral or nasopharyngeal lesion that fails to 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, 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. 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. Ultrasound is preferred for children to avoid radiation exposure and 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, 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 of Neck Mass

Treatment of a neck mass is directed at the cause.

Key Points

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

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

  • Thorough oropharyngeal examination is important.

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