Etiology
There are many causes of a neck mass, including infectious, cancerous, and congenital causes (see table Some Causes of Neck Mass).
Some Causes of Neck Mass
Cause |
Suggestive Findings |
Diagnostic Approach |
Lymphadenopathy due to infectious disorders |
||
|
High-risk groups Generalized, painless adenopathy |
Serologic testing for HIV |
|
|
Multiple, nontender or moderately tender 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, often tender Multiple enlarged nodes sometimes present with viral URI |
Clinical evaluation Sometimes throat culture |
|
Acute, isolated, tender adenopathy |
Clinical evaluation |
|
|
High-risk groups Matted, painless adenopathy, sometimes fluctuant |
PPD Culture |
|
Cancer* |
||
|
Local primary (eg, oropharyngeal, thyroid, salivary) 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 |
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 |
||
|
Thyroid enlargement or one or more nodules |
Thyroid function testing Thyroid scan Ultrasonography |
|
|
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 of a neck mass in younger patients include the following:
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, toxoplasmosis, tubercular lymphadenitis, and actinomycosis infections. Some systemic infections (eg, mononucleosis, HIV, tuberculosis) 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, subacute thyroiditis, nodular thyroid disease, and, less often, thyroid 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 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 GI cancer.
Other lymph nodes are palpated (eg, axillary, inguinal).
Red flags
Interpretation of findings
Important differentiating factors for a neck mass (see table 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 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 and chest x-ray. Those with findings suggesting specific causes should also have testing for those disorders (see table 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 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.
