Patients or their family members may notice a mass in the neck, or a mass 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 a Neck Mass
There are many causes of a neck mass, including infectious, cancerous, and congenital causes (see table Some Causes of Neck Mass). Most neck masses are enlarged lymph nodes.
The most common causes of a neck mass 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 examples of primary bacterial lymph node infection are cat-scratch disease, toxoplasmosis, tubercular lymphadenitis, and actinomycosis. 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 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, subacute thyroiditis, nodular thyroid disease, and, less often, thyroid cancer.
A submandibular salivary gland can enlarge if it is blocked by a stone, becomes infected, or develops a cancer.
Evaluation of a Neck Mass
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, 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.
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, a possible finding in gastrointestinal tract cancer.
Other lymph nodes (eg, axillary, inguinal) are palpated.
Red flags
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)
A history of persistent hoarseness or dysphagia
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 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 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 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.
Testing
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).
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.
Key Points
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.
