The important concepts in understanding neck lumps are
- Solitary or multiple
- Associated symptoms
The vast majority of lumps in children and young adults will be either inflammatory or congenital. Single lateral neck lumps in an adult over 40 must be considered cancerous until proven otherwise.
- sebaceous cyst
- epidermoid cyst
Midline lumps – these are often congenital i.e. present at birth at least in vestigial form. Under the chin they may represent dermoid cysts, thyroglossal cysts (especially around the hyoid).
In the lower neck they may represent thyroid abnormalities and will elevate with swallowing.
Angle of jaw – most of these are parotid lumps. Most are benign parotid tumours but lymph nodes involved by skin cancer occur increasingly with age.
Under the body of the mandible – usually related to abnormalities of the submandibular gland such as blocked gland, infection, tumour. As with parotid lumps, lymph nodes involved by skin cancer occur increasingly with age. In Polynesian patients in particular, a cystic swelling may be due to a plunging ranula which is due to chronic leakage of mucus from the sublingual gland (under the tongue) into the neck.
Lateral neck – usually are enlarged lymph nodes. In adolescents and young adults a branchial cyst may come up almost over night and present as a firm swelling in the upper neck.
Any persisting lateral neck lump in an adult must be treated with suspicion for malignancy. Other possibilities include nerve tumours, carotid body tumours.
Lower neck in front of or deep to the neck muscles – often represent thyroid abnormalities and will elevate with swallowing. Most thyroid lumps are benign but still require investigation as some are cancers.
Multiple lumps are generally lymph nodes and the most common cause is inflammation e.g. glandular fever, toxoplasmosis. However multiple non-tender nodes can be due to malignancy either primarily of lymph nodes (lymphoma) or secondarily by spread from a cancer of the head and neck (nodal metastasis).
Generally lumps that have been present for years are benign but not necessarily so e.g. parotid or thyroid cancers can be quiescent for years before taking on a more aggressive course.
Most inflammatory lumps will begin to resolve within 3 weeks. Any lumps that are persisting or growing over a few weeks or months must be investigated for malignancy.
Inflammatory nodes are generally associated with systemic symptoms such
as tenderness, fever, malaise, sore throat. Serology for glandular fever
or toxoplasmosis may be positive.
Lymphomatous nodes can have similar symptoms of fever, night sweats, weight loss, and tenderness. Any nodes that persist for more than 3 weeks in the absence of a diagnosis should be investigated.
Lateral neck nodes in adults may be metastases from the throat. These patients may be heavy smokers and may experience throat or ear discomfort, voice change or swallowing difficulty. Some will have a past history of skin cancers.