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Neck lump - Management
What should I look for on examination?

  • Look for signs of stridor or superior vena cava compression (swelling of the face and/or neck with fixed elevation of jugular venous pressure).
  • Examine the neck.
    • Look at the neck to identify visible masses and pulsation.
    • Standing behind the person, palpate the different areas of the neck.
      • Anterior triangle (borders: midline, anterior border of sternocleidomastoid muscle, and the body of the mandible).
      • Posterior triangle (borders: posterior border of sternocleidomastoid muscle, trapezius, and the clavicle).
      • Midline.
  • If a neck lump is identified:
    • Assess its size and mobility (whether it is fixed to underlying structures).
    • Assess whether it is subcutaneous or part of the skin.
    • Determine the characteristics of the lump, for example whether it is compressible (such as a branchial cyst) or pulsatile (suggesting a vascular cause).
    • Ask the person to swallow and assess whether the lump moves (thyroid lumps and thyroglossal cysts move upwards on swallowing).
    • Ask the person to protrude their tongue (thyroglossal cysts move superiorly).
    • If it is a thyroid lump, determine whether it is nodular or diffuse.
  • Also examine:
    • The skin of the head and neck — for malignant or premalignant lesions (for example actinic keratoses).
    • The ears — for infection (such as otitis externa).
    • The nose — for malignancy.
    • The tonsils and pharynx — infection may cause lymphadenopathy.
    • The oral mucosa and tongue — for occult malignancy in the oral cavity (dentures may have to be removed). Use a tongue depressor to examine the lateral borders of the tongue.
    • Specific areas where a suspected lymph node metastasis (a firm lump) may have originated.
      • In general, if the suspected lymph node metastasis is in the upper or mid neck, the primary is likely to be a head and neck tumour (including thyroid).
      • Lateral lymph nodes may be enlarged because of metastasis from squamous cell cancer of mouth, pharynx, and upper oesophagus.
      • If the suspected lymph node metastasis is in the lower neck (supraclavicular lymph nodes), the primary may be from the thyroid, pyriform sinuses, upper oesophagus, or from below the clavicle (for example breast, lung, or intra-abdominal malignancy). An enlarged lymph node in the left supraclavicular fossa may indicate gastric cancer (Virchow lymph node).
    • The abdomen for hepatosplenomegaly, and the axillae and groins for lymphadenopathy (if haematological malignancy is suspected).

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