Head & Neck
Lumps on the Neck
Neck lumps are a common clinical finding and can arise from various structures within the neck. It is crucial to differentiate between different types of neck lumps to determine their underlying cause and appropriate management. The following are some of the features that help diagnose neck lumps:
Age - Children and young adults are most likely to encounter inflammatory and congenital lumps. These can include enlarged lymph nodes due to infections or benign cysts arising from developmental remnants. These lumps often resolve with time or respond well to conservative management. In contrast, in adults, a persistent neck lump is more likely to be neoplastic, and the possibility of malignancy must be carefully evaluated and excluded. Common malignancies that present as neck lumps in adults include metastatic tumours from cancers elsewhere in the body, as well as primary cancers such as thyroid carcinoma or lymphoma. Prompt assessment, often involving imaging studies and biopsy, is crucial to establish a diagnosis and initiate appropriate treatment promptly.
Site - Neck lumps commonly appear in the midline or lateral region, although masses may appear on other areas including back of the neck or ear, submandibular region and angle of jaw. In the back of the neck, superficial masses such as lipomas, sebaceous cysts, and vascular or lymphatic malformations are commonly found. These types of masses can develop anywhere on the neck or body. Posterior to the ear (postauricular area), enlarged lymph nodes may result from inflammation, lymphoma, or metastatic tumours like melanoma or squamous cell carcinoma (SCC) originating from the posterior scalp.
Neck lumps can also be distinguished by size, edge, consistency, colour, attachment, transillumination, pulsation, tenderness and nodes.
Infrahyoid masses are typically thyroid in origin and are commonly seen in young individuals. Suprahyoid masses refer to lumps or swellings located above the hyoid bone in the neck. A dermoid cyst is a type of developmental inclusion cyst that can occur in various parts of the body, including the head and neck region, but may not become evident until later in life.
A lateral neck mass is more complex and refers to a swelling or lump located on the side of the neck, away from the midline. Solid lesions in the lateral neck are enlargement of lymph nodes due to reactive changes, inflammation, or metastasis. They may present as palpable masses that are firm to touch and do not fluctuate like cystic lesions. The latter refers to fluid-filled sacs or cavities that can develop in various anatomical structures. These lesions can present with different characteristics and clinical implications. Unfortunately, distinguishing between benign branchial cleft cysts and cystic metastases can be challenging, and a thorough history of upper aerodigestive tract symptoms is crucial for accurate diagnosis.
Lumps in the submandibular area can arise from various causes, including stones or sludge blocking the submandibular duct. Those at the angle of the jaw can originate from several structures, primarily involving the parotid gland or adjacent lymph nodes.
i. Lymphadenopathy
The enlargement of lymph nodes can occur due to inflammatory, infectious, or malignant causes. They are typically bilateral and multiple and are often soft and mobile, unless associated with inflammation or infection (may then be tender and firm). Its causes may be infectious (viral or bacterial), inflammatory (like rheumatoid arthritis or sarcoidosis), or malignant (metastatic spread from cancers elsewhere in the body).
ii. Thyroid Nodules
These lumps are solid or fluid-filled growths within the thyroid gland characterised by their location which is usually in the midline of the neck or slightly to one side. They may be solitary or multiple and of varied consistency (solid, cystic, or mixed).
Some nodules like adenomas or colloid nodules are benign while others, malignant, like thyroid cancer (papillary, follicular, medullary, anaplastic).
iii. Salivary Gland Lesions
The enlargement or tumours arising from the salivary glands (parotid, submandibular, sublingual) are typically unilateral and located near the jawline or beneath the ear. These lesions may be associated with pain or facial nerve weakness (if involving the facial nerve). Benign causes could be pleomorphic adenoma or Warthin tumour while malignant ones include mucoepidermoid carcinoma or adenoid cystic carcinoma.
iv. Cysts
Cysts on the neck are fluid-filled sacs that can develop in various structures in the area. These are normally soft, fluctuant in size and painless, and are often mobile. Branchial cysts arise from remnants of embryonic branchial arches, while thyroglossal duct cysts arise from remnants of the thyroglossal duct.
v. Vascular Lesions
Vascular lesions like haemangiomas and vascular malformations are abnormal growths involving blood vessels. They may be compressible and may be typically present since birth (congenital), or develop later in life. Benign tumours called haemangiomas and vascular malformations are two types of vascular lesions that could affect the neck.
Gallery
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Dr Naveed Basheeth & The Differential Diagnosis Approach
To determine the nature of a neck lump, Dr Naveed Basheeth employs a comprehensive diagnostic approach that includes medical history and physical examination by assessing the various features of the lump like its size, location, consistency and mobility. Imaging techniques like flexible endoscopy, ultrasound, fine needle biopsy, and CT and MRI scans are often necessary for further evaluation.
Based on the investigation results, the lump will typically be classified as benign, possibly malignant or cancerous. Malignant lumps require further treatment planning, which may involve surgery, radiation therapy, chemotherapy, or a combination thereof.
This systematic approach ensures a comprehensive evaluation of neck lumps, providing accurate diagnosis and guiding appropriate management strategies based on the specific findings. An appropriate referral to specialists (e.g. otolaryngologist-head and neck surgeon, endocrinologist etc.) are crucial for accurate diagnosis and management planning.
