Conditions: Neck Mass
(swelling or lump)
A lump in the neck could be one of many things, ranging from normal to life-threatening. Evaluation by an expert with knowledge of the neck (and the face, mouth, and throat) is important to identify which swellings can be watched and which require more immediate additional evaluation.
Evaluation of a neck mass
Evaluation of a neck mass to determine its cause and treatment options consists of obtaining a history and physical exam and potentially additional studies such as imaging, endoscopy, fine needle aspiration biopsy, or open (incisional) biopsy.
Factors such as one’s age, smoking history, history of an impaired immune system or cancers offer clues for the evaluating physician. An experienced physician’s physical exam is essential for accurate assessment and choice of any further studies.
The specific anatomic location of the mass is a big clue to the diagnosis. The presence or absence of any other abnormal findings in the mouth, throat, nose, neck, and skin is also very important. Various types of neck masses based on tissue type are detailed below.
• Animated YouTube video explaining neck mass evaluation
• Animated YouTube video explaining seven (usually) pediatric neck mass conditions
Looking in the nose and throat with a scope is often very helpful.
Imaging (CT, ultrasound, or MRI) is often used as well.
Needle biopsy is a safe and often highly informative means of identifying the type of problem at hand.
The lymphatic system is a series of channels carrying chyle (lymphatic fluid) with interspersed lymph nodes along these channels.
Lymph node
The neck contains many lymph nodes, and these are usually too small to be seen or felt. Enlargement of one or more neck lymph nodes can occur as a result of inflammation (such as with infection) or growth of a tumor within lymph node(s).
In children, most enlarged neck lymph nodes arise from nearby infection, such as tonsillitis for example. More concerning for older individuals, especially those with risk factors, persistent enlargement (and especially unrelenting growth) of a lymph node is a concern because this may represent a situation in which cancer is in this lymph node, either having spread from somewhere else (as in squamous cell carcinoma, for example) or starting within the lymph node (as in lymphoma).
Lymph nodes may become enlarged in cancerous (malignant) disease. Cancer, such as squamous cell carcinoma from the mouth or throat, can spread to one or more lymph nodes and grow in that structure. Alternatively, enlarged lymph nodes may represent a cancer of the lymph node itself, as in lymphoma (both Hodgkin's and non-Hodgkin's) or lymphocytic leukemia, Enlargement of a lymph node that lasts less than two weeks or more than one year with no progressive size increase has a very low likelihood of being neoplastic.
Lymph nodes with cancer spread to them (“metastatic lymph nodes”) become enlarged because tumor cells have detached from the primary tumor, moved to a lymph node, and grown in the lymph node. Since cancer generally occurs somewhat more frequently in older people, this kind of lymphadenopathy is more common in older persons. Metastatic lymph nodes tend to feel hard and may be fixed to underlying tissues and may or may not be tender. Usually the lymph nodes that directly drain the area of the cancer are affected by the spread. Sometimes metastatic cervical lymph node is detected before the main cancer. In such cases, this discovery leads to a search for the primary malignancy—where the cancer originally arose.
Thyroid
Located in the low neck, the thyroid gland produces thyroid hormone, which acts to keep the body’s various systems running. Thyroid glands are somewhat prone to developing growths (nodules), some of which produce an excess of thyroid hormone, others not; some are malignant and can spread to other parts of the body, others benign.
salivary gland
We have three paired salivary glands, the parotid, the submandibular, and the sublingual glands, as well as thousands of minor salivary glands. These can develop into benign or cancerous tumors (neoplasms), which are distinctly different from a swelling due to infection or trauma. Diagnosis of a salivary gland neoplasm is often confirmed with a fine needle aspiration biopsy and imaging may be included in the evaluation. Treatment options depend on diagnosis, but generally include observation, medication, and surgery. Salivary gland tumors may be categorized according to the specific gland involved or by the pathologic appearance under a microscope, which generally predicts its behavior.
Skin
Sebaceous cyst of the back of the neck
Scrofula, also known as mycobacterium cervical lymphadenitis, is an infection of a mycobacterium (including tuberculosis) involving lymph nodes of the neck, possibly extending to skin.
The skin itself may be the source of a neck mass, and many different types of growth in the skin exist. The head and neck skin is exposed to sunlight more than most other skin, increasing its risk for skin cancer. Other conditions of the skin including infections, epidermal cysts, and dermatitis may present as a neck mass requiring evaluation, diagnosis, and management. Many skin conditions exist, some dangerous and others not. Some cause for concern may include large size, growth, pigmentation, or a skin wound that does not heal.
Cutaneous squamous cell carcinoma, a common type of skin cancer.
Melanoma of the skin.
Thyroglossal duct cyst
A thyroglossal duct cyst can become evident as a lump in the upper neck near midline, deep to the skin. Although they are known to be the most common pediatric mass, they also present in adults with some frequency. It can occur as a result of development as an embryo, when the thyroid gland normally passes from the tongue down to the low neck but occasionally this process leaves a tunnel or sac behind that can fill with fluid later in life. In other words, if present, it is present at birth, but may not show itself until later in life. Characteristically, a thyroglossal duct cyst will elevate with tongue protrusion or swallowing, which is not true of other types of neck masses. Infection of a thyroglossal duct cyst can occur, and can cause pain and difficulty breathing. The mass is benign in 99% of cases, and in the 1% that is malignant, the type of cancer is typically either papillary thyroid carcinoma or squamous cell carcinoma.
Branchial cleft cyst
A branchial cleft cyst is another benign condition that can develop at any time, can become infected, and requires definitive diagnosis to differentiate it from cancer. Branchial cleft cysts account for almost 20% of neck masses in children. Most branchial cleft cysts present in late childhood or early adulthood as a solitary, painless mass, which went previously unnoticed, that has now become infected (typically after an upper respiratory tract infection).
HOW TO GET THE MOST FROM YOUR APPOINTMENT
Appointment time is valuable. Below are some suggestions to make the most of your appointment. This preparation will help you and your doctor maximize efficiency and accuracy, freeing up time for questions and answers.
• Click here to prepare for your neck mass/swelling/lump appointment.
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