Neck Tumors

evaluation of a neck mass

Many different causes of a lump in the neck exist, including infections, cysts, salivary gland swelling, and tumors, both benign and malignant. When a lump in the neck is the first problem noticed by a patient or their physician, the evaluation involves sorting out what it is and whether further testing, such as a scope examination, imaging or a biopsy, is needed. The approach below follows the 2017 clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery Foundation, which was written to shorten delays in diagnosing head and neck cancer [1].

Who is at higher risk

The guideline identifies features that raise the concern for cancer [1]:

• History. The mass has been present for 2 weeks or more without getting smaller, or for an unknown length of time, and there is no clear sign of infection.

• Examination. The mass is fixed to nearby tissue, firm, larger than 1.5 cm, or the skin over it has broken down (ulcerated).

• Other suspicious findings. These include tobacco or heavy alcohol use, age over 40, a history of head and neck cancer, hoarseness, trouble or pain with swallowing, ear pain on one side, unexplained weight loss, or a sore in the mouth or throat that does not heal.

Real-world data support these features. In the Kaiser Permanente study of 4,103 adults referred for a neck mass, cancer was found in 2.1% of people younger than 40 and 8.4% of those 70 or older. It was found in 3% of masses smaller than 1 cm and in more than 31% of masses 2 cm or larger. A mass of 1.5 cm or more, two or more masses, and an irregular appearance on imaging each raised the odds of cancer [2].

The examination

Beyond feeling the neck, the head and neck examination includes the mouth, tonsils, base of tongue, voice box and the rest of the throat. Most of these areas cannot be seen without a small flexible scope passed through the nose, done in the office with topical numbing. The guideline recommends this targeted examination for anyone whose mass carries an increased risk of cancer [1].

Antibiotics

A course of antibiotics is often tried for a neck lump. The guideline recommends against routinely prescribing antibiotics unless there are signs of a bacterial infection, such as fever, redness, tenderness or a recent dental or throat infection, because a trial of antibiotics in someone without infection mainly delays the diagnosis [1].

Imaging

The guideline's one strong recommendation is a CT scan or MRI of the neck with contrast for any adult whose neck mass carries an increased risk of cancer [1]. Imaging shows where the mass sits, what structure it comes from, whether it is solid or cystic, whether other nodes are involved, and sometimes where a hidden primary tumor is. Ultrasound is widely used as well, especially for thyroid and salivary masses and to guide a needle biopsy. A PET-CT scan may be added when cancer has been found but its starting point has not.

Needle biopsy

When the diagnosis is not clear, the guideline recommends fine-needle aspiration (FNA) rather than an open biopsy [1]. FNA is done in the office or radiology suite, often with ultrasound guidance, and takes a few minutes. In a meta-analysis of 30 studies and more than 3,400 head and neck aspirates, FNA had a sensitivity of about 90% and a specificity of about 97% for cancer [9]. In other words, FNA detects most cancers and rarely calls a benign mass malignant, but a negative or nondiagnostic result does not fully rule out cancer.

A core needle biopsy uses a slightly larger needle to take a thin strip of tissue rather than loose cells. It is useful when the mass may be a lymphoma, because lymphoma diagnosis depends on seeing how the cells are arranged. In a meta-analysis of ultrasound-guided core biopsy in the head and neck, accuracy for detecting cancer was about 96%, and a specific diagnosis was reached in 87% of cases without major complications [10]. In a separate meta-analysis of 1,120 patients with lymphoma in the neck, core biopsy gave a diagnosis that could guide treatment in about 82% [11]. A 2025 series of 158 ultrasound-guided neck biopsies reported a diagnostic yield of about 98% for core biopsy and 89% for FNA [12].

Why an open biopsy is avoided at first. Cutting into a lymph node that contains squamous cell carcinoma, before the primary tumor is found and a treatment plan is made, can spill tumor into the neck tissues and complicate later treatment. An older surgical series found higher rates of wound breakdown, neck recurrence and distant spread in patients who had an open node biopsy before definitive treatment [13]. That study is retrospective and predates modern treatment, but it underlies the guideline's advice that, when the needle biopsy does not give a diagnosis, the next step should be an examination of the upper airway and throat under anesthesia, often with biopsies of likely primary sites, before any open neck biopsy. If an open biopsy is still needed, the surgeon plans it so that it can be extended to a neck dissection if necessary [1].

Cystic masses and further testing

A cyst in the neck of an adult is followed until a firm diagnosis is made, rather than assumed to be benign [1]. FNA of a cystic node often draws out fluid with few cells and can be falsely reassuring. Testing the fluid or the cells for HPV, and newer blood tests for circulating HPV tumor DNA, can help. In a 2026 study of 32 adults with a cystic neck mass and a nondiagnostic FNA, a positive blood test for HPV tumor DNA was always correct (specificity 100%), but the test missed about 1 in 6 HPV-related cancers [14]. These blood tests are promising, but they are still being studied for this use.

If no diagnosis is reached

When the mass is not suspicious and goes away, no further testing may be needed. When a mass at increased risk remains without a diagnosis, the guideline recommends ongoing follow-up and a clear plan, not reassurance alone [1].

• Link to Neck Mass in Adults article on the ENTHealth website.

Removal of neck lymph nodes (cervical lymphadenectomy or neck dissection)

When lymph nodes of the neck are either known to contain cancer or are at high risk of containing it, treatment typically includes the lymph nodes in that region. This can be done with radiation (with or without chemotherapy) or with surgery. When the lymph nodes are surgically removed, the specimen is sent for pathology, allowing us to learn more about the cancer, such as how many lymph nodes were involved and whether aggressive, high-risk features are present, such as a tumor that has grown beyond the capsule of the lymph node. This information factors into any recommendation for additional treatment after surgery, such as radiation.

Types of neck dissection

Neck dissections are named by how much of the neck is cleared and which structures are kept [16]:

• Radical neck dissection removes the lymph nodes of levels I through V together with three non-lymph structures: the spinal accessory nerve (which powers the trapezius muscle of the shoulder), the internal jugular vein and the sternocleidomastoid muscle. It is now rarely needed.

• Modified radical neck dissection removes the same node levels but keeps one or more of those three structures, most importantly the spinal accessory nerve.

• Selective neck dissection removes only the levels most at risk for a particular primary site, such as levels I to III for many mouth cancers or levels II to IV for many throat and voice box cancers. It is the most common type today.

• Extended neck dissection removes additional node groups or structures when the cancer involves them.

Elective and therapeutic neck dissection

A therapeutic neck dissection treats nodes that are known to contain cancer. An elective neck dissection removes nodes that look normal but are at meaningful risk of hidden (microscopic) cancer. For early mouth cancer, this question was answered by a randomized trial of 500 patients in India with node-negative oral cancer. Patients who had an elective neck dissection at the time of their primary surgery had a 3-year overall survival of 80%, compared with 67.5% for patients whose necks were watched and operated on only if nodes appeared later [3]. Based on this and other evidence, the American Society of Clinical Oncology (ASCO) guideline recommends treating the neck in most patients with early oral cancer, by elective neck dissection or, in selected cases, sentinel node biopsy (see below) [17].

For cancers treated first with radiation and chemotherapy, the question is different: whether the neck needs surgery afterward. In the PET-NECK trial of 564 patients, most with HPV-related throat cancer, patients who had a PET-CT scan 12 weeks after chemoradiation, and a neck dissection only if the scan showed a poor response, had survival equal to that of patients who had a planned neck dissection for everyone. The PET-CT approach avoided surgery in most patients (54 neck dissections compared with 221) and cost less [4].

What the pathology report adds

After a neck dissection, the pathologist counts the nodes removed and the nodes involved, and looks for extranodal extension, meaning the cancer has broken through the capsule of the node into the surrounding tissue. Two large randomized trials, one in Europe (EORTC 22931) and one in North America (RTOG 9501), tested adding chemotherapy (cisplatin) to radiation after surgery for high-risk head and neck cancer [18, 19]. A combined analysis of both trials found that extranodal extension and cancer at the edge of the removed tissue (positive margins) were the two features for which adding chemotherapy clearly improved outcomes [20]. For this reason, finding extranodal extension usually leads to a recommendation for radiation with chemotherapy after surgery.

Risks and recovery

The technical goal of surgery to remove the lymph nodes is to thoroughly remove the lymph nodes in the area at risk while preserving normal structures. The surrounding structures are still at some risk. Possible effects include numbness to the skin of the neck and ear, weakness of the lower lip, and weakness in raising the arm above the head in a jumping jack position. These typically improve with time. Other risks include bleeding, infection, a collection of lymph fluid (a chyle leak, usually from dissection low on the left side), swelling, and neck stiffness.

The shoulder. Shoulder pain and weakness are the best-studied long-term effects. They come mainly from stretching or injury of the spinal accessory nerve, which runs through levels II and V. A systematic review of 75 studies found that shoulder pain was most common after radical neck dissection (10% to 100% across studies) and least common after selective neck dissection (9% to 25%). Keeping the accessory nerve lowers the risk of shoulder problems but does not remove it [21]. Exercise helps. In a randomized trial of patients with shoulder dysfunction after neck dissection, a 12-week progressive resistance training program reduced shoulder pain and disability and improved strength more than standard range-of-motion therapy [22]. A later meta-analysis rated the evidence for progressive resistance training as moderate in certainty [23]. Early referral to a physical therapist is reasonable for anyone with shoulder weakness after surgery.

Most patients go home within a few days of a neck dissection performed alone, often with a small drain that is removed in the hospital or at an early clinic visit. The length of stay is longer when the neck dissection is part of a larger operation.

• Link to a well-written article on the American Head and Neck Society website explaining the purpose and risks of removing lymph nodes in the neck.

sentinel node biopsy (sentinel lymph node biopsy)

The sentinel lymph node is the first lymph node, or small group of nodes, that drains (filters fluid from) a cancer. It is the node most likely to contain cancer if spread has occurred. Removing and testing the sentinel node can therefore show whether spread has occurred, even when it is too small to be felt on examination or seen on imaging. A sentinel node biopsy is the identification, removal and analysis of the sentinel lymph node (or sentinel lymph nodes, if a few good candidates are found) of a particular tumor.

How it is done

A small amount of a radioactive tracer is injected around the tumor, usually a few hours or the day before surgery, and a scan maps which nodes take it up. In the operating room, a handheld probe, and sometimes a dye, guides the surgeon to those nodes through a small incision. The nodes are examined in detail by the pathologist. If they contain cancer, further treatment of the neck is recommended, usually a neck dissection, radiation, or both. If they are clear, the rest of the neck is watched.

Evidence in oral cancer

For early (T1 and T2) mouth cancers with no enlarged nodes, sentinel node biopsy is an alternative to elective neck dissection.

• In a European study of 415 patients, a sentinel node was found in 99.5% of cases, and the test correctly identified 86% of patients with spread to the neck. Three-year disease-specific survival was 94% [24].

• A French randomized trial of 279 patients with early oral and oropharyngeal cancer found that control of cancer in the neck at 2 years was equivalent with sentinel node biopsy (90.7%) and neck dissection (89.6%). Hospital stays were shorter, and shoulder and neck function was better for the first 6 months, with the sentinel node approach [5].

• A Japanese randomized trial of 271 patients with early oral cancer found that 3-year overall survival with a sentinel node-guided approach (87.9%) was not inferior to elective neck dissection (86.6%), with better neck function [6].

The main limitation is that sentinel node biopsy misses some hidden spread, about 1 in 7 patients with node involvement in the European study [24], so careful follow-up of the neck is essential. It also requires experience and access to nuclear medicine. The ASCO guideline lists sentinel node biopsy as an option for selected patients with early oral cancer, in centers with expertise [17].

Evidence in melanoma and other skin cancers

Sentinel node biopsy is a standard staging test for many melanomas, including those of the head and neck. In the MSLT-I trial of 2,001 patients, sentinel node biopsy provided accurate staging and improved disease-free survival for intermediate-thickness and thick melanomas, although overall melanoma-specific survival did not differ between groups [25]. In the follow-up MSLT-II trial, patients with a positive sentinel node who were watched with ultrasound had the same melanoma-specific survival as those who had an immediate completion lymph node dissection, with much less lymphedema (6.3% compared with 24.1%) [26]. As a result, many patients with a positive sentinel node are now monitored with imaging rather than having a full dissection. Sentinel node biopsy is also used in selected high-risk skin cancers such as Merkel cell carcinoma; see the skin cancer page.

• Link to the National Cancer Institute webpage on sentinel node biopsy.

Lymphedema

Lymphedema is swelling (edema) of tissue caused by insufficient clearance of fluid by the lymphatic system. It can occur after surgery, radiation, or both, because both can interrupt the lymphatic channels and nodes that drain the head and neck. New drainage pathways develop over time, but treatments such as manual lymphatic drainage performed by a trained therapist, or a home-use device, speed up and improve clearance of lymphedema. When severe and untreated, lymphedema can restrict movement, which can allow scar tissue (fibrosis) to develop and limit movement permanently.

How common it is

Lymphedema after head and neck cancer treatment is more common than many patients expect. In a study of 81 patients examined at least 3 months after treatment, 75% had some form of lymphedema [27]. It can be external, visible as fullness under the chin, in the neck or in the face, or internal, affecting the lining of the throat and voice box, where it can contribute to hoarseness and trouble swallowing. Half of the affected patients had both types [27].

Treatment

• Complete decongestive therapy, led by a certified lymphedema therapist, combines manual lymphatic drainage (a gentle massage technique that moves fluid toward working lymph channels), compression garments, exercise and skin care. Manual lymphatic drainage is the best-studied treatment, but a systematic review found that most of the evidence comes from cohort studies rather than large randomized trials [28].

• Pneumatic compression devices designed for the head and neck can be used at home. In a randomized wait-list trial of 49 patients, daily use of such a device was safe and reduced visible swelling and pain, and patients reported better control of their lymphedema [29]. The trial was small, so the evidence is described as preliminary.

• Surgical options, such as liposuction or lymphatic microsurgery, have been reported in small numbers of patients with persistent lymphedema [28].

Starting therapy early, before fluid has turned into firm scar tissue, is generally recommended. Anyone who notices new or increasing swelling after treatment should mention it at follow-up.

• Link to an article for patients explaining lymphedema and its treatment on the American Head and Neck Society website.

tracheostomy

A tracheostomy is a surgical opening from the skin of the neck into the windpipe (trachea), so that air can pass in and out of the lungs without needing to pass through the nose, mouth and throat. A tube placed through the opening keeps it open. In head and neck surgery, a tracheostomy is most often temporary. It is used to protect the airway while swelling settles after major surgery of the mouth, throat or voice box, or when a tumor narrows the airway. A tracheostomy can be removed and the neck allowed to heal once the need for it has resolved.

Speaking and eating

A new tracheostomy usually prevents talking for a few days, after which speech is usually functional again. Once the airway above the tube is open enough and the tube's cuff (a small balloon that seals the windpipe) can be deflated, a one-way speaking valve can be placed on the tube. Air goes in through the tube and out through the voice box, allowing speech. The tracheostomy care consensus statement from the American Academy of Otolaryngology–Head and Neck Surgery addresses when cuffs can be deflated, when speaking valves can be used, and how communication is supported [30]. Many patients can eat with a tracheostomy in place, often after a swallowing evaluation with a speech-language pathologist; see the swallowing page.

Care and safety

The consensus statement covers the first tube change, routine cleaning, humidification, suctioning, emergencies such as a blocked or dislodged tube, and the education patients and caregivers need before going home [30]. A guideline from the American Association for Respiratory Care found that dedicated tracheostomy teams and standard care protocols are associated with fewer complications, shorter time to tube removal and more frequent use of speaking valves in hospitalized adults [31].

Removing the tube

Removal (decannulation) is considered once the reason for the tracheostomy has resolved, the patient can manage secretions and breathe comfortably through the mouth and nose, and a trial with the tube capped is tolerated [30]. Usually the tube is downsized or capped first. After removal, a dressing is placed and the opening usually closes on its own within days to a few weeks.

• Link to a fairly in-depth description of a tracheostomy, why it is done, how it is done, and how to care for it afterwards.

Summary

Most neck lumps are not cancer, but an adult with a lump that lasts more than about two weeks without a clear infection should have a full head and neck examination, imaging when cancer is a concern, and a needle biopsy rather than an open biopsy [1, 2, 9]. When cancer involves or threatens the lymph nodes of the neck, treatment often includes the nodes. Randomized trials show that elective neck dissection improves survival in early oral cancer [3], that PET-CT can safely spare many patients a neck dissection after chemoradiation [4], and that sentinel node biopsy is a reasonable alternative to elective neck dissection for selected early oral cancers and a standard staging tool in melanoma [5, 6, 25]. Shoulder weakness and lymphedema are the main long-term effects of treating the neck, and both respond to targeted therapy [22, 29]. A tracheostomy, when needed, is usually temporary.

References

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2. Kshirsagar RS, Anderson M, Boeckermann LM, et al. The Adult Neck Mass: Predictors of Malignancy. Otolaryngol Head Neck Surg. 2021;165(5):673-681. doi:10.1177/0194599821996293

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17. Koyfman SA, Ismaila N, Crook D, et al. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline. J Clin Oncol. 2019;37(20):1753-1774. doi:10.1200/JCO.18.01921

18. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med. 2004;350(19):1945-52. doi:10.1056/NEJMoa032641

19. Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med. 2004;350(19):1937-44. doi:10.1056/NEJMoa032646

20. Bernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (# 9501). Head Neck. 2005;27(10):843-50. doi:10.1002/hed.20279

21. Gane EM, Michaleff ZA, Cottrell MA, et al. Prevalence, incidence, and risk factors for shoulder and neck dysfunction after neck dissection: A systematic review. Eur J Surg Oncol. 2017;43(7):1199-1218. doi:10.1016/j.ejso.2016.10.026

22. McNeely ML, Parliament MB, Seikaly H, et al. Effect of exercise on upper extremity pain and dysfunction in head and neck cancer survivors: a randomized controlled trial. Cancer. 2008;113(1):214-22. doi:10.1002/cncr.23536

23. Almeida KAM, Rocha AP, Carvas N, et al. Rehabilitation Interventions for Shoulder Dysfunction in Patients With Head and Neck Cancer: Systematic Review and Meta-Analysis. Phys Ther. 2020;100(11):1997-2008. doi:10.1093/ptj/pzaa147

24. Schilling C, Stoeckli SJ, Haerle SK, et al. Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer. Eur J Cancer. 2015;51(18):2777-84. doi:10.1016/j.ejca.2015.08.023

25. Morton DL, Thompson JF, Cochran AJ, et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014;370(7):599-609. doi:10.1056/NEJMoa1310460

26. Faries MB, Thompson JF, Cochran AJ, et al. Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma. N Engl J Med. 2017;376(23):2211-2222. doi:10.1056/NEJMoa1613210

27. Deng J, Ridner SH, Dietrich MS, et al. Prevalence of secondary lymphedema in patients with head and neck cancer. J Pain Symptom Manage. 2012;43(2):244-52. doi:10.1016/j.jpainsymman.2011.03.019

28. Tyker A, Franco J, Massa ST, et al. Treatment for lymphedema following head and neck cancer therapy: A systematic review. Am J Otolaryngol. 2019;40(5):761-769. doi:10.1016/j.amjoto.2019.05.024

29. Ridner SH, Dietrich MS, Deng J, et al. Advanced pneumatic compression for treatment of lymphedema of the head and neck: a randomized wait-list controlled trial. Support Care Cancer. 2021;29(2):795-803. doi:10.1007/s00520-020-05540-8

30. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. doi:10.1177/0194599812460376

31. Mussa CC, Gomaa D, Rowley DD, et al. AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting. Respir Care. 2021;66(1):156-169. doi:10.4187/respcare.08206