Neck swellings and lumps
Neck lumps are a classic surgical and medical exam topic.
They can arise from congenital, inflammatory, or neoplastic causes.
👉 Think in terms of position, pathology, movement, and consistency.
A systematic approach with history, examination, and investigations is essential to avoid missing sinister causes like lymphoma or thyroid cancer.
📍 Neck Lumps by Position
- Midline
- Thyroid goitre (moves on swallowing)
- Thyroid nodule / cancer
- Thyroglossal cyst (moves on tongue protrusion 👅)
- Dermoid cyst (does not move)
- Anterior Triangle
- Lymphadenopathy (reactive, TB, lymphoma, metastasis)
- Submandibular gland swelling (stone, tumour)
- Branchial cyst (young adults, lateral, fluctuant)
- Carotid body tumour (pulsatile, splaying of vessels)
- Carotid artery aneurysm (expansile pulsation)
- Laryngocele (swelling ± hoarseness, enlarges with cough)
- Pharyngeal pouch (elderly, regurgitation of food, gurgling lump)
- Posterior Triangle
- Lymphadenopathy (infection, TB, lymphoma, metastasis)
- Cystic hygroma (paediatric, congenital, transilluminates)
- Cervical rib (palpable bony structure, may cause thoracic outlet syndrome)
- Subclavian aneurysm (pulsatile mass, bruit)
- Parotid Region
- Parotid gland tumour (painless, slow-growing, facial nerve involvement = malignant)
- Sialolithiasis (stone causing pain on eating)
- Parotitis (painful swelling, often infective e.g. mumps, bacterial)
📋 History & Examination
- Onset & Duration: Acute (infection, abscess) vs chronic (cancer, cyst).
- Pain: Painful lumps = infection/inflammation; painless = tumour until proven otherwise.
- Systemic features: B symptoms (fever, night sweats, weight loss) → lymphoma.
- Movement:
- With swallow ➝ thyroid lesions
- With tongue protrusion ➝ thyroglossal cyst
- Pulsatile/expansile ➝ vascular lesion
- Examination: Site, size, shape, surface, consistency, mobility, transillumination, overlying skin changes.
🔬 Investigations
- 🧪 Bloods: FBC, ESR/CRP, thyroid function, EBV/monospot if viral.
- 🖼️ Imaging: Ultrasound ± FNAC (first-line for most neck lumps); CT/MRI if deep or malignant suspicion.
- 🧬 Biopsy: FNAC for diagnosis (except suspected lymphoma → excisional biopsy preferred).
🛠️ Management
- Infective causes: Antibiotics, drainage if abscess.
- Congenital cysts (thyroglossal, branchial, dermoid): Surgical excision (e.g. Sistrunk’s for thyroglossal cyst).
- Neoplastic:
- Benign ➝ surgical excision if symptomatic.
- Malignant ➝ MDT approach: surgery ± radiotherapy/chemotherapy.
- Vascular: Vascular surgery review ± embolisation/resection.
🧾 Key Pathologies
| Pathology |
Typical Features |
Diagnosis |
Management |
| Thyroglossal Cyst 👅 |
Midline, moves with tongue out/swallow, children/young adults. |
USS ± FNAC |
Sistrunk’s operation (cyst + central hyoid excision) |
| Branchial Cyst 💧 |
Lateral, anterior to SCM, young adults, fluctuant ± infected. |
USS ± FNAC |
Surgical excision |
| Cystic Hygroma 🌟 |
Congenital, posterior triangle, transilluminates, soft, children. |
USS/MRI |
Surgical excision or sclerotherapy |
| Carotid Body Tumour ⚡ |
At bifurcation, mobile laterally but not vertically, pulsatile. |
CT/MRI angiography |
Surgical resection ± embolisation |
| Lymphadenopathy 🧬 |
Tender = infection, rubbery = lymphoma, hard = metastasis. |
USS + FNAC, bloods, CXR (TB/lymphoma), biopsy if unclear. |
Treat cause (antibiotics, TB treatment, oncology referral). |
| Parotid Tumour 🦠 |
Painless, slow-growing, firm. Facial nerve palsy = malignant. |
USS + FNAC |
Superficial/total parotidectomy ± radiotherapy |
💡 Clinical Pearls
- 👉 Painless lump = malignancy until proven otherwise.
- 👉 Midline vs lateral + movement on swallow/tongue protrusion helps localise origin.
- 👉 Always assess for systemic signs (weight loss, fever, night sweats, hepatosplenomegaly).
- 👉 FNAC is first-line for most neck lumps but avoid excision biopsy unless lymphoma suspected.
Cases — Neck Lumps
- Case 1 — Thyroid Nodule (Endocrine):
A 35-year-old woman presents with a painless anterior neck lump noticed 3 months ago. Exam: firm, mobile thyroid nodule that moves with swallowing. Thyroid function tests are normal.
Diagnosis: Solitary thyroid nodule (most benign, but malignancy must be excluded).
Management: Ultrasound ± fine needle aspiration (FNA); thyroid MDT if suspicious.
- Case 2 — Branchial Cleft Cyst (Congenital):
A 20-year-old man has a soft, fluctuant swelling on the left side of his neck, just anterior to the sternocleidomastoid. It enlarges intermittently after upper respiratory tract infections.
Diagnosis: Branchial cleft cyst.
Management: Ultrasound to confirm cystic nature; surgical excision if recurrent or symptomatic.
- Case 3 — Lymphoma (Malignant):
A 28-year-old man presents with a progressively enlarging, firm, non-tender cervical lymph node. He also has night sweats, fever, and weight loss.
Diagnosis: Lymphadenopathy due to Hodgkin lymphoma.
Management: Excisional lymph node biopsy (not FNA); staging with CT/PET; chemotherapy (ABVD regimen).
- Case 4 — Reactive Lymphadenitis (Infective):
A 10-year-old boy presents with a tender, enlarged right anterior cervical lymph node following a sore throat. Exam: erythematous pharynx, fever.
Diagnosis: Reactive cervical lymphadenitis secondary to streptococcal pharyngitis.
Management: Oral antibiotics (penicillin or amoxicillin), analgesia, reassurance; usually resolves in 1–2 weeks.
Teaching Commentary 🧾
Neck lumps can be grouped into 4 key categories:
1. Congenital (thyroglossal cyst, branchial cyst),
2. Inflammatory/infective (reactive lymphadenitis, abscess),
3. Neoplastic (lymphoma, thyroid cancer, metastatic SCC),
4. Miscellaneous (vascular malformations, dermoid cysts).
Key exam point: ask if the lump moves with swallowing (thyroid) or with tongue protrusion (thyroglossal cyst). Ultrasound is first-line for most, with FNA or biopsy depending on suspicion.
