An Overview of Neck Lumps
In the emergency setting, a good starting point is to decide whether the lump is infective or not. If it is, it will need ENT input sooner (via ENT emergency clinic or emergency department) than if it is not. If a lump is not infective, the next priority is to consider whether it could represent a malignancy.
Potentially malignant neck lumps should be seen in a consultant-led head and neck clinic, and not in ENT emergency clinic. However, people with malignancies do occasionally present acutely via the emergency department. From time to time, very large neck lumps can exert local pressure effects leading to airway compromise, dysphagia, nerve palsies etc. If a patient with a large neck lump shows any signs of airway compromise, follow the algorithm in the Airway section and inform your senior.
As always, a careful history and examination will yield a short differential diagnosis. Head and neck specialists prefer to divide the neck into 'levels' with the following boundaries:
The American HEAD AND NECK SOCIETY (AHNS) LEVELS OF THE NECK
Figure 1. The levels of the neck, with surface anatomical landmarks.
This is a brief/simplified version of the levels of the neck using anatomical landmarks. The midline is the central dividing line.
Level I: submental and submandibular triangles. Along the body of the mandible to the angle, then inferomedially along disgastric to the hyoid bone.
Level II: the upper third of the sternomastoid above the level of the hyoid bone.
Level III: the middle third of the sternomastoid between the level of the hyoid bone and the level of the cricoid cartilage.
Level IV: the lower third of the sternomastoid beneath the level of the cricoid cartilage.
Level V: posterior triangle. The triangle formed by the posterior border of sternomastoid, anterior border of trapezius and superior border of the clavicle.
Level VI: anterior compartment. Below the hyoid bone, between both common carotid arteries inferiorly down to the sternum.
Figure 2. The AHNS levels and sublevels of the neck. Taken from: Consensus Statement on the Classification and Terminology of Neck Dissection, Arch Otolaryngol Head Neck Surg
Possible diagnoses by level (anatomical sieve)
This list is not exhaustive and rare diagnoses are marked as such.
Anywhere: Enlarged lymph node: Think a) reactive e.g. secondary to tonsillitis, dental abscess or systemic infection; b) infective e.g. tuberculosis or toxoplasmosis; c) neoplastic e.g. SCC, lymphoma or other malignancy.
Sebaceous cyst, lipoma, skin neoplasms e.g. basal cell carcinoma, sarcoid nodule (rare), lymphangioma (rare; cystic hygromas are usually Level V but can be found anywhere)
Level I: submandibular gland infection/blockage (sialadenitis), dental abscess, submandibular gland tumour.
Level II: lymph node, parotid tail lump (usually benign), branchial cyst
Level III: branchial cyst, lymph node
Level IV: lymph node
Level V: lymph node, cystic hygroma, lipoma
Level VI and midline: thyroid multinodular goitre/single nodule, thyroglossal duct cyst, dermoid cyst.
Possible diagnoses by surgical sieve
Congenital:
Lymphangioma (including cystic hygroma)
Branchial cyst
Thyroglossal duct cyst
Dermoid and epidermoid cysts
Thymic cyst
Acquired:
Vascular: paraganglioma, carotid aneurysm
Infective: reactive lymphadenopathy, toxoplasmosis, tuberculosis, actinomycosis
Inflammatory/granulomatous: sarcoidosis
Neoplastic: lymphoma, thyroid neoplasm, salivary neoplasm, lymph node metastasis from aerodigestive tract primary, primary skin neoplasms e.g. basal cell carcinoma
Page last reviewed: 1 December 2022