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 A&E) 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 occasionally malignancies can present via the emergency department.

Occasionally neck lumps can exert local pressure effects leading to airway compromise, dysphagia, nerve palsies etc.  If a patient with a 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 Memorial Sloan-Kettering Cancer Centre boundaries

    Figure 1. The levels of the neck, with surface anatomical landmarks.

 

Figure 1. The levels of the neck, with surface 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 to the hyoid bone and then superomedially back to the mandible.
  • 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. The anterior part of the neck along the hyoid bone to its lateral tip then inferiorly along the anterior border of sternomastoid up to the midline.
    Figure 2. The levels and sublevels of the neck. Taken from: Consensus Statement on the Classification and Terminology of Neck Dissection,   Arch Otolaryngol Head Neck Surg

 

Figure 2. The 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.

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: 27 July 2018