An Overview of Neck Lumps
A good starting point is to decide whether the lump is infected or not. If it is infected, it will need ENT input sooner (via ENT emergency clinic or A&E) than if it is not.
Occasionally neck lumps can exert more serious local pressure effects like airway compromise, dysphagia, nerve palsies and so forth. This typically builds up gradually rather than coming on suddenly.
More commonly, local pressure effects are intrusive but not immediately serious like uncomfortable swallowing, tightness on neck movement and undesirable appearance. We would usually see people with serious complications as an emergency and others in outpatients.
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
The midline is the central dividing line.
- Level I: submental and submandibular. Along the body of the mandible to the angle, then inferomedially to the hyoid bone and then superomedially back to the mandible.
- Level II: upper sternomastoid. The upper third of the sternomastoid above the level of the hyoid bone.
- Level III: middle sternomastoid. The middle third of the sternomastoid between the level of the hyoid bone and the level of the cricoid cartilage.
- Level IV: lower sternomastoid. 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.
Possible diagnoses by level (anatomical sieve)
Anywhere: Lymph node; 'think' a) reactive eg tooth abscess or systemic infection; b) infective eg tuberculosis or toxoplasmosis; c) neoplastic eg lymphoma or metastasis. Feel for other lymph nodes in axilla and groin.
Sebaceous cyst, lipoma, skin neoplasms eg basal cell carcinoma, sarcoid nodule, lymphangioma (cystic hygromas are usually Level V but can be found anywhere)
Level I: submandibular gland pathology, tooth abscess, ranula, osteosarcoma
Level II: parotid pathology, branchial cyst
Level III: branchial cyst, paragangliomas eg carotid body tumour, carotid graft infection (eg post carotid endarterectomy)
Level IV: paragangliomas
Level V: cystic hygroma
Level VI and midline: thyroid goitre/nodule, thyroglossal duct cyst, dermoid and epidermoid cysts, thymic cyst
Possible diagnoses by surgical sieve
Lymphangioma (including cystic hygroma)
Thyroglossal duct cyst
Dermoid and epidermoid cysts
Vascular: paraganglioma, carotid aneurysm, carotid graft infection (eg post carotid endarterectomy)
Infective: reactive lymphadenopathy, toxoplasmosis, tuberculosis, actinomycosis
Neoplastic: lymphoma, thyroid neoplasm, salivary neoplasm, lymph node metastasis from aerodigestive tract primary, skin neoplasms eg basal cell carcinoma
Page last reviewed: 23 September 2016