Neck swellings are commonly encountered and present at all ages. The differential diagnosis of a neck mass is extensive. In the community inflammatory lymph nodes are most common, while in the hospital environment the thyroid swelling or goiter is most frequently seen. It therefore behoves all clinicians to understand the embryology and anatomy to aid with making the correct diagnosis and following an appropriate management algorithm.

Anatomy of the normal neck

The normal glandular structures are consistent in their location; the thyroid gland is a bilobed structure located along the midline of the neck on either side of the trachea, above the sternal notch, and below the cricoid cartilage. The parotid gland is found in front of the ear or pinna, and extends from the cheek bone (zygoma) above, down and behind to the mastoid tip, below into the upper neck near the hyoid bone and forward onto the cheek for about 2–3 cms. The submandibular gland, is, located below the posterior half of the mandible, but not extending beyond the angle of the mandible, above the hyoid bone (Figure 23.1) (see Chapter 1).

Figure 23.1 Common neck lumps.

Within each side of the neck there are located more than 100 lymph nodes, usually impalpable, and distributed mainly along the jugular chain, to be found within each of the 5 clinically and anatomically described levels in the anterior neck and in the single but divided level in the posterior neck. The posterior border of the SCM muscle separates the anterior neck from the posterior neck (Figure 23.2). While there are other major structures within the neck, such as nerves, blood vessels, muscles, cartilages and bones, knowledge of their anatomic outline should allow the examiner to consider any such abnormal enlargement or swellings in certain anatomic locations to be included within a differential diagnosis.

Figure 23.2 The lateral neck. Anterior triangle is bounded posteriorly by the posterior border of the SCM muscle, and the posterior triangle is between the posterior border of the SCM and the anterior border of the trapezius muscle and the clavicle inferiorly.

Reaching a diagnosis

The first consideration should be the patient’s age group (Table 23.1). In general, neck masses in children and young adults are more commonly inflammatory than congenital and only occasionally neoplastic. However, the first consideration in the older adult should be that the mass is neoplastic. The “rule of 80” is often applied as a useful guide. In adults 80% of non-thyroid neck masses are probably neoplastic and 80% of these masses are malignant. This statement probably refers to masses over 2 cm in diameter, in patients over 35 years of age, and for clinicians who are not regularly seeing patients with neck masses. A neck mass in a child, on the other hand, has a 90% probability of being a benign condition of which 55% are congenital.

Table 23.1 Age in relation to possible diagnoses.

History

Onset and duration of symptoms is one of the most important historical points. Inflammatory disorders are usually acute in onset and resolve within 2–6 weeks. Cervical lymphadenitis is often associated with a recent upper respiratory tract infection. In contrast, congenital masses are often present since birth as a small, asymptomatic mass which enlarges rapidly after a mild upper respiratory tract infection. Metastatic carcinoma tends to have a short history with progressive enlargement. Transient post-prandial (after meals) swelling in the submandibular or parotid area is suggestive of salivary gland duct obstruction—a stone or a stenosis. Bilateral diffuse tender parotid enlargement is suggestive of parotitis, most commonly mumps, usually school children, and manifests in local epidemics and can only get the disease once!

One must also be mindful that associated symptoms both specifically to the mass and symptoms suggestive of a systemic process such as fever, night sweats, fatigue or weight loss (consider lymphoma) must be sought and documented (Figure 23.3). Symptoms of sore throat or upper respiratory tract infection may suggest an inflammatory cervical lymphadenopathy. Persistent hoarseness or sore throat, pain on swallowing, cough and sensation of a lump in the throat are risk symptoms of an upper aerodigestive tract malignancy. The symptoms are particularly relevant in patients who are over the age of 40 years and smoke cigarettes. These are the patients who should be referred via the ‘Two week proforma’ to the local ENT service.

Figure 23.3 An adult patient with a large neck mass with systemic symptoms—proven lymphoma.

Location

While congenital and organ masses are more consistent in their locations, metastatic nodes follow a predictive pattern and help in identifying the primary malignancies (see Chapter 1).

Examination

A full head and neck examination (see Chapter 1) including mucosal surfaces is important, especially when suspecting malignancies (Table 23.2).

Table 23.2 Examination checklist.

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