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Neck Lump

The etiology of neck lumps are numerous and present a good opportunity to cover the "surgical sieve"

The surgical sieve allows you to answer a "what are the causes of..." question (whether on ward rounds or exams) in a systematic way. Using the VITAMIN CD acronym, for neck lumps it can be constructed like this:

Vascular: AV malformation, aneurysm 

Inflammatory: Submandibular sialadenitis

Traumatic: Ranula, haematoma

Autoimmune/allergic: Thyroiditis 

Metabolic: Goitre

Infective: Lymphadenitis, reactive lymphadenopathy, TB

Benign: Carotid body tumour/chemodectoma
Malignant: Metastatic squamous cell carcinoma, thyroid cancer, lymphoma

Congenital: Branchial cyst, thyroglossal duct cyst, dermoid cyst


If you'd like to read more about surgical sieves see
Now more about neck lumps...

Branchial cleft cyst


Thyroglossal duct cyst

Click on the images to get a description



Important points to cover when taking a neck lump history:

- Pain: chronic oral pain is suspicious of malignancy and referred unilateral otalgia can be associated with tumours at the base of the tongue, larynx and laryngopharynx (due to CN IX and X innervating both the pharynx and the ear)

- Dysphagia: range of occasional "catching" to inability of swallowing solids. Tumours generally cause gradual decline in ability to swallow food and weight loss. Nasal regurgitation or aspiration suggests neurological cause.

- Stridor: inspiratory sounds - caused by airflow blockage at or above the vocal cords i.e. is a symptom of upper respiratory obstruction.

- Hoarseness: suggests laryngeal disease - needs referral to ENT

- Constitutional symptoms: weight loss, night sweats, anorexia, chills/fevers - suggestive of malignancy

- Social factors: smoking and alcohol - highly associated with head and neck cancers. HPV from sexual partners is fast overtaking smoking as a risk factor

Pre-operative photo

Intra-operative photo

Cervical lymph nodes


Requires a full ENT examination as cancer can hide in a lot of places! A full ENT examination includes:

1. A thorough neck examination including the thyroid, lymph nodes, parotid & submandibular glands - Note: the neck is examined from behind the patient after initial inspection

Lumps should be assessed for:

Contour - smooth, craggy
Texture - soft, firm, hard or fluctuant

2. Examination of the ears

3. Anterior rhinoscopy - using a headlight and thudicum speculum

4. Oral cavity examination

5. Cranial nerve exam

6. Flexible nasendoscopy

7. Skin of the head and neck - looking for malignant lesions - especially important in New Zealand and Australia

8. Look for signs of hypo- or hyper- thyroidism

Please watch the videos at the start of each section as they highlight examination techniques and findings


1. Imaging: Ultrasound, CT or MRI

2. Cytology/histology: Fine needle aspiration (FNA) or biopsy

3. Blood tests
FBC - useful if haematological condition suspected
Thyroid function tests - useful in thyroid disease

After the above: ENT specialists, in conjunction with other specialties, may order tertiary investigations such as PET-CT and carry out tertiary invasive investigations such as panendoscopy. However, this is beyond medical school curricula

CT head and neck

The CT on the right is of a patient who presented with a neck lump and weight loss over 6 months. On examination the patient had a large neck mass at the right angle of the jaw. It was firm, smooth, minimally mobile and non-tender. The patient also had lymphadenopathy in the left cervical chain, left and right axillae.
Click on the picture to enlarge and see what you think it may be


The CT shows a ~4cm mass in the area of the jugulodigastric lymph node. The CT along with the history and examination is suggestive of a lymphoma.

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