Neck Lumps

A neck lump is an abnormal growth or swelling that occurs within the region of the jawline to the collarbone.

Neck lumps are very common, and can appear and disappear from time to time. Indeed, the majority of neck lumps are benign in nature, and resolve spontaneously or after conservative management or a course of antibiotics. The main cause of concern of a neck lump, however, particularly for an adult, is that it may be the first presentation of a cancer.

Clinical assessment and investigations are geared therefore towards excluding the possibility of an underlying malignancy.

There are three basic categories neck lumps:

• Congenital
• Infective and Inflammatory
• Neoplastic

Congenital Lumps

Congenital lumps present at birth, but are often not noticed until late childhood or early adulthood when they have had some time to grow. Besides a lump detectable by careful inspection or palpation, most of these lumps are completely asymptomatic. Common congenital lumps include:

• Thyroglossal cysts
• Branchial Cleft Cysts
• Cystic hygromas

Congenital neck lumps are often harmless, but may be recommended removal if they are symptomatic or are enlarging over time.

Infective and Inflammatory Lumps

Lymph nodes are small bean shaped structures that measure between 3 – 5mm and are stationed at various zones in the head and neck (termed "levels"), as well as at other regions of the body. A normal lymph node cannot usually be seen or felt. An integral part of the immune system, these lymph nodes filter tissue fluid from organs and structures within the head and neck, and mount a response by producing antibodies when subjected to a source of infection or inflammation. At that point they swell up, and become noticeable as tender lumps measuring between 1 – 2 cm in diameter at the sides and back of the neck. The infective agent in most instances is viral, such as the flu or a common cold, or bacterial as in throat, sinus or tonsil infections.

Infective or inflamed lymph nodes are the most common causes of head and neck lumps.

They are benign, and as with most infections, are self-limiting after symptomatic treatment or a short course of antobiotics. The lymph nodes will typically revert to their normal size within 4 – 6 weeks of resolution of the infection.

Any enlarged lymph node that persists beyond 4 – 6 weeks after recovery from an infection needs to be carefully evaluated to exclude any underlying malignancy.

It should be mentioned that Tuberculosis is fairly common in the Asian subcontinent, and a persistent enlarged lymph node is occasionally the first presentation for Tuberculosis in a young, otherwise healthy patient.

Neoplastic Lumps

Neoplasms are tumorous growths, that may be either benign (non-cancerous) or malignant (cancerous).

Neoplastic lumps most commonly arise from the

• Thyroid gland
• Major salivary glands like the parotid or submandibular gland
• Upper aero-digestive tract
• Lymph nodes

Thyroid lumps or nodules present as central neck swellings that move well on swallowing. They are otherwise completely asymptomatic. The vast majority of thyroid nodules are benign, but should be evaluated by an ultrasound and a fine needle biopsy.

Parotid and submandibular tumors present as painless lumps at the angle of the jaw (beneath the ear) or just below the jawline, on either side of the chin, respectively. The risk of cancer in a major salivary gland in inversely proportional to the size of the gland. 75 – 80% of parotid gland tumors are benign, while 40 - 50% of submandibular gland tumors are cancerous. Neoplasms of the parotid and submandibular gland are often recommended surgical removal.

Tumors arising from the upper aero-digestive tract, often simply referred to as Head and Neck tumors, may present with hard painless neck lumps, or with a variety of symptoms related to the site of origin, eg throat pain, difficulty swallowing and voice change for throat or voice box cancer, or a non-healing tongue ulcer or tooth socket for cancers of the oral cavity.

Hard, painless neck lumps are often the first manifestation of a head and neck cancer. These lumps represent lymph nodes swollen by the spread of cancer. Unlike lymph nodes swollen from infection or inflammation, lymph nodes swollen by cancer do not decrease or resolve over time.

Finally, cancer can arise from the lymph nodes themselves, a condition called lymphoma. Patients with lymphoma may be completely asymptomatic except for the neck lump, or may have systemic symptoms like fever, night sweats or joint pain. Lymphoma should be considered for a patient with persistently enlarged lymph nodes and no other detectable abnormality in the head and neck.

Patients with neoplastic lumps need to be very carefully assessed, and further investigations like an ultrasound, fibreoptic nasoendoscopy, fine needle aspiration biopsy (FNAB) and CT or MRI scans.