Neck Lumps
Differential Diagnosis
Common Diagnoses
- Reactive Lymphadenitis Due to a Local Infection
- Prominent Normal Lymph Nodes
- Goitre
- Sebaceous Cyst
- Thyroglossal Cyst
Occasional Diagnoses
- Thyroid Carcinoma
- Branchial Cyst
- Pharyngeal Pouch
- Cervical Rib
- Primary Lymphoma or Secondary Neoplastic Metastasis
Rare Diagnoses
- Tuberculosis of Cervical Lymph Nodes (King’s Evil; Scrofula)
- Actinomycosis
- Carotid Body Tumour or Aneurysm
- Sarcoidosis
- Cystic Hygroma
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Lymphadenitis | Normal Nodes | Goitre | Sebaceous Cyst | Thyroglossal Cyst | |
|---|---|---|---|---|---|
| Tender | Yes | No | Possible | No | No |
| Other Symptoms | Yes | No | Possible | No | No |
| Moves with Swallowing | No | No | Yes | No | Yes |
| Midline | No | No | No | Possible | Yes |
| Fixed to Skin | No | No | No | Yes | No |
Possible Investigations
Likely:TFTs if thyroid swelling.
Possible:FBC, ESR/CRP, CXR.
Small Print:Thyroid ultrasound, radioisotope studies, barium swallow, biopsy.
- TFT in all cases of thyroid enlargement: May reveal hypo- or hyperthyroidism.
- FBC and ESR/CRP in persistent enlarged nodes: Check WCC and investigate further if abnormal or if ESR/CRP high.
- CXR: May reveal primary lung carcinoma, lymphoma or other more obscure pathologies.
- Thyroid ultrasound and/or radioisotope studies if lump felt within the thyroid – usually arranged by endocrinologist after referral.
- Barium swallow: To confirm and outline a pharyngeal pouch.
- Biopsy: Specialist procedure to establish nature of a persistent, suspicious neck lump.
Top Tips
- Establish the patient’s concerns – cancer fear is common with this symptom.
- Unless the lump is obviously suspicious, employ the ‘diagnostic use of time’ – a judicious delay often resolves the problem, or it may reveal the true diagnosis.
- Children with normal or reactive neck glands are often presented by anxious parents. Take time to explain the nature of the problem to properly allay fears and prevent inappropriate repeat attendances.
Red Flags
- A neoplastic-type lymph node enlargement – usually involving a single, gradually enlarging and non-tender node – without any obvious cause should be referred urgently for detailed ENT assessment.
- Dysphagia with a neck lump is a serious symptom unless associated with a transient sore throat. Further investigation by endoscopy is necessary.
- Beware of a hard swelling developing rapidly in the thyroid – carcinoma must be excluded.