Management of a neck lump is something many GPs will regularly face. It is important to be able to triage patients and identify those who may need urgent specialist management.
Broadly, neck lumps in an adult patient can be placed into the following common categories:
- Inflammatory lesions
- Neoplasms – benign
- Neoplasms – malignant
- Vascular lesions
- Congenital lesions
A good history should either enhance or reduce the level of concern. Is the lump new, changing or related to certain activities? Is the lump painful or painless?
A neck lump that is new, painless, steadily increasing in size, and unilateral should be treated with suspicion of neoplastic aetiology. The full head and neck history will then allow further characterization, particularly when combined with general features such as smoking and alcohol history, skin cancers and family history of thyroid cancer.
In Queensland, sun exposure and skin cancer risk should not be underestimated. Secondary metastases to the parotid and upper neck from a facial or scalp squamous cell carcinoma (SCC) are a common entity faced by a head and neck surgeon. Other common neoplasms would be a parotid gland pleomorphic adenoma, an upper neck metastasis from an oropharyngeal (tonsil and tongue base) SCC, and papillary thyroid cancer metastases.
An in-depth examination will include the neck (including the parotid and thyroid glands), oral cavity, skin and the nose and ears. History taking will have revealed any voice change or breathing difficulties already.
Standard blood tests for infection, inflammatory markers will be helpful particularly if fevers are part of the presentation profile, but imaging and cytological examination are the next important step. A good CT scan of the neck can be combined with staging scans, an MRI can provide important soft tissue detail, and a PET scan can assist in staging or finding a primary when malignancy is confirmed, but USS +/- FNA is the next critical investigation.
An USS guided FNA will increase the chances of an accurate result many-fold and in the uncommon vascular lesion (such as a glomus tumour or vascular malformation) the ultrasonographer will identify those features and abandon the FNA. If there is some concern about urgency and waiting for the above result, a phone call to a trusted Head and Neck Surgeon will allow discussion and planning to ensue in a timely manner.