The Dreaded Neck Lump
Presenting to a doctor with a lump in the neck is a fairly common manifestation for head and neck malignancy, lymphoma, thyroid tumours or other cancers. However, it is to be noted that many “lumps” in the neck are not necessarily cancers.
For some patients, having a sore throat and a big lymph node in the neck may be related. However, for many individuals, there are often no related symptoms. This noted lump or mass in the neck may be something new or has been there for a period of time. It may also be noticed by a spouse, family member, friend or family doctor.
The neck lump or neck mass may be the only clue to a potentially serious underlying condition in the adult and needs evaluation. There are many potential causes of a neck lump.
History and physical exmination
In deciding if a patient presenting with a neck lump is serious, the history and physical examination of the patient plays a very important role in the evaluation. The age of the patient is important and an adult with a neck mass above 40 years old should be considered neoplastic and potentially malignant. Any enlarging neck lump should also be evaluated regardless of age.
Some aspects of history and exmination to consider are:
Neck lumps can be lymph nodes. Lymph nodes are present throughout the body and an examination of other lymph node sites is needed. The causes of multiple lymph node sites enlargement could be lymphoma or infections (such as infectious mononucleosis, human immunodeficiency virus (HIV) etc).
The neck mass that has been present for years without change or minimal change is likely to be benign (not cancer). However, there are some low grade lymphomas or low grade malignancies that can also present with a lymph node for many years. Some of the benign tumours can be salivary gland tumours, or tumours related to nerves (peripheral nerve sheath tumours, paragangliomas).
A neck lump that enlarges quickly could be an aggressive lymphoma or an infection causing lymph node enlargement. There may be associated symptoms related to fever, weight loss or night sweats. A rapidly enlarging mass can also cause external compression and impinge on surrounding structures in the neck such as major blood vessels and nerves.
This in turn may give rise to symptoms such as difficulty swallowing, drooping of eyelids (ptosis) or double vision (diplopia). Tuberculosis still exists in Singapore and may be a cause of neck lymphadenopathy. At OncoCare Cancer Centre, we have also seen patients with two concurrent pathologies. A recent patient had lung cancer and tuberculosis (TB) of the neck lymph node and vocal cords.
A mass that changes in size with time and may increase with infection such as flu or upper respiratory tract infection may turn out to be a congenital cyst.
The thyroid gland lies in the middle of the neck and in some people it may be enlarged. Thyroid cancers present as lumps as well which move with the thyroid gland on swallowing. However, not all lumps in the thyroid are thyroid cancers.
Sinister symptoms that should prompt evaluation of the neck mass are:
Pain in the mass – which may be related to rapid growth of tumour or direct invasion.
Voice changes – hoarseness may be related to vocal cord palsy.
Difficulty swallowing food or repeated choking of food or water.
Pain in the ear, hearing loss, fullness in the ear.
Blood from the nose (epistaxis), blood when one blows his nose, or blood in the phlegm especially in the mornings from swallowed blood may be an early indication of nasopharyngeal cancer (NPC). Nasopharyngeal carcinoma is not common in western populations compared to South East Asians. A high index of suspicion is needed for diagnosis.
Eye and vision changes such as double vision, drooping eyelids especially if on one side only.
Systemic symptoms refer to symptoms not just localised to the head and neck area. These may be fever, weight loss, night sweats, and joint pains. Systemic lupus erythematosus (SLE) for example, an autoimmune condition can have multiple lymph nodes enlargement but also other associated systemic symptoms.
Blood Tests, Imaging and Diagnostic Studies
Some causes of an enlarged lymph node in the neck are relatively straightforward such as an infected tooth. In other cases, the diagnosis is not so clear a series of blood tests and imaging may be needed.
A simple full blood count shows if the white cell count is elevated as in an infection. Other blood tests such as blood cultures, serology to look for certain viral conditions, autoimmune markers are sometimes done. These tests may be guided by the history and physical examination mentioned earlier.
Imaging with CT scan of the neck and in Singapore, we also need the CT scan to cover the posterior nasal space (PNS) especially when nasopharyngeal cancer (NPC) is suspected. MRI scan or PET/CT whole body scan may be arranged sometimes.
For some patients, a fine needle aspiration can provide initial tissue sampling, but is not always definitive. If lymphoma is suspected, removal of a whole lymph node would often be needed. NPC diagnosis would need an endoscopy to look into the posterior nasal space (PNS) to do a biopsy.
A neck mass is a worrying thing for some patients. This is especially true if it is newly discovered. Unfortunately, no amount of explanation and self-assurance will make it disappear if it is truly something that needs evaluation. Patients should have their diagnosis sorted out in an efficacious manner as this will affect early treatment. At OncoCare Cancer Centre, Singapore, we can arrange for evaluation quickly for our patients. We can arrange blood tests or CT scans within the same or next working day if patients need them. Many malignancies or cancers can be treated if detected early!
Dr Kevin Tay
ABIM Int. Med (USA)
ABIM Med Onc(USA)
FAMS (Medical Oncology)
Dr Peter Ang
MMed (Int Med)
FAMS (Medical Oncology)