Adult Neck Mass

SEPTEMBER 1, 2002 / VOLUME 66, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 831

The tail of each parotid gland extends belowthe angle of the mandible, inferior to the ear-lobe. The submandibular glands are locatedwithin a triangle bounded by the sternoclei-domastoid muscle, the posterior belly of thedigastric muscle, and the body of themandible. In older patients, these glands maybecome ptotic and appear more prominent.

Lymph nodes are located throughout thehead and neck region and are the most com-mon sites of neck masses. Fixed, firm, or mat-ted lymph nodes and nodes larger than 1.5 cmrequire further evaluation.

HistoryA careful medical history can provide

important clues to the diagnosis of a neckmass.1 The patient’s age and the size and dura-tion of the mass are the most significant pre-dictors of neoplasia.1 The patient’s age is mostimportant, because the risk of malignancybecomes greater with increasing age.2

The occurrence of symptoms and theirduration must also be determined. Acutesymptoms, such as fever, sore throat, andcough, suggest adenopathy resulting from anupper respiratory tract infection. Chronicsymptoms of sore throat, dysphagia, change invoice quality, or hoarseness are often associ-ated with anatomic or functional alterationsin the pharynx or larynx.

When an adult patientpresents with a neckmass, malignancy is thegreatest concern. Al-though differentiating

benign and malignant masses can be difficult,a methodical approach will usually result in anaccurate diagnosis and appropriate treatment.This article reviews the differential diagnosisof neck masses in adults and provides a frame-work for clinical decision-making.

Normal AnatomyAccurate diagnosis of a neck mass requires a

knowledge of normal structures. With practiceand experience, normal variations in anatomycan be distinguished from true pathologywithout the need for additional diagnostictesting or subspecialist consultation.

The hyoid bone, thyroid cartilage, andcricoid cartilages are located within the centralportion of the neck.The thyroid gland is usu-ally palpable in the midline below the thyroidcartilage. Carotid arteries are pulsatile and canbe quite prominent if atherosclerotic disease ispresent. The sternocleidomastoid musclesshould be palpated along their entirety, withcareful attention given to deep jugular lymphnodes.

The parotid glands are located in the preau-ricular area on each side in the lateral neck.

Family physicians frequently encounter neck masses in adult patients. A careful med-ical history should be obtained, and a thorough physical examination should be per-formed. The patient’s age and the location, size, and duration of the mass are impor-tant pieces of information. Inflammatory and infectious causes of neck masses, such ascervical adenitis and cat-scratch disease, are common in young adults. Congenitalmasses, such as branchial anomalies and thyroglossal duct cysts, must be consideredin the differential diagnosis. Neoplasms (benign and malignant) are more likely to bepresent in older adults. Fine-needle aspiration and biopsy and contrast-enhanced com-puted tomographic scanning are the best techniques for evaluating these masses. Anotolaryngology consultation for endoscopy and possible excisional biopsy should beobtained when a neck mass persists beyond four to six weeks after a single course ofa broad-spectrum antibiotic. (Am Fam Physician 2002;66:831-8. Copyright© 2002 Amer-ican Academy of Family Physicians.)

The Adult Neck MassERIC SCHWETSCHENAU, M.D., and DANIEL J. KELLEY, M.D.,Temple University School of Medicine, Philadelphia, Pennsylvania

This article exemplifies the AAFP2002 Annual ClinicalFocus on cancer: prevention, detection,management, support,and survival.

Recent travel, trauma to the head andneck, insect bites, or exposure to pets or farmanimals suggests an inflammatory or infec-tious cause for a neck mass. A history ofsmoking, heavy alcohol use, or previous radi-ation treatment increases the likelihood ofmalignancy.

A review of associated medical conditionsand previous treatments is useful in narrow-ing the differential diagnosis and formulat-ing an appropriate treatment plan.

Physical ExaminationThe skin on the head and neck should be

inspected for premalignant or malignantlesions resulting from chronic sun exposure.The otologic examination may show a sinusor fistula associated with a branchial anomaly.Evidence of chronic sinusitis or pharyngitissuggests reactive adenopathy as the most likelycause of a neck mass.

The physician should pay particular atten-tion to mucosal surfaces. For examination ofthe mucosa, dentures or other dental appli-ances may need to be removed. Palpation ofthe tongue, including the base of the tongue,can reveal occult lesions. Attention shouldbe paid to ulcerations, submucosal swelling,or asymmetry, particularly in the tonsillarfossa.

Examination of the larynx and pharynx isaccomplished by indirect or flexible laryn-goscopy. Palpation during swallowing or dur-ing a Valsalva’s maneuver may identify pathol-ogy within the larynx and thyroid gland.Rotation of the head in both flexion andextension aids examination of the posteriortriangle of the neck.

For initial assessment and serial examina-tion, the size of the mass may be measuredusing calipers or a tape measure.

Differential DiagnosisCONGENITAL ANOMALIES

Although congenital anomalies of the neckare more common in children, they alsoshould be considered in the differential diag-nosis of neck masses in adults.

Lateral Neck. Branchial anomalies are themost common congenital masses in the lateralneck. These masses, which include cysts,sinuses, and fistulae, may be present anywherealong the sternocleidomastoid muscle.3 Themasses are typically soft, slow-growing, andpainless. A history of infection, spontaneousdischarge, and previous incision and drainageis not uncommon.

Computed tomographic (CT) scanning canusually demonstrate cystic masses medial tothe sternocleidomastoid muscle at the level ofthe hyoid bone in the neck. Treatment is com-plete surgical excision, with preparation andexamination of frozen sections to excludemalignancy. Fine-needle aspiration and biopsyshould be performed before excision becauseof the possibility of cystic metastases fromsquamous cell carcinoma within Waldeyer’stonsillar ring.4

Other congenital anomalies of the lateralneck include cystic hygromas (lymphan-giomas) and dermoids.

Central Neck. The thyroglossal duct cyst isthe most common congenital anomaly of thecentral portion of the neck (Figure 1). Thisanomaly is caused by a tract of thyroid tissuealong the pathway of embryologic migrationof the thyroid gland from the base of thetongue to the neck. The thyroglossal duct cystis intimately related to the central portion ofthe hyoid bone and usually elevates along withthe larynx during swallowing. It may containthe patient’s only thyroid tissue.5 Thyroid car-cinoma has been reported within thyroglossalduct cysts.

With regard to thyroglossal duct cysts, theextent of preoperative assessment is contro-versial and ranges from physical examinationto serologic testing and diagnostic imaging.6,7

832 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 5 / SEPTEMBER 1, 2002

Malignancy is the greatest concern in a patient with a neck mass.

If serum thyroid function test results areabnormal, thyroid scanning should be per-formed to determine the amount of thyroidtissue in the neck. Some investigators advocateroutine ultrasonography or nuclear scanningto avoid permanent hypothyroidism. As withbranchial cysts, a history of infection, sponta-neous discharge, and previous incision anddrainage is not uncommon.

The treatment of choice is the Sistrunk pro-cedure, which involves complete excision ofthe thyroglossal duct cyst, including the cen-tral portion of the hyoid bone. If necessary,excision extends to the base of the tongue.

Other congenital midline neck massesinclude thymic rests and dermoids.

INFLAMMATORY AND INFECTIOUS CONDITIONS

Inflammation. Lymph node groups in theneck include the submandibular nodes withinthe submandibular triangle, the jugular chainof nodes located along the internal jugularvein, and the posterior-triangle nodes locatedbetween the sternocleidomastoid and trapez-ius musculature.

Inflammatory lymphadenopathy is typi-cally self-limited and resolves spontaneouslyover a period of weeks. Chronic sialadenitisas a result of salivary stones or duct stenosiscan result in gland hypertrophy and fibro-

sis.8 Chronic inflammation may result in amass within the submandibular or parotidglands. Treatment is usually conservativeunless pain is severe enough to justify surgi-cal excision.

Cervical adenitis is probably the most com-mon cause of an inflammatory mass in theneck. This condition is characterized bypainful enlargement of normal lymph nodesin response to infection or inflammation.9

Infection. Both bacterial and viral infectionscan cause neck masses. Occasionally, thelymph node becomes necrotic, and an abscessforms. Staphylococcus and Streptococcusspecies are the organisms most commonlycultured from neck abscesses.10 In manyinstances, however, the infection is polymicro-bial. A neck abscess usually requires intra-venous antibiotic therapy, and surgicaldrainage may be necessary.

Typical and atypical mycobacterial infec-tions are less common infectious causes ofneck masses. Mycobacterial infection gener-ally presents as a single enlarged node that israrely tender or painful. Tuberculous infectiongenerally presents in older patients with a his-tory of tuberculosis exposure and a positivepurified protein derivative (PPD) tuberculinskin test. Therapy with antituberculousantibiotics for six to 12 months is the treat-ment of choice.11

Atypical mycobacterial infection is usuallyfound in children with a nonreactive PPD skintest and no exposure history. Left untreated,the lymph node may drain spontaneously,leading to a chronic fistula. Surgical removalwith curettage is the standard treatment.Antibiotic therapy is generally reserved forrecurrent disease.12

In recent years, the incidence of typicalmycobacterial infections has increased in

Neck Mass


The risk of having a malignant neck mass becomes greaterwith increasing age.

FIGURE 1. Clinical appearance of thyroglossalduct cyst.

adults who test positive for the humanimmunodeficiency virus (HIV) and in chil-dren who test negative for the virus.13,14 HIVinfection should be considered in any adultwith cervical adenopathy, and appropriateserologic testing is indicated. HIV-positiveadult patients with a nontuberculous myco-bacterial infection involving cervical lymphnodes are typically treated with clar-ithromycin (Biaxin). Surgical intervention isreserved for use in patients with resistant orunresponsive disease.15

Cat-scratch disease is another less commoncause of neck masses. Accurate diagnosis maybe difficult because the adenopathy canappear days to months after the originalinjury. The etiologic agent in cat-scratch dis-ease (Bartonella henselae) was recently identi-fied.16 In general, only one lymph node isenlarged, and the node returns to normal sizewithout treatment.

Toxoplasmosis sometimes causes neckmasses. This infection generally presents as asingle enlarged node in the posterior trian-gle.17 The clinical course is benign, and antibi-otic therapy is not needed.18

Infectious mononucleosis usually presentswith acute pharyngitis, cervical adenopathy,and an elevated Epstein-Barr virus titer.

Fungal infections such as actinomycosis canalso cause neck masses.

TRAUMA

Neck masses resulting from trauma have acharacteristic history and physical findings.Although new or organized hematomas gen-erally resolve, they may persist as firm massesbecause of fibrosis.

Pseudoaneurysm or an arteriovenous fis-tula of a major arterial vessel in the neck israre and is usually associated with the shear-ing effects of major blunt-force trauma, suchas occurs in an automobile accident.19 If theinjury is not recognized at the time of initialtrauma, the patient may present later with apulsatile, soft, fixed mass over which a thrill orbruit can generally be auscultated.

METABOLIC, IDIOPATHIC, AND

AUTOIMMUNE CONDITIONS

Metabolic disorders are rare causes of neckmasses. Gout and tumoral calcium pyrophos-phate dihydrate deposition disease have beenreported to present as neck masses.20,21

Idiopathic conditions, such as inflamma-tory pseudotumor, Kimura’s disease, andCastleman’s disease, can also present with aneck mass.22-24 A neck mass may also be thepresenting symptom of sarcoidosis.25

Kimura’s disease is an uncommon chronicinflammatory condition involving subcuta-neous tissue. The etiology is unknown. Thedisease presents as a tumor-like lesion with apredilection for the head and neck region.

Castleman’s disease is a benign lympho-proliferative disorder that most frequentlyinvolves the mediastinal lymph nodes. Ittypically presents in the head and neck ascervical adenopathy of unknown etiology.Multiple biopsies showing florid lymphoidhyperplasia are frequently required to estab-lish the diagnosis.

NEOPLASM

Benign Masses. Lipomas, hemangiomas,neuromas, and fibromas are benign neo-plasms that occur in the neck. They are allcharacterized by slow growth and lack ofinvasion. Lipomas are soft masses that are iso-dense with a fat signal on magnetic resonanceimaging. Hemangiomas typically occur withcutaneous manifestations and are relativelyeasy to recognize. Neuromas may arise fromnerves in the neck and rarely present withsensory or motor deficits. Most of thesebenign masses are diagnosed at the time ofsurgical excision.26

Malignant Masses. Retrospective studies ofopen biopsies have shown high rates of malig-nancy for neck masses in adults.27 A malignantneoplasm in the neck can arise as a primarytumor or as metastasis from the upper aerodi-gestive tract or a distant site.

Thyroid cancer, salivary gland cancer,


lymphomas, and sarcomas are examples ofprimary malignancies.28 The most commonpresentation for thyroid or salivary glandcancer is an asymptomatic nodule withinthe gland. Further diagnostic evaluationand management of the nodule is alwaysindicated.29

Risk factors for mucosal head and neck can-cer (oral cavity, larynx, pharynx) includechronic sun exposure, tobacco and alcoholuse, poor dentition, industrial or environmen-tal exposures, and family history.30 Symptomsinclude a nonhealing ulcer within the oralcavity or oropharynx, persistent sore throat,dysphagia, change in voice, and recent weightloss.

Metastatic disease to lymph nodes of theneck from a head-and-neck primary site usu-ally follows well-defined patterns31,32 (Figure 2).For example, cancers of the oral cavity typicallymetastasize to the submandibular triangle (Fig-ure 3), whereas cancers from most other sites in

Neck Mass


FIGURE 2. Lymph node groups with the most likely sites of the primary lesion.

FIGURE 3. Clinical appearance of cervicallymph node metastasis to the submandibulartriangle of the neck.

Upper jugular chain orjugulodigastric area

(posterior auricular nodes): metastasis from nasopharynx

Posterior triangle (posterior-triangle lymphnodes): metastasis from nasopharynx, posteriorscalp, ear, temporal bone,or skull base

Lower jugular chain area (supraclavicular nodes): metastasis from thyroid, pyriform sinuses, upper esophagus; rarely, from primary tumor below clavicle

Submandibular triangle(submandibular group):metastasis from anteriortwo thirds of tongue, floorof mouth, gums, mucosaof cheek

Submental triangle (submental nodes): rarelyinvolved early, except inmetastasis from cancer of lip

Midjugular chain area (deep lateral cervical nodes): metastasisfrom any portion of oral cavity,pharynx, or larynx (especiallyfrom growths in Waldeyer’s tonsillar ring [nasopharynx, tonsil, base of tongue])

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the head and neck spread to the lateral neck.Patients with palpable lymphadenopathy inthe supraclavicular fossa should be evaluatedfor malignancy below the clavicles (e.g., lungcancer).

ManagementMany inflammatory lymph nodes

resolve with no treatment, although closeobservation is required. A single course oftherapy with a broad-spectrum antibioticand reassessment in one to two weeks is areasonable treatment choice when a patientwith a neck mass has signs and symptomsof an inflammatory process (i.e., fever,painful mass, erythema) or a history ofrecent infection.

Thyroid and salivary gland nodulesshould undergo fine-needle aspiration andbiopsy. This diagnostic procedure shouldalso be performed when a neck mass per-sists beyond four to six weeks. In experi-enced hands, the sensitivity and specificity

of fine-needle aspiration and biopsy exceed90 percent.33

Local recurrences have been reported fol-lowing stereotactic core-needle biopsy ofsolid tumors, including breast, liver, colon,pancreas, and lung cancers.34,35 The use oflarge-diameter needles has been associatedwith the seeding of head and neck carcino-mas.36,37 However, no cases of seeding or dis-semination have been reported with the useof fine-needle aspiration, and the risk oftumor seeding of the biopsy site is consideredto be exceedingly low. Fine-needle aspirationand biopsy are typically indicated when nocause for a neck mass is found on the initialevaluation.38

Contrast-enhanced CT scanning is thebest imaging technique for evaluating a neckmass. This modality should be used when-ever the diagnosis is unclear. Assessment of aneck mass also requires a recent chest radio-graph. Routine serologic tests can excludemetabolic disorders and other uncommoncauses of neck masses in the vast majority ofpatients.

Cytopathologic differentiation of benignand malignant adenopathy can be difficult.Cytologic or radiographic evidence of condi-tions other than reactive lymphadenopathywarrants consultation with an otolaryngolo-gist for endoscopic evaluation, with possibleexcisional biopsy or neck dissection.

Biopsy should be considered for neckmasses with progressive growth, locationwithin the supraclavicular fossa, or size greaterthan 3 cm. Biopsy also should be considered ifa patient with a neck mass develops symptomsassociated with lymphoma. Frozen-sectionexamination of the mass followed by neck dis-section should be performed if the massproves to be metastatic carcinoma.

An algorithm for the evaluation and man-agement of a neck mass in an adult patient isprovided in Figure 4.

The authors indicate that they do not have any con-flicts of interest. Sources of funding: none reported.


The Authors

ERIC SCHWETSCHENAU, M.D., is chief resident in the Department of Otolaryngologyand Bronchoesophagology at Temple University School of Medicine, Philadelphia. Dr.Schwetschenau received his medical degree from the University of Cincinnati Collegeof Medicine.

DANIEL J. KELLEY, M.D., is assistant professor and director of head and neck oncol-ogy/skull base surgery in the Department of Otolaryngology and Bronchoesophagol-ogy at Temple University School of Medicine. Dr. Kelley graduated from Bowman GraySchool of Medicine, Wake Forest University, Winston-Salem, N.C. He completed a res-idency in otolaryngology–head and neck surgery at the University of Cincinnati Schoolof Medicine and a fellowship in advanced training in head and neck surgery at Memo-rial Sloan-Kettering Cancer Center, New York City.

Address correspondence to Daniel J. Kelley, M.D., Temple University School of Medi-cine, Department of Otolaryngology and Bronchoesophagology, 3400 Broad St.,Philadelphia, PA 19140 (e-mail: [email protected]). Reprints are not avail-able from the authors.

Fine-needle aspiration and biopsy for a neck mass are typically indicated when no cause is found for a mass at theinitial evaluation.

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Neck Mass


Neck Mass in an Adult

Congenital anomaly Inflammatory or infectious condition

Neoplasm (also basedon consideration of riskfactors, including age>45 years)

CT (contrast medium optional)

Single course of broad-spectrumantibiotic; close follow-up for 2 to 4 weeks

Contrast-enhanced CT scan andfine-needle aspiration biopsy

Observation; reassessment in 2 to 4 weeks

Chest radiograph and PPD tuberculin skin test

Contrast-enhanced CT scan and fine-needle aspiration biopsy

Subspecialist consultation

Positive PPD test Negative PPD test or findingssuggestive of neoplasm

Treatment or subspecialistconsultation

Management based on histology and stage

Excisional biopsy

Clinical improvement

No clinical improvement orprogression of neck mass

Subspecialist consultationfor endoscopy

Diagnosis suggested by history and physical examination

Adult patient presenting with neck mass

FIGURE 4. Evaluation and management of a neck mass in the adult patient. (CT = computedtomographic; PPD = purified protein derivative)

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