A painless, hard lump in the neck: when is it investigated, and in what order?

Most swellings you can feel in the neck are lymph nodes. Lymph nodes filter the fluid coming from the mouth, teeth, throat and ears, and they enlarge when there is an infection in this area. A node like this is usually painful and tender, slides when pushed with a finger and shrinks as the infection passes. Our page on swollen lymph nodes in the neck covers this common picture in detail. The subject of this page is narrower: a lump that is painless, hard and does not shrink on its own.

There is an age-related reason for this distinction. The 2017 guideline on the neck mass in adults from the American Academy of Otolaryngology-Head and Neck Surgery writes that in children most neck lumps are caused by infections, while in adults most persistent neck lumps are tumours, with malignant ones leading among them. The guideline stresses that a neck lump causing no symptoms can be the first or only visible sign of squamous cell cancer of the mouth and throat, lymphoma, or thyroid or salivary gland cancer. This sentence may seem frightening, but it does not say that any single lump is cancer; what it says is that a persistent lump should not be left unexplained.

The guideline's two-week rule is exactly this: if the person has no recent history of infection and the lump has been there for 2 weeks or longer without clearly getting smaller and bigger, or if nobody knows how long it has been there, the person is regarded as at high risk of a malignant cause. In other words, the rule is not to panic after two weeks; it is that a lump that has not changed for two weeks and cannot be explained by an infection should now be investigated rather than watched. A lump you noticed by chance, without knowing how long it has been there, falls into the same group.

The four signs on examination come from the same guideline: being fixed to the tissues underneath, a hard feel, being larger than 1.5 centimetres, and an ulcer on the skin over it. The presence of any one of them puts the person in the high-risk group. When checking yourself at home, you can note the following: whether the lump moves up and down when you swallow, whether it slides when pushed with a finger or stays fixed in place, and whether it is growing when measured at the same spot a week apart. These observations do not make a diagnosis, but they make it easier to tell the doctor how long it has been there and how it has changed.

The location matters too. A swelling in the lower front of the neck that moves when you swallow mostly comes from the thyroid gland. The NHS describes the main symptom of thyroid cancer as a lump in the lower front of the neck that is usually hard, slow-growing and painless; at the same time, it adds that thyroid enlargement, known as a goitre, is also usually painless and mostly not serious. A lump in front of the ear or at the angle of the jaw suggests a salivary gland, and one under the jaw a salivary gland or a lymph node. The NHS lists a gland you can feel just above or below the collarbone among the signs that should be shown to a doctor; NICE also recommends considering a chest X-ray, with the lungs in mind, for gland enlargement in this area at the age of 40 and over.

Being young and a non-smoker does not reduce this possibility to zero. MSD Manuals writes that around 70–80% of cancers of the tonsil and tongue base region (the oropharynx) in Europe and North America are linked to human papillomavirus (HPV), and that the age of patients has fallen as HPV has become more widespread. The same source states that in these cancers a neck lump, often filled with fluid, is a common first symptom, and that because the symptoms resemble an ordinary upper respiratory tract infection, referral to a specialist often takes months. The good news is in the same source: survival is much higher with HPV-related tumours.

A fluid-filled (cystic) lump is not automatically counted as benign either. The guideline recommends that a lump shown to be cystic by a fine needle or imaging continues to be investigated until a diagnosis is made, and that it is not assumed to be benign. In a study of 79 adults from Croatia and Sri Lanka, 38.8% of single cystic lumps in the side and back regions of the neck turned out to be malignant, compared with 3.3% of those in the front region. This is a small, retrospective series; the rates cannot be generalised, but it shows that a cystic lump at the side should not be brushed off as a cyst you were born with.

The mouth is part of this investigation too. The NHS lists among the symptoms of mouth cancer a mouth ulcer lasting longer than 3 weeks, a red or white patch in the mouth, a lump in the mouth or on the lip, difficulty swallowing and speaking, and a lump in the neck or throat, and states that a dentist can also assess these ulcers, patches and lumps. NICE, England's national guideline body, recommends considering the fast referral pathway for suspected mouth cancer with a persistent, unexplained neck lump, for suspected laryngeal cancer with an unexplained neck lump at the age of 45 and over, and for suspected thyroid cancer with an unexplained thyroid lump.

Neither list is for making a diagnosis; they are for seeing how quickly you need to act. The signs in the first list suggest a temporary swelling caused by infection, but any lump that has not shrunk in 2 weeks moves to the second list.

The sequence below is based on the American Academy of Otolaryngology-Head and Neck Surgery guideline on the neck mass in adults. There may be small differences from country to country and from hospital to hospital.

1. 1

   Ruling out urgent signs

   If there is shortness of breath, a wheeze or high-pitched sound when breathing in, or a fast-growing, painful swelling with a high temperature, the assessment is done at A&E; call 112. If these are absent, the next step is a planned examination.

2. 2

   History and risk assessment

   The doctor asks how long the lump has been there, whether it has grown, whether there was an infection beforehand, about smoking and alcohol, and whether there is a hoarse voice, difficulty swallowing, earache, weight loss or night sweats. The guideline counts this history as the first step in determining risk.

3. 3

   Examination of the mouth, throat and voice box

   For people at high risk, the guideline recommends a targeted examination that includes seeing the voice box, the base of the tongue and the inside of the throat. This is usually done in the clinic with a thin camera through the nose. The source of the lump is often found in one of these areas.

4. 4

   Contrast imaging of the neck

   The guideline's strong recommendation is a contrast CT or MRI scan of the neck for people at high risk. Ultrasound is also often used, especially for thyroid lumps and lumps near the surface.

5. 5

   Fine needle aspiration

   If the diagnosis is still unclear, the guideline recommends taking a cell sample with a fine needle rather than an open surgical biopsy. Removing the lump surgically at the outset, or cutting out a piece, can make later treatment harder if it turns out to be cancer.

6. 6

   Carrying on with a cystic lump and an unclear result

   The guideline recommends continuing the investigation of a cystic lump until a diagnosis is made; additional tests if no diagnosis can be made after the fine needle and imaging; and, if no source is found, examining the mouth, throat and voice box under general anaesthetic before an open biopsy.

7. 7

   A follow-up plan if the risk is low

   If the lump is not high risk, the guideline recommends that the doctor explains which changes call for coming back, and writes a check-up plan to confirm that the lump has disappeared or a diagnosis has been made. Follow-up does not mean forgetting about it.

The following are common causes of a painless neck lump in an adult. Examination, imaging and a fine needle together show which one it is.

The guideline writes that delays in diagnosis are common in this area, and that with cancer in the neck, delay directly worsens the stage and the outcome. The following are the commonest routes to that delay.

The length of the investigation varies with the hospital and the first results. The course below summarises the usual sequence and what you can do during this time.

1. The day you notice it

   Note the position and size of the lump and the date; take a photo with your phone. Try to remember whether you have recently had a throat, dental or ear infection.

2. The first 2 weeks

   A gland after an infection starts to shrink within this time. With a painless, hard lump, or if there is no history of infection, you can see a doctor before the 2 weeks are up; the guideline counts the duration and the examination signs as separate risk criteria, and a lump that is hard, fixed or larger than 1.5 centimetres is regarded as high risk regardless of how long it has been there.

3. The ear, nose and throat examination

   Examination of the mouth, throat and voice box is usually done at the first appointment; imaging and a fine needle follow.

4. The results

   The fine needle result may give the diagnosis or may call for further tests. If the result is unclear, the guideline recommends continuing the investigation; do not leave with an unclear result without a check-up date.

5. Follow-up

   If the lump is found to be low risk, go to the check-up on the date your doctor gives you. If the lump grows, becomes harder or a new symptom appears, do not wait for the check-up.

We do not give figures here, because the scope varies a great deal with the lump's risk group and the first results. The items that determine the scope:

Risk group

With a low-risk lump, an examination and follow-up may be enough, while with a high-risk lump imaging and a fine needle are added.

Type of imaging

Ultrasound, a contrast CT scan or an MRI scan; sometimes a whole-body scan.

Whether the diagnosis is made at the first attempt

If the fine needle result is unclear, further tests, an examination under general anaesthetic or a surgical biopsy may be needed.

Where the source lies

Whether the lump comes from the thyroid, a salivary gland, the mouth, the throat or a lymph node changes the treatment and the specialty involved.