Neck Lump Algorithm · Reasoning GP

Safety

Red Flags — Exclude Malignancy and Emergency Causes

Done

Any neck lump presenting for the first time in a patient over 40 must be assumed malignant until proven otherwise. Don't be falsely reassured by a "soft" or "mobile" lump.

Hard, fixed, non-tender lump Especially in patient >40 or smoker/drinker. No improvement after 3 weeks → 2WW Head & Neck

Persistent lump >3 weeks Any age, any character. Unexplained neck mass >3 weeks without obvious infective cause → 2WW Head & Neck

Associated dysphagia / odynophagia Difficulty or pain on swallowing with neck mass → 2WW Head & Neck / UGI

Hoarseness >3 weeks With neck lump — laryngeal malignancy with nodal involvement → 2WW Head & Neck

Unexplained weight loss >5% in 3 months with neck mass → lymphoma or metastatic malignancy → 2WW Haematology or H&N

Night sweats + fever + lump B-symptoms: drenching night sweats, fever, weight loss + lymphadenopathy → lymphoma → 2WW Haematology

Airway compromise Stridor, drooling, muffled voice, inability to open mouth — Ludwig's angina or retropharyngeal abscess → 999

Rapidly enlarging lump Doubling in days with fever (neck abscess) or weeks (aggressive lymphoma / anaplastic thyroid) → Same-day assessment

Thyroid mass + features Hard, fixed thyroid mass; nodule >1 cm with hoarseness; solitary nodule with risk factors (previous radiotherapy, family history MTC) → 2WW Endocrine/H&N

A neck lump in a patient over 40 is malignant until proven otherwise — the probability exceeds 50% in this group. NICE NG12 mandates 2WW referral for unexplained neck lump >3 weeks in patients ≥45 with no obvious infective cause. B-symptoms (any two of: weight loss >10%, fever, drenching night sweats) in combination with lymphadenopathy have a PPV of ~60% for lymphoma. Ludwig's angina (spreading floor-of-mouth cellulitis) can close the airway within hours — stridor or drooling is a 999 emergency. Metastatic squamous cell carcinoma in a neck node (unknown primary) accounts for 2–5% of all head and neck cancers — early detection is curative.

Diagnose

Focused History — Characterise the Lump and Patient Risk

Done

The most important diagnostic tool is a structured history. Risk factors + lump characteristics together drive urgency.

Duration and change

Hours/days = reactive lymphadenopathy or abscess. Weeks–months = lymphoma, malignancy. Years, static = benign cyst or lipoma

Age and sex

<20: reactive lymphadenopathy, congenital cysts (branchial/thyroglossal), lymphoma. 20–40: thyroid disease, lymphoma, reactive. >40: metastatic SCC, thyroid cancer, lymphoma

Smoking and alcohol

Both are major risk factors for head and neck SCC. Pack-year history. HPV-associated oropharyngeal cancer rising in non-smokers aged 35–55

Associated symptoms

Sore throat / ear pain / oral ulcer: head and neck primary. Dysphagia: oesophageal/hypopharyngeal. Otalgia (referred ear pain): tongue base or tonsil cancer. Haemoptysis: thyroid/lung

Constitutional features

Fever, night sweats, weight loss (B-symptoms) → lymphoma. Fatigue + lymphadenopathy in young → EBV/CMV

Travel / infections

TB: country of origin, TB contacts, BCG status. Cat scratch disease: animal contact + LAP in axilla/groin/neck. HIV risk factors

Thyroid symptoms

Hyperthyroid: palpitations, weight loss, heat intolerance, tremor. Hypothyroid: fatigue, cold intolerance, constipation. Lump moving on swallowing = thyroid origin

Previous malignancy / radiotherapy

Prior head and neck cancer, lymphoma, or cervical radiotherapy significantly increases risk of new malignancy

HPV-positive oropharyngeal SCC is rising by 7% per year in the UK and typically presents as a neck node in a non-smoker aged 35–55 — this demographic must not be falsely reassured by absence of risk factors. Referred otalgia (pain in the ear without visible ear cause) is a classic presentation of base-of-tongue or tonsillar carcinoma — always check the oropharynx. BCG status and TB contact history are essential in a UK context given the high rates of TB-related lymphadenopathy in immigrant communities. Cat scratch disease (Bartonella henselae) is a treatable cause of prolonged lymphadenopathy often missed without specific enquiry about animal contact.

Diagnose

Classify by Anatomical Location and Lump Character

Done

Location narrows the differential significantly. Combine with consistency and mobility to generate a working diagnosis.

Anterior triangle

Reactive lymphadenopathy (commonest); metastatic SCC; lymphoma; branchial cyst (2nd arch, anterior to SCM, young adult); carotid body tumour (pulsatile, transmitted)

Posterior triangle

Lymphoma; metastatic cancer (especially from posterior scalp/neck primary); TB lymphadenitis; lipoma; accessory nerve neuroma

Midline

Thyroglossal duct cyst (moves on tongue protrusion and swallowing — pathognomonic); dermoid cyst; submental lymphadenopathy; thyroid isthmus

Thyroid region

Multinodular goitre; toxic adenoma; thyroid cancer (especially if hard/fixed/hoarse); Hashimoto's thyroiditis (diffuse, firm); thyroid cyst

Parotid / submandibular

Pleomorphic adenoma (benign, slow-growing); Warthin's tumour (bilateral, smokers); mucoepidermoid carcinoma; submandibular sialadenitis; calculus

Characteristics: Benign

Soft/fluctuant; clearly defined; mobile; tender; present <2 weeks; young patient; recent URTI; spontaneously reduces

Characteristics: Malignant concern

Hard; fixed to skin or deep structures; non-tender; progressive enlargement; rubbery (lymphoma); multiple nodes; >1 cm and persisting >3 weeks

Cystic character

Fluctuant, transilluminates — branchial cyst, thyroglossal, dermoid. NB: metastatic SCC can be cystic (especially HPV-associated)

Location is the single most discriminating feature after age. A midline lump moving on tongue protrusion is almost exclusively a thyroglossal duct cyst — no further investigation needed before ENT referral. Branchial cysts historically were treated as benign, but a cystic anterior triangle mass in a patient over 40 is a metastatic HPV-positive SCC until proven otherwise — this is a NICE NG12 red flag. Rubbery, matted lymphadenopathy in the posterior triangle is characteristic of lymphoma and should trigger urgent haematology referral. Parotid lumps: 80% of parotid masses are pleomorphic adenomas — but carcinoma is suggested by facial nerve involvement or rapid growth.

Diagnose

Targeted Examination — Systematic Head and Neck Assessment

Done

A structured head and neck examination takes 3–4 minutes and significantly changes management.

Lump characterisation

Size (measure in mm), consistency (soft/rubbery/hard/fluctuant), borders (smooth/irregular), mobility, overlying skin (erythema/tethering/punctum), tenderness, transilluminability

Lymph node chains

Palpate systematically: submental → submandibular → anterior cervical → posterior cervical → supraclavicular → parotid → occipital → axillary. Document number, size, character

Oropharynx

Inspect with good light: tonsils (asymmetry, mass), posterior pharynx, tongue base. Indirect laryngoscopy if available for hoarseness. Don't miss a mucosal primary

Thyroid gland

Inspect from front — visible goitre. Palpate from behind. Assess swallowing — thyroid moves on swallowing. Note nodularity, tenderness, bruit. Check for tracheal deviation

Lump mobility test

Swallowing → moves = thyroid/thyroglossal. Tongue protrusion → moves = thyroglossal cyst. Fixed to skin = skin primary. Fixed deeply = malignant invasion

Salivary glands

Bimanual palpation of submandibular gland (calculus). Parotid mass — assess facial nerve function (VII). Any weakness = malignancy until proven otherwise

Supraclavicular fossa

Virchow's node (left supraclavicular fossa) = metastatic GI malignancy. Right supraclavicular = thoracic/pulmonary. Always examine carefully

General

Hepatosplenomegaly, axillary LAP, skin for rash or primary tumour (melanoma, SCC). Temperature if infective cause considered

Facial nerve palsy with a parotid mass is a surgical emergency — it indicates perineural invasion by malignancy. The oropharyngeal examination is critical and often omitted in primary care — a missed tonsillar asymmetry or base-of-tongue mass causes delayed diagnosis of curable HPV-associated cancer. Virchow's node in the left supraclavicular fossa (Troisier's sign) has a PPV of >70% for GI malignancy. Bimanual palpation of the floor of mouth can reveal submandibular duct calculi that will not be apparent on external examination alone. Systematic palpation of all node chains prevents the common error of fixating on the presenting lump and missing more sinister distant disease.

Diagnose

Investigations — Targeted Bloods and Imaging

Done

Investigations should not delay 2WW referral if red flags are present. Order in parallel, not sequentially.

FBC + CRP All

Lymphocytosis/atypical lymphocytes → EBV. Lymphocytosis (mature) → CLL. Raised WBC + CRP → infection. Pancytopenia + LAP → bone marrow infiltration

LDH + uric acid Lymphoma screen

LDH raised in lymphoma, leukaemia, aggressive disease. Uric acid raised in rapid cell turnover. Request if B-symptoms or multiple LAP

Paul-Bunnell / monospot

EBV screen — most useful in age 15–25 with bilateral posterior LAP, sore throat, splenomegaly. Sensitivity 85% in acute EBV

TFTs + thyroid USS Thyroid lump

TSH first-line. Free T4 if TSH abnormal. USS neck: arrange via secondary care if 2WW. In primary care: TSH + refer. Don't delay referral waiting for TFTs

Chest X-ray Suspected lymphoma

Mediastinal widening (Hodgkin's); hilar LAP; lytic bone lesions. Request if B-symptoms, bilateral cervical/supraclavicular LAP, or cough

HIV test

Offer to all patients with unexplained generalised lymphadenopathy >3 months. Persistent generalised lymphadenopathy is a common HIV presentation

Mantoux / IGRA test

Suspect TB lymphadenitis if patient from endemic country, immunosuppressed, or known TB contact. Do not biopsy potential TB node without TB team involvement (risk of fistula)

Do NOT order

CT/MRI in primary care without specialist input (unless patient on 2WW pathway). FNA/biopsy in primary care. PET-CT. Tumour markers without indication

Investigations in neck lump are largely to characterise systemic disease and should not delay specialist referral for suspected malignancy. LDH is a cheap, widely available prognostic marker in lymphoma — elevation at diagnosis is incorporated into the International Prognostic Index. Biopsy of a neck node without USS guidance risks inadequate sampling and, critically, risks sinus formation in TB lymphadenitis (cervical TB). FNA under USS guidance in secondary care has sensitivity >90% for lymphoma and metastatic SCC. Monospot/Paul-Bunnell tests have high false-negative rates in early infection and in children — a negative result does not exclude EBV in the first week.

Refer

Referral Criteria — Urgency and Destination

Done

Use NICE NG12 criteria. When in doubt, refer — the cost of over-referral is far less than missed malignancy.

999

Stridor; drooling; muffled 'hot potato' voice; inability to swallow; signs of airway obstruction (Ludwig's angina, epiglottitis, retropharyngeal abscess)

Same-day ED

Rapidly enlarging neck mass with fever + pain (abscess); haemodynamic instability; anaplastic thyroid cancer signs (very rapidly growing, hard, infiltrating)

2WW Head & Neck

Unexplained neck lump >3 weeks, age ≥40 (NICE NG12). Hoarseness >3 weeks + neck lump. Dysphagia + neck lump. Cystic mass age >40. All suspected head and neck SCC

2WW Haematology

B-symptoms + lymphadenopathy. Mediastinal widening on CXR. Lymphadenopathy + pancytopenia or raised LDH. Suspected Hodgkin's or NHL

2WW Endocrine/H&N

Hard/fixed thyroid nodule. Solitary nodule >1 cm with hoarseness or rapid growth. Previous neck irradiation + thyroid nodule. Family history MEN2 / medullary thyroid cancer

Urgent routine ENT

Branchial cyst age <40 with no red flags. Thyroglossal cyst (surgical excision needed — Sistrunk procedure). Salivary calculus. Pleomorphic adenoma (non-urgent surgical removal)

Routine GP management

Reactive lymphadenopathy — watch and wait 3–4 weeks maximum. Reassure if clearly infective cause, painful, bilateral, and improving. Always review and re-refer if persists

NICE NG12 (2015, updated 2021) specifically states: "consider a suspected cancer pathway referral for head and neck cancers in people aged 45 and over with an unexplained lump in the neck of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks." The key error in GP practice is watching a neck lump for too long — the UK Landmark trial showed median delay to ENT referral was 3.2 months. Thyroglossal duct cysts require the Sistrunk procedure (excision of cyst + central hyoid bone + tract to tongue base) — simple excision alone has 30% recurrence. Pleomorphic adenoma, while benign, undergoes malignant transformation in 5% over 20 years — elective surgical excision is recommended.

Treat

Primary Care Treatment — Infective and Benign Causes

Done

Most primary care management is conservative. Antibiotics only when clear infective cause. Do not treat empirically for malignancy.

Bacterial lymphadenitis

Amoxicillin 500 mg TDS × 5 days 1st line

If penicillin allergic: clarithromycin 500 mg BD × 5 days. Fluctuant abscess → same-day ENT for drainage. Review at 5–7 days.

Infectious mononucleosis (EBV)

Supportive — no antibiotics

Paracetamol/ibuprofen for fever/pain. Avoid amoxicillin (rash in 80%). Advise contact sports avoidance 4 weeks (splenomegaly rupture risk). Expected resolution 2–6 weeks.

Reactive lymphadenopathy (viral URTI)

Watch and wait

Review in 3–4 weeks maximum. Advise to return immediately if enlarging, hard, or associated red flags develop. Set safety-net clearly in writing.

Thyroid nodule (benign on USS)

TFTs + surveillance

If euthyroid with benign USS features: monitor with USS 12-monthly. Levothyroxine suppression not recommended. Refer if growth >20% in 12 months.

TB lymphadenitisRefer to TB clinic — do not start antibiotics empirically. Standard 6-month RHEZ/RH regimen initiated by TB team. Notify PHE (statutory notification).

Hyperthyroid goitreRefer endocrinology urgently. Interim: propranolol 40 mg TDS for symptomatic tachycardia/tremor while awaiting specialist (not definitive treatment).

Antibiotic prescribing for reactive lymphadenopathy is common and inappropriate — viral causes account for >80% of cases in children and young adults. Amoxicillin in EBV causes a florid maculopapular rash in 80% of cases (due to ampicillin sensitivity, not allergy) and should never be prescribed if mononucleosis is suspected. Splenic rupture in EBV affects 0.1–0.5% of cases and is almost always associated with contact sport or trauma — advice about 4-week avoidance is mandatory. TB is a statutory notifiable disease — all cases must be notified to PHE. Empirical antibiotics for suspected TB lymphadenitis can sterilise the node and make microbiological diagnosis impossible.

Lifestyle

Health Promotion and Cancer Risk Reduction

Done

While the lump is under investigation, use the consultation as an opportunity for primary prevention of head and neck cancer.

Smoking cessation Tobacco is the single biggest modifiable risk factor for head and neck SCC — 75% of cases are attributable to smoking. Refer to NHS stop-smoking service. NRT + varenicline doubles cessation rates.

Alcohol reduction Alcohol + smoking are synergistic for head and neck cancer risk (relative risk >35× vs neither). Target: ≤14 units/week. Refer to alcohol service if hazardous use.

HPV vaccination counselling HPV 16/18 causes 60–70% of oropharyngeal SCC. NHS routine vaccination at age 12–13. Advise eligible patients who have not been vaccinated. Consider catch-up referral.

Safe oral practices Betel nut/paan chewing is a major risk factor for oral SCC in South Asian communities. Advise cessation. Regular dental check-ups for oral mucosal examination.

Symptom awareness Advise: return promptly for any new hoarseness >2 weeks, dysphagia, ear pain without ear cause, oral ulcer >3 weeks, new neck swelling. Earlier presentation improves outcomes.

Sun protection Lip SCC and skin primary with nodal metastasis — advise SPF ≥30 on face/neck, avoid midday sun, check moles. Melanoma can present as neck node.

Nutrition and immunity In EBV/reactive LAP: adequate fluids, rest, return to normal activity gradually. Advise no immune-suppressants (high-dose steroids) without specialist guidance in lymphoma.

Psychological support Investigation for suspected neck malignancy causes significant anxiety. Acknowledge this. NICE recommends cancer CNS support from point of 2WW referral. Signpost Macmillan / CRUK.

Head and neck cancer incidence is rising in the UK, primarily driven by HPV-associated oropharyngeal cancer. The 5-year survival for stage I oropharyngeal SCC is 80–90% versus 30–40% for stage IV — primary prevention and early detection are transformative. UK data shows mean GP delay of 2.3 appointments before 2WW referral for head and neck cancer — symptom awareness in patients directly reduces this. Betel nut/areca nut chewing is an under-recognised risk factor in British South Asian communities; oral submucous fibrosis is a direct precancerous consequence. HPV vaccination programme coverage remains suboptimal in catch-up cohorts — every consultation is an opportunity.

Safety

Follow-Up, Safety-Netting and Monitoring

Done

If you decide NOT to refer immediately, you accept responsibility for structured review. Three weeks is the maximum safe observation period.

3–4 weeks (max)

Any neck lump without clear benign cause. At review: if not fully resolved → 2WW referral regardless. Do not give a second course of antibiotics and re-review

5–7 days

Bacterial lymphadenitis on antibiotics — confirm improving. Abscess formation (fluctuance) → same-day ENT drainage

EBV review

2–3 weeks: fatigue, splenomegaly resolving? Liver function (hepatitis in 80% EBV). FBC (haemolytic anaemia/thrombocytopenia in 5%). Contact sports advice reiterated

Thyroid nodule

12-monthly USS if benign on initial imaging. TFTs 6-monthly if goitre. Any change in nodule size >20% or new features → re-refer urgent

Safety-net 999

Stridor or breathing difficulty; severe swelling, unable to swallow saliva; rapidly enlarging lump over hours; collapse or anaphylaxis

Safety-net same-day

Lump doubling over 1–2 weeks; new fever + increased pain; new hoarseness or voice change; new dysphagia; skin tethering appearing

Documentation

Document: lump size in mm, site, character. Date of first presentation. Safety-net advice given. Date of next review or 2WW referral sent. Mandatory for medicolegal protection

2WW tracking

Record 2WW referral date in notes. Check patient has received appointment. Contact secretary if no response within 5 working days

The "watch and wait" approach in neck lumps is a common source of delayed diagnosis — NICE explicitly states that a lump persisting >3 weeks with no obvious benign cause must trigger 2WW referral. A second course of antibiotics for a non-resolving neck lump is inappropriate and causes diagnostic delay — this is a recurrent theme in head and neck cancer inquests. Documentation of lump size in mm at initial presentation is essential medicolegally — if the lump is later found malignant, a contemporaneous record of size demonstrates whether there was unreasonable delay. The MDT at head and neck cancer centres see a median of 40% "unnecessary" 2WW referrals — this is acceptable given the consequences of missing malignancy.