Reasoning GP · Algorithm · 1-page summary
Neck lump in adults
For: adults with a new neck lump in primary care. Not for: children. Thyroid disease, lymphadenopathy/lymphoma, salivary-gland mass and suspected TB continue on their own specialist pathways once identified.
Core rule: an unexplained or persistent neck lump in an adult goes on the suspected cancer pathway, not under observation — there is no 3-week rule, and a soft or mobile lump excludes nothing. Stridor is a 999 call.
0Stop — call 999 now — airway and sepsis
- Airway: stridor, severe respiratory distress, drooling or unable to swallow saliva, muffled “hot potato” voice, rapidly progressive airway swelling → 999
- Deep-neck infection with airway risk or systemic illness (Ludwig's angina, retropharyngeal abscess, epiglottitis) → 999
- Severe sepsis, haemodynamic instability, anaphylaxis or collapse → 999
1Triage by behaviour of the lump
| Lump | Action |
|---|---|
| Rapid + unwell | Painful, febrile, fluctuant, unwell, or neuro / vascular signs → Same-day hospital / ENT |
| Rapid, painless | No emergency features (anaplastic thyroid, lymphoma) → Suspected cancer pathway |
| Unexplained | Persistent, progressive, hard or fixed → block 2 now; do not observe. |
| Clearly reactive | Infective cause, improving → treat; document review date and escalation criteria. |
2Screen — NICE NG12 (consider)
- Persistent unexplained neck lump (oral), or unexplained lump or persistent hoarseness at ≥45 (laryngeal) → consider Suspected cancer: head & neck
- Unexplained thyroid lump → consider Suspected cancer pathway; check TSH but do not delay referral.
- Unexplained lymphadenopathy or splenomegaly → consider Suspected cancer: haematology; B-symptoms not required.
- Supraclavicular or persistent cervical nodes, aged ≥40 → consider Urgent CXR ≤2 weeks
- Leukaemia features (generalised nodes, hepatosplenomegaly, bruising, petechiae) → consider Very urgent FBC ≤48 h
- Lump + dysphagia, unilateral otalgia, oral lesion, cranial neuropathy; new lateral cyst → Head & neck (or upper GI) pathway
3Assess
☐ Lump: size in mm, site, level, consistency, fixation ☐ All node groups incl. supraclavicular ☐ Mouth, tonsils, tongue base ☐ Thyroid, cranial nerves VII, X, XI, XII ☐ Liver, spleen, skin; smoking, alcohol, TB, HIV risk
Tests only where useful: FBC ± film, CRP/ESR; TSH for a thyroid lump; HIV test if indicated. IGRA/Mantoux do not exclude active TB. Not in primary care: blind biopsy; CT, MRI or PET that delays or duplicates the pathway; tumour markers.
4Classify
- Reactive node (commonest) — tender, mobile, recent URTI, skin or dental infection → treat, review.
- Thyroid — moves on swallowing → TSH; USS via specialist pathway if malignancy suspected.
- Congenital cyst — thyroglossal, branchial, dermoid → ENT; a new lateral cyst in an adult may be SCC.
- Salivary — calculus, pleomorphic adenoma; parotid mass with facial weakness → urgent referral.
- TB — endemic origin, contact, immunosuppression → Urgent local TB service; notifiable.
- Malignant or uncertain — hard, fixed, rubbery or progressive → block 2.
5Treat today
- Convincing bacterial lymphadenitis only: antibiotic per local antimicrobial guidance; fluctuant abscess → Same-day ENT drainage
- EBV: supportive (paracetamol, ibuprofen); avoid aminopenicillins; individual activity advice.
- Suspected TB: no empirical TB treatment or antibiotics.
- No antibiotics for an unexplained lump. Doses: NICE/SPC, BNF, local formulary.
6Refer routinely — and follow up
- Confirmed benign congenital cyst, thyroglossal cyst, salivary calculus, pleomorphic adenoma → ENT (non-urgent).
- Hyperthyroid goitre → endocrinology. Benign thyroid nodule → specialist USS/FNAC pathway; no fixed yearly scan.
- Reactive lump not resolving as expected → refer, not another antibiotic course.
- Suspected cancer referral: record the date and check an appointment arrives.
7Never reassure by
- A soft, mobile or cystic lump — cystic metastatic SCC mimics a branchial cyst.
- Young age or no smoking or alcohol — HPV oropharyngeal cancer.
- No B-symptoms.
- A normal TSH or pending tests — refer in parallel.
- Watching for an arbitrary period or a second antibiotic course.
- A neck-only examination — check the mouth, oropharynx and all nodes.
8Safety-net — say it, then document it
999 “Call 999 for noisy breathing or difficulty breathing, if you cannot swallow your saliva, the swelling grows over hours, or you collapse.” Same day “Get seen today if the lump grows quickly, you get a fever with more pain or a soft fluctuant swelling, a new hoarse voice, new trouble swallowing, or the skin becomes tethered.”
Urgent appointment: “Ear pain with no ear cause, a mouth ulcer over 3 weeks, weight loss or drenching night sweats — book in urgently. If the lump is not settling as expected at your review, we refer rather than wait.”
✓Safe to leave primary care only if — all five, documented
No airway, sepsis or rapid-growth feature
Mouth, oropharynx and all nodes examined
NG12 criteria checked (age, site, persistence)
Size in mm, presumed cause and review date recorded
Safety-net given; referral tracked if sent
Summary of the full Reasoning GP neck lump algorithm, which holds the history, sites, examination, investigations and evidence. Sources: NICE NG12 Suspected cancer (updated April 2026); NICE NG145 Thyroid disease; NICE NG230 Thyroid cancer; NICE NG33 Tuberculosis; UKHSA TB guidance; local antimicrobial guidance; ENT UK head and neck guidelines. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.