The history should include specific questions relating to the duration of the mass and whether it has changed in size or character, fluctuations in its size, associated local symptoms of pressure or pain, as well as possible changes in characteristics of the skin overlying the mass. Associated symptoms of hoarseness, shortness of breath, dysphagia, haemoptysis, or weight loss are important. Weakness of motion of the face, lower lip, shoulder, or tongue should be investigated as they suggest nerve impairment. Any history of the use of tobacco or alcohol should also be pursued.

The physical examination must include a complete description of the mass itself. A thorough examination of the head and neck, as well as of the chest and abdomen when appropriate, is also mandatory. Certain normal structures may mimic disease (Fig. 1) 2338: the lateral process of the second cervical vertebra can be quite prominent and in a thin neck this may appear to be a firm mass. Similarly, an elongated styloid process may present itself underneath the angle of the mandible. Other skeletal structures such as the hyoid bone may be splayed laterally and palpated in the upper lateral neck. The lateral process of the sixth cervical vertebra, the tip of the mastoid bone, and an anomalous cervical rib can be palpated as a firm mass in the neck. The critical finding in assessment of all of these circumstances is the bilateral symmetry of these masses. A dilated carotid bulb or distended jugular vein can also be confused with an abnormal mass. The skin of the head and neck and the fundi should also be examined, because of the possibility of malignant melanoma.

A thorough examination of the oral cavity should note the presence of any mucosal lesions, their size, character, and ‘feel’ since palpation is an integral part of the examination. The lateral and posterior aspects of each side of the tongue must be examined carefully: lingual carcinomas arising in this region give minimal symptoms of pain or discomfort. Motion of the tongue should also be checked, and its base palpated. Size and symmetry of the tonsils should be assessed and a nasal examination should be performed in conditions with adequate lighting.

The presence of a unilateral mass within a nasal passage, particularly in an adult, is of concern. Although the nasopharynx may be difficult to examine, every attempt should be made to do so, and evidence of mucoid, purulent, or bloody drainage should be noted. The hypopharynx and larynx will often require a mirror examination or, when possible, fibreoptic endoscopy: these studies can be performed simply with the appropriate equipment and with minimal anaesthesia. Excellent results can also be achieved with rigid endoscopes that have high-quality optical characteristics. Laryngeal stroboscopy can provide a ‘slow motion’ picture of the larynx: symmetry of laryngeal motion and any abnormality of the overlying mucosa should be particularly noted. Attention should be placed on the configuration of the epiglottis and the piriform sinuses, which lie on either side of the aryepiglottic folds.

Palpation of the neck should be performed to assess neck symmetry. The mass in question should be described in terms of location, size, consistency, and whether pain or tenderness can be elicited. The size should be measured so that any change can be detected in subsequent examinations. Fixation of the mass to surrounding structures may be difficult to assess, but degree of mobility should be noted, particularly if the mass moves with swallowing. The location of multiple or bilateral masses in the neck is often essential to defining a site of origin.

The neck itself should be considered to be divided into submental, submandibular, jugular, (high, mid, low), posterior cervical, supraclavicular, and anterior midline regions (Fig. 2) 2339. A diagram should be entered in the patient's chart, as well as a written description of the mass.

Additional laboratory studies which may be required for diagnosis include a complete blood count, urinalysis, and a biochemical profile. Occasionally, studies for mononucleosis, toxoplasmosis, Epstein-Barr virus, or cytomegalovirus may be warranted if the condition is felt to be inflammatory. The relevance of a positive HIV test is gaining more importance, particularly in the context of opportunistic infections and lymphoma.

When warranted, the thyroid gland may be examined by either scan or ultrasound. A chest radiograph looking for a single nodule or multiple densities may disclose a primary tumour or metastases. An apical lordotic view should be ordered to assess the upper lobes. A computerized tomographic (CT) scan is invaluable in determining the location of a neck mass, particularly in reference to surrounding structures. A skilled radiologist may be able to identify cervical nodes as small as 1 cm in diameter. The CT scan, combined with a good physical examination, increases diagnostic accuracy; one should not necessarily supplant the other. The CT scan may also reveal the nature of the mass, whether solid or cystic. A magnetic resonance imaging (MRI) scan is particularly useful for soft tissue evaluation and gadolinium enhancement will help define the vascularity of the mass in question. Consultation with a radiologist for the best techniques to use in the study of any individual lesion is always beneficial. A barium swallow should be obtained in patients complaining of dysphagia. In patients with a supraclavicular mass, further radiographic studies of the oesophagus, stomach, pancreas, and colon are appropriate in searching for a primary disease process.

The vast majority of neck masses can be diagnosed on the basis of history and physical examination alone; additional studies are required only where appropriate. In patients over 40 years of age, and particularly in those with a history of cigarette smoking and alcohol ingestion, the primary concern must be a malignancy until proven otherwise. The primary tumour is most often discerned within the head and neck, a cervical mass being metastatic. Masses presenting in the anterior midline are usually thyroid-related.

Although most congenital lesions present before adolescence, it is not unusual for a congenital neck mass to become apparent in adulthood. Such masses often remain silent until they become infected. First-cleft branchial cysts present near the angle of the mandible, while those on the second and third pouch are found anterior to the sternocleidomastoid muscle, sometimes associated with a fistulous draining tract.

Thyroglossal duct cysts are located in the anterior midline of the neck in the vicinity of the thyrohyoid membrane; they can occasionally be confused with submental masses. These lesions arise at the base of the tongue, at the foramen caecum, and then proceed in close proximity to the hyoid bone, manifesting themselves as far inferiorly as the thyroid gland itself. The tract does not necessarily remain in the midline, but may be paramedian. The tract or associated cyst may become infected, with the appearance of an inflammatory mass: appropriate antibiotic therapy is required before excision is undertaken. To prevent recurrence, the midline body of the hyoid bone must be excised along with the entire tract to the tongue base.

Less common congenital lesions include laryngoceles, which arise from the laryngeal ventricle and may protrude through the thyrohyoid membrane as a mass anterior to the sternocleidomastoid muscle. Occasionally an internal component is also present as well and this can impinge on the airway. Therapy is surgical excision.

Any infection of the upper respiratory tract can be associated with cervical adenitis. The causative agent can be determined by cultures of the appropriate site or, if an abscess forms by culture and sensitivity testing of aspirate. All pathogens should be considered particularly in the immunocompromised host. If an abscess is suspected, a CT scan may be of value since the presence of fluctuance often occurs as a late physical manifestation. Incision and drainage is required, particularly if compromise of the airway or great vessels of the neck is likely to occur.

In the adolescent, infectious mononucleosis may begin with diffuse adenopathy and associated pharyngitis, gingival hyperplasia, and, occasionally, tonsillar hypertrophy. The diagnosis can be confirmed by the presence of more than 10 per cent atypical lymphocytes in a white blood cell count, and the presence of antibodies against Epstein-Barr virus. Infections by Toxoplasma gondü and cytomegalovirus may have a similar clinical picture; the detection of specific antibodies is the mainstay of differential diagnosis.

Chronic granulomatous diseases are endemic in various parts of the world and must be considered in the geographic areas in question. In particular cervical tuberculosis (scrofula) should be considered in young adults with a solitary painless neck mass. Pulmonary disease does not need to be active for the cervical lymph glands to become involved, but the skin test is often positive. A neck mass occurs in two-thirds of patients with extrapulmonary lymphadenitis due to Mycobacterium tuberculosis. Histoplasmosis, coccidiodomycosis, and actinomycosis can also produce cervical lymphadenopathy.

Salivary gland inflammation or infection of either the parotid gland or the submandibular glands can produce a neck mass, often related to obstruction of the duct by a stone and secondary bacterial infection. The presence of swelling, pain, and purulence from the duct help suggest the diagnosis. Neoplastic disease should be suspected when the physical findings listed above are absent and, in particular, when neurological defects are present. A mass in the tail of the parotid gland may be difficult to differentiate from an upper cervical lymph node, and such a mass cannot often easily be separated from the angle of the mandible by palpation.

Sarcoidosis often affects the mediastinal and tracheal lymph nodes but cervical adenopathy is also common. These enlarged neck nodes are often non-tender and discrete, measuring up to 3 cm in diameter, and they tend to resolve spontaneously.

Reactive lymphoid hyperplasia may also be caused by sinus histiocytosis with massive lymphadenopathy, a disorder that affects young adults or children. This causes enlarged nodes, often in the neck and in extranodal sites such as the nasal cavity, tongue, oral mucosa, salivary glands, pharynx, trachea, and orbit, and is a self-limiting disorder which eventually regresses. Rarely, lymphatic hyperplasia can be induced by the hydantoin family of anticonvulsant drugs, resolving upon cessation of the medication. Occasionally these enlarged nodes may mimic lymphoma histologically.

Other benign conditions that may present as masses in the neck are lipoma, schwannoma, and paraganglioma.

Hayes Martin, one of the century's foremost head and neck cancer surgeons, said that ‘asymptomatic enlargement of one or more cervical nodes in the adult is almost always cancerous.’ Midline masses are almost always associated with thyroid disorders and usually represent a benign process or low grade malignancy. Some masses are inflammatory and secondary to sinusitis, pharyngitis, otitis, or a dental infection. A firm mass over 2 cm in diameter demands further investigation and must be assumed to be neoplastic.

Nearly 90 per cent of malignant neoplasms in the neck excluding those arising from the thyroid gland are epithelial in origin. Most malignant masses in the cervical region are metastatic: The only primary process seen in this area is carcinoma arising from a branchial cleft cyst, a highly unlikely occurrence. Only a few cases have been reported which fulfil the criteria for such diagnosis, which include a neoplasm located in the region of branchial tissue which is histologically compatible with the diagnosis, that no other primary site be discovered, and that the carcinoma itself must arise from a cyst wall.

If one assumes that the neck mass under investigation is metastatic, the primary source will often be found during a thorough examination of the head and neck. The location of the metastasis frequently suggests the site of the primary tumour (Fig. 4) 2341: tumours of the oral cavity and oropharynx often metastasize to the submandibular triangle, whereas tumours of the nasopharynx produce adenopathy in the posterior cervical triangle. A mass in the region of the cephalic portion of the jugular vein and the digastric triangle can be due to a tumour arising from the nasopharynx, the base of tongue, the hypopharynx, the larynx, or the tonsil. In the supraclavicular triangle, however, the primary neoplasm arises from below the clavicle in 75 per cent of cases, as a source in the lung or the gastrointestinal and genitourinary tracts.

Certain clues should raise the suspicion of a neoplastic process. Patients with a history of heavy smoking and alcohol ingestion, particularly men over 50 years of age, are at high risk. A history of prior excision of even small lesions within the head and neck must be pursued. Certain areas such as the lateral border of the tongue, the base of tongue, the nasopharynx, and the piriform sinuses may often hold small primary cancers that give rise to a cervical metastasis.

A neck CT scan should be performed prior to any invasive procedure. A fine-needle aspiration biopsy using a 22 gauge needle or smaller, has also become a time-saving and critical asset in evaluation and ultimate treatment (Fig. 5) 2342. The actual technique is quite simple and an epithelial tumour can be diagnosed or suspicion of lymphoma confirmed by an experienced cytologist. In no circumstance should a premature excisional biopsy of a neoplastic lymph node be undertaken: such excision carries a high incidence of wound necrosis, local recurrence, and distant metastases. Open biopsies should only be performed at the time of endoscopy, when the surgeon is prepared to proceed with definitive therapy.

If a primary head and neck neoplasm is suspected by examination and by a positive cytological aspiration of the neck mass, a complete endoscopic examination should be performed under anaesthesia. This should include examination of the nasopharynx, hypopharynx, and larynx. Oesophagoscopy is more accurate in the detection of oesophageal disease than is a barium swallow. Although bronchoscopy with washings can be performed, its diagnostic yield is low if a routine chest radiograph is normal. Any suspicious areas seen on endoscopy should be biopsied for examination. If none is found, biopsies of the tongue base and the piriform sinus may be warranted. Biopsy specimens should be obtained from the ipsilateral side and as directed by the location of the neck mass. If a primary neoplasm is found, the diagram should depict the primary as well as metastasis (Fig. 6) 2343. The tumour should be staged according to established critera, and second primaries should be sought, since they occur in up to 15 per cent of patients with head and neck tumours.

No one treatment is applicable to all patients. If a thorough search for a primary tumour of the head and neck is unsuccessful, an excisional biopsy can be performed. The incision created should be such that it can be incorporated into a neck dissection. If carcinoma is diagnosed the options exist of completing a neck dissection, modified as appropriate for the site, or of closing the incision and treating with radiation therapy if no primary site is discovered. I prefer radiation treatment, with radiation being delivered to potential primary sites, including the nasopharynx, the base of tongue, and the piriform sinus, as well as to the neck. Repeated examinations performed during the course of radiation therapy may disclose the primary site. If any residual disease is left after a full course of radiation therapy, a neck dissection may be performed.

If a full neck dissection is performed, it is advisable to administer postoperative radiation therapy to the sites most likely to be affected by metastases, in patients with large nodes. However, patients presenting with masses greater than 4 cm in diameter have an exceptionally low survival, as do those with metastatic adenocarcinoma arising from a site other than the head and neck.

Adenocarcinomas may arise from parotid and submandibular glands; these glands must be resected at the time of neck dissection. Metastatic adenocarcinoma arising from the thyroid gland, particularly that from a well differentiated thyroid neoplasm, often carries a good prognosis and should be treated simply along with a thyroidectomy.

Adams GL. Decisions and management of metastatic cancer with an unknown primary site. In: McQuarrie DG, Adams GL, Shors AR, Browne GA, eds. Head and Neck Cancer—Clinical Decisions and Management Principles. Chicago, Yearbook, 1985: 441–8.

Bataini JP, Rodriquez J, Jaullery C, Brugere J, Glossein VA. Treatment of metastatic neck nodes secondary to an occult epidermoid carcinoma of the head and neck. Laryngoscope 1987; 97: 1080–4.

Batsakis JG. The pathology of head and neck tumors: The occult primary and metastases to the head and neck. Head Neck Surg 1981; 3: 409–23.

Damion J, Hybels R. The neck mass: general concepts and congenital causes. Postgrad Med 1987; 81: 75–76, 81–88, 93.

Damion J, Hybels R., The neck mass: Inflammatory and neoplastic causes. Postgrad Med 1987, 81: 97–103, 106–7.

deBraud F, et al. Metastatic squamous cell carcinoma of an unknown primary localized to the neck. Advantages of an aggressive treatment. Cancer 1989; 64: 510–5.

Fried MP, Diehl W, Brownson R, Sessions DG, Ogura JH. Cervical metastasis from an unknown primary. Ann Otol Rhinol Laryngol 1975; 84: 152–7.

Jaffe BF, Jaffe N. Diagnosis and treatment. Head and neck tumors in children. Pediatrics 1973; 51: 731–40.

Martin H, Romieu C. The diagnostic significance of a ‘lump in the neck.’ Postgrad Med 1952; 11: 491–500.

McQuirt WF, McCabe BF. Significance of node biopsy before definitive treatment of cervical metastatic carcinomas. Laryngoscope 1978; 88: 594–7.

Shapshay SM, Hung WK, Fried MP, Sismanis A, Vaughan CW, Strong MS. Simultaneous carcinoma of the esophagus and upper aerodigestive tract. Otolaryngol Head Neck Surg 1980; 2: 509–12.

Weymuller EA, Kiviat NB, Duckeret LG. Aspiration cytology: an efficient and cost-effective modality. Laryngoscope 1983; 93: 561–4.