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Endocrine and metabolic Skin and nail

Neck lump

Last revised in May 2025

There are multiple possible causes of neck lumps, including: skin infections, lymphadenopathy, tumours, salivary glands, congenital lumps

Neck lump: Summary

  • A neck lump is defined as an abnormal lesion (congenital or acquired) visible, palpable, or seen on an imaging study, which is below the mandible, above the clavicle, and deep to the skin.
    • A neck lump can present in any age group and may be due to a number of causes, including skin infections, lymphadenopathy, benign tumours, primary malignant tumours, thyroid lumps, salivary gland lumps, congenital and developmental lumps, carotid body tumours and aneurysms, and trauma.
    • Children are most likely to have a benign cause for neck lump, such as reactive cervical lymphadenopathy.
    • Single neck lumps are often due to a congenital cause, or inflammation.
    • Malignancy is rare, with lymphomas, thyroid cancer, and soft tissue sarcomas being most likely. The likelihood of malignancy increases with age, and is more likely in people over 40 years old.
  • Assessment of a person with a neck lump should include:
    • Asking about the site of the lump(s), onset, size and growth, any changes, and the associated timescale; red flag symptoms suggestive of local malignancy (such as dysphagia or odynophagia, persistent cough, sore throat, or hoarseness, haemoptysis); red flag symptoms suggestive of haematological malignancy (such as persistent fatigue, night sweats, unexplained fever, or weight loss); risk factors for malignancy (such as smoking, excess alcohol, previous head and neck cancer or irradiation); co-morbidities; and family history.
    • Assessing for signs of stridor, superior vena cava compression, or dysphagia with aspiration, any of which require emergency admission.
    • Examining the neck to assess the position, size, pulsatility, consistency, tenderness, mobility, and nodularity of the lump(s); and overlying skin appearance.
    • Examining for associated localized or generalized lymphadenopathy.
    • Performing a head and neck and general examination of the skin, ears, nose, throat, oral cavity, and examination of the chest, and abdomen, to assess for associated features that may suggest an underlying cause.
    • Not arranging investigations in primary care may delay specialist referral.
  • Management of a suspected neck lump in primary care depends on the likely underlying cause, and may include:
    • Treating any superficial skin infection or deep abscess.
    • Treating any suspected bacterial infection causing lymphadenopathy, if appropriate, and providing safety-netting advice.
    • Arranging urgent referral for a suspected malignant primary tumour of the head and neck.
    • Arranging an urgent full blood count and/or urgent referral for a suspected haematological malignancy, depending on the clinical presentation.
    • Arranging an urgent chest X-ray and urgent referral if appropriate, for suspected lung cancer.
    • Arranging an urgent referral for a suspected oral or laryngeal cancer, depending on the clinical presentation.
    • Arranging routine or urgent referral for a suspected thyroid mass or nodule, depending on the clinical presentation.
    • Arranging referral for a suspected congenital, developmental, or carotid neck lump, the urgency depending on clinical judgement.
    • Arranging an urgent neck ultrasound scan and urgent referral if appropriate, for an unexplained neck lump that is increasing in size, to assess for soft tissue sarcoma.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the diagnosis of a neck lump and the management of common or important causes of a neck lump.

This CKS topic does not cover the detailed management of less common or less clinically important causes of a neck lump.

There are separate CKS topics on Boils, carbuncles, and staphylococcal carriage, Glandular fever (infectious mononucleosis), Head and neck cancers - recognition and referral, Haematological cancers - recognition and referral, HIV infection and AIDS, Mumps, Palliative care - malignant skin ulcer, and Sore throat - acute.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2025 — reviewed. A literature search was conducted in March 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

Previous changes

September to October 2020 — reviewed. A literature search was conducted in August 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. Recommendations have been updated in line with published evidence. 

December 2015 to January 2016 — reviewed. A literature search was conducted in November 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The age range has been altered to include children from 1 month of age. Recommendations have been updated in line with the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral (2015).

September 2011 — minor update. Typographical error corrected and broken link fixed.

October 2009 to February 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2025.

Systematic reviews and meta-analyses

No new systematic review or meta-analyses since 1 March 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2025.

New policies

No new national policies or guidelines since 1 March 2025.

New safety alerts

No new safety alerts since 1 March 2025.

Changes in product availability

No changes in product availability since 1 March 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Identify a neck lump and make a provisional diagnosis.
  • Initiate investigations in primary care, where appropriate.
  • Manage the cause of the neck lump in primary care, where appropriate.
  • Arrange referral within an appropriate timescale to a relevant specialist, if necessary.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Suspected cancer

  • GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
  • People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.

[NICE, 2021]

Background information

What causes it?

Normal structures

  • Some people may be concerned that they have a neck lump, when in fact they have identified a normal part of the anatomy of the neck for the first time, for example:
    • Transverse process of C1 or C2 vertebra.
    • Hyoid bone.
    • Thyroid or cricoid cartilage.
    • Submandibular glands.

[Hobbs, 2010; Pynnonen, 2017; Jackson, 2018]

Skin infections

  • A skin infection, such as an abscess (focal bacterial infection with inflammation and pus accumulation) or infected epidermoid cyst, may be the cause of a neck lump [Prakash, 2002; Dwivedi, 2013]. See the CKS topic on Boils, carbuncles, and staphylococcal carriage for more information.
    • Local signs and symptoms of infection include warmth, erythema of the overlying skin, localized swelling, and tenderness to palpation [Pynnonen, 2017].
    • Skin abscess may be suggested by a fluctuant, painful mass with overlying erythema [Reynolds, 2020].
  • 'Cat scratch disease' arises following a bite or scratch from a cat infected with Bartonella henselae. A bulbous or vesicular lesion typically develops at the injury site, followed by ipsilateral cervical lymphadenopathy [Chorath, 2021].

Lymphadenopathy

  • Inflammatory lymphadenopathy
    • In children, benign reactive lymph nodes are the most likely cause of neck lump [Haynes, 2015; Jackson, 2018; Reynolds, 2020; Chorath, 2021; Stanford, 2024].
      • The most common cause of cervical lymphadenopathy is infection or inflammation, which usually presents as acute-onset, multiple small tender, mobile bilateral lymph nodes, which may be red and warm.
    • Infection should be suspected if the neck lump developed within a few days or weeks of an upper respiratory tract infection, dental problem, trauma (including insect bites), travel, or exposure to certain animals (including cat scratch disease) [Haynes, 2015; Pynnonen, 2017; Smith, 2019; Chorath, 2021; Rodolfi, 2024; Stanford, 2024].
    • Non-infective causes such as amyloidosis, sarcoidosis, or connective tissue disease may cause painless generalized lymphadenopathy [Rodolfi, 2024; Stanford, 2024]. See the CKS topic on Sarcoidosis for more information.
    • Kawasaki disease generally affects children under five years of age and is suggested by asymmetrical cervical lymphadenopathy following a fever that has persisted for at least five days, as well as non-purulent conjunctivitis, desquamation of the hands and feet, a diffuse maculopapular rash, and mucosal changes including sore, reddened lips and mouth. If untreated, it can lead to acquired heart disease [Stanford, 2024].
      • Note: be aware that infection of an underlying congenital or neoplastic mass may present similarly to reactive lymphadenopathy [Smith, 2019].

Benign tumours

  • Benign tumours are usually slow-growing and non-invasive (for example lipoma, fibroma, chondroma, neuromas, and vascular tumours) [Prakash, 2002; Chorath, 2021].
    • The most common benign soft tissue tumour in the neck is a lipoma, which usually presents in mid-adulthood onwards as a painless, soft, mobile, discrete subcutaneous mass, which may occur anywhere on the body [Roland, 2014; Haynes, 2015; Jackson, 2018].
    • Chondromas are uncommon sometimes multiple hard swellings that mainly arise in the larynx and cause endolaryngeal swelling [Ammar, 2017].
    • Neural tumours (neuromas) commonly involve cranial nerves and may present as an isolated lesion or as part of a syndrome. Neurofibromas (schwannomas) associated with neurofibromatosis type 1 may be associated with cafe-au-lait spots and a positive family history [Jackson, 2018].
    • Vascular tumours such as infantile haemangiomas present shortly after birth as a flat or slightly raised red patch, typically on the head or neck. They typically proliferate, then stabilize, then involute. Complications such as ischaemia, ulceration, or bleeding are more likely in the initial proliferation phase [Reynolds, 2020].

Malignant primary tumours

  • Squamous cell carcinomas of the upper respiratory tract (such as nasopharynx, oropharynx, or larynx) and upper gastrointestinal tract are the most common primary neoplasms of the head and neck, and their metastases are often the source of cervical lymphadenopathy of unknown origin [Haynes, 2015; Pynnonen, 2017; Chorath, 2021] . See the section on Lymphadenopathy for more information.
    • Malignant neck lumps in children are uncommon [Jackson, 2018; Chorath, 2021]. The likelihood of malignancy increases with age, particularly in adults over the age of 40 years [Haynes, 2015; Pynnonen, 2017].
    • Malignant primary tumours may present as an asymptomatic nodule or mass, and may arise in glandular tissue, for example the salivary, thyroid, or parathyroid glands [Prakash, 2002; Haynes, 2015; Pynnonen, 2017].
    • Soft tissue tumours of the head and neck include osteosarcomas and chondrosarcomas, which are rare in the neck area, but may present as a firm-to-hard swelling [Ammar, 2017]. Most cases are sporadic, but an association with neurofibromatosis exists for some sarcomas [Prakash, 2002; Smith, 2019].

Thyroid lumps

  • Thyroid swellings (goitre) may be nodular (a discrete lesion) or diffuse (generalized enlargement of the whole gland), but all move upwards on swallowing [BTA, 2014].
    • In adults, thyroid nodules are common and can be detected by palpation in 3–7% of people [BTA, 2014]. In addition, they may be detected by ultrasound in 19–67% of asymptomatic people without suspected thyroid disease [Burman, 2015; Chorath, 2021].
    • They may be associated with symptoms and signs of hyperthyroidism (for example in Graves' disease or toxic multinodular goitre) or hypothyroidism (for example in Hashimoto's thyroiditis), or symptoms of compression (for example dysphagia, stridor, voice changes, and superior vena cava syndrome) [Prakash, 2002; Haynes, 2015]. See the CKS topics on Hypothyroidism and Hyperthyroidism for more information.
  • Most thyroid nodules are benign and include colloid nodules, hyperplastic nodules, cysts, or follicular adenomas [Bailey, 2018; Chorath, 2021].
  • The risk of malignancy in solitary thyroid nodules is about 7–15% depending on underlying risk factors [Haugen, 2016; Bailey, 2018], and maybe due to papillary, follicular, medullary, or anaplastic carcinomas, or other malignancy such as lymphoma or metastases from other sites such as the breast, kidney, or prostate [Bailey, 2018; Walker, 2019; Chorath, 2021].

Salivary gland lumps

Salivary gland tumours

  • Salivary gland tumours are more common in older people and are rare in children [Homer and Silva, 2003]. Nearly 80% of salivary gland tumours are benign and arise in the parotid gland [Haynes, 2015]. The incidence of malignancy is higher in the submandibular and minor salivary glands than the parotid gland [Wilson, 2014; Sood, 2016].
    • Benign tumours typically present as a solitary neck mass that is well-defined, painless, slow-growing, and mobile [Wilson, 2014; Haynes, 2015; Sood, 2016].
    • Malignant tumours are rare, and typically present as a solitary neck mass with accompanying clinical features such as pain, rapid growth, skin fixation, paraesthesia and facial nerve involvement if the parotid gland is affected [Haynes, 2015; Sood, 2016]. Examples of salivary gland cancers include mucoepidermoid carcinoma, adenocarcinoma, and metastatic squamous cell carcinoma [Hobbs, 2010; Sood, 2016]. In addition, a history of skin malignancy of the face or scalp, such as squamous cell carcinoma, may result in a parotid mass caused by a metastasis [Wilson, 2014; Mantravadi, 2019].

Salivary gland calculi (sialolithiasis)

  • Stones can form in the salivary gland ducts, most commonly affecting the submandibular gland [Wilson, 2014].
    • Characteristically, swelling and tenderness worsens when the person is eating due to an increase in saliva production. Symptoms may last for a few minutes or hours before settling. If symptoms last for a few days, suspect secondary infection [Homer and Silva, 2003]. The resulting swelling from sialadenitis or a stone can sometimes be felt on bimanual palpation along the course of the duct [Homer and Silva, 2003; Wilson, 2014].
    • Persistent gland enlargement and inflammation can result in a permanently swollen salivary gland (chronic obstructive sialadenitis) [Hobbs, 2010]. 

Salivary gland infection (sialadenitis)

  • Acute infection of the salivary glands can be bacterial (usually Staphylococcus aureus) or viral (most commonly caused by mumps, or sometimes HIV infection) [Hobbs, 2010; Wilson, 2014].
    • Acute sialadenitis most commonly affects the parotid gland and is more likely in older people with dehydration or following recent dental procedures. It may present with rapid-onset of pain and swelling, with local erythema, oedema, induration, and localized tenderness. Bimanual compression towards the duct opening may cause purulent discharge into the oral cavity [Wilson, 2014; Haynes, 2015].
    • Mumps is an acute viral illness usually characterized by bilateral parotid swelling, which may be tender, with possible associated otalgia and trismus [Wilson, 2014]. See the CKS topic on Mumps for more information.
    • HIV infection may cause a gradual, non-tender enlargement of one or more of the major salivary glands, most commonly the parotid, and there may be associated dry mouth [Wilson, 2014]. See the CKS topic on HIV infection and AIDS for more information.
  • Chronic or recurrent sialadenitis is more likely to be due to inflammation caused by obstruction of the duct and reduced salivary flow due to a stone or stricture [Wilson, 2014; Haynes, 2015].
    • It most commonly affects the parotid gland and presents with repeated episodes of mild to severe pain and swelling, typically with meals. Examination may show an enlarged or firm salivary gland that may be tender, or the gland may be normal. It may also be caused by granulomatous disease (such as tuberculosis or sarcoidosis) or autoimmune disease (such as Sjögren's syndrome) [Homer and Silva, 2003; Haynes, 2015].

Congenital and developmental lumps

Thyroglossal cyst

  • This is the most common congenital cyst, and usually presents in young children. It is often slow-growing, but may grow rapidly after an upper respiratory tract infection [Haynes, 2015; Jackson, 2018; Smith, 2019; Chorath, 2021; Taha, 2022].
    • It arises from persistent epithelial tissue along the thyroglossal duct, and may be found anywhere along the embryological pathway of the thyroid, from the base of the tongue to the thyroid gland. 
    • It usually presents as a mid-line well-defined, non-tender cystic lump that is adjacent to the hyoid bone, and moves upwards when the person swallows or protrudes their tongue.
    • Remnants are present in approximately 7% of the adult population.
    • Occasionally a thyroglossal cyst may be found off-centre at the lateral edge of the thyroid cartilage . 
    • It may become secondarily infected and can present as an inflammatory swelling [Taha, 2022]. 

Branchial cyst

  • This may present in children or young adults as a painless, slow-growing, smooth, fluctuant swelling in the lateral neck, typically becoming noticeable after an upper respiratory tract infection [Prakash, 2002; Hobbs, 2010; Roland, 2014; Haynes, 2015; Chorath, 2021].
    • It arises from any of the first to fourth pharyngeal clefts.
    • It usually occurs along the line of the deep cervical lymph nodes at the junction of the upper one-third and lower two-thirds of the anterior border of the sternomastoid muscle.

Other

  • Dermoid cyst — this is an inclusion cyst occurring along lines of fusion (for example in the submental triangle, under the tongue, or on the palate), typically presenting in children and young adults. There is typically a superficial mid-line lump that is well-defined, soft, and painless, and unlike a thyroglossal cyst, is tethered to the underlying skin [Hobbs, 2010; Haynes, 2015; Jackson, 2018; Smith, 2019].
  • Lymphangioma (cystic hygroma) — a poorly defined soft, transluminant, fluctuant mass under the skin with a dough-like consistency, which is in the posterior triangle of the neck and usually present from birth [Hobbs, 2010; Jackson, 2018; Reynolds, 2020; Chorath, 2021].
  • Infantile haemangioma — this typically presents shortly after birth as a flat or slightly raised pink patch on the overlying skin, typically on the head or neck [Jackson, 2018; Reynolds, 2020]. They usually proliferate, then stabilize, then involute without the need for intervention. Complications such as ischaemia, ulceration, or bleeding are more likely in the initial proliferation phase [Reynolds, 2020; Chorath, 2021].
  • Venous malformation — this is apparent from birth as an irregular, compressible neck mass with bluish overlying skin, which may be more prominent when an infant is straining. They grow with the child, and may expand rapidly with hormonal changes or trauma [Reynolds, 2020; Chorath, 2021].

Carotid body tumours and aneurysms

  • Carotid body tumours usually present in adults as slow-growing, painless swellings in the oropharyngeal or upper anterior triangle of the neck [Roland, 2014; Haynes, 2015]. They are usually pulsatile over the carotid bifurcation, compressible with a bruit or thrill, and can be moved from side to side, but not up and down [Hobbs, 2010; Haynes, 2015].
    • They are usually asymptomatic, but there may be associated symptoms of flushing, palpitations, hypertension, dysphagia, dyspnoea, or Eustachian tube dysfunction [Haynes, 2015].

Trauma

  • Trauma to the neck may cause a haematoma that is typically self-limiting, but may be complicated by subsequent fibrosis [Haynes, 2015].
  • A history of trauma and shearing forces may allow the formation of a pseudoaneurysm or arteriovenous fistula, characterized by a soft, pulsatile mass with a palpable thrill or audible bruit [Haynes, 2015; Chorath, 2021].
  • A laryngocele may develop in the anterior triangle as a traumatic neck mass due to chronic coughing or repetitive blowing (for example when playing a musical instrument). This causes herniation of the laryngeal diverticulum through the lateral thyrohyoid membrane [Haynes, 2015]. It more commonly presents in adulthood [Jackson, 2018].
    • It usually presents as an intermittent air-filled neck swelling in the midline superior to the thyroid cartilage that is resonant to percussion, and becomes palpable when the person performs the Valsalva manoeuvre [Roland, 2001; Haynes, 2015].

Diagnosis of neck lump

Assessment

If a person presents with a suspected neck lump, assess the clinical features to try to determine the underlying cause.

  • Ask about:
    • The site of the lump(s), onset, size and growth, any changes, and the associated timescale.
      • Congenital and developmental lumps are often present at birth and may enlarge rapidly after a mild upper respiratory tract infection. They can also present in adulthood and increase in size over a longer timescale.
      • Persistent or rapidly-growing neck masses (for example present for more than 6 weeks) are more likely to be malignant.
      • A lymph node diameter greater than 3 cm may be indicative of malignancy.
      • Lymph node metastases are more likely to have a short history with progressive increase in size.
    • Red flag symptoms that are suggestive of malignancy:
      • Dysphagia or pain on swallowing (odynophagia); cough; persistent voice change or hoarseness; ipsilateral otalgia, nasal obstruction, or epistaxis; sore throat, loose or misaligned teeth; haemoptysis; or sensation of lump in the throat — may suggest local malignancy (such as of the upper airway or upper gastrointestinal tract). See the CKS topics on Head and neck cancers - recognition and referral and Gastrointestinal tract (upper) cancers - recognition and referral for more information.
      • Persistent fatigue, night sweats, unexplained fever, weight loss; unexplained bruising, bleeding, or petechiae; unexplained persistent or recurrent infections, bone pain, and alcohol-induced lymph node pain — may suggest haematological malignancy (such as leukaemia or lymphoma). See the CKS topic on Haematological cancers - recognition and referral for more information.
      • Note: have a higher index of suspicion for malignancy if the person is 40 years of age or older and/or there are risk factors such as smoking, excess alcohol intake, betel nut use; previous history of head and neck cancer or irradiation; history of Hashimoto's thyroiditis (increased risk of lymphoma). Also determine if there is a family history of head and neck cancer or endocrine tumour (such as multiple endocrine neoplasia [MEN] type 2 affecting thyroid, adrenal, and parathyroid glands).
    • Other features suggesting a specific underlying cause, such as:
      • Fever, general malaise, cough, sore throat, otalgia, or dental pain —  suggesting reactive lymphadenopathy. Note: be aware that infection of an underlying congenital or neoplastic mass may present similarly to reactive lymphadenopathy.
      • Clinical features of hypo- or hyperthyroidism — see the CKS topics on Hypothyroidism and Hyperthyroidism for more information.
      • A history of localised trauma — suggesting haematoma or fibrosis.
      • Post-prandial pain and swelling in the submandibular or parotid gland — suggesting salivary gland obstruction.
      • Recent travel, insect bites, or exposure to pets or other animals — suggesting an inflammatory or infectious cause, which usually have an acute onset and persist for 2–6 weeks.
      • Associated co-morbidities including immunocompromised state — may cause generalized lymphadenopathy.
      • A family history of autoimmune disorders or vascular abnormalities.
  • Examine the person:
    • Assess for signs of stridor or superior vena cava compression (swelling of the face and/or neck with fixed elevation of jugular venous pressure).
    • Standing behind the person, palpate the different areas of the neck to assess the position of the neck lump(s) and possible cause.
      • Anterior triangle (borders: midline, anterior border of sternocleidomastoid muscle, and the body of the mandible) — thyroid swellings (lobe), pharyngeal pouch, submandibular gland swelling, branchial cyst, lymph nodes (reactive, infective, or malignant), parotid swelling.
      • Posterior triangle (borders: posterior border of sternocleidomastoid muscle, trapezius, and the clavicle) — lymph nodes (reactive or malignant), carotid artery aneurysm, carotid body tumour, cervical rib, lipoma.
      • Midline — thyroid swellings (isthmus), thyroglossal cyst, laryngeal swellings, submental lymph nodes, dermoid cysts.
    • Assess any identified neck lump:
      • Note its position, size (and any fluctuation), pulsatility (suggesting a vascular cause), tenderness (more likely to be infectious or inflammatory), mobility (whether it is fixed to adjacent or underlying structures which may suggest malignancy); nodularity including number of nodules, size, and consistency (if a thyroid lump is identified); and the appearance of overlying skin (skin ulceration may suggest skin malignancy or metastatic cancer).
      • Determine skin temperature, lump consistency (hard, irregular masses are more suspicious of malignancy), and whether it is compressible (such as a branchial cyst).
      • Assess for associated lymphadenopathy, and whether this is localized or generalized.
      • Ask the person to swallow and assess whether the lump moves (thyroid lumps and thyroglossal cysts move upwards).
      • Ask the person to protrude their tongue (thyroglossal cysts move superiorly).
    • Perform a head and neck examination and general examination.
      • Skin — for pallor, petechiae, or bruising (leukaemia); excoriation (lymphoma); generalized rash (adenovirus, cytomegalovirus, Epstein-Barr virus); jaundice (cytomegalovirus, Epstein-Barr virus); and pre-malignant/malignant skin lesions.
      • Head, neck, and scalp — for signs of infection, trauma, insect bites, swelling, or skin ulceration.
      • Ears — for infection such as otitis externa that may cause lymphadenopathy. Be aware that a unilateral middle ear effusion may suggest nasopharyngeal malignancy.
      • Nasal cavity — for infection or malignancy that may cause lymphadenopathy.
      • Oropharynx — remove dentures (if appropriate); assess for dental infection and mucosal lesions including malignancy (use a tongue depressor to examine the lateral borders of the tongue). Assess for tonsillar enlargement or asymmetry. Palpate the floor of the mouth to identify ulcers or masses, and perform bimanual compression of a salivary gland duct if acute sialadenitis is suspected.
      • Chest — for signs of lung disease.
      • Abdomen — for hepatosplenomegaly; axillae and groin for lymphadenopathy (if haematological malignancy is suspected).
  • If initial assessment suggests a possible serious underlying cause, do not delay specialist referral by undertaking investigations in primary care.
    • See the section on Management for more information on appropriate investigations in primary care, depending on the suspected underlying cause.

Basis for recommendation

The recommendations on assessment are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral [NICE, 2025], the British Thyroid Association (BTA) publication Guidelines for the management of thyroid cancer [BTA, 2014], the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline Evaluation of the neck mass in adults [Pynnonen, 2017], the American Thyroid Association (ATA) Guidelines Task Force publication 2015 Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer [Haugen, 2016], the ATA Guidelines Task Force on pediatric thyroid cancer publication Management guidelines for children with thyroid nodules and differentiated thyroid cancer [Francis, 2015], and expert opinion in review articles on neck lumps in adults [Dwivedi, 2013; Haynes, 2015; Tan, 2020; Chorath, 2021], on neck lumps in children [Jackson, 2018; Smith, 2019; Reynolds, 2020; Stanford, 2024], and on thyroid nodules [Burman, 2015; Bailey, 2018; Walker, 2019].

History taking

Examination

  • The recommendations on examination are based on the BTA publication [BTA, 2014], the AAO-HNSF clinical practice guideline [Pynnonen, 2017], the ATA guideline [Haugen, 2016], and expert opinion in review articles [Dwivedi, 2013; Haynes, 2015; Jackson, 2018; Smith, 2019; Tan, 2020].
    • The recommendation to assess for stridor and superior vena cava obstruction is based on the BTA publication [BTA, 2014] and expert opinion in a review article [Dwivedi, 2013].
    • The information on how to assess the position of the neck lump and the anatomical boundaries and drainage areas of the neck is based on expert opinion in review articles [Haynes, 2015; Jackson, 2018; Smith, 2019; Tan, 2020].
    • The recommendations on how to assess the clinical features of the neck lump are based on the AAO-HNSF clinical practice guideline [Pynnonen, 2017], the ATA guideline [Haugen, 2016], and expert opinion in review articles [Jackson, 2018; Tan, 2020].
    • The recommendations on performing a head and neck and general examination to help identify an underlying cause are based on the AAO-HNSF clinical practice guideline [Pynnonen, 2017] and expert opinion in review articles [Jackson, 2018; Smith, 2019; Tan, 2020].
      • The information on the potential significance of a unilateral middle ear effusion is based on expert opinion in a review article [Tan, 2020].

Not routinely arranging investigations in primary care

  • This recommendation is extrapolated from the NICE clinical guideline [NICE, 2025], the BTA publication [BTA, 2014], and expert opinion in review articles [Dwivedi, 2013; Stanford, 2024], which state that if any concerning symptoms are present, specialist evaluation should not be delayed.

Management

Scenario: Skin lump

From age 1 month onwards.

Management of a skin lump

  • If the skin lump has any concerning features (for example dark or irregular pigmentation, irregular shape, or irregular surface; ulceration, skin fixation, or bleeding):
  • If a benign lump can be confidently diagnosed (such as a lipoma or epidermoid cyst):
    • Reassure the person that no further action is usually needed, unless there is recurrent infection, for example.
  • If there is suspected skin infection and/or abscess:
  • If there is uncertainty about the diagnosis or management of a neck lump that appears to be related to the skin:
    • Arrange referral to an ear, nose, and throat surgeon or maxillofacial surgeon, the urgency depending on clinical judgement.

Basis for recommendation

The recommendations on management of neck lumps on the skin are extrapolated from the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral [NICE, 2025], together with expert opinion in review articles on neck lumps in children Evaluation and management of pediatric neck masses: an otolaryngology perspective [Jackson, 2018], Paediatric neck lumps: an approach for the primary physician [Smith, 2019] and An approach to neck lumps in adults [Tan, 2020]. They are also pragmatic, based on what CKS considers to be good clinical practice, and are in line with the expert opinion of previous external reviewers of this CKS topic.

Scenario: Lymphadenopathy

From age 1 month onwards.

Management of lymphadenopathy

  • If there is suspected upper airway obstruction with symptoms such as stridor, signs of superior vena cava obstruction, or dysphagia with aspiration, arrange emergency hospital admission.
  • If there is a suspected infective cause for lymphadenopathy:
    • If there is a suspected viral upper respiratory tract infection, arrange medical review if the person becomes systemically unwell, or lymphadenopathy persists or grows progressively after 7 days (may be indicative of non-infective swelling or abscess formation).
      • If there is a suspected specific underlying infection such as Epstein-Barr virus (EBV), cytomegalovirus (CMV), or HIV, arrange appropriate investigations and onward management, depending on clinical judgement.
      • See the CKS topics on Glandular fever and HIV infection and AIDS for more information.
    • If there is a suspected bacterial infection, assess the need for antibiotic treatment depending on the likely underlying source of infection.
  • If you suspect Kawasaki disease in a child, arrange emergency hospital admission.
  • If there are clinical features of a malignant primary tumour of the head and neck, arrange an urgent suspected cancer pathway referral.
  • If there is unexplained lymphadenopathy:
    • Arrange an urgent full blood count (within 48 hours) to assess for leukaemia if lymphadenopathy is generalized, and arrange onward management as appropriate. See the CKS topic on Haematological cancers - recognition and referral for more information.
    • Consider arranging an urgent suspected cancer pathway referral to exclude a diagnosis of lymphoma, if there is unexplained lymphadenopathy or splenomegaly for adults aged 25 years or more; and within 48 hours for children and young people up to and including 24 years of age, depending on clinical judgement. See the CKS topic on Haematological cancers - recognition and referral for more information.
    • Consider arranging an urgent chest X-ray for people aged 40 years and over with supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, to exclude a diagnosis of lung cancer (or tuberculosis or sarcoidosis), and arrange onward management as appropriate. See the CKS topics on Lung and pleural cancers - recognition and referral and Tuberculosis for more information.
    • Consider arranging an urgent suspected cancer pathway referral to exclude a diagnosis of oral cancer if lymphadenopathy is persistent, particularly if there is also unexplained ulceration in the oral cavity lasting for more than 3 weeks. See the CKS topic on Head and neck cancers - recognition and referral for more information.
    • Consider arranging ran urgent suspected cancer pathway referral to exclude a diagnosis of laryngeal cancer in people aged 45 years and over, particularly if lymphadenopathy is associated with persistent unexplained hoarseness. See the CKS topic on Head and neck cancers - recognition and referral for more information.

Basis for recommendation

The recommendations on management of lymphadenopathy are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral [NICE, 2025], the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline Evaluation of the neck mass in adults [Pynnonen, 2017], and expert opinion in review articles Neck lumps [Roland, 2014], A child with neck swelling [Sinha et al, 2012], Paediatric neck lumps: an approach for the primary physicia [Smith, 2019], An adult with a neck lump [Dwivedi, 2013], and An approach to neck masses in adults [Tan, 2020].

Arranging emergency hospital admission
  • This recommendation is based on the expert opinion of previous external reviewers of this CKS topic. It is also pragmatic, based on what CKS considers to be good clinical practice.
Managing suspected infection
  • The recommendations on management of suspected viral upper respiratory tract infection are based on expert opinion in a review article [Sinha et al, 2012].
    • The recommendation to consider the need for additional investigations is based on the AAO-HNSF clinical practice guideline [Pynnonen, 2017]. This approach is supported by expert opinion in a review article that notes that targeted blood tests for atypical infections may be needed if a person has associated risk factors, or if a presumed reactive lymphadenitis has not improved with conservative management [Smith, 2019].
  • The recommendation to consider the need for antibiotics for suspected bacterial infection is based on the AAO-HNSF clinical practice guideline, which recommends that antibiotics should not be routinely prescribed unless there are signs or symptoms of bacterial infection, based on observational studies, as inappropriate prescribing may lead to a delayed diagnosis of malignancy or other serious illness [Pynnonen, 2017]. This approach is supported by expert opinion in review articles [Dwivedi, 2013; Roland, 2014]. 
    • The recommendation to consider specialist referral if lymphadenopathy is not resolving within 2–4 weeks following antibiotic treatment is based on expert opinion in review articles [Roland, 2014; Smith, 2019]. 
      • Expert opinion in one review article recommends to observe the person if there is suspected reactive lymphadenitis with no red flags for malignancy and no deep abscess for 6 weeks, and to investigate after 4 weeks if a neck mass persists or symptoms have not improved after antibiotic treatment [Smith, 2019].
      • In addition, the AAO-HNSF clinical practice guideline notes the possibility of developing infection in a necrotic metastatic lymph node, which may initially present as a presumed reactive lymphadenitis [Pynnonen, 2017].
Managing suspected Kawasaki disease

  • This recommendation is extrapolated from information within a review article which states that children with Kawasaki disease often experience extended hospital stays due to misdiagnosis and failure to recognise that cervical lymphadenopathy is a key feature, often prior to the development of additional pathognomic features [Stanford, 2024]. It is also pragmatic, based on what CKS considers to be good clinical practice as timely treatment reduces the risk of acquired heart disease as a consequence of Kawasaki disease.

Managing a suspected malignant primary tumour
  • This recommendation is extrapolated from the NICE clinical guideline [NICE, 2025] and expert opinion in a review article, which recommends referral to a head and neck surgeon for possible imaging and biopsy [Smith, 2019]. It is also pragmatic, based on what CKS considers to be good clinical practice. 
Managing unexplained lymphadenopathy
  • The recommendations on management for suspected leukaemia or lymphoma are based on the NICE clinical guideline [NICE, 2025].
    • Expert opinion in a review article notes that unexplained anaemia or thrombocytopenia may suggest a diagnosis of haematological malignancy, while the white cell differential may suggest a viral or bacterial pathology [Smith, 2019].
  • The recommendation on when to arrange an urgent chest X-ray and onward referral are based on the NICE clinical guideline [NICE, 2025]. The information that this may additionally exclude a diagnosis of tuberculosis or sarcoidosis is based on the AAO-HNSF clinical practice guideline [Pynnonen, 2017] and expert opinion in a review article [Tan, 2020].
  • The recommendations on when to refer for suspected oral cancer or laryngeal cancer are based on the NICE clinical guideline [NICE, 2025].

Scenario: Thyroid lump

From age 1 month onwards.

Management of a thyroid lump

  • If a thyroid lump is suspected on examination, or noted as incidental finding following imaging:
    • Arrange emergency hospital admission if there are symptoms of upper airway obstruction, such as stridor.
    • Arrange an urgent suspected cancer pathway referral to a thyroid surgeon or endocrinologist if there is:
      • An unexplained thyroid lump. 
      • A thyroid mass associated with unexplained hoarseness or voice change.
      • A thyroid mass associated with cervical lymphadenopathy or supraclavicular lymphadenopathy.
      • Sudden onset of a rapidly expanding painless thyroid mass, significantly increasing in size over days and weeks.
      • A suspected thyroid nodule with other red flags or risk factors for malignancy.
      • A suspected thyroid nodule with associated compressive symptoms, such as breathlessness or dysphagia.
    • Arrange an urgent referral (via an urgent suspected cancer pathway if appropriate) to a general paediatrician or a paediatric endocrinologist, for a child with a thyroid nodule or goitre, depending on local service provision.
  • For all other people with a suspected thyroid lump:
    • Arrange serum thyroid function tests (TFTs) in primary care.
    • Arrange a routine endocrinology referral if there is: 
      • A non-suspicious thyroid nodule or nodular goitre and abnormal TFT results — the risk of thyroid malignancy is low. See the CKS topics on Hyperthyroidism and Hypothyroidism for more information on interpreting abnormal TFT results, and when a more urgent referral may be appropriate.
      • A non-suspicious thyroid nodule with normal TFT results.
      • Sudden-onset painful expansion in a pre-existing thyroid lump (likely to be due to haemorrhage into a benign thyroid cyst).
      • A thyroid nodule picked up incidentally on an ultrasound scan, CT, or MRI, which is more than 1 cm in diameter, if there are no suspicious features of malignancy.
    • Consider monitoring the person in primary care with no need for specialist referral, depending on clinical judgement, if there is:
      • An adult with a history of a longstanding unchanging thyroid nodule or mass over several years, with no palpable cervical lymphadenopathy and no other red flags or risk factors for malignancy.
      • A non-palpable, asymptomatic thyroid nodule picked up incidentally on an ultrasound scan, CT, or MRI, which is less than 1 cm in diameter, with no associated lymphadenopathy and no other red flags or risk factors for malignancy.
    • Do not routinely arrange further investigations such as a neck ultrasound scan in primary care, as this may cause diagnostic delay.

Basis for recommendation

The recommendations on management of a suspected thyroid lump are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral [NICE, 2025], the British Thyroid Association (BTA) publication Guidelines for the management of thyroid cancer [BTA, 2014], the American Thyroid Association (ATA) Guidelines Task Force publication 2015 Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer [Haugen, 2016], the ATA Guidelines Task Force on pediatric thyroid cancer publication Management guidelines for children with thyroid nodules and differentiated thyroid cancer [Francis, 2015], the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline Evaluation of the neck mass in adults [Pynnonen, 2017], and expert opinion in review articles Thyroid nodule [Burman, 2015], Differentiating between benign and malignant thyroid nodules: an evidence-based approach in general practice [Bailey, 2018], Thyroid nodules: a clinical update for primary care  [Walker, 2019] and An approach to neck masses in adults [Tan, 2020], Evaluation and Management of a Neck Mass [Chorath, 2021].

Arranging emergency hospital admission 
Arranging urgent specialist referral
  • The recommendation regarding an unexplained thyroid lump is based on the NICE clinical guideline, which aims to exclude a diagnosis of thyroid cancer using this approach [NICE, 2025].
  • The recommendation regarding thyroid mass with associated unexplained hoarseness or voice change is based on the BTA publication [BTA, 2014]. In addition, expert opinion in review articles notes that associated symptoms such as voice changes may suggest underlying malignancy [Bailey, 2018], and recent onset of hoarseness may be due to tumour invasion of the recurrent laryngeal nerve [Burman, 2015].
  • The recommendation regarding thyroid mass associated cervical or supraclavicular lymphadenopathy is based on the BTA publication [BTA, 2014]. In addition, expert opinion in a review article notes that the presence of cervical lymph nodes ipsilateral to the thyroid nodule may indicate thyroid malignancy [Burman, 2015].
  • The recommendation regarding a sudden-onset rapidly expanding thyroid mass is based on the BTA publication, as this may be a rare presentation of anaplastic thyroid cancer or thyroid lymphoma [BTA, 2014]. This is supported by expert opinion in a review article [Burman, 2015].
  • The recommendation regarding a thyroid nodule with other red flags or risk factors for malignancy is based on expert opinion in a review article [Walker, 2019].
  • The recommendation regarding a thyroid nodule with associated compressive symptoms is extrapolated from expert opinion from review articles, which note that associated symptoms such as dysphagia may suggest underlying malignancy [Bailey, 2018; Walker, 2019]. It is also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation to refer all children urgently is based on the BTA publication [BTA, 2014]. In addition, the ATA Guidelines Task Force publication notes that thyroid nodules are more likely to be malignant in children than in adults, and some forms of thyroid cancer in children may present with diffuse enlargement of a thyroid lobe or the entire thyroid gland, prompting the need for further imaging [Francis, 2015].
Arranging serum thyroid function tests (TFTs) in primary care
  • This recommendation is based on the BTA publication, which notes that TFT results may be useful to help guide the appropriate referral pathway [BTA, 2014]. This is supported by expert opinion in a review article, which notes that baseline TFTs are particularly useful if there is suspected hypo- or hyperthyroidism [Walker, 2019].
  • The AAO-HNSF clinical practice guideline notes that an elevated thyroid-stimulating hormone (TSH) level may be associated with toxic multinodular goitre, and a decreased TSH level may be associated with Hashimoto's thyroiditis or Graves' disease [Pynnonen, 2017].
  • The ATA Guidelines Task Force publication strongly recommends that TFTs should be measured during the initial assessment of a person with a suspected thyroid nodule on examination or when picked up incidentally on imaging, based on moderate-quality evidence [Haugen, 2016]. This approach is also supported by expert opinion in a review article [Burman, 2015].
Arranging routine specialist referral
  • The recommendation to refer if there is a non-suspicious thyroid nodule and abnormal TFTs is based on the BTA publication, which notes there is a low risk of malignancy in this population [BTA, 2014]. The ATA Guidelines Task Force publication strongly recommends that if the TSH is below the normal range, further assessment such as radionuclide scan is needed to assess whether there is an overactive thyroid gland or hyperfunctioning thyroid nodule, based on moderate-quality evidence [Haugen, 2016].
  • The recommendation to refer if there is a non-suspicious thyroid nodule and normal TFTs is extrapolated from the BTA publication [BTA, 2014]. This approach is supported by expert opinion in a review article [Walker, 2019].
  • The recommendation to refer if there is suspected haemorrhage into a benign thyroid cyst is based on the BTA publication [BTA, 2014] and expert opinion in a review article [Burman, 2015].
  • The recommendation to refer if there is an incidental thyroid nodule that is more than 1 cm in diameter is extrapolated from expert opinion in a review article [Walker, 2019].
Arranging monitoring in primary care
  • The recommendation regarding monitoring a longstanding non-suspicious thyroid nodule or mass in primary care is based on the BTA publication [BTA, 2014].
  • The recommendation regarding monitoring a small, asymptomatic incidental thyroid nodule in primary care is based on the BTA publication [BTA, 2014]. In addition, expert opinion in a review article notes that such nodules have a very low likelihood of malignancy, and if cancer is detected, it is likely to be indolent with a good prognosis [Walker, 2019].
Not routinely arranging further investigations in primary care
  • The recommendation not to routinely arrange neck or thyroid ultrasound in primary care is based on the BTA publication, which states that this may delay a diagnosis of thyroid cancer. The guideline does note, however, that ultrasound is an extremely sensitive examination for thyroid nodules, can be specific for the diagnosis of thyroid carcinoma, and aids decision-making about on which nodules to perform fine-needle aspiration cytology (FNAC) [BTA, 2014].
    • CKS also notes that numerous guidelines and review articles in the literature highlight the benefits of arranging a neck ultrasound if a thyroid nodule is suspected, including providing information on nodule size, clinical features for risk stratification of malignancy, and guiding the need for additional investigations [Burman, 2015; Haugen, 2016; Pynnonen, 2017; Bailey, 2018; Tan, 2020; Chorath, 2021].

Scenario: Salivary gland lump

From age 1 month onwards.

Management of a salivary gland lump

  • If there is a parotid or submandibular gland swelling that is persistent and/or unexplained:
    • Arrange urgent referral (for an appointment within 2 weeks) to an ear, nose, and throat surgeon.
  • If there is a suspected salivary gland calculus:
    • Arrange referral to an ear, nose, and throat surgeon or maxillofacial surgeon, depending on local service provision, the urgency depending on clinical judgement.

Basis for recommendation

The recommendations on management of salivary gland swellings are based on the UK publication Management of salivary gland tumours: United Kingdom national multidisciplinary guidelines [Sood, 2016] and expert opinion in review articles Salivary gland disorders [Wilson, 2014] and AHNS series: do you know your guidelines? Diagnosis and management of salivary gland tumors [Mantravadi, 2019].

Management of persistent or unexplained salivary gland swelling
  • This recommendation is largely based on the UK publication on the management of salivary gland tumours, which recommends referral to a rapid access neck lump clinic if there is suspected malignancy. Additional investigations may include ultrasound-guided fine-needle aspiration cytology (FNAC) and core biopsy before possible surgical intervention [Sood, 2016].
  • This approach is supported by expert opinion in a review article, which notes that surgery is the most common initial treatment for salivary gland tumours, the extent of surgery depending on the tumour location, histology, and degree of local invasion [Mantravadi, 2019]. Expert opinion in an additional review article recommends urgent referral if there is suspected salivary gland malignancy [Wilson, 2014].
Management of suspected salivary gland calculi
  • This recommendation is based on expert opinion in a review article, which states that additional investigation such as salivary gland ultrasound or CT may show a stone or dilated duct, and eventual surgical removal of the stone or salivary gland excision may be needed, depending on the location of the stone [Wilson, 2014]. This recommendation is supported by the expert opinion of previous external reviewers of this CKS topic.

Scenario: Congenital or developmental lumps

From age 1 month onwards.

Management of congenital or developmental lumps

  • If a branchial or thyroglossal cyst is suspected, arrange referral to an ear, nose, and throat surgeon or head and neck surgeon, depending on local service provision, the urgency depending on clinical judgement.
  • If a venous malformation is suspected, arrange referral to an ear, nose, and throat surgeon or head and neck surgeon, depending on local service provision, the urgency depending on clinical judgement.

Basis for recommendation

The recommendations on the management of suspected congenital and developmental neck lumps are based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline Evaluation of the neck mass in adults [Pynnonen, 2017], and expert opinion in review articles Thyroglossal Duct Cyst, a Case Report and Literature Review  [Taha, 2022], Neck swellings [Roland, 2014], Evaluation of neck masses in adults [Haynes, 2015],  An approach to neck masses in adults [Tan, 2020], Evaluation and Management of a Neck Mass [Chorath, 2021], Evaluation and management of pediatric neck masses: an otolaryngology perspective [Jackson, 2018; Smith, 2019], Fifteen-minute consultation: the infant with a neck lump [Reynolds, 2020].

  • The AAO-HNSF guideline recommends that people with a suspected cystic neck mass should be investigated until a diagnosis is obtained, and it should not be assumed that a cystic neck mass is benign, as fluid-filled cystic masses may also be malignant. A cervical cystic lymph node metastasis related to papillary thyroid carcinoma, lymphoma, or oropharyngeal carcinoma, for example, can mimic a branchial cyst clinically [Pynnonen, 2017]. Similarly, expert opinion in review articles notes that human papillomavirus (HPV)-positive oropharyngeal cancer is more likely to present with an asymptomatic neck mass that may be cystic, and that may be misdiagnosed as a branchial cyst if not properly investigated, leading to delayed diagnosis and treatment [Tan, 2020; Chorath, 2021].
  • Expert opinion in an additional review article also recommends referral for a suspected branchial cyst, as they may become infected and usually require surgical excision [Roland, 2014].
  • The recommendation on referral of a suspected thyroglossal cyst is based on the fact surgical excision is the usual treatment to confirm the diagnosis and prevent future infections [Roland, 2014; Jackson, 2018; Taha, 2022]. Additional review articles note that surgical excision may be needed for congenital cysts if there is a history of recurrent infection or compressive symptoms [Haynes, 2015; Reynolds, 2020].
  • The recommendation on referral for a suspected venous malformation is based on the fact it may be treated by surgical excision, sclerotherapy, or laser therapy, particularly if symptomatic or causing complications such as airway compromise, dysphagia, or pain [Reynolds, 2020].

Scenario: Carotid lump

From age 1 month onwards.

Management of a carotid lump

  • If a carotid lump is pulsatile or appears to be related to the carotid artery:
    • Arrange emergency hospital admission if the neck lump: 
        • Occurred after local trauma.
        • Is affecting a person with underlying vascular disease.
        • Is affecting a person with known vasculitis.
        • Appeared after surgical intervention.
    • For all other people, arrange referral to a vascular surgeon or head and neck surgeon for further management, depending on local service provision, the urgency depending on clinical judgement.

Basis for recommendation

The recommendations on management of a suspected carotid lump are based on expert opinion in a review article on neck lumps in adults, which states that CT angiography is the first-line investigation for pulsatile neck lumps of possible vascular origin [Haynes, 2015]. They are also supported by a case study [Cerullo, 2022], are pragmatic, based on what CKS considers to be good clinical practice, and are in line with the expert opinion of previous external reviewers of this CKS topic.

Scenario: Unknown cause

From age 1 month onwards.

Management of a neck lump of unknown cause

  • Arrange emergency hospital admission if there are symptoms such as stridor, signs of superior vena cava obstruction, or dysphagia with aspiration.
  • Consider arranging an urgent suspected cancer pathway referral to a head and neck surgeon if:
    • There is an unexplained neck lump in a person aged 45 years or older, or
    • There is a persistent and unexplained neck lump in a person at any age.
      • A neck lump is persistent if it is present beyond the time that would normally be associated with a self-limiting problem.
      • A neck lump is unexplained if a diagnosis has not been made in primary care after initial assessment.
      • See the section on lymphadenopathy for more information about assessment and management. 
  • Consider arranging a neck ultrasound scan if there is an unexplained neck lump that is increasing in size.
    • For adults aged 25 years and older, arrange an urgent neck ultrasound scan appointment. 
      • Consider arranging an urgent suspected cancer pathway referral if the ultrasound scan findings are uncertain or suggestive of soft tissue sarcoma.
    • For children and young people up to and including 24 years of age, arrange a very urgent neck ultrasound scan appointment within 48 hours. 
      • Consider arranging a very urgent referral (for an appointment within 48 hours) if the ultrasound findings are uncertain, or suggestive of soft tissue sarcoma.

Basis for recommendation

The recommendations on management of a neck lump of unknown cause are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral [NICE, 2025], the British Thyroid Association (BTA) publication Guidelines for the management of thyroid cancer [BTA, 2014], and expert opinion in review articles An adult with a neck lump [Dwivedi, 2013], Evaluation of neck masses in adults [Haynes, 2015].

Arranging emergency hospital admission
  • This recommendation is extrapolated from the BTA publication [BTA, 2014] and expert opinion in a review article [Dwivedi, 2013]. It is also in line with the expert opinion of previous external reviewers of this CKS topic.
Arranging an urgent specialist referral
  • The recommendation on arranging referral in a person with an unexplained neck lump is based on the NICE clinical guideline, in order to exclude a diagnosis of laryngeal cancer [NICE, 2025].
  • The recommendation on arranging referral in a person with a persistent and unexplained neck lump is based on the NICE clinical guideline, in order to exclude a diagnosis of oral cancer [NICE, 2025]. 
  • Expert opinion in a review article notes that if there is no obvious underlying cause for a neck lump from the clinical features, further imaging and possible surgical intervention may be needed by a head and neck surgeon [Haynes, 2015].
Arranging a neck ultrasound scan
  • These recommendations are based on the NICE clinical guideline, in order to exclude a diagnosis of soft tissue sarcoma [NICE, 2025].

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer: recognition and referral [NICE, 2025], the British Thyroid Association (BTA) publication Guidelines for the management of thyroid cancer [BTA, 2014], the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline Evaluation of the neck mass in adults [Pynnonen, 2017], and expert opinion in review articles. The rationale for recommendations is summarized in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of neck lump. 

Search dates

August 2020 - March 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 10th August 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.  

S10 S1 OR S5 OR S6 OR S7 OR S8 OR S9
S9 TI ((branchial or thyroglossal) N2 cyst*)
S8 (MH "Thyroglossal Cyst") 
S7 TI (parotid or carotid or submandibular or salivary gland*) N3 (lump* or mass* or swelling*) OR TI salivary gland* N2 (cancer* or malignan* or neoplasm* or tumor* or tumour* or calculi or calculus or lump* or swelling* or mass* or infection* or inflammation) 
S6 TI thyroid N3 (lump* or mass* or swelling* or nodule*) 
S5 TI (neck N3 lymphadenopath*) 
S4 S2 AND S3 
S3 (MH "Neck+") 
S2 (MH "Lymphadenopathy+") 
S1 AB ( neck N3 (lump* or swelling* or mass*) ) OR TI ( neck N3 (lump* or swelling* or mass*) ) 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

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  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
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  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
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  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

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Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
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  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Ammar, M.I., Oeppen, R.S., Bowles, C. and Brennan, P.A. (2017) Hard neck lumps: a review of uncommon and sometimes overlooked causes of these worrying presentations. British Journal of Oral and Maxillofacial Surgery 55(9), 899-903. [Abstract]
  • Bailey, S. Wallwork, B. (2018) Differentiating between benign and malignant thyroid nodules: an evidence-based approach in general practice. Australian Journal of General Practice 47(11), 770-774. [Abstract]
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