GPAtlas🧭 When to suspect
Suspect significant pathology in any patient with a new or persistent neck swelling. Separate the very common reactive node from the lump that needs an urgent suspected cancer pathway referral – the most useful discriminator is persistence.
Raise suspicion of malignancy when a lump is persistent (present beyond about 3 weeks), unexplained, hard, fixed, or rapidly enlarging.
Associated red flags – hoarseness, dysphagia, odynophagia, otalgia with normal otoscopy, or unexplained weight loss – sharply increase concern.
Risk rises with:
• Age (especially over 45).
• A smoking and alcohol history (squamous cell carcinoma, SCC).
• Prior head and neck or skin cancer.
• Immunosuppression or HIV.
A useful rule: a persistent, unexplained neck lump in an adult is malignant until proven otherwise, and the absence of pain or other symptoms must never be taken as reassurance.
| Likely category | Pointers in primary care |
|---|---|
| Reactive/infective (most common) | • Tender, mobile • Follows a sore throat, tonsillitis, dental or skin infection • Glandular fever (Epstein–Barr virus, EBV) in young adults • Usually settles within ~4–6 weeks |
| Thyroid | • Midline or para-midline • Moves upward on swallowing • May coexist with thyroid dysfunction |
| Salivary gland | • Parotid (in front of or below the ear) or submandibular • Pain and swelling that worsen with eating suggest a duct stone |
| Congenital (younger patients) | • Thyroglossal cyst (midline, moves on tongue protrusion) • Branchial cyst (upper anterior triangle) • Typically long-standing |
| Neoplastic | • Hard, fixed, painless and persistent • Lymphoma (rubbery, may be generalised) • Metastatic SCC • A supraclavicular node points to thoracic or intra-abdominal disease |
Source: NICE NG12
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