GPAtlas🧭 When to suspect
Suspect significant pathology in any patient with a new or persistent neck swelling. The core primary-care skill is to separate the very common reactive node from the lump that needs an urgent suspected cancer pathway referral – and the single 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, and 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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