When an adult presents with a head or neck lump, your workup should focus first and foremost on ruling out cancer, says Dr Julia Crawford, a Sydney-based ENT specialist and head and neck surgeon.

The anatomical location of a lump within the head or neck is an indicator of the likelihood of malignancy.

For cervical lymph nodes, the level of involvement correlates with probable primary sites.

“So for instance, if you have an oral cancer, it’s probably going to spread to the area just underneath the chin and the jaw, so the submental and submandibular region, which is levels one and two,” Dr Crawford says.

“Whereas if you’re thinking about some of the more hidden sites within the upper aerodigestive tract—things like the nasal cavity, the back of the nose, the pharynx—most of those will metastasise to levels two or three in the neck, so the jugular digastric chain, the lateral neck chain.”

This is particularly important given the upper aerodigestive tract cannot be visualised during routine clinical examination, so the presenting neck node may be the first and only clinical sign of malignancy.

These patients should be referred to an ENT or head and neck surgeon who can perform a flexible nasendoscopy and laryngoscopy, Dr Crawford says.

For salivary gland masses, location similarly signifies malignancy risk.

“If we’re looking at the parotid gland, the chance of it being malignant is quite low. If you’re thinking about a submandibular gland, it’s about 50-50. And if you’re thinking about a sublingual gland, most of those will be malignant,” she says.

The six-week rule and red flag symptoms

Any lateral neck mass present for more than six weeks in an adult carries a high probability of malignancy and warrants prompt investigation, Dr Crawford says.

Other local symptoms to look out for include:

A foreign body sensation in the throat – unlike the typical globus sensation associated with allergy and reflux, patients with an upper aerodigestive tract malignancy “usually describe it as feeling like they’ve got a grain or a hair stuck in their throat,” Dr Crawford explains.

Odynophagia, dysphagia, or a change in voice – such as a husky voice or a “hot potato voice” that sounds like you’ve got something stuck in your throat.

Haemoptysis – particularly if it’s coming from the upper airway.

Otalgia in a normal-appearing eardrum – which can be pain from upper airway pathology referred via the glossopharyngeal nerve.

Unilateral epistaxis with increasing nasal obstruction – which should prompt ENT evaluation.

Recurrent middle ear infections – in which case a specialist should investigate the nasopharynx to exclude masses as cause of eustachian tube dysfunction.

Practice tip: It’s important to note that for HPV-related head and neck cancers, which account for up to 70% of all head and neck cancers, local symptoms are often not present until advanced stages.

Investigations

The key investigation for lymph nodes is an ultrasound guided fine needle aspirate biopsy, Dr Crawford says.

“With a fine needle aspirate, there’s two things that are important to ask for on the request form. One being flow cytometry, because you’re trying to rule out a lymphoma or lymphoproliferative process. And the other is something called P16 staining.”

P16 is a breakdown product of human papillomavirus, she explains. “And if the tumours, which will usually come back as a poorly differentiated squamous cell carcinoma, stain more than 70% for P16, then this is going to be an HPV-related tumour.”

A CT scan can be a helpful second line investigation. It must be done with intravenous contrast “because otherwise it’s really difficult to differentiate a vessel in the neck from a lymph node,” she says.

However, it has limited value for identifying primary upper aerodigestive tract lesions because supine positioning during scanning causes mucosal collapse, which can obscure smaller tumours.

“But it will help pick up any cervical neck nodes that are enlarged,” Dr Crawford says.

Blood tests are reasonable but may have limited diagnostic value apart from LDH levels—which can help distinguish haematological from upper aerodigestive tract malignancies, she adds.

Surgical sequencing

Importantly, no one should have an excisional biopsy of a cervical lymph node performed as first line investigation. This is because it eliminates surgery as a treatment option, Dr Crawford stresses.

It is important to remember that congenital abnormalities like a branchial cleft cyst do not tend to present in later life.

“In an adult who presents with a cystic neck mass, the first thought must be that this represents a cancer and they should be referred to a ENT/Head and Neck Surgeon who works in a Head and Neck Cancer Multidisciplinary team for review. Doing an excision lymph node biopsy will disrupt the lymph draining pathways and will likely limit the treatment choice to radiation, eliminating the chance of a purely surgical cure,” Dr Crawford explains.

For younger patients with HPV-related cancers, this limitation is particularly crucial. While both surgery and radiation therapy offer equivalent cure rates for these malignancies, radiation is “the gift that keeps on giving” in terms of side effects, she says.

“If you have treatment in your 40s, by the time you get to 80, you’re going to have more significant side effects related to radiation and the added risk of a second primary within the upper aerodigestive tract.”

“So in the right patients, we really should be at least offering them surgery if that’s applicable for their particular tumour.”

With robotic assistance, surgeons can now get to previously inaccessible sites without large facial incisions, making surgical resection a viable option for many oropharyngeal cancers.

Salivary gland masses

Primary parotid masses should be investigated with ultrasound and fine needle aspirate biopsy and are usually benign, Dr Crawford says. “We do need to be mindful though that, in Australia, skin cancers metastasising to the parotid gland is common. The fine needle biopsy will help differentiate between a metastatic skin cancer and a primary parotid mass. “

However, even with a benign FNA biopsy, patient should be referred to a ENT/Head and Neck Surgeon for review because, with the most common benign parotid tumour, a pleomorphic adenoma, there is a 1% annual risk of conversion to a malignant lesion.

This is relevant when counselling patients about treatment options, she adds.

“If you have an 85-year-old who’s got a new diagnosis of pleomorphic adenoma, they probably don’t need an operation. But if you have a 45-year-old with a 40-year chance of conversion, they’re the people who probably need to have an operation to remove that lesion.”

Submandibular gland masses are usually inflammatory, and a CT soft tissue of the neck is the best investigation. Sublingual gland masses are rare but almost always malignant.

Most patients with salivary gland lesions will “need an operation of some description, so it’s good to refer to an ENT head and neck,” Dr Crawford says.

Thyroid nodules

About half of all adults have thyroid nodules and most do not need further investigations, Dr Crawford says.

“The ones that do will be people who’ve had previous radiation exposure, people who’ve got a family history of thyroid cancer, anything that’s rapidly growing or compressive.”

A good ultrasound report will include the lesion’s TI-RADS category, which provides guidance on which patients need biopsy, Dr Crawford says.

The biopsy report should include Bethesda staging, which guides treatment decisions.

“A Bethesda three and above will probably end up needing referral to an ENT head and neck or endocrine surgeon, because anything from four and above will almost definitely need operative intervention,” Dr Crawford says.

Key takeaways 

• Always rule out cancer first when an adult presents with a head or neck lump.
• Any lateral neck mass persisting >6 weeks in an adult is suspicious for malignancy and should be investigated.
• Ultrasound with a fine needle aspirate biopsy is the first line of investigation for cervical lymph nodes and parotid masses and a CT soft tissue of the neck with IV contrast will often be needed as well. A CT soft tissue of the neck is the best investigation for submandibular gland masses.
• Thyroid nodules are mostly benign, but investigate if rapidly growing, compressive, post-radiation, or with family history. TI-RADS (US) and Bethesda (biopsy) guide referrals.
• Any concerning neck mass, salivary gland lesion, or thyroid nodule should be referred to ENT/head and neck surgery.