Why Neck Lump History Is High-Yield
A neck lump is a common OSCE presenting complaint because it tests multiple skills simultaneously: structured history taking, anatomical knowledge, differential diagnosis, and safe recognition of red flags for malignancy. Examiners want to see that you can narrow the differential using the history, not just list every possible cause.
Your First Question Sets the Tone
Open with: "Can you tell me about the lump you've noticed? When did you first become aware of it?"
Then systematically explore the lump and associated symptoms.
The Lump Itself: Systematic Questions
| Feature | Question |
|---|---|
| Duration | "How long have you noticed it?" |
| Change over time | "Has it grown? Has it changed in size, shape, or firmness?" |
| Number | "Is it just the one lump or are there others?" |
| Pain | "Is it painful to touch? Was it painful when it first appeared?" |
| Skin changes | "Has the skin over it changed colour or broken down?" |
| Associated lumps elsewhere | "Have you noticed any lumps in your armpits or groin?" |
A lump that has been growing rapidly over weeks in an adult is malignant until proven otherwise.
Anatomical Differential by Location
The location narrows the differential immediately:
| Location | Common causes |
|---|---|
| Anterior triangle (in front of sternocleidomastoid) | Lymph node (reactive or malignant), thyroid goitre/nodule, branchial cyst, submandibular gland |
| Posterior triangle (behind sternocleidomastoid) | Lymph node (reactive or malignant), cervical rib, cystic hygroma in children |
| Midline | Thyroglossal duct cyst (moves up with tongue protrusion), thyroid goitre, dermoid cyst, lymph node |
| Parotid region | Parotid gland enlargement (tumour, calculus, infection) |
| Supraclavicular | Lymph node: left supraclavicular (Virchow's node, Troisier's sign = gastric or other GI cancer); right = lung or oesophageal |
⚠️ Red Flag
A left supraclavicular lymph node (Virchow's node, Troisier's sign) is a red flag for intra-abdominal malignancy, classically gastric cancer. Ask about dyspepsia, weight loss, and abdominal symptoms.
Red Flag Symptoms: Must Ask Every Time
⚠️ Red Flag
Cancer red flags for a neck lump:
- Duration over 3 weeks in an adult
- Firm, hard, or fixed lump (fixed = likely malignant)
- Progressive enlargement
- Unexplained weight loss
- Night sweats
- Hoarseness or change in voice (recurrent laryngeal nerve involvement or laryngeal cancer)
- Dysphagia (difficulty swallowing: pharyngeal or oesophageal cancer)
- Dyspnoea or stridor (tracheal compression)
- Haemoptysis (blood in coughed-up sputum: lung or laryngeal cancer)
- Otalgia (referred ear pain from pharyngeal cancer)
- Trismus (jaw stiffness: nasopharyngeal or parapharyngeal spread)
Lymphoma B Symptoms
If lymphoma is on the differential, specifically ask:
- "Have you had any drenching night sweats, where you wake up soaking?"
- "Have you lost any weight without trying? How much in how long?"
- "Have you had unexplained fevers?"
- "Do you get itching all over your body, without a rash?" (Pel-Ebstein fever and pruritus in Hodgkin's lymphoma)
- "Have you noticed that alcohol triggers the pain in the lump?" (rare but pathognomonic for Hodgkin's lymphoma)
💎 Clinical Pearl
B symptoms (fever above 38 degrees, drenching night sweats, weight loss over 10% in 6 months) are staging features that indicate more aggressive disease in Hodgkin's and non-Hodgkin's lymphoma. Asking about all three shows examiners you know the criteria.
Thyroid Lump Questions
If the lump is midline or moves with swallowing:
- "Does the lump move when you swallow?" (thyroid lump moves with swallowing)
- "Does it move when you stick your tongue out?" (thyroglossal cyst moves with tongue protrusion, thyroid lump does not)
- "Any symptoms of an overactive thyroid? Weight loss, heart racing, feeling hot, tremor, loose stools?"
- "Any symptoms of an underactive thyroid? Weight gain, feeling cold, constipation, fatigue, hair thinning?"
- "Any difficulty swallowing or breathing?" (pressure symptoms from large goitre)
- "Any voice changes?" (recurrent laryngeal nerve involvement by malignant nodule)
- "Any family history of thyroid cancer or MEN syndrome?"
Risk Factors for Malignancy
Ask about:
- Smoking and alcohol: major risk factors for squamous cell carcinoma of the head and neck
- HPV exposure: oropharyngeal cancer (base of tongue, tonsil) in younger non-smokers
- EBV: risk factor for nasopharyngeal carcinoma
- Previous cancer history: cervical node metastasis from a known primary
- Immunosuppression: risk of lymphoma (HIV, organ transplant recipients)
- Radiation to neck: thyroid cancer risk
Social History
- Occupation (relevant to radiation exposure)
- Smoking history (pack-years)
- Alcohol intake (units per week)
- Recent travel (tuberculosis is a common cause of cervical lymphadenopathy globally)
2-Week Wait Referral Criteria (NICE NG12)
Refer on a 2-week wait cancer pathway if:
- Unexplained lump in the neck that is persistent (over 3 weeks) in an adult
- Any lump in the head and neck area with no obvious infective cause
- Lump with associated hoarseness, dysphagia, or unexplained weight loss
- Unilateral cervical lymphadenopathy with any red flag symptom
Frequently Asked Questions
"A 55-year-old smoker presents with a 6-week history of a firm neck lump and hoarseness. What is your differential and next step?"
In a 55-year-old smoker with a persistent firm neck lump and hoarseness, the diagnosis is squamous cell carcinoma of the head and neck (laryngeal, oropharyngeal, or hypopharyngeal primary with cervical nodal metastasis) until proven otherwise. Hoarseness indicates involvement of the larynx or recurrent laryngeal nerve. Other possibilities include thyroid malignancy with RLN invasion, and lymphoma. This patient requires urgent 2-week wait referral to head and neck surgery. Further history should cover dysphagia, haemoptysis, weight loss, alcohol use, and prior cancer history. Examination should include palpation of all cervical node groups, the thyroid, and the oropharynx. A panendoscopy (direct laryngoscopy, oesophagoscopy, bronchoscopy) under general anaesthetic is often performed to find the primary tumour if not obvious.
"What are B symptoms and which haematological malignancies are they associated with?"
B symptoms are constitutional symptoms used in the staging of lymphoma: unexplained fever above 38 degrees Celsius; drenching night sweats that require a change of nightclothes; and unexplained weight loss of 10% or more of body weight in the previous 6 months. Their presence is designated "B" in the Ann Arbor staging system (e.g. stage IIIB) and indicates more aggressive disease biology, poorer prognosis, and typically higher-intensity treatment. They are associated with both Hodgkin's lymphoma and non-Hodgkin's lymphoma. In Hodgkin's lymphoma, additional features include pruritus (generalised itching without rash) and Pel-Ebstein fever (cyclical fevers). Alcohol-induced pain at lymphoma sites is rare but, when present, is near-pathognomonic for Hodgkin's lymphoma and is a notable examination question.
"What is the significance of a left supraclavicular lymph node?"
A left supraclavicular lymph node is called Virchow's node, and enlargement is called Troisier's sign. It is significant because the thoracic duct drains into the left subclavian vein in this region, carrying lymph from the abdominal viscera. Enlargement therefore suggests lymphatic spread from an intra-abdominal or intrathoracic malignancy, most classically gastric cancer but also pancreatic, colonic, ovarian, renal, and testicular cancers. Ask specifically about dyspepsia, early satiety, weight loss, change in bowel habit, and haematuria. A right supraclavicular node is more likely to reflect intrathoracic pathology: lung, oesophageal, or mediastinal disease. Any supraclavicular lymph node in an adult without obvious infective cause must be investigated urgently.
"How do you distinguish a thyroglossal duct cyst from a thyroid lump on history and examination?"
Thyroglossal duct cysts arise from remnants of the thyroglossal tract, the developmental pathway along which the thyroid gland descends from the base of the tongue to its final position. They classically present in children or young adults as a midline or paramidline neck swelling, most often at or below the level of the hyoid bone. The distinguishing feature is that they move upwards with tongue protrusion, because the cyst remains tethered to the base of the tongue via the thyroglossal tract. They also move with swallowing. Thyroid lumps also move with swallowing (because the thyroid is attached to the larynx via the pretracheal fascia) but do NOT move with tongue protrusion. In the history, a young patient with a painless midline neck swelling present since childhood that moves with tongue protrusion is very likely to have a thyroglossal cyst; a mobile midline mass in an adult that moves only with swallowing is likely to be thyroid in origin.