Neck Lumps (including Goitre)

Overview

Please see Clinical Knowledge Summaries for guidance on assessment and management of Neck Lumps (1) .

For patients with more specific neck lumps consider the following pages:

• Salivary Gland Problems (Remedy BNSSG ICB)
• Tonsils (Remedy BNSSG ICB)
• Children & Young People - 2WW (Remedy BNSSG ICB) - includes a guide on lymphadenopathy in children.

Who to Refer

For patients with suspected malignancy please see criteria for referral in the Red Flag section below.

Patients in whom malignancy has been excluded or where it is not suspected can usually be managed in primary care.

Indications for referral are listed in the CKS Neck Lumps guidance.

Red Flags

Suspected Malignancy

The most likely malignancy presenting as a neck lump is a metastatic node from an oral, pharyngeal or laryngeal primary site or lymphoma. Soft tissue sarcomas are exceptionally rare.

Please see the Urgent Suspected Cancer (2WW) page for referral criteria:

Suspected Head and Neck Cancer :

• An unexplained palpable lump in the neck i.e. of recent onset or a previously undiagnosed lump that has changed over a period of 3 – 6 weeks 
• An unexplained persistent swelling in the parotid or submandibular gland

Patients with neck lumps meeting 2WW criteria should be referred via the 2WW pathway to request investigation. Do not arrange a neck USS outside of this pathway.

For neck lumps not meeting 2WW criteria, please see advice on the USS guidance page

A suspected branchial cyst should also be referred via the USC (2WW) referral pathway . Cystic neck node metastases from the oropharynx or thyroid can masquerade as a branchial cyst. Branchial cysts are not common, and it is better to diagnose one rapidly than to delay the diagnosis of a malignancy.

If a confident diagnosis of a thyroglossal cyst can be made, routine referral is acceptable. If the diagnosis is not clear, patients with a lump where thyroglossal cyst is in the differential should be referred via the USC (2WW) pathway.

Lymphadenopathy

If there is widespread lymphadenopathy above and below diaphragm / B symptoms then USC (2WW) pathway should be considered, please see Haematology - USC (2WW) page.

Suspected Thyroid Cancer:

Unexplained thyroid lump (consider). Please perform thyroid function test in parallel with referral.

Airway Obstruction

• If there are concerning symptoms e.g., signs of airway obstruction contact on call ENT team.

Carotid Lump

• The carotid is a normal structure although it can be felt as a lump if there is atherosclerosis. For criteria for urgent assessment see : Carotid lump | Management | Neck lump | CKS.

What to do before Referral

Imaging

Patients with suspected cancer should be referred via the USC(2WW) pathway without requesting imaging beforehand as this may lead to delays in diagnosis (see Red Flags above). 

Imaging for benign lesions in the neck is not otherwise usually required. See Ultrasound guidance (Remedy BNSSG ICB).

Imaging is not indicated in the following situations and ICE requests may be returned if there is no clinical indication to scan:

• Established nodules/goitre.
• FNA of benign nodules.
• Routine follow up of benign nodules – the risk of malignancy based on US findings requires stratification under BTA guidelines (2) (BTA guidelines for the management of thyroid cancer - 2014)
• Patients with hyperthyroidism/ hypothyroidism unless associated with a goitre.

Bloods

For patients with a goitre arrange TFT to exclude hypo or hyperthyroidism.:

Referral

Referral for patients where malignancy is not suspected or has been excluded is not usually required but the following referrals may be considered if appropriate:

Refer to Endocrinology

If there is goitre with hyperthyroidism (? toxic multinodular goitre) then refer via eRS to Endocrinology. See Hyperthyroidism (Remedy BNSSG ICB) page for details.

Refer to ENT

If there is a large symptomatic goitre where malignancy has been excluded, then refer via eRS to ENT (if there are symptoms or signs of airway obstruction then discuss with ENT on call). Patients with asymptomatic goitre where malignancy has been excluded should not be referred, as surgery is not offered for cosmetic reasons (see EFR policy: Cosmetic Surgery or Treatment - NHS BNSSG ICB).

If a branchial or thyroglossal cyst is suspected please see Red Flag section above for advice when USC(2WW) referral may be more appropriate.

Other referral routes

If there are salivary gland swelling/calculus where malignancy has been excluded then consider Max fax or ENT referral. See Salivary Gland Problems (Remedy BNSSG ICB) page for details.

If there is a suspected vascular lesion then consider vascular referral via eRS (RAS).

Resources

(1) Neck lump | Health topics A to Z | CKS | NICE

(2) British Thyroid Association Guidelines (british-thyroid-association.org)

(3) Neck Lumps and Bumps. What Neck Lumps are and what to do | Patient

 Patient information: 

Goitre - NHS (www.nhs.uk)

Thanks to Mr Graham Porter (Consultant ENT at UHBW) for his help with this page.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.