The ENT neck exam
- Examination
The ENT neck exam describes any lump precisely and then searches the mouth, nose and throat for its source.
What it is
The ENT neck exam builds on the lymph node and thyroid semiology pages and adds the specialist's logic: a neck lump in an adult is a sign, not a diagnosis, and the primary cause is usually found in the upper aerodigestive tract. The examiner inspects, palpates systematically from behind, describes each mass (site, size, consistency, tenderness, mobility, fixation), checks movement with swallowing and tongue protrusion, feels the salivary glands and then examines the scalp, ears, nose, mouth, pharynx and larynx. Age, risk factors and the duration of the lump decide how fast to act.
Findings and interpretation
- Tender, mobile node with a recent throat infection: reactive lymph node, the most common cause in young people.
- Hard, fixed, painless node in a smoker or heavy drinker: metastatic squamous cell carcinoma until proven otherwise.
- Soft, fluctuant mass with fever and tenderness suggests an abscess or infected node.
- Long-standing lateral cyst in a young adult: branchial cleft cyst is likely, but a cystic metastasis must be excluded in older adults.
- Rubbery nodes in several groups with fever, sweats or weight loss suggest lymphoma or a systemic infection such as tuberculosis.
- A palpable supraclavicular node is always suspicious and may come from the chest or abdomen.
How it is done
- Inspect from the front with the neck slightly extended: asymmetry, skin changes, scars, sinuses and movement on swallowing.
- Palpate from behind with the neck slightly flexed, group by group and side by side, comparing both sides.
- For any lump describe site, size, shape, consistency, tenderness, mobility and fixation to skin or deep tissue.
- Ask the patient to swallow and then to stick out the tongue: thyroid and thyroglossal masses move.
- Feel the parotid and submandibular glands, the submandibular region bimanually with one finger inside the mouth.
- Examine the likely primary sites: scalp, ears, nose, mouth, oropharynx and, with a mirror or endoscope, the nasopharynx, hypopharynx and larynx.
- Complete with other node groups (axillary, inguinal), the liver and the spleen when lymphoma or a systemic infection is possible.
Neck mass: features, likely cause, next step
| Features | Likely cause | Next step |
|---|---|---|
| Tender, soft, mobile, recent sore throat | Reactive lymph node | Re-examine; investigate if it persists |
| Hard, fixed, painless, adult with risk factors | Metastatic squamous cell carcinoma | Full head and neck exam, FNA, CT; urgent referral |
| Midline, moves on swallowing | Thyroid nodule or goitre | Ultrasound and thyroid function |
| Midline, rises with tongue protrusion | Thyroglossal duct cyst | Ultrasound and ENT referral |
| Several rubbery node groups, systemic symptoms | Lymphoma | Blood count, chest X-ray, urgent specialist referral |
Common mistakes
- Doing an open biopsy of a neck node before a full head and neck exam and fine-needle aspiration.
- Giving repeated antibiotics to an adult with a painless, persistent neck mass instead of investigating.
- Missing the primary tumour because the tongue base, tonsils and nasopharynx were not examined.
Next step / Initial management
- Persistent mass: blood count and chest X-ray; ultrasound (first choice in children and for thyroid masses); neck CT and fine-needle aspiration when cancer is possible.
- Adult with a hard, fixed or growing mass or any red flag: urgent referral (within 2 weeks) to ENT or head and neck surgery for full examination and FNA.
- Child with a tender mass and signs of infection: a trial of antibiotics and re-examination; refer if it does not regress.
- Neck mass with stridor or inability to swallow: same-day referral to emergency care.
Test yourself
Think of the answer, then tap the question to see it.
A 60-year-old smoker has had a hard, painless 3 cm lump at the angle of the jaw for 6 weeks. What is the first tissue test?
Fine-needle aspiration, after a complete head and neck examination looking for the primary; open biopsy is avoided.
Why is an open (incisional) biopsy of a neck node discouraged as a first step?
It leaves a cut tumour in the neck and can compromise later treatment; fine-needle aspiration is preferred.
A midline neck mass rises when the patient sticks out the tongue. What is it?
A thyroglossal duct cyst.
Which neck mass features suggest malignancy?
Hard, fixed, larger than 1.5 cm, ulcerated overlying skin, new in an older patient, or with persistent hoarseness or difficulty swallowing.
Elsewhere in DurgiPedia
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Neck Mass (MSD Manual Professional Edition, 2026); Evaluation of the Patient With Nasal and Pharyngeal Symptoms (MSD Manual Professional Edition, 2026); Oral Cancer (NIDCR, National Institutes of Health, 2024).
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Representative model, for educational purposes only.