Intended for healthcare professionals

Practice Rational Imaging

Imaging of neck lumps

BMJ 2014; 349 doi: (Published 21 October 2014) Cite this as: BMJ 2014;349:g6136
  1. Paula Bradley, specialist registrar, otolaryngology1,
  2. Nigel Beasley, consultant otolaryngology2,
  3. Iain Au-Yong, consultant radiologist3
  1. 1Northern Deanery, Newcastle Upon Tyne, UK
  2. 2Queens Medical Centre, Nottingham, UK
  3. 3Kings Mill Hospital, Sutton in Ashfield NG17 4JL, UK
  1. Correspondence to: I Au-Yong iauyong{at}
  • Accepted 28 July 2014

Learning points

  • “Red flags” for head and neck cancer include the persistence of oral ulceration or red-white mucosal patches, hoarseness, dysphagia, unilateral otalgia, or a neck mass

  • Consider urgent referral of patients with these features to a specialist, without first arranging imaging in primary care, because this may delay diagnosis

  • Ultrasound imaging with fine needle aspiration or core biopsy is useful in the initial investigation of neck lumps, with good sensitivity and high specificity for the diagnosis of pathological lymph nodes

  • Computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography are used in the hospital setting to stage the tumour by defining the extent of the primary tumour, locoregional disease, and metastatic disease

A 47 year old man presented to his primary care physician with a six month history of a left sided sore throat, ipsilateral otalgia, and a six week history of a left sided neck mass. He had never smoked and drank less than 5 units of alcohol a week. He was referred urgently to an otolaryngologist with suspected cancer.


Head and neck cancer has traditionally been associated with tobacco and alcohol consumption, although increasing numbers of patients are being diagnosed with tumours that are positive for human papillomavirus group 16 (HPV-16).1 2

Squamous cell carcinoma of the head and neck can arise from any mucosal surface in the upper aerodigestive tract. Any patient presenting with “red flag” signs and symptoms (box 1) should be urgently referred to a head and neck service for suspected cancer (a two week wait pathway in the UK). Disease can be rapidly progressive, so timely diagnosis and treatment is crucial.

Box 1: Red flag signs and symptoms for cancer of the head and neck3

  • Hoarseness for more than six weeks

  • Ulceration of oral mucosa of more than three weeks’ duration

  • Oral swellings of more than three weeks’ duration

  • All red or white patches of the oral …

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