A 49-year-old male presents with a 2-month history of a painless mass in the upper part of the right neck. He is a lifelong smoker and heavy drinker and has recently noticed right-sided earache.

Lateral neck masses can arise from any of the tissues therein; they may be benign or malignant. In general, lateral neck lumps may be solid or cystic. In adults, the majority are solid.

Enlarged lymph nodes account for the majority of solid lesions. Lymphadenopathy may be benign or malignant. Viral (EBV, CMV, HIV), bacterial (pyogenic, TB or cat scratch) or protozoal (toxoplasmosis) infection may be responsible. Malignant lymphadenopathy may be primary (lymphoma) or secondary (metastatic deposits from a primary head and neck or rarely chest / abdominal neoplasm).

It is vital to recognise abnormal lymph nodes. Hospital series have shown that 6% of all head and neck neoplasms presented with isolated lateral neck masses. Of this subset, metastases from squamous cell primaries (40%) and lymphoma (39.5%) accounted for the majority¹. Both require specialist referral. Early recognition of specific warning symptoms and signs facilitate accurate diagnosis and speedy referral to an appropriate specialist. This avoids diagnostic delay, thereby reducing morbidity and mortality.

Subcutaneous cystic lesions are uncommon. A branchial cyst typically presents in the 2^nd or 3^rd decades but may occasionally present late. Usually painless, this swelling projects from the anterior border of the sternocleidomastoid at the junction of its middle and upper thirds. A branchial cyst in a patient over 40 years of age warrants urgent referral to exclude cystic metastasis.

In our scenario the patient has an enlarging solid lesion consistent with a malignant cervical node. On examination, the anatomical location and associated features will indicate a lymph node.

Commonly the patient with a metastatic node is asymptomatic, only complaining of a steadily enlarging painless neck lump. Symptoms may arise from the primary tumour. In our scenario otalgia is a key feature. Such symptoms should be sought, together with risk factors for head and neck cancer and associated generalised features of malignancy. Malignant nodes may have specific physical characteristics. If found, one must proceed to examine for a possible primary in the head and neck, not forgetting the small possibility of a chest or abdominal primary, in particular associated with supraclavicular lymphadenopathy.

Lymphoma is commoner in young adults and the elderly, most of whom are asymptomatic. Constitutional upset (fever, night sweats) and weight loss, aching bones and pruritis are a feature in 25%. Palpable lymph node(s) may have a rubbery consistency. Nodes typically remain separate and distinct. Other nodal groups, the liver and the spleen should all be examined for enlargement. Here referral to a haematologist is warranted.

A likely malignant node, with or without symptoms and signs of a primary malignancy, demands urgent referral to a specialist. Reactive lymphadenopathy is common and resolves spontaneously; persistence after a short trial of antibiotics at a 2-week review, warrants referral. In the absence of infection, a lateral neck mass is metastatic squamous cell carcinoma, or lymphoma, until proven otherwise and should be promptly referred².