Neck

 

This guideline applies to adults aged 17 years and over.

 

Introduction

Do not routinely arrange direct access imaging (ultrasound, CT or MRI) of the neck in general practice.

Direct access ultrasound very rarely yields a diagnosis of malignancy and may cause increased patient anxiety due to significant detection of incidental thyroid findings (up to 17% on a local radiology audit). This can also lead to unnecessary further investigations and interventions for benign nodules and clinically insignificant indolent small papillary thyroid cancers ^1-3.

 

When to arrange neck imaging

Only consider direct access imaging if there is diagnostic uncertainty regarding a neck lump, in the absence of red flag features suggestive of malignancy.

Ultrasound is the preferred modality for imaging neck lumps if the lump is in a region amenable to ultrasound.

Please see Neck Lumps in Adults guideline for further information.

 

When not to request neck imaging

Direct access imaging should be avoided if:

• Red flag features suggestive of malignancy:
  • un-investigated, unexplained palpable neck lump, which is inconsistent with normal anatomy
  • particularly in association with hoarse voice, difficulty swallowing, difficulty breathing and/or stridor, B-symptoms (weight loss, fevers and night sweats) and/or known history of malignancy
• Clinically benign lymphadenopathy
• Skin lesion i.e. sebaceous cyst
• Disorders of thyroid function, parathyroid and/or salivary glands
• Neck pain
• Globus sensation
• Diffuse neck swelling without a discrete lump
• Craniofacial soft tissue masses (nose, orbits, pinna are not amenable to ultrasound)
• Posterior neck and scalp lumps

Alternative referral pathways are appropriate for several of these situations – see Neck Lumps in Adults guideline for further information.

 

Fast Track Suspected Cancer

Adults withpreviously un-investigated, unexplained palpable neck lump (including thyroid, parotid and submandibular glands), excluding posterior neck and scalp lumps:

• Refer via the Fast Track ENT Suspected Cancer Referral Form. Ultrasound is not required prior to referral and may delay the patient being seen.

 

Adults with scalp and posterior neck lumps (posterior to trapezius and paracervical muscles) which are suspected to be malignant (these are almost never related to ENT pathology, and therefore do not meet the criteria for Fast Track ENT Suspected Cancer):

• Refer via Fast Track Skin Suspected Cancer Referral Form, if concerned about skin cancer.
• Refer via Fast Track Sarcoma Referral Form, if concerned about sarcoma.

 

Adults with suspected lymphoma:

• Refer via Fast Track Haematology Referral Form.

 

Advice and Guidance

Direct radiological queries to the Radiology advice email: rch-tr.GPRadiologyEnquiries@nhs.net

Consider seeking ENT Advice and Guidance if:

• Patient falls outside referral criteria.
• Continuing diagnostic uncertainty and lump not amenable to ultrasound.
• Queries about primary care management.
• An option for benign congenital / developmental mass demonstrated on neck ultrasound.

 

Supporting Information

For professionals:

NICE CKS – Neck Lump

BMUS – Justification of Ultrasound Requests

 

For patients:

RCHT – Throat Symptoms (Patient Info Leaflet)

Patient UK – Neck Lumps and Bumps

 

References

1. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours BMJ 2013;347:f4706 27 August 2013
2. British Thyroid Association Guidelines for the Management of Thyroid Cancer. Clinical Endocrinology Vol 81 Sup 1 July 2014
3. Local audit. Contact benjamin.rock@nhs.net if further information required.

 

Page Review Information

Review date	02/05/2024
Next review date	02/05/2026
GP speciality lead	Dr Laura Vines
Contributors	Mr Venkat Reddy, Consultant ENT Surgeon Dr Ben Rock, Consultant Radiologist