Feel a Neck Lump? See Your Doctor

Terminal cancer patient releases his first public service announcement (PSA) aimed at encouraging faster diagnosis of head and neck cancer.

It was November 25th, 2015, the day before Thanksgiving and I was working from home. After responding to some emails that morning, I got ready and tiptoed gingerly up and down the cold white tiles of our bathroom floor, waiting for the shower water to heat up.

In the mirror’s reflection, I suddenly noticed something different about the right side of my neck. Placing my hand there, I could feel a solid lump just under my jawline that was about 3 centimeters in diameter (see Figure 1). The left side of my neck appeared normal.

The bulge wasn’t there the day before, or I would have felt it while shaving. It was a solid mass and wasn’t sore at all to the touch. It didn’t feel warm and seemed tethered to its location.

Putting my shower on hold, I threw my sweatpants and t-shirt back on and hurried back to my computer to do a quick search on the medical literature website PubMed from the U.S. National Library of Medicine. I quickly came across one medical journal article that contained a startling statistic: More than 75% of lateral (side) neck masses in patients older than 40 years are caused by malignant tumors.

The same article continued with guidance that “in the absence of overt signs of infection, a lateral neck mass is metastatic squamous cell carcinoma or lymphoma until proved otherwise.” The results made me nervous enough to reach for the phone and call our family physician for an appointment that day.

The most common cause for enlargement of the lymph nodes is infection or inflammation. However, such lymph nodes are often swollen, tender, and mobile. They can also exhibit abnormal redness of the surrounding skin and feel warm to the touch. Other than being swollen, my enlarged lymph node didn’t have any of these other symptoms.

My physician prescribed an antibiotic and instructed me to follow up with an Ear, Nose, and Throat (ENT) specialist if the lymph node didn’t decrease in size or got worse after the weekend. Unfortunately, there was no change in the size of my lymph node and subsequent testing confirmed the diagnosis of advanced oropharyngeal squamous cell carcinoma (OPSCC).

I’m thankful that my physician gave me a short course of antibiotic treatment. An article from the American Family Physician suggests a 2-week trial of antibiotics and then referring the patient for a biopsy if no resolution. However, every delay of 1 week in the referral of an OPSCC patient to secondary care correlates with a more advanced cancer stage at presentation and is associated with poorer survival. Specifically, researchers estimate that for every 1 week of delay in referral, the stage of presentation will progress by 0.045 of ‘a stage’.

Call to action: Men and women over the age of 40 who discover a suspicious lump or mass on either side of their neck shouldn’t delay in seeking medical attention. Many patients should also avoid being treated by courses of antibiotics for weeks or months, as this causes a delay in referral to secondary care, generally to an ENT specialist. Don’t delay — get a suspicious neck lump checked out today!

Disclaimer: Michael Becker is not a doctor and does not have formal medical training. His commentary should not be construed as recommendations, endorsements, or medical advice.

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Figure 1: Self-portrait showing the neck mass (blue side) is visible


Review CT results with ENT

IMG_6876At the physician’s office, the CD took a while to load on his laptop.  I suggested that while we were waiting for the images to load, perhaps we could discuss the accompanying radiology report.  I knew that the radiologist would provide a written assessment of his/her findings, so I wanted to get straight to the results.  My physician, however, excused himself for a bit since the CD was taking a while to load and to me, this was another red flag of bad news to come.  When he returned a short while later, the discussion centered around the enlarged lymph node and the fact that it “may” show evidence of necrosis at the center. I was more certain than ever that I had cancer and based on everything I read it was likely squamous cell carcinoma.  The real question was where the cancer originated – my lungs? The next step was to biopsy the enlarged lymph node to obtain more information through a procedure known as fine needle aspiration.

The physician injected novocaine directly into the enlarged mass prior to inserting a needle twice to extract fluid from the area.  He remarked that not a lot of fluid was easily obtained, which helped rule out to some extent the possibility of a cyst.  Once again, all arrows pointed to cancer.  The novocaine injection was the most painful aspect of the procedure, with the minor exception of some discomfort towards the end of the second needle stick.  The physician laid out a series of glass slides on the counter an applied the contents from the syringe onto them all.  That was it; now to wait for the pathology report.  Much to my chagrin, the doctor indicated that it could be up to a week to receive the report.  More waiting!  I wasn’t sleeping at night, so I was prescribed Ativan (lorazepam) to take before bed.

Initial Visit with ENT

endoscopeThe antibiotics did nothing to alter the size of the lateral neck mass, which prompted a visit to an ENT.  At this point, I was 100% convinced that I had cancer based on everything that I read.  The only question was what “type” of cancer and its stage.  After spraying my nasal cavity with a numbing agent, the physician looked at my throat using an endoscope (e.g., examining my throat using a tiny, flexible camera inserted through the nasal cavity) that didn’t seem to indicate anything out of the ordinary.  The next logical step was a CT scan to obtain additional information, which I promptly scheduled.

Discovery – Day Zero

401779-smallIt was the day before Thanksgiving and I was waiting for the water to heat up before getting into the shower.  Glancing at my reflection in the mirror, I noticed that the right side of my neck looked a bit larger than the other side.  Placing my hand on my neck, I could easily feel an unusual lump just under my jaw line that clearly wasn’t there the day before.  It was a solid mass and wasn’t sore at all to the touch.  A quick search on Google made me nervous enough to reach out to my general physician and they were kind enough to get me in that afternoon.  I’m not generally a pessimistic person, but I had already prepared myself for either lymphoma or head/neck cancer.

Remarking that he could sense the level of concern on our faces, the physician suggested that the lump was a blocked salivary gland and that such a condition could be either painful or not.  He prescribed an antibiotic (levofloxacin, 500mg) and stated that the lump should decrease after a few days unless there was a stone or other obstruction causing the blockage.  In any event, I was to follow-up with him around Monday unless there was severe pain or discomfort in which case I could consider going to the emergency room over the weekend.  In the back of my mind, I was still convinced we were dealing with something different. As stated in the peer-reviewed literature, “More than 75% of lateral neck masses in patients older than 40 years are caused by malignant tumours, and the incidence of neoplastic cervical adenopathy continues to increase with age.”¹

¹ Gleeson M, Herbert A, Richards A. Management of lateral neck masses in adults. BMJ : British Medical Journal. 2000;320(7248):1521-1524.