What distinguishes a neck sprain from a neck lump?

Distinguishing Neck Sprain from Neck Lump

A neck sprain presents with diffuse pain, tenderness, and restricted range of motion following injury or strain, while a neck lump is a discrete, palpable mass that persists regardless of neck movement and requires systematic evaluation to exclude malignancy.

Key Distinguishing Features

Neck Sprain Characteristics

• Pain pattern: Diffuse, aching pain that worsens with movement and improves with rest 1
• Mechanism: History of trauma, sudden movement, poor posture, or repetitive strain 1, 2
• Physical findings: Tenderness over muscles and soft tissues without a discrete mass, muscle spasm, and restricted cervical range of motion 1, 3
• Palpation: Diffuse tenderness without a distinct, movable lump 3
• Timeline: Symptoms typically improve within days to weeks with conservative management 2, 4

Neck Lump Characteristics

• Physical finding: A discrete, palpable mass that you can feel with your fingertips - measure its size (one fingertip wide, two fingertips wide, etc.) 5
• Persistence: The mass remains present regardless of neck position or movement 6
• Tenderness: Nontender neck masses are more suspicious for malignancy than tender masses 5
• Location: Can be anywhere in the neck, but location helps determine etiology 6
• Duration: Any neck mass present for more than 2 weeks without clear infectious cause must be considered malignant until proven otherwise 6

Critical Red Flags Requiring Urgent Evaluation

For Suspected Neck Mass (Not Simple Sprain)

• Difficulty or pain with swallowing 5, 6
• Voice changes or hoarseness 5, 7
• Unilateral ear pain without ear pathology 5
• Unexplained weight loss 5
• Fever >101°F 5
• Tobacco or alcohol use history 7, 6
• Mass persisting beyond 2-3 weeks 7, 6

For Neck Sprain with Neurological Concerns

• Weakness in arms or legs 8
• Balance difficulty 8
• Numbness or radiating pain 8, 2
• Lower extremity spasticity suggesting cervical myelopathy 3

Diagnostic Approach Algorithm

Step 1: Palpate the Neck Systematically

• Feel for a discrete mass: Use your fingertips to palpate all neck regions 5
• Avoid common pitfalls: Normal structures often mistaken for pathologic masses include submandibular glands, hyoid bone, transverse process of C2, and carotid bulb 5, 8
• Assess tenderness: Nontender masses are more concerning for malignancy 5

Step 2: If Discrete Mass Present

• Measure and document size weekly using fingertip width 5
• Order contrast-enhanced CT neck or MRI as initial imaging for any palpable neck mass in adults, particularly with cancer risk factors 6
• Refer to ENT/head and neck surgery within 1 week for non-thyroid masses with malignancy features 6
• Do NOT give empiric antibiotics unless clear infectious etiology, as this delays cancer diagnosis 6
• Consider fine needle aspiration (FNA) as first-line tissue sampling for masses at increased malignancy risk 6

Step 3: If No Discrete Mass (Likely Sprain)

• For acute neck pain (<6 weeks) without radiculopathy or red flags: No imaging indicated; treat conservatively with NSAIDs and physical therapy 8
• For chronic pain (>6 weeks) without neurologic findings: Start with plain cervical radiographs 8
• For pain with radiculopathy or neurological symptoms: MRI cervical spine without contrast is the initial imaging of choice 8

Common Clinical Pitfalls

Pitfall 1: Mistaking Normal Anatomy for Pathology

The submandibular glands, hyoid bone, C2 transverse process, and carotid bulb are frequently misidentified as neck masses 5, 8. Systematic palpation and anatomic knowledge prevent unnecessary workup.

Pitfall 2: Delaying Evaluation of Persistent Masses

Any mass present for more than 2 weeks without infectious cause requires urgent evaluation 6. Waiting to "see if it goes away" risks delayed cancer diagnosis and worse outcomes.

Pitfall 3: Giving Antibiotics for Non-Infectious Masses

Empiric antibiotics for neck masses without clear infection can mask malignancy and delay definitive diagnosis 6. Only treat with antibiotics if infectious etiology is evident.

Pitfall 4: Over-Imaging Simple Neck Sprains

Acute neck pain without red flags or neurological symptoms does not require imaging 8. Overimaging leads to incidental findings that don't correlate with symptoms and drive unnecessary interventions 8.

Pitfall 5: Under-Imaging Neurological Symptoms

Weakness, balance difficulty, or radiculopathy with neck pain suggests cervical myelopathy or cord compression requiring prompt MRI cervical spine without contrast 8. Delaying imaging risks irreversible neurological damage 8.

Follow-Up Recommendations

For Neck Masses

• Monitor size weekly by palpation 5
• Infectious masses should resolve completely or return to much smaller size within 2-3 weeks 5
• Return immediately if: Mass enlarges, doesn't resolve, or recurs after resolution 5

For Neck Sprains

• Follow up in 2-4 weeks if symptoms persist 8
• Return sooner if: Red flag symptoms develop or pain significantly worsens 8
• If pain persists beyond 4-6 weeks or worsens: Obtain MRI cervical spine without contrast 8