I have a bruise-like lump on my neck without any known trauma; what could cause it and how should it be evaluated?

Evaluation of a Bruise-Like Lump on the Neck Without Trauma

A bruise-like lump on the neck without known trauma requires urgent evaluation to exclude malignancy, particularly if it has been present for ≥2 weeks, is >1.5 cm, feels firm, or is fixed to underlying tissues. 1

Immediate Risk Stratification

You need to determine if this mass meets high-risk criteria for malignancy based on specific features:

High-Risk History Features 1

• Duration ≥2 weeks without significant fluctuation or uncertain duration
• No history of recent infection (absence of infectious etiology makes malignancy more likely)
• Age >40 years
• Tobacco or alcohol use
• Associated symptoms: throat pain, difficulty swallowing, ear pain on the same side, voice changes

High-Risk Physical Examination Features 1

• Size >1.5 cm (lymph node metastases cause nodal enlargement)
• Firm or hard consistency (malignant nodes are firm due to absence of tissue edema, unlike soft infectious nodes with tissue edema)
• Fixation to adjacent tissues (metastatic cancer may violate the lymph node capsule and invade adjacent structures)
• Reduced mobility of the mass
• Ulceration of overlying skin (metastatic cancer may break through the capsule)

Critical Diagnostic Algorithm

If ANY High-Risk Feature is Present 1, 2

1. Order CT neck with contrast immediately (or MRI with contrast if CT contraindicated) - this is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery 1

2. Perform or refer for targeted physical examination including visualization of the larynx, base of tongue, and pharynx to identify occult primary malignancy 1

3. Perform fine-needle aspiration (FNA) instead of open biopsy if the diagnosis remains uncertain after imaging - this is strongly recommended over open biopsy 1

4. Do NOT prescribe antibiotics unless there are clear signs and symptoms of bacterial infection (fever, warmth, erythema, rapid onset) - antibiotics delay diagnosis and promote resistance 1, 2

If No High-Risk Features are Present 1

• Document a specific follow-up plan to reassess the mass
• Educate the patient about warning signs that would trigger immediate re-evaluation: growth, development of firmness, fixation, skin changes, or persistence beyond 2 weeks
• Avoid empiric antibiotics unless clear infectious signs are present 1

Common Pitfalls to Avoid

Do not assume a cystic mass is benign. Papillary thyroid carcinoma, lymphoma, oropharyngeal carcinoma, and salivary gland malignancies can all present as cystic neck masses and mimic benign branchial cleft cysts clinically, radiologically, and even histologically 1, 3. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends continuing evaluation of cystic masses until a diagnosis is obtained 1.

Do not perform open biopsy before completing the diagnostic workup. If malignancy is present and the diagnosis remains uncertain after FNA and imaging, examination of the upper aerodigestive tract under anesthesia should be performed before open biopsy to identify the primary tumor site 1.

The "bruise-like" appearance does not exclude serious pathology. Metastatic lymph nodes can have varied appearances, and the absence of trauma history makes this more concerning for an underlying mass rather than simple bruising 1.

Specific Next Steps for Your Case

Given the absence of trauma, you should:

1. Measure the exact size of the lump in centimeters 1
2. Assess consistency (soft vs. firm vs. hard) and mobility (mobile vs. fixed) 1
3. Check for skin changes over the lump 1
4. Determine duration - has it been present ≥2 weeks? 1
5. Review for associated symptoms listed above 1

If the mass is >1.5 cm, firm, fixed, or present ≥2 weeks without infectious symptoms, proceed directly to contrast-enhanced CT neck and specialist referral 1, 2. Do not wait or trial antibiotics 1, 2.