From the Guidelines
The evaluation and treatment of a patient presenting with a neck lump should begin with a thorough history and physical examination to identify patients at increased risk for malignancy, as recommended by the clinical practice guideline: evaluation of the neck mass in adults 1. The initial assessment should focus on risk factors such as smoking, alcohol use, and duration of the lump.
- Key factors to consider in the history include:
- Duration of the lump
- Associated symptoms like weight loss or night sweats
- History of smoking or alcohol use
- The physical examination should evaluate the characteristics of the mass, including:
- Fixation to adjacent tissues
- Firm consistency
- Size >1.5 cm
- Ulceration of overlying skin Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx), for patients with a neck mass deemed at increased risk for malignancy, as stated in Statement 5 of the guideline 1. Imaging studies such as ultrasound for superficial masses or CT/MRI for deeper lesions should be considered, and clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy, as strongly recommended by Statement 6 of the guideline 1. Fine-needle aspiration (FNA) is recommended instead of open biopsy for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain, as stated in Statement 7 of the guideline 1. Treatment depends on the underlying etiology, and patients with concerning features or those at increased risk for malignancy should be promptly referred to specialists for further management.
- The urgency of evaluation increases with risk factors such as:
- Age over 40
- History of smoking or alcohol use
- Prior head and neck radiation It is essential to follow the guideline recommendations to ensure appropriate evaluation and treatment of patients with a neck lump, prioritizing morbidity, mortality, and quality of life as the outcome.
From the Research
Evaluation of Neck Lump
The evaluation of a neck lump involves a thorough gathering of historical information and a complete physical examination to develop a differential diagnosis 2, 3, 4. The location of the mass, its time of onset, and duration are important factors to consider, as neoplastic processes are more likely in patients older than 40 years 2.
Diagnostic Approach
A careful medical history and physical examination should be performed to guide the need for further evaluation with imaging, biopsies, and specialist referrals 3. The diagnostic approach may involve:
- Imaging studies, such as computed tomography scanning with contrast, to evaluate the mass and surrounding structures 2, 4, 5
- Fine-needle aspiration biopsy to provide diagnostic information via cytology, Gram stain, and bacterial and acid-fast bacilli cultures 5
- Ultrasound-guided core biopsy, which offers the advantage of preserving tissue architecture with increased tissue yield 6
Treatment
The treatment of a neck lump depends on the underlying cause, which may be malignant or benign 5. Referral to an otolaryngologist is frequently warranted to obtain a definitive diagnosis and develop an appropriate treatment plan, which is predominantly surgical 2. In some cases, excisional biopsy may be necessary to obtain a diagnostic sample 6.