What is the best course of action for a 55-year-old male patient presenting with a painful bump on the right side of his neck, which has been present for six months and hurts with neck movement or when lying down?

From the Guidelines

The best course of action for a 55-year-old male with a painful neck bump present for six months is to seek prompt medical evaluation by a primary care physician or ENT specialist. This persistent mass requires professional assessment to determine its nature, as it could represent various conditions ranging from benign cysts to more concerning pathologies like lymphadenopathy or malignancy, as suggested by the clinical practice guideline for evaluation of the neck mass in adults 1. The physician will likely perform a thorough physical examination and may order imaging studies such as ultrasound, CT scan, or MRI to visualize the mass, with a strong recommendation for neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy 1. Blood tests might be ordered to check for signs of infection or other systemic issues. Depending on findings, a fine needle aspiration or biopsy may be necessary for definitive diagnosis, with a strong recommendation for FNA 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 1.

While waiting for medical evaluation, the patient can temporarily manage pain with over-the-counter analgesics like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or ibuprofen (400-600mg every 6-8 hours with food). A warm compress applied to the area for 15-20 minutes several times daily may also provide relief. The duration of symptoms (six months) and pain with movement are concerning features that warrant professional evaluation rather than continued self-management, as neck masses can represent a wide spectrum of conditions requiring specific treatments. It is essential to follow up with the provider to assess resolution or final diagnosis, and the patient should be advised of criteria that would trigger the need for additional evaluation, as outlined in the guideline for the evaluation of the neck mass in adults 1.

Key points to consider in the assessment and plan for this patient include:

• A thorough physical examination to identify patients with a neck mass who are at increased risk for malignancy based on physical examination characteristics such as fixation to adjacent tissues, firm consistency, size >1.5 cm, and/or ulceration of overlying skin 1
• Imaging studies such as ultrasound, CT scan, or MRI to visualize the mass
• Fine needle aspiration or biopsy for definitive diagnosis if necessary
• Patient education on the significance of being at increased risk for malignancy and explanation of recommended diagnostic tests 1
• Follow-up to assess resolution or final diagnosis, with documentation of a plan for follow-up 1

Given the potential for malignancy, prompt medical evaluation and adherence to the recommended diagnostic workup are crucial to ensure timely diagnosis and optimal outcomes.

From the Research

Assessment Notes

• The patient is a 55-year-old male presenting with a painful bump on the right side of his neck, which has been present for six months and hurts with neck movement or when lying down.
• Palpation revealed no nodes, and the patient reports that the bump started about six months ago.
• The patient's symptoms and history suggest the possibility of a neoplastic process, given the location and duration of the mass, as well as the patient's age 2.
• Other potential causes, such as inflammatory, congenital, or traumatic processes, should also be considered, although they are less likely in this age group.

Plan Notes

• An ultrasound has been ordered for further assessment of the neck mass.
• Diclofenac cream has been prescribed for pain management.
• The patient has been advised to perform neck stretching exercises daily, which may help alleviate pain and disability, particularly if the patient's symptoms are related to musculoskeletal issues 3, 4.
• Referral to an otolaryngologist may be warranted to obtain a definitive diagnosis and develop an appropriate treatment plan, which may include surgical intervention 2, 5.
• The patient's response to the initial treatment plan should be monitored, and adjustments made as necessary to ensure optimal outcomes.
• Consideration should be given to the potential for underlying conditions, such as a retropharyngeal abscess, although this is less likely given the patient's presentation and lack of trauma history 5.