What is the initial workup for an enlarged neck lymph node?

Initial Workup for Enlarged Neck Lymph Node

The initial workup for an enlarged neck lymph node should include a thorough history and physical examination to identify risk factors for malignancy, followed by appropriate imaging and biopsy if the mass has been present for ≥2 weeks or has suspicious features. 1

Risk Assessment for Malignancy

Suspicious Historical Features

• Duration of mass ≥2 weeks without fluctuation or uncertain duration
• Absence of infectious etiology
• Age >40 years (higher risk of head and neck squamous cell carcinoma)
• Tobacco and alcohol use
• History of prior head and neck malignancy
• Symptoms such as:
  • Hoarseness
  • Dysphagia
  • Odynophagia
  • Otalgia
  • Weight loss
  • Hemoptysis
  • Nasal obstruction

Suspicious Physical Examination Features

• Fixation to adjacent tissues
• Firm consistency
• Size >1.5 cm
• Ulceration of overlying skin
• Nontender mass (tender masses more likely infectious)
• Multiple enlarged nodes
• Nodes in supraclavicular region (higher risk of malignancy)

Diagnostic Algorithm

Step 1: Initial Assessment

1. Complete history focusing on duration, associated symptoms, and risk factors
2. Physical examination of neck and complete head and neck examination including:
   • Oral cavity inspection (remove dentures)
   • Oropharynx examination with bright light and tongue depressor
   • Palpation of neck and thyroid gland

Step 2: Categorize Risk

Based on history and physical examination, categorize the patient as:

• Low risk: Recent infection, tender node, fluctuating size, <2 weeks duration
• High risk: ≥1 suspicious feature from history or physical examination

Step 3: Management Based on Risk

For low-risk patients with likely infectious etiology:

• Consider a single course of broad-spectrum antibiotics
• Reassess within 2 weeks
• If complete resolution occurs, follow up in 2-4 weeks to ensure no recurrence
• If incomplete resolution, proceed to workup for malignancy

For high-risk patients:

• Proceed directly to diagnostic workup without empiric antibiotics 1

Step 4: Diagnostic Testing

1. Imaging:

   • Ultrasound of the neck (first-line imaging)
   • CT scan of neck, thorax, abdomen, and pelvis if malignancy is suspected
   • PET-CT if localized disease is suspected and considering radiotherapy 1

2. Biopsy:

   • Excisional lymph node biopsy is preferred for definitive diagnosis 1
   • Core biopsies only for patients without easily accessible lymph nodes
   • Fine-needle aspiration is not recommended for initial diagnosis of lymphoma 1

Special Considerations

Thyroid Nodules

If thyroid nodule is suspected:

• Ultrasound of thyroid and central neck
• FNA of suspicious nodules based on size and ultrasound characteristics
• Consider serum TSH measurement 1

Lymphoma Workup

If lymphoma is suspected:

• Complete blood count
• Lactate dehydrogenase (LDH)
• Beta-2 microglobulin
• Hepatitis B, C, and HIV screening
• Bone marrow biopsy if advanced disease is suspected 1

Common Pitfalls to Avoid

1. Empiric antibiotics without follow-up: Antibiotics may mask malignancy and delay diagnosis. Always reassess within 2 weeks if antibiotics are given.

2. Inadequate biopsy: Fine-needle aspiration is insufficient for lymphoma diagnosis. Excisional biopsy provides better diagnostic accuracy.

3. Incomplete examination: Always examine the entire head and neck region, including oral cavity and oropharynx, as neck masses often represent metastatic disease from a primary site.

4. Delayed referral: Patients with suspicious features should be referred promptly to a specialist, as early diagnosis of malignancy improves outcomes.

5. Incomplete imaging: For suspected malignancy, comprehensive imaging is essential to determine the extent of disease and guide treatment planning.

Remember that approximately 38% of persistently enlarged cervical lymph nodes represent malignancy 2, with metastatic carcinoma and lymphoma being the most common malignant etiologies. Early and appropriate workup is essential to improve patient outcomes.