What is the diagnosis and treatment for a mass under the skin in the neck?

Neck Mass Diagnosis and Management

A neck mass is most commonly a neoplastic, inflammatory, or congenital lesion that requires thorough evaluation to rule out malignancy, particularly in adults over 40 years of age. 1

Diagnostic Categories of Neck Masses

Neck masses generally fall into three main categories:

1. Neoplastic

   • Malignant: Head and neck squamous cell carcinoma, lymphoma, thyroid cancer, metastatic disease
   • Benign: Lipoma, fibroma, salivary gland tumors

2. Inflammatory/Reactive

   • Reactive lymphadenopathy
   • Infectious lymphadenitis (bacterial, viral, mycobacterial)

3. Congenital/Developmental

   • Thyroglossal duct cysts
   • Branchial cleft cysts
   • Dermoid cysts
   • Vascular malformations
   • Hemangiomas

Risk Assessment for Malignancy

High-Risk Features in History

• Age >40 years
• Mass present ≥2 weeks without fluctuation
• Mass of uncertain duration
• Absence of infectious etiology
• Tobacco and alcohol use
• Unexplained weight loss
• Prior head and neck malignancy
• Voice changes, dysphagia, or otalgia 1

High-Risk Features on Physical Examination

• Fixation to adjacent tissues
• Firm consistency
• Size >1.5 cm
• Ulceration of overlying skin
• Nontender mass
• Tonsil asymmetry 1

Diagnostic Approach

1. Initial Assessment

   • Determine if patient is at increased risk for malignancy based on history and physical exam
   • Do not prescribe antibiotics unless clear signs of bacterial infection are present 1

2. For Patients at Increased Risk for Malignancy:

   • Perform targeted physical examination including visualization of mucosa of larynx, base of tongue, and pharynx
   • Order neck CT or MRI with contrast
   • Perform fine-needle aspiration (FNA) instead of open biopsy
   • For cystic masses, continue evaluation until diagnosis is obtained (do not assume benignity)
   • Consider additional ancillary tests based on history and physical examination 1

3. For Patients Not at Increased Risk:

   • Advise on criteria that would trigger need for additional evaluation
   • Document follow-up plan to assess resolution or final diagnosis 1

Common Pitfalls to Avoid

1. Misdiagnosing malignancy as infection

   • Avoid prescribing antibiotics for neck masses without clear signs of infection
   • A non-resolving "infectious" mass should raise suspicion for malignancy 1

2. Assuming cystic masses are benign

   • Cystic masses can be malignant and require thorough evaluation 1

3. Performing open biopsy before proper workup

   • FNA is preferred over open biopsy for initial tissue diagnosis
   • For patients at high risk without diagnosis after FNA and imaging, examination under anesthesia of the upper aerodigestive tract should be performed before open biopsy 1

4. Inadequate follow-up

   • Even seemingly benign masses require follow-up to ensure resolution 1

By following this structured approach to neck mass evaluation, clinicians can ensure timely diagnosis and appropriate management, potentially improving morbidity and mortality outcomes for patients with malignant conditions.