What is the recommended workup for a non-movable anterior neck mass?

Workup for a Non-Movable Anterior Neck Mass

A non-movable anterior neck mass requires a systematic diagnostic approach with contrast-enhanced CT or MRI followed by fine-needle aspiration as the initial diagnostic procedures, as fixation to adjacent tissues is a concerning physical finding that significantly increases risk for malignancy. 1

Risk Assessment

The first step in evaluating a non-movable anterior neck mass is to determine the risk of malignancy based on:

Physical Examination Characteristics Indicating High Risk

• Fixation to adjacent tissues (non-movable mass) - this is a critical finding that immediately places the patient at increased risk 1
• Firm consistency
• Size >1.5 cm
• Ulceration of overlying skin

Historical Features Indicating High Risk

• Lack of infectious etiology
• Mass present for ≥2 weeks without fluctuation
• Mass of uncertain duration
• Risk factors such as smoking, alcohol use, or prior radiation exposure

Diagnostic Algorithm for Non-Movable Anterior Neck Mass

Step 1: Targeted Physical Examination

• Complete head and neck examination including visualization of:
  • Larynx
  • Base of tongue
  • Pharynx
  • Thyroid gland
  • All lymph node regions

Step 2: Imaging (Strong Recommendation)

• Contrast-enhanced CT is the initial diagnostic test of choice 1, 2
• MRI with contrast is an acceptable alternative if CT is contraindicated
• Imaging must be completed before any invasive procedures

Step 3: Fine-Needle Aspiration (Strong Recommendation)

• FNA should be performed instead of open biopsy 1
• Provides diagnostic information via:
  • Cytology
  • Gram stain (if infection suspected)
  • Cultures as indicated

Step 4: Additional Testing Based on Initial Results

• If FNA is non-diagnostic or cystic features are present:
  • Do not assume benign nature, especially with a non-movable mass 1
  • Obtain ancillary tests based on clinical suspicion:
    • Thyroid function tests if thyroid origin suspected
    • EBV or other viral studies if lymphoma suspected
    • Tuberculin testing if TB suspected

Step 5: Advanced Diagnostic Procedures

• If diagnosis remains uncertain after imaging and FNA:
  • Examination of upper aerodigestive tract under anesthesia
  • This must be done BEFORE any open biopsy 1

Important Caveats

1. Avoid Antibiotic Therapy: Do not prescribe antibiotics unless clear signs of bacterial infection are present (warmth, erythema, fever) 1

2. Cystic Masses: Even if imaging or FNA suggests a cystic mass, continue evaluation until definitive diagnosis is obtained 1

3. Open Biopsy: Should only be considered after:

   • Imaging completed
   • FNA attempted
   • Examination under anesthesia performed
   • Primary site not identified by other means 1

4. Patient Education: Explain the significance of a non-movable mass and the increased risk of malignancy 1

5. Specialist Referral: Given the high-risk feature of fixation to adjacent tissues, early referral to an otolaryngologist or head and neck surgeon is appropriate 2

A non-movable anterior neck mass is a concerning finding that warrants thorough and expeditious evaluation. The fixation to adjacent tissues significantly increases the risk of malignancy, making prompt diagnosis essential to improve patient outcomes related to morbidity and mortality.