What is the initial workup for a mass in the neck?

Initial Workup for a Neck Mass in Adults

The initial workup for a neck mass in adults should include a thorough history and physical examination to identify risk factors for malignancy, followed by contrast-enhanced CT or MRI imaging and fine-needle aspiration (FNA) for patients at increased risk of malignancy. 1

Risk Assessment for Malignancy

History Features Suggesting Increased Risk for Malignancy:

• Mass present ≥2 weeks without significant fluctuation or of uncertain duration
• Absence of infectious etiology
• Age >40 years
• Tobacco and alcohol use
• Symptoms such as:
  • Pharyngitis (sore throat)
  • Dysphagia (difficulty swallowing)
  • Otalgia (ear pain) ipsilateral to the neck mass
  • Recent voice change

Physical Examination Features Suggesting Increased Risk for Malignancy:

• Fixation to adjacent tissues (reduced mobility)
• Firm consistency
• Size >1.5 cm
• Ulceration of overlying skin
• Oral cavity or oropharyngeal ulcer
• Supraclavicular location

Diagnostic Algorithm

1. Initial Risk Stratification:

   • Determine if patient has any high-risk features from history or physical exam
   • Consider all adult neck masses potentially malignant until proven otherwise 1

2. For Patients at Increased Risk for Malignancy:

   • Imaging: Order contrast-enhanced CT or MRI of the neck 1
     • CT is preferred for most cases due to accessibility and lower cost
     • MRI may be preferred for patients concerned about radiation exposure or with contraindications to CT

3. Targeted Physical Examination:

   • Complete visualization of mucosa of the larynx, base of tongue, and pharynx
   • Refer to specialist if unable to perform complete examination 1

4. Fine-Needle Aspiration (FNA):

   • Perform FNA or refer to someone who can perform it when diagnosis remains uncertain 1
   • FNA is preferred over open biopsy due to:
     • High sensitivity and specificity for diagnosis
     • Minimal discomfort
     • Low risk of complications
     • Cost-effectiveness

5. Additional Ancillary Tests (based on clinical suspicion):

   • Complete blood count
   • Specific serologies if infection suspected

6. For Cystic Neck Masses:

   • Continue evaluation until diagnosis is obtained
   • Do not assume benign nature based solely on cystic appearance 1

7. If Diagnosis Remains Unclear:

   • Consider evaluation of the upper aerodigestive tract under anesthesia before open biopsy 1

Important Caveats

• Avoid routine antibiotic therapy unless there are clear signs of bacterial infection 1
• Do not perform open biopsy as initial diagnostic procedure due to higher risk of complications 1
• For patients not at increased risk for malignancy, provide clear follow-up instructions and criteria that would trigger additional evaluation 1
• A neck mass in an adult should be considered malignant until proven otherwise, especially in patients >40 years old 1

Common Pitfalls to Avoid

• Delaying diagnosis by prolonged empiric antibiotic treatment
• Performing open biopsy before adequate imaging and FNA
• Assuming a cystic mass is benign without definitive diagnosis
• Failing to examine the entire upper aerodigestive tract in patients with suspicious neck masses
• Neglecting to explain to patients the significance of being at increased risk for malignancy

By following this systematic approach, clinicians can ensure timely diagnosis and appropriate management of neck masses in adults, potentially improving outcomes for patients with malignant disease.