What is the approach to diagnosing and managing neck swelling?

Approach to Neck Swelling

The diagnostic approach to neck swelling should follow a systematic algorithm that first identifies patients at increased risk for malignancy, followed by appropriate imaging and tissue sampling, while avoiding unnecessary antibiotic use unless clear signs of infection are present. 1

Initial Assessment

History - Risk Factors for Malignancy

• Duration ≥2 weeks without fluctuation or uncertain duration 1
• Absence of infectious etiology 1
• Age >40 years (especially concerning) 1
• Tobacco use and alcohol abuse 1
• HPV risk factors (increased number of sexual partners, oral sex) 1
• Immunocompromised status 1
• Prior history of head and neck malignancy 1

Concerning Symptoms

• Hoarseness, otalgia, hearing loss 1
• Intraoral swelling/ulceration, oral numbness 1
• Dyspnea, odynophagia, dysphagia 1
• Weight loss, hemoptysis, blood in saliva 1
• Nasal congestion, unilateral epistaxis 1
• For lymphoma: fever, night sweats, weight loss, distant lymphadenopathy 1

Physical Examination - Suspicious Findings

• Fixation to adjacent tissues 1, 2
• Firm consistency 1, 2
• Size >1.5 cm 1, 2
• Ulceration of overlying skin 1, 2
• Nontender mass (more suspicious for malignancy than tender mass) 1

Diagnostic Algorithm

Step 1: Determine Risk for Malignancy

• If any suspicious history OR physical exam findings are present, consider the patient at increased risk for malignancy 1
• Clinical evaluation alone may underestimate the extent of deep neck infections in up to 70% of patients 3

Step 2: Avoid Inappropriate Antibiotic Use

• Do not prescribe antibiotics unless clear signs of bacterial infection are present 1, 2
• Signs of infection include: warmth, erythema, tenderness, fever, tachycardia 1
• Inappropriate antibiotic use delays diagnosis of malignancy 1

Step 3: For Patients at Increased Risk for Malignancy

1. Perform targeted physical examination including visualization of mucosa of larynx, base of tongue, and pharynx (or refer to specialist who can) 1, 2
2. Order imaging - CT with contrast or MRI with contrast 1, 2
   • Strong recommendation from guidelines 1
   • CT better delineates bony structures; MRI better for soft tissue evaluation 2
3. Perform fine-needle aspiration (FNA) if diagnosis remains uncertain after imaging 1, 2
   • FNA is strongly preferred over open biopsy 1, 2
   • Continue evaluation of cystic masses until diagnosis is obtained (don't assume benign) 1
4. Consider ancillary tests based on history and physical examination 1
5. Recommend examination under anesthesia of the upper aerodigestive tract before open biopsy if diagnosis remains uncertain 1

Step 4: For Patients Not at Increased Risk for Malignancy

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

Common Pitfalls and Caveats

1. Underestimating extent of disease: Clinical evaluation alone underestimates the extent of deep neck infections in 70% of patients 3

2. Assuming cystic lesions are benign: Continue evaluation of cystic masses until diagnosis is obtained 1

3. Premature open biopsy: Always perform FNA before considering open biopsy 1

4. Missing metastatic disease: Neck masses in adults are more likely to be neoplastic than infectious, especially in patients >40 years 4

5. Inappropriate antibiotic use: Delays diagnosis of malignancy and contributes to antibiotic resistance 1, 2

6. Normal structures misinterpreted as masses: Be aware of normal anatomic structures that can be mistaken for pathologic masses 1

7. Incomplete examination: Failure to examine the entire upper aerodigestive tract may miss the primary site of malignancy 1, 2

The systematic approach outlined above ensures thorough evaluation of neck masses while minimizing delays in diagnosis and inappropriate treatments, ultimately improving patient outcomes related to morbidity and mortality.