What is the evaluation and management of a swollen lymph node in the neck?

Evaluation and Management of Swollen Lymph Nodes in the Neck

Any adult with a neck mass present for ≥2 weeks or of uncertain duration should undergo prompt evaluation for malignancy, especially if the mass is >1.5 cm, firm, fixed to adjacent tissues, or has overlying skin ulceration. 1, 2

Initial Assessment

High-Risk Features for Malignancy

Physical Examination Characteristics

• Size >1.5 cm (particularly concerning in any cervical location)
• Firm consistency (though HPV-positive malignancies may present as soft, cystic masses)
• Fixed/reduced mobility in longitudinal and transverse planes
• Ulceration of overlying skin
• Nontender (tender masses are more likely inflammatory)
• Multiple, grouped, or matted lymph nodes 1

Patient History Red Flags

• Age >40 years (especially with smoking history)
• Tobacco and alcohol use
• Prior head and neck malignancy (including skin cancers)
• Immunocompromised status
• HPV risk factors (increased number of sexual partners, oral sex)
• Unexplained weight loss 1, 2

Associated Symptoms Raising Concern

• Hoarseness or voice changes
• Dysphagia or odynophagia
• Otalgia (especially with normal ear exam)
• Unilateral hearing loss
• Oral cavity or oropharyngeal ulceration
• Nasal obstruction or epistaxis
• For lymphoma: fever, night sweats, distant lymphadenopathy 1, 2

Diagnostic Approach

When to Consider Infectious Etiology

• Presence of local signs: warmth, erythema, tenderness, localized swelling
• Systemic signs: fever, tachycardia
• Recent upper respiratory infection, dental problem, trauma, or animal exposure
• Rapid onset (days to weeks) 1

Imaging Studies

1. First-line imaging for suspicious neck masses:

   • Contrast-enhanced CT neck OR
   • Contrast-enhanced MRI neck

   Both are equally effective for clinical oncologic evaluation and allow precise localization of masses and assessment of relationship to major vessels 1, 2

2. Ultrasound may be appropriate:

   • As initial imaging for suspected thyroid or salivary masses
   • To expedite sampling/biopsy guidance 1

Tissue Sampling

• Fine-needle aspiration (FNA) is often used initially
• If FNA is negative but suspicion remains high, consider:
  • Repeat imaging
  • Repeat FNA
  • Open lymph node biopsy 2

Management Algorithm

1. For masses with infectious features:

   • A single course of broad-spectrum antibiotics may be prescribed
   • Patient must be reassessed within 2 weeks
   • If mass has not completely resolved, proceed with malignancy workup
   • Even if resolved, reassess in 2-4 weeks to monitor for recurrence 1

2. For suspicious masses (no infectious features):

   • Avoid empiric antibiotics
   • Proceed directly to imaging and tissue sampling 1, 2

3. If malignancy is confirmed or highly suspected:

   • Refer to appropriate specialist (otolaryngology, oncology)
   • Additional workup may include:
     • CT of chest and abdomen
     • PET scan for more accurate staging
     • Complete blood count, ESR, liver function tests
     • Screening for hepatitis B, C, and HIV 2

Common Pitfalls to Avoid

• Misdiagnosing malignancy as infection - especially in adults where neck masses are more commonly neoplastic than infectious 1
• Delayed diagnosis - antibiotics should not be used without clear evidence of infection 1, 2
• Incomplete examination - all mucosal surfaces of the head and neck should be thoroughly examined 2
• Failure to recognize HPV-related malignancies - these can occur in younger patients without traditional risk factors and may present as cystic masses 1
• Missing thyroid cancer - which is common in women <40 years 1

Remember that in adults, especially those over 40, a neck mass is most likely to be either neoplastic or inflammatory, with malignancy being the predominant concern 1.