What is the next step for a patient presenting with a lump on the right side of the anterior neck in a walk-in clinic?

Management of a Neck Mass in a Walk-in Clinic Setting

The next step for a patient presenting with a lump on the right side of the anterior neck in a walk-in clinic should be a targeted physical examination followed by contrast-enhanced CT or MRI of the neck if the patient has risk factors for malignancy. 1, 2

Initial Assessment

Risk Stratification

First, determine if the patient is at increased risk for malignancy based on:

• History factors 1, 2:

  • Mass present ≥2 weeks without fluctuation or uncertain duration
  • Absence of infectious etiology
  • Age >40 years
  • Tobacco use or alcohol abuse
  • HPV risk factors (multiple sexual partners, oral sex)
  • Prior history of head and neck cancer
  • Immunocompromised status

• Physical examination findings 1, 2:

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

• Associated symptoms 1, 2:

  • Voice change/hoarseness
  • Trouble or pain with swallowing (odynophagia/dysphagia)
  • Ear pain or hearing loss on same side as neck mass
  • Persistent sore throat
  • Unexplained weight loss
  • Fever >101°F
  • Hemoptysis or blood in saliva
  • Oral numbness or intraoral swelling/ulceration

Targeted Physical Examination

Perform a comprehensive head and neck examination including 1, 2:

• Complete visualization of oral cavity and oropharynx
• Palpation of the neck mass (noting size, consistency, mobility, tenderness)
• Examination of cranial nerves
• Examination of other lymph node regions

Diagnostic Pathway

For Patients at Increased Risk for Malignancy:

1. Imaging 1, 2:

   • Order contrast-enhanced CT or MRI of the neck (strong recommendation)
   • These imaging studies help evaluate the extent of disease and potential nodal involvement

2. Fine-needle aspiration (FNA) 1, 2:

   • Perform FNA instead of open biopsy if diagnosis remains uncertain after history, examination, and imaging
   • FNA is less invasive and has lower risk of complications than open biopsy

3. Additional testing if diagnosis remains uncertain 1, 2:

   • Ancillary tests based on patient's specific history and examination findings
   • Examination under anesthesia of the upper aerodigestive tract before considering open biopsy

For Patients Not at Increased Risk for Malignancy:

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

Important Caveats

• Avoid premature antibiotic therapy unless clear signs of bacterial infection are present (warmth, erythema, tenderness, fever) 1, 2

  • Inappropriate antibiotic use can delay diagnosis of malignancy

• Do not assume cystic lesions are benign 1, 2

  • Continue evaluation of cystic neck masses until a definitive diagnosis is obtained

• Avoid open biopsy before complete evaluation 1, 2

  • Open biopsy should only be considered after other diagnostic measures have failed

• Refer to specialist when appropriate 1, 2:

  • Patients with high-risk features should be referred to an otolaryngologist or head and neck specialist
  • Urgent referral is needed for patients with highly suspicious findings

Remember that neck masses in adults are more commonly neoplastic than infectious, particularly in patients over 40 years of age 3. A systematic approach to evaluation is essential to avoid delays in diagnosis of potentially life-threatening conditions.