What is the appropriate workup for a neck mass?

Appropriate Workup for a Neck Mass in Adults

The workup of a neck mass in adults should follow a systematic approach that prioritizes early detection of malignancy, with fine-needle aspiration (FNA) and contrast-enhanced CT or MRI as the cornerstone diagnostic tests for patients at increased risk for malignancy. 1

Risk Assessment for Malignancy

History Factors Suggesting Increased Risk

• Mass present for ≥2 weeks without significant fluctuation or of uncertain duration 1
• Absence of infectious etiology 1
• Progressive symptoms (e.g., hoarseness, dysphagia) 2

Physical Examination Findings Suggesting Increased Risk

• Fixation to adjacent tissues 1, 2
• Firm consistency 1, 2
• Size >1.5 cm 1
• Ulceration of overlying skin 1
• Location in supraclavicular region 3

Diagnostic Algorithm

Step 1: Initial Assessment

• Perform targeted physical examination including visualization of the mucosa of the larynx, base of tongue, and pharynx 1
• Document characteristics of the mass (size, consistency, mobility, location) 1
• Evaluate for associated symptoms (pain, dysphagia, hoarseness) 2

Step 2: Imaging

• Order contrast-enhanced CT or MRI of the neck for patients at increased risk for malignancy 1, 2
• Imaging helps characterize the mass, evaluate relationship to surrounding structures, and identify potential primary sites 2

Step 3: Tissue Sampling

• Perform FNA instead of open biopsy for patients at increased risk for malignancy when diagnosis remains uncertain 1, 2
• FNA offers high sensitivity and specificity with minimal discomfort, low complication rate, and reduced risk of tumor seeding compared to open biopsy 2
• If FNA is inadequate or indeterminate, consider repeat FNA (possibly ultrasound-guided) 2

Step 4: Additional Testing

• For patients at increased risk for malignancy with non-diagnostic FNA and imaging, obtain additional ancillary tests based on clinical presentation 1
• For cystic masses, continue evaluation and do not assume benignity 1, 2

Step 5: Advanced Evaluation

• Recommend examination of the upper aerodigestive tract under anesthesia before open biopsy if diagnosis remains uncertain after FNA, imaging, and ancillary tests 1
• Open biopsy should be considered only after all other diagnostic methods have failed 1, 2

Common Pitfalls to Avoid

• Prescribing antibiotics without clear evidence of bacterial infection 1
• Assuming a cystic mass is benign without adequate follow-up 1, 2
• Proceeding directly to open biopsy without first attempting FNA and imaging 1, 2
• Delaying diagnosis by prolonged observation of concerning masses 4
• Failing to recognize that most persistent neck masses in adults are neoplasms, with malignant neoplasms far exceeding any other etiology 1, 4

Follow-up for Low-Risk Patients

• For patients not at increased risk for malignancy, advise about criteria that would trigger need for additional evaluation 1
• Document a plan for follow-up to assess resolution or final diagnosis 1
• Consider re-evaluation if mass persists beyond 2-4 weeks or develops concerning features 1

Patient Education

• Explain the significance of being at increased risk for malignancy and the rationale for recommended diagnostic tests 1
• Discuss the importance of timely diagnosis, as delayed diagnosis of head and neck cancer directly affects tumor stage and worsens prognosis 1, 4