What are the evaluation and treatment options for a nodule on the neck?

Evaluation and Management of Neck Nodules

For adults with a neck nodule, clinicians should perform a targeted physical examination, order contrast-enhanced CT or MRI, and perform fine-needle aspiration (FNA) for diagnosis, as most adult neck masses are neoplastic rather than infectious in nature. 1

Initial Assessment

Risk Stratification for Malignancy

• Patients should be considered at increased risk for malignancy if the mass has been present for ≥2 weeks without significant fluctuation or is of uncertain duration 1
• Physical examination findings suggesting malignancy include: fixation to adjacent tissues, firm consistency, size >1.5 cm, and/or ulceration of overlying skin 1
• Additional concerning features include: age >40 years, history of tobacco use, alcohol abuse, prior radiation exposure, and associated symptoms such as hoarseness, dysphagia, or odynophagia 1

Targeted Physical Examination

• Comprehensive examination should include visualization of the mucosa of the larynx, base of tongue, and pharynx 1
• Palpation should assess for fixation, consistency, size, and overlying skin changes 1
• Bimanual palpation of the floor of mouth should be performed when indicated 1
• Location of the mass should be documented according to neck levels (I-VII) as this helps narrow the differential diagnosis 1

Diagnostic Approach

Imaging

• Contrast-enhanced CT or MRI of the neck is strongly recommended for patients with neck masses at increased risk for malignancy 1
• CT offers advantages of being more readily available, less expensive, faster acquisition time, and less susceptible to motion artifacts compared to MRI 1
• MRI provides superior soft tissue contrast and is preferred when perineural spread is suspected or in cases where radiation exposure is a concern 1
• Ultrasound may be used as an adjunct, particularly for thyroid or salivary gland masses, or to guide FNA 1

Fine-Needle Aspiration

• FNA should be performed instead of open biopsy for patients with neck masses at increased risk for malignancy 1
• FNA has high sensitivity (88-100%) and specificity (52-55%) for diagnosing malignancy 2
• For cystic masses, FNA should target any solid components or the cyst wall 1
• If initial FNA is non-diagnostic, it should be repeated, possibly with image guidance 1

Special Considerations for Cystic Masses

• Cystic neck masses in adults should not be assumed to be benign, as up to 14% of cystic thyroid lesions and up to 80% of cystic neck masses in patients >40 years old may be malignant 1, 2
• HPV-positive oropharyngeal squamous cell carcinomas frequently present as cystic neck masses 1
• Imaging characteristics suggesting malignancy in cystic lesions include: large size, central necrosis with rim enhancement, multiple enlarged lymph nodes, extracapsular spread, asymmetric wall thickness, and nodularity 1

Management Algorithm

1. For patients at low risk for malignancy:

   • Document criteria that would trigger additional evaluation 1
   • Schedule follow-up to assess resolution or establish final diagnosis 1

2. For patients at increased risk for malignancy:

   • Obtain contrast-enhanced CT or MRI of the neck 1
   • Perform FNA of the mass 1
   • Consider ancillary tests based on clinical suspicion (e.g., EBV serology for suspected lymphoma) 1

3. If diagnosis remains uncertain after initial evaluation:

   • Repeat FNA, possibly with image guidance 1
   • Consider examination under anesthesia of the upper aerodigestive tract before open biopsy 1
   • For persistent cystic masses without diagnosis, excisional biopsy may be necessary 1

Common Pitfalls and Caveats

• Avoid empiric antibiotics unless there are clear signs and symptoms of bacterial infection (warmth, erythema, tenderness, fever) 1
• Inappropriate antibiotic use can delay diagnosis of malignancy, contribute to bacterial resistance, and increase healthcare costs 1
• Do not assume that a cystic mass is benign, as many malignancies (particularly HPV-related oropharyngeal cancers) can present as cystic neck masses 1, 2
• FNA may be less reliable for cystic lesions (sensitivity 88% vs 100% for solid masses) due to insufficient diagnostic material 2
• Location of the mass provides important diagnostic clues: 80% of masses in levels I-III arise from supraclavicular primary malignancies, while 50% of masses in level IV and supraclavicular fossa arise from primary malignancies below the clavicle 1