What is the appropriate workup for a patient presenting with an anterior neck mass?

Workup for Anterior Neck Mass

The appropriate workup for a patient presenting with an anterior neck mass should begin with risk stratification for malignancy, followed by targeted imaging with CT or MRI with contrast, and fine-needle aspiration (FNA) for tissue diagnosis. 1

Risk Assessment for Malignancy

• Patients should be identified as having increased risk for malignancy if the mass has been present for ≥2 weeks without significant fluctuation or is of uncertain duration 1, 2
• Physical examination findings that increase risk of malignancy include:
  • Fixation to adjacent tissues 1, 2
  • Firm consistency 1, 2
  • Size >1.5 cm 1, 2
  • Ulceration of overlying skin 1, 2
• Additional concerning features in history include:
  • History of smoking or alcohol use 2
  • Previous head and neck cancer or radiation exposure 2
  • Constitutional symptoms such as weight loss 2
  • Voice changes, dysphagia, or persistent sore throat 2

Initial Diagnostic Approach

• Avoid routine prescription of antibiotics unless there are clear signs and symptoms of bacterial infection (warmth, erythema, tenderness, fever) 1
• Perform a targeted physical examination including visualization of the mucosa of the larynx, base of tongue, and pharynx for patients at increased risk for malignancy 1, 2
• Essential components of physical examination include:
  • Examination of the skin and scalp 2
  • Otoscopy 2
  • Cranial nerve assessment 2
  • Examination of oral cavity, oropharynx, nasal cavity, nasopharynx, and hypopharynx 2

Imaging Studies

• Order neck CT or MRI with contrast for patients with neck mass deemed at increased risk for malignancy 1, 3
• CT scan advantages include showing both soft tissue and bones, and brief scan time 2
• MRI advantages include superior soft tissue detail and no radiation exposure 2
• Ultrasonography may be used as an initial imaging study for palpable masses, particularly if developmental in origin 4

Tissue Sampling

• Perform FNA instead of open biopsy for patients with a neck mass at increased risk for malignancy when diagnosis remains uncertain 1, 3
• Benefits of FNA include high sensitivity and specificity, minimal discomfort, low complication rate, and low risk of tumor seeding compared to open biopsy 3
• If FNA is inadequate or indeterminate, consider repeat FNA (possibly ultrasound-guided) 3
• If cystic components are found on FNA or imaging, continue evaluation until a diagnosis is obtained (do not assume benignity) 1, 2

Additional Diagnostic Steps

• Obtain additional ancillary tests based on patient's history and physical examination when a patient with a neck mass is at increased risk for malignancy and/or does not have a diagnosis after FNA and imaging 1
• Recommend examination of the upper aerodigestive tract under anesthesia, before open biopsy, for patients without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests 1, 2

Common Pitfalls to Avoid

• Delaying diagnosis by prescribing antibiotics without clear evidence of infection 2
• Assuming a cystic mass is benign without adequate follow-up 2
• Proceeding directly to open biopsy without first attempting FNA and imaging 3, 2
• Failing to recognize that an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer 2
• Overlooking vascular anomalies that can present as anterior neck masses (e.g., high riding innominate artery) 5

Follow-up Recommendations

• For patients not at increased risk for malignancy, advise about specific criteria that would trigger need for additional evaluation 1
• Document a clear follow-up plan to assess resolution or determine final diagnosis 1
• Patients should be taught to recognize warning signs requiring prompt medical attention, including persistent or worsening pain 6