What is the appropriate evaluation and treatment for left-sided neck swelling?

Evaluation and Management of Left-Sided Neck Swelling

For an adult presenting with left-sided neck swelling, you must immediately assess for malignancy risk factors and avoid empiric antibiotics unless clear signs of bacterial infection are present, as most adult neck masses are neoplastic rather than infectious. 1

Initial Risk Stratification

High-Risk Features Requiring Aggressive Workup

Identify patients at increased risk for malignancy based on these specific criteria 1:

History-based red flags:

• Mass present ≥2 weeks without significant fluctuation 1
• Mass of uncertain duration 1
• Absence of infectious etiology (no recent URI, dental problems, trauma, or animal exposure) 1

Physical examination red flags:

• Firm consistency 1
• Size >1.5 cm 1
• Fixation to adjacent tissues 1
• Ulceration of overlying skin 1

Additional concerning features:

• Age >40 years with tobacco/alcohol use 1
• Hoarseness, dysphagia, odynophagia, otalgia 1
• Unexplained weight loss 2

Low-Risk Features (Infectious Etiology)

Only consider infection if all of the following are present 1:

• Warmth and erythema of overlying skin 1
• Tenderness to palpation 1
• Fever and tachycardia 1
• Recent URI, dental problem, or trauma 1
• Rapid onset (days to 1-2 weeks) 1

Management Algorithm

For HIGH-RISK Patients (Presumed Malignancy)

Step 1: Targeted Physical Examination 1

• Perform or refer for visualization of larynx, base of tongue, and pharynx (flexible laryngoscopy) 1
• Palpate all cervical lymph node chains bilaterally 1
• Examine oral cavity, oropharynx, and skin of head/neck for primary lesions 1

Step 2: Imaging 1

• Order CT neck with contrast (or MRI with contrast if CT contraindicated) 1
• This is a strong recommendation and should not be delayed 1
• Imaging helps characterize the mass, identify primary tumors, and assess extent 1

Step 3: Tissue Diagnosis 1

• Perform fine-needle aspiration (FNA) rather than open biopsy if diagnosis remains uncertain after imaging 1
• This is a strong recommendation to avoid tumor seeding and disruption of tissue planes 1
• Send FNA for cytology and consider ancillary tests (immunohistochemistry, flow cytometry) 1

Step 4: Special Consideration for Cystic Masses 1

• Do NOT assume cystic masses are benign 1
• Continue evaluation until definitive diagnosis obtained 1
• Cystic metastases (especially from papillary thyroid cancer or HPV-related oropharyngeal cancer) are common 1

Step 5: Ancillary Testing 1

• Based on history/exam findings, consider: 1
  • EBV serology (nasopharyngeal carcinoma) 1
  • HIV testing (lymphoma risk) 1
  • Thyroid function tests (thyroid mass) 1

Step 6: If No Diagnosis After FNA and Imaging 1

• Recommend examination under anesthesia with panendoscopy BEFORE open biopsy 1
• This allows identification of occult primary tumors in upper aerodigestive tract 1
• Directed biopsies of nasopharynx, base of tongue, tonsils, and pyriform sinuses 1

For LOW-RISK Patients (Presumed Infection)

Only if clear infectious signs present:

• Prescribe appropriate antibiotics targeting common pathogens (Staph aureus, Strep pyogenes) 1
• Consider incision and drainage if fluctuant abscess 3, 4

Mandatory follow-up: 1

• Document clear follow-up plan 1
• Educate patient to return if mass persists >2 weeks, enlarges, or develops high-risk features 1, 2
• Check mass size weekly 2

Critical Pitfalls to Avoid

Do NOT prescribe empiric antibiotics without clear infectious signs 1

• Most adult neck masses are neoplastic, not infectious 1
• Antibiotics delay diagnosis, promote resistance, and provide false reassurance 1
• Reactive lymphadenopathy from URI typically resolves within days of infection resolution 1

Do NOT perform open biopsy before completing workup 1

• Open biopsy disrupts tissue planes and complicates subsequent surgery 1
• Always perform FNA first 1
• If FNA non-diagnostic, proceed to panendoscopy before open biopsy 1

Do NOT assume cystic masses are benign 1

• Cystic metastases are common in head and neck cancers 1
• Continue evaluation until definitive diagnosis 1

Do NOT delay imaging in high-risk patients 1

• CT neck with contrast is mandatory for risk stratification and surgical planning 1

Special Considerations

Post-surgical neck swelling: If recent thyroid or neck surgery, consider hematoma requiring urgent evacuation 1

Acute airway compromise: If stridor, respiratory distress, or rapidly expanding mass, secure airway immediately and consider emergent surgical drainage 1, 4

Metastatic workup: If malignancy confirmed, PET/CT may be indicated for staging 1