What is the initial workup for a patient presenting with neck enlargement?

Initial Workup for Neck Enlargement in Adults

Begin by conducting a focused history and physical examination to stratify malignancy risk, then proceed with imaging and tissue diagnosis for high-risk patients—avoid empiric antibiotics unless clear signs of bacterial infection are present. 1

Step 1: Risk Stratification Through History

Identify high-risk features that mandate aggressive workup:

Historical Red Flags for Malignancy

• Mass present ≥2 weeks without significant fluctuation or uncertain duration 1
• No history of infectious etiology (no recent URI, dental infection, or systemic illness) 1
• Age >40 years 1
• Tobacco use or alcohol abuse 1
• HPV-related risk factors: increased number of sexual partners, oral sex 1
• Prior head and neck cancer or radiation exposure to head/neck 1
• Immunocompromised status or immunosuppressive medications 1

Associated Symptoms Suggesting Malignancy

• Hoarseness, otalgia, or hearing loss 1
• Dysphagia, odynophagia, or weight loss 1
• Hemoptysis or blood in saliva 1
• Intraoral swelling/ulceration or new numbness in oral cavity 1
• Unilateral nasal congestion or epistaxis 1

Lymphoma-Specific Symptoms

• Fever, night sweats, weight loss (B symptoms) 1
• Lymphadenopathy distant from head and neck 1

Step 2: Physical Examination Findings

Examine for characteristics that increase malignancy risk:

High-Risk Physical Examination Features

• Fixation to adjacent tissues 1
• Firm consistency 1
• Size >1.5 cm (upper limit of normal even for jugulodigastric nodes) 1
• Ulceration of overlying skin 1
• Nontender mass (more suspicious than tender) 1

Required Examination Components

• Scalp and face inspection for ulcerations, pigmented lesions, or asymmetry 1
• Oral cavity examination (remove dentures): inspect all surfaces, palpate floor of mouth, assess tongue mobility with gauze 1
• Oropharynx visualization with bright light and tongue depressor (patient should NOT protrude tongue as this obscures view) 1
• Neck and thyroid palpation 1

Common pitfall: Physical examination alone is insufficient—history is equally important in determining infectious vs. malignant etiology. 1

Step 3: Management Based on Risk Stratification

For HIGH-RISK Patients (Any Red Flag Present)

Proceed immediately with the following algorithmic workup:

A. Targeted Physical Examination

• Perform or refer for visualization of larynx, base of tongue, and pharynx (flexible laryngoscopy or mirror examination) 1
• This cannot be adequately performed in primary care and typically requires ENT referral 1

B. Imaging (STRONG RECOMMENDATION)

• Order CT neck with contrast (or MRI with contrast if CT contraindicated) 1
• This is a strong recommendation based on the highest quality evidence 1
• Do not delay imaging while awaiting specialist consultation 1

C. Tissue Diagnosis

• Fine-needle aspiration (FNA) is preferred over open biopsy when diagnosis remains uncertain after imaging 1
• Refer to someone who can perform FNA if you cannot 1

D. Special Consideration for Cystic Masses

• Do NOT assume cystic masses are benign—continue evaluation until diagnosis obtained 1
• Cystic appearance on FNA or imaging does not exclude malignancy 1

E. Ancillary Testing

• Obtain additional tests based on clinical suspicion: 1
  • Thyroid function tests if thyroid mass suspected
  • EBV serology for nasopharyngeal carcinoma risk
  • HIV testing if immunocompromised suspected
  • Chest imaging if lymphoma suspected

F. Examination Under Anesthesia

• Recommend before any open biopsy if no diagnosis or primary site identified with FNA, imaging, and ancillary tests 1
• This allows comprehensive upper aerodigestive tract examination 1

For LOW-RISK Patients (No Red Flags)

Observation with structured follow-up is appropriate:

• Educate patient on warning signs requiring re-evaluation 1
• Document specific follow-up plan to assess resolution or obtain final diagnosis 1
• Advise weekly self-monitoring of mass size 2
• Return criteria: worsening pain, new symptoms, lack of improvement, fever >101°F, dysphagia, weight loss 2

Critical Management Principles

What NOT to Do

Avoid empiric antibiotics unless clear bacterial infection signs present (fever, erythema, fluctuance, purulent drainage) 1

• Most adult neck masses are neoplastic, not infectious 1
• Antibiotics delay malignancy diagnosis and promote resistance 1
• This is a recommendation based on observational evidence showing preponderance of benefit over harm 1

Do not perform open biopsy before:

• Imaging completion 1
• FNA attempt 1
• Examination under anesthesia to identify primary site 1

Patient Education Requirements

For high-risk patients, explain: 1

• Significance of increased malignancy risk
• Rationale for recommended diagnostic tests
• Expected timeline for specialist consultation
• Risk factor modification (tobacco cessation, alcohol reduction) 1

Timing Considerations

Urgent specialist referral is warranted when high-risk features present 1

• Communicate urgency directly to specialist 1
• Ensure thorough evaluation, testing, and follow-up occur within short timeframe 1

Evidence Quality Note

This algorithmic approach is based on the 2017 American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guideline 1, which represents the most comprehensive and recent guideline on this topic. The imaging and FNA recommendations carry strong recommendation strength, while other components are standard recommendations based on observational evidence. 1