What is the diagnosis and management for a patient with stiff neck, limited ROM, difficulty swallowing, palpitations, and a fatty anterior neck mass?

Diagnosis and Management of Neck Mass with Associated Symptoms

Most Likely Diagnosis

This presentation most likely represents thyroid pathology (goiter, thyroiditis, or thyroid mass) given the anterior neck location, dysphagia, and palpitations, though malignancy must be ruled out given the duration and associated symptoms. 1

Differential Diagnosis

High Priority (Must Rule Out)

• Thyroid pathology (goiter, thyroiditis, thyroid neoplasm): The anterior neck location ("fatty anterior neck"), dysphagia, and palpitations strongly suggest thyroid involvement 2, 3
• Malignant neck mass: Any neck mass present for several days to weeks without infectious etiology must be considered malignant until proven otherwise 1
• Metastatic lymphadenopathy: Head and neck squamous cell carcinoma commonly presents as neck mass with dysphagia 1

Moderate Priority

• Lipoma with compressive symptoms: Large neck lipomas can cause dysphagia, dyspnea, and even cardiac arrhythmias through compression of neurovascular structures 4, 5, 6
• Subacute thyroiditis: Can present with anterior neck pain/stiffness and palpitations from thyrotoxicosis 2
• Reactive lymphadenopathy: Less likely given the anterior location and lack of clear infectious history 7

Risk Stratification for Malignancy

This patient has multiple concerning features that place them at increased risk for malignancy: 1

• Mass present >2 weeks without infectious etiology 1
• Difficulty swallowing (dysphagia/odynophagia) 1
• Location in anterior neck (if thyroid-related, requires evaluation) 1
• Age 44 years (thyroid cancer common in women <40, but malignancy risk increases with age overall) 1

Physical examination findings that would further increase malignancy risk include: 1

• Size >1.5 cm 1
• Firm consistency 1
• Fixation to adjacent tissues 1
• Nontender mass (more suspicious than tender) 1

Initial Evaluation

History and Physical Examination

Conduct a thorough head and neck examination focusing on: 1

• Oral cavity: Remove dentures if present; inspect all surfaces and palpate floor of mouth for ulcers or masses 1
• Oropharynx: Use bright light and tongue depressor without tongue protrusion; assess for tonsil asymmetry, masses, or ulcers 1
• Neck palpation: Assess mass characteristics (size, consistency, mobility, tenderness), thyroid gland, and distinguish from normal structures (submandibular glands, hyoid bone, C2 transverse process, carotid bulb) 1
• Scalp and face: Inspect for ulcerations or pigmented lesions suggesting cutaneous malignancy 1
• Laryngeal examination: If incomplete visualization, refer to specialist for flexible laryngoscopy 1

Key historical red flags to assess: 1

• Tobacco or alcohol use 1
• Weight loss, fever, night sweats (lymphoma) 1
• Hemoptysis, blood in saliva 1
• Prior head/neck malignancy or radiation 1
• Hoarseness, otalgia 1

Imaging

Order contrast-enhanced CT neck (or MRI with contrast) immediately for this patient given increased malignancy risk. 1

• CT neck with IV contrast is the preferred initial imaging modality for a palpable neck mass in an adult, particularly given cancer risk 1
• Provides superior spatial resolution and can identify extent of disease, lymphadenopathy patterns, and guide search for primary malignancy 1
• If thyroid origin is suspected, imaging should follow thyroid-specific protocols 1
• Dual-phase imaging (with and without contrast) is not usually necessary 1

Ultrasound may be appropriate if: 1, 7

• Discrete cystic lesion is suspected 1
• Thyroid nodule characterization is needed 1
• Guiding fine needle aspiration 8

Tissue Diagnosis

If imaging confirms a neck mass at increased risk for malignancy, proceed with fine needle aspiration (FNA) as the first-line tissue sampling technique. 1, 9

• FNA is minimally invasive, well-tolerated, and provides excellent diagnostic yield 1, 9
• Ultrasound-guided FNA increases specimen adequacy, especially for cystic masses 8
• On-site cytopathology evaluation can reduce inadequacy rates 1, 8

Important considerations: 1, 9, 8

• If lymphoma is suspected clinically, core needle biopsy may be preferred (sensitivity 92% vs 74% for FNA) 1, 7
• If initial FNA is inadequate or indeterminate, repeat FNA before proceeding to open biopsy 1, 8
• For cystic masses, do NOT assume benign etiology—up to 80% malignancy risk in adults >40 years 8

Management Algorithm

Immediate Actions (Within Days)

1. Complete head and neck physical examination as detailed above 1
2. Order contrast-enhanced CT neck (or MRI) given malignancy risk factors 1
3. Check thyroid function tests (TSH at minimum) given anterior location and palpitations 2, 3

Based on Imaging Results

If thyroid pathology confirmed:

• Refer to endocrinology or thyroid surgery depending on findings 2, 3
• Levothyroxine for hypothyroidism if present 2
• Beta-blockers for symptomatic hyperthyroidism 2

If non-thyroid mass with malignancy features:

• Urgent referral to head and neck surgery/ENT (within 1 week) 1
• Proceed with FNA or core biopsy as appropriate 1, 9
• Do not delay with empiric antibiotics if no clear infectious etiology 1

If benign-appearing but symptomatic (e.g., large lipoma):

• Surgical excision indicated for compressive symptoms (dysphagia, dyspnea, palpitations) 4, 5, 6

Critical Pitfalls to Avoid

• Never assume a cystic neck mass is benign—papillary thyroid carcinoma, lymphoma, and oropharyngeal carcinoma can all present as cystic masses 1, 8
• Do not treat empirically with antibiotics unless clear infectious etiology, as this delays cancer diagnosis 1
• Do not perform open biopsy before FNA—this is more invasive with higher complication risk 1
• Do not skip imaging in high-risk patients—physical examination alone has limited sensitivity for malignancy 1
• Recognize that large lipomas can cause serious symptoms including cardiac arrhythmias through neurovascular compression 5

Follow-Up

If treated for presumed benign etiology, reassess within 2 weeks: 1

• Mass should decrease significantly or resolve completely 1
• If mass persists, enlarges, or recurs after initial resolution, proceed with imaging and tissue diagnosis 1
• Patient should monitor weekly and report any worsening symptoms (dysphagia, dyspnea, weight loss, fever >101°F) 1