Evaluation of a Neck Mass Present for Two Years Without Change
A neck mass present for two years without change still requires complete malignancy workup, as duration alone does not exclude cancer—particularly HPV-positive oropharyngeal carcinoma and other slow-growing malignancies that can remain stable for extended periods. 1, 2
Why Duration Does Not Provide Reassurance
- The 2-week threshold is a minimum, not a maximum: The American Academy of Otolaryngology-Head and Neck Surgery identifies masses present ≥2 weeks without infectious etiology as high-risk, but this does not mean masses present longer are safer 1
- Slow-growing malignancies exist: HPV-positive oropharyngeal cancer, thyroid cancer, lymphoma, and certain salivary gland malignancies can remain stable or grow imperceptibly over months to years 1, 2
- Cystic metastases mimic benign lesions: Up to 62% of metastases from oropharyngeal sites are cystic and can be mistaken for benign branchial cleft cysts, with 80% of cystic neck masses in patients >40 years proving malignant 1
Mandatory Risk Stratification
Assess for high-risk features that mandate immediate workup regardless of duration:
Historical Red Flags 1, 2
- Age >40 years
- Tobacco and/or alcohol use
- Absence of recent infection or dental problems
- Symptoms: dysphagia, odynophagia, hoarseness, otalgia, unexplained weight loss
Physical Examination Red Flags 1, 2
- Size >1.5 cm
- Firm or hard consistency
- Fixed to adjacent tissues (reduced mobility)
- Nontender
- Ulceration of overlying skin
Required Workup Algorithm
If ANY high-risk feature is present (which includes the 2-year duration itself), proceed with full malignancy evaluation:
Step 1: Imaging 1, 2
- Order contrast-enhanced CT neck or MRI immediately—this is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery 1
- Do not wait for additional symptoms or changes in size 2
Step 2: Specialist Referral 1, 2
- Refer to otolaryngology for targeted physical examination including visualization of the larynx, base of tongue, and pharynx with flexible laryngoscopy 1
- This examination cannot be adequately performed in primary care 1
Step 3: Tissue Diagnosis 1, 3
- Fine-needle aspiration (FNA) is strongly preferred over open biopsy as the initial diagnostic test 1, 3
- If FNA is nondiagnostic, ultrasound-guided repeat FNA or core biopsy should be performed 1, 3
- Never assume a cystic mass is benign—continue evaluation until definitive diagnosis is obtained 1, 3
Step 4: Examination Under Anesthesia 1
- If FNA, imaging, and ancillary tests fail to identify a primary site or diagnosis, the American Academy of Otolaryngology-Head and Neck Surgery recommends examination of the upper aerodigestive tract under anesthesia before open biopsy 1
Critical Pitfalls to Avoid
- Do not prescribe antibiotics without clear infectious signs (fever, warmth, erythema, tenderness)—this delays cancer diagnosis and provides false reassurance 1, 2
- Do not assume stability equals benignity—many malignancies grow slowly or remain stable for extended periods 2
- Do not rely on "watchful waiting" for a 2-year-old mass—the time for observation has long passed 1
- Do not perform open biopsy before imaging and FNA—this violates standard of care and can compromise future surgical management 1, 3, 4
Special Consideration: HPV-Positive Oropharyngeal Cancer
- This malignancy is rapidly increasing in incidence and frequently presents as cystic cervical metastases in younger patients (<40 years) without tobacco/alcohol exposure 2
- These patients often have stable, nontender lateral neck masses that mimic benign branchial cleft cysts 2
- HPV testing on FNA specimen should be considered if oropharyngeal primary is suspected 2
If No High-Risk Features Are Present
Even without classic high-risk features, a 2-year duration itself warrants evaluation: