How do I document soft tissue swelling in the neck on physical exam?

Documentation of Soft Tissue Swelling in the Neck on Physical Exam

When documenting soft tissue swelling in the neck, you must systematically describe the location, size, consistency, mobility, overlying skin changes, and associated features—this structured approach is critical because specific physical examination characteristics determine malignancy risk and guide urgent management decisions. 1

Essential Documentation Elements

Location and Size

• Specify the precise anatomic location using standard neck landmarks: supraclavicular fossa, anterior triangle, posterior triangle, submandibular region, or specific cervical levels 2, 3
• Measure and document the size in centimeters—masses >1.5 cm are considered high-risk for malignancy and require immediate further evaluation 1
• Avoid vague descriptors like "neck swelling" or "raised neck tendon"; use specific anatomic terminology 2

Consistency and Texture

• Document whether the mass is firm, hard, or soft 1
  • Firm consistency suggests malignancy due to absence of tissue edema 1
  • Soft consistency may indicate infectious etiology (due to tissue edema) or cystic lesions (which can still be malignant) 1
  • Hard consistency is particularly concerning for malignancy 3

Mobility Assessment

• Assess and document whether the mass is mobile or fixed to adjacent tissues 1, 2
  • Fixation to underlying structures is a high-risk feature indicating possible capsular invasion by metastatic cancer 1
  • Reduced mobility suggests direct invasion of adjacent structures 1

Overlying Skin Changes

• Examine and document any skin abnormalities 1, 2
  • Ulceration of overlying skin indicates either capsular breakthrough with skin invasion or primary cutaneous malignancy with neck extension 1
  • Skin changes are a high-risk feature requiring urgent evaluation 1

Tenderness

• Note whether the mass is tender or nontender 2, 3
  • Nontender masses are more concerning for malignancy 2, 3
  • Tender masses may suggest infectious or inflammatory etiology 3

High-Risk Features Requiring Immediate Documentation

If any of the following are present, the patient is at increased risk for malignancy and requires urgent imaging and specialist evaluation: 1

• Size >1.5 cm 1
• Firm consistency 1
• Fixation to adjacent tissues 1
• Ulceration of overlying skin 1
• Mass present ≥2 weeks without significant fluctuation 1
• Absence of infectious etiology 1

Required Additional Examination Components

Complete Head and Neck Examination

• Visualize the oropharynx, base of tongue, and larynx to identify potential primary malignancy sites 2, 3
• Examine the oral cavity for ulceration, masses, or decreased tongue mobility 1
• Inspect the scalp and face for skin lesions 3
• Palpate the thyroid gland 3

Associated Symptoms to Document

Document presence or absence of: 1

• Hoarseness or voice changes (laryngeal/pharyngeal malignancy) 1
• Dysphagia or odynophagia (aerodigestive tract involvement) 1
• Otalgia ipsilateral to the mass (referred pain from pharynx) 1
• Hearing loss ipsilateral to the mass (nasopharyngeal malignancy with eustachian tube obstruction) 1
• Nasal obstruction or epistaxis (sinonasal malignancy) 1
• Unexplained weight loss (cachexia from malignancy) 1

Documentation Template Example

A practical documentation format: 1, 2, 3

"[Size in cm] mass in the [specific anatomic location], [firm/soft/hard] consistency, [mobile/fixed to adjacent tissues], [tender/nontender], with [normal overlying skin/ulceration/erythema]. No associated cervical lymphadenopathy. Duration: [timeframe]. Associated symptoms: [present/absent for each relevant symptom]. Oropharyngeal examination: [findings]."

Critical Management Implications

Do not prescribe empiric antibiotics unless clear signs of bacterial infection are present (fever, erythema, warmth, fluctuance), as most adult neck masses are neoplastic, not infectious 1, 3

For high-risk patients, immediately order CT neck with contrast (or MRI with contrast) and arrange urgent specialist referral 1, 2, 3

Common Pitfalls to Avoid

• Never describe a neck mass as simply "swelling" or "enlarged lymph node" without the detailed characteristics above—this delays appropriate risk stratification 2, 3
• Do not assume cystic masses are benign—cystic neck masses can be malignant and require complete evaluation until diagnosis is obtained 1
• Avoid delaying imaging in high-risk patients while attempting observation or antibiotic trials 1, 3