Initial Workup for Neck Lump in Adults
Begin with risk stratification through focused history and physical examination, then proceed directly to CT or MRI with contrast for high-risk patients, followed by fine-needle aspiration if diagnosis remains uncertain—avoiding empiric antibiotics and open biopsy until imaging and primary site examination are complete. 1
Risk Stratification Through History
High-Risk Historical Features
- Mass present ≥2 weeks without significant fluctuation 1
- Age over 40 years (neoplastic processes are highly likely in this population) 1, 2
- Tobacco use or alcohol abuse 1
- Prior head and neck cancer or radiation exposure 1
- Immunocompromised status 1
Red Flag Symptoms Requiring Urgent Evaluation
- Hoarseness or voice change 3, 1
- Dysphagia or odynophagia 3, 1
- Otalgia or hearing loss on the same side as the mass 3, 1
- Unexplained weight loss 3, 1
- Hemoptysis or blood in saliva 1
- Intraoral swelling or ulceration 1
- Unilateral nasal congestion or epistaxis 1
Physical Examination Components
Required Examination Elements
- Scalp and face inspection 1
- Complete oral cavity examination (dentures must be removed) 3, 1
- Oropharynx visualization 1
- Neck and thyroid palpation 1
- Visualization of larynx, base of tongue, and pharynx mucosa (perform yourself or refer to a clinician with appropriate equipment) 3
High-Risk Physical Examination Findings
- Firm consistency (not soft or doughy) 1, 4
- Fixation to adjacent tissues (not mobile) 1, 4
- Size greater than 1.5 cm 1, 4
- Ulceration of overlying skin 1, 4
- Nontender mass 1
Diagnostic Testing Algorithm
For High-Risk Patients (Any Red Flag Present)
- Order CT neck with contrast or MRI with contrast immediately 1, 4
- Perform fine-needle aspiration (FNA) if diagnosis remains uncertain after imaging—FNA is strongly preferred over open biopsy 1, 4, 5
- Refer urgently to otolaryngology with direct communication of urgency 1, 2
For Low-Risk Patients (No Red Flags)
- Structured observation with specific follow-up plan 1
- Patient education on warning signs 1
- Document timeline for re-evaluation 1
Critical Management Pitfalls to Avoid
Do NOT Prescribe Empiric Antibiotics
Most adult neck masses are neoplastic, not infectious—antibiotics delay appropriate diagnosis unless clear signs of bacterial infection are present (fever >101°F, fluctuance, erythema) 3, 1, 4
Do NOT Perform Open Biopsy Prematurely
Open biopsy should not be performed before: 1, 4
- Imaging completion
- FNA attempt
- Examination under anesthesia to identify primary site
This sequence prevents tract seeding and allows proper surgical planning 5
Do NOT Assume Bilateral Masses Are Benign
Apply the same risk stratification criteria to bilateral masses as unilateral masses—bilateral presentation does not exclude malignancy 4
Special Consideration for Cystic Masses
Up to 80% of cystic neck masses in patients over 40 years are malignant—continued evaluation is mandatory until diagnosis is confirmed 4
Timeline and Follow-Up
Ensure thorough evaluation, testing, and follow-up within a short timeframe for high-risk patients, with documented communication of urgency to specialists 3, 1