Emergency Department Management of Suspected Head or Neck Lesion
For a patient presenting to the emergency department with a suspected head or neck lesion, immediately assess for hard signs of vascular or aerodigestive injury requiring emergent surgical exploration, then obtain CT angiography with contrast for hemodynamically stable patients to guide definitive management. 1, 2
Immediate Assessment: Hard Signs vs. Soft Signs
Hard Signs Requiring Immediate Surgical Exploration (No Imaging)
- Active hemorrhage or pulsatile/expanding hematoma 1, 2
- Hemodynamic instability 1
- Airway compromise or air bubbling through wound 1
- Massive hemoptysis or hematemesis 1
- Bruit or thrill over the wound 1
- Unilateral upper extremity pulse deficit 1
- Symptoms of cerebral ischemia (though these patients may be stable enough for imaging first) 1
Critical Pitfall: Do not delay surgical exploration for imaging when hard signs are present—this significantly increases mortality. 2
Soft Signs Warranting Imaging Before Intervention
- Non-pulsatile or non-expanding hematoma 1
- Venous oozing 1
- Dysphagia or dysphonia 1
- Subcutaneous emphysema 1
Imaging Protocol for Stable Patients
First-Line: CT Angiography with Contrast
Order neck CT angiography (or MRI if contrast contraindicated) for all hemodynamically stable patients with suspected head/neck lesions at increased malignancy risk. 1
- CTA demonstrates 90-100% sensitivity and 98.6-100% specificity for vascular injuries 1, 2
- Simultaneously evaluates extravascular soft tissue and aerodigestive injuries with 100% sensitivity and 93.5-97.5% specificity 1, 2
- Use a "no-zone" approach focusing on clinical signs rather than anatomic zones 1, 2
Additional Imaging Considerations
- CT esophagography: Perform in conjunction with CTA for suspected digestive tract injuries (95-100% sensitivity) 1, 2
- Plain radiographs: May demonstrate radio-opaque foreign bodies, soft-tissue swelling, airway patency, fractures, and subcutaneous emphysema, but should be followed by CT/CTA 1
- Catheter angiography: Reserved for equivocal CTA findings or when endovascular therapy is planned 1
Avoid: MRI/MRA in the acute trauma setting due to scan length, patient instability, and concern for metallic foreign bodies. 1
Risk Stratification for Malignancy (Non-Trauma Presentations)
High-Risk Features Requiring Comprehensive Workup
Identify patients at increased malignancy risk based on history and physical examination findings, as these require targeted evaluation including laryngoscopy and imaging. 1
Suspicious History (≥1 criterion):
- Mass present ≥2 weeks without significant fluctuation or uncertain duration 1
- No history of infectious etiology 1
- Tobacco use (>10 pack-years) 1
- Alcohol use (>6 drinks/day) 1
- Age >40 years 1
- Prior head and neck malignancy or radiation treatment 1
Suspicious Physical Examination (≥1 criterion):
- Fixation to adjacent tissues 1
- Firm consistency 1
- Size >1.5 cm 1
- Ulceration of overlying skin 1
- Non-tender mass 1
Additional Red Flags:
- Persistent hoarseness, dysphagia, odynophagia, or otalgia 1
- Unilateral serous otitis media (suggests nasopharyngeal malignancy) 1
- Tonsil asymmetry 1
- Unexplained weight loss 1
- Skin lesions on face, neck, or scalp 1
Targeted Physical Examination
Perform or refer for comprehensive mucosal examination including flexible laryngoscopy to visualize the larynx, base of tongue, and pharynx in all high-risk patients. 1
Essential Examination Components:
- Skin and scalp assessment for cutaneous malignancy 1
- Otoscopy for unilateral effusion 1
- Complete cranial nerve examination 1
- Visual and digital examination of oral cavity (tongue, floor of mouth) 1
- Oropharynx inspection and palpation (soft palate, tonsillar fossae, tongue base) 1
- Nasal cavity and nasopharynx visualization 1
- Hypopharynx and larynx examination (requires flexible laryngoscopy) 1
- Bimanual neck palpation assessing mass firmness, size, fixation, location 1
- Salivary gland and thyroid palpation 1
Common Pitfall: Do not use flexible nasendoscopy without adequate personal protective equipment in patients with suspected infectious etiology. 1
Diagnostic Algorithm for High-Risk Masses
Step 1: Imaging
- Strong recommendation: Order neck CT with contrast (or MRI if contraindicated) for all high-risk patients 1
Step 2: Tissue Diagnosis
- Strong recommendation: Perform fine-needle aspiration (FNA) instead of open biopsy when diagnosis remains uncertain after imaging 1
- FNA should be performed or patient referred to someone who can perform it 1
Step 3: Cystic Lesions
- Continue evaluation of cystic neck masses until diagnosis is obtained—do not assume benignity 1
- Cystic appearance on FNA or imaging does not exclude malignancy 1
Step 4: Ancillary Testing
- Obtain additional tests based on history/physical when malignancy risk is high and diagnosis remains unclear after FNA and imaging 1
Step 5: Examination Under Anesthesia
- Recommend panendoscopy under anesthesia before open biopsy for high-risk patients without diagnosis after FNA, imaging, and ancillary tests 1
Management of Low-Risk Patients
For patients NOT at increased malignancy risk, document a clear follow-up plan and educate patients on warning signs requiring re-evaluation. 1
Follow-Up Protocol:
- Advise patients to check mass size weekly using fingertips 1
- Document criteria triggering additional evaluation 1
- Ensure resolution or final diagnosis is confirmed 1
Antibiotic Use
Do not routinely prescribe antibiotics unless clear signs and symptoms of bacterial infection are present (fever, erythema, warmth, tenderness, fluctuance). 1
- Most adult neck masses are neoplastic, not infectious 1
- Inappropriate antibiotic use delays malignancy diagnosis, promotes resistance, and causes unnecessary side effects 1
Trauma-Specific Considerations
Airway and Hemodynamic Management
- Maintain systolic blood pressure >110 mmHg in suspected spinal cord injury 2
- Initiate massive transfusion protocol for ongoing hemorrhage 2
- Transfer patients in hemorrhagic shock directly to operating room 2