Management of Anterior Neck Mass with Normal Thyroid Function
Stratify the patient's malignancy risk immediately using specific clinical criteria, then proceed with contrast-enhanced CT or MRI if high-risk features are present, followed by fine-needle aspiration if diagnosis remains uncertain. 1, 2
Risk Stratification for Malignancy
High-Risk Historical Features
- Mass present ≥2 weeks without significant fluctuation or of uncertain duration 1, 2
- History of tobacco or alcohol use 2
- Prior head and neck cancer or radiation exposure to head/neck region 1, 2
- Constitutional symptoms including unexplained weight loss 2
- Voice changes, dysphagia, or persistent sore throat 2
- Age >40 years (particularly in smokers) 3
High-Risk Physical Examination Findings
- Size >1.5 cm 1, 2
- Firm consistency (not soft or mobile) 1, 2
- Fixation to adjacent tissues 1, 2
- Ulceration of overlying skin 1, 2
- Cranial nerve deficits 2
- Unilateral serous otitis media (suggests nasopharyngeal malignancy) 2
- Nontender masses are more suspicious than tender masses 1
Essential Physical Examination Components
Perform a comprehensive head and neck examination beyond just palpating the mass itself: 1, 2
- Inspect scalp and face for ulcerations or pigmented lesions 1
- Examine oral cavity (remove dentures) including floor of mouth, lateral tongue surfaces, and all mucosal surfaces 1
- Visualize oropharynx with patient's mouth open but tongue NOT protruded (protrusion obscures the view) 1
- Assess for tonsil asymmetry or masses 1
- Perform otoscopy bilaterally (unexplained otalgia with normal ear exam suggests referred pain from pharyngeal malignancy) 1
- Evaluate cranial nerve function 2
- Palpate thyroid gland separately from the mass 1
- Distinguish normal anatomic structures often mistaken for pathology: submandibular glands, hyoid bone, C2 transverse process, carotid bulb 1
Diagnostic Algorithm
For High-Risk Patients
Order contrast-enhanced CT neck or MRI immediately (strong recommendation) 1, 2
- CT advantages: visualizes both soft tissue and bone, rapid acquisition 2
- MRI advantages: superior soft tissue detail, no radiation exposure 2
If diagnosis remains uncertain after imaging, proceed to fine-needle aspiration (FNA) rather than open biopsy 2, 3
- FNA sensitivity: 77-97%, specificity: 93-100% for malignancy detection 3
- Provides cytology, Gram stain, and culture capabilities 3
If FNA, imaging, and ancillary tests fail to identify diagnosis or primary site, recommend examination of upper aerodigestive tract under anesthesia BEFORE any open biopsy 2
For Low-Risk Patients
Document a specific follow-up plan to ensure resolution or final diagnosis 1
- Instruct patient to check mass size weekly using fingertips 1
- Mass from infection should resolve completely or return to much smaller size within 2-3 weeks 1
- Follow-up may be in-person, telephone, or electronic communication 1
Educate patient on red flags requiring immediate re-evaluation: 1
- Mass enlarges or persists beyond expected timeframe
- Mass resolves then recurs
- Development of dysphagia, odynophagia, voice change, or unexplained weight loss
- Ear pain or hearing loss ipsilateral to mass
- Fever >101°F
Critical Pitfalls to Avoid
Do NOT prescribe antibiotics without clear evidence of bacterial infection 2, 4
- Delaying diagnosis with empiric antibiotics is a common error that worsens outcomes 2
- Antibiotics should only be given when specific infectious signs/symptoms are present 4
Do NOT assume cystic masses are benign 2, 5
- Up to 80% of cystic neck masses in patients >40 years are malignant 5
Do NOT perform open biopsy before complete evaluation of upper aerodigestive tract 2
- This can compromise subsequent cancer staging and treatment 2
Do NOT assume bilateral masses are automatically benign 5
- Apply the same risk stratification criteria regardless of laterality 5
Recognize that asymptomatic neck masses may be the only manifestation of head and neck cancer 2