What is the treatment plan for a 2-day history of a firm, tender, and 5 cm diameter right anterior cervical enlargement in an afebrile adult with no significant past medical history and no signs of upper respiratory infection?

Treatment Plan for Right Anterior Cervical Enlargement

This patient requires urgent contrast-enhanced CT or MRI of the neck followed by fine-needle aspiration (FNA), not empiric antibiotics, because the firm 5 cm mass present for 2 days without fever or upper respiratory symptoms places them at high risk for malignancy. 1, 2

Why This Patient is High-Risk for Malignancy

This presentation meets multiple red flags established by the American Academy of Otolaryngology-Head and Neck Surgery:

• Size >1.5 cm (this mass is 5 cm, well above the threshold) 1, 2
• Firm consistency on palpation 1
• Absence of infectious etiology (afebrile, no upper respiratory symptoms) 1, 2
• Duration ≥2 days without infectious context warrants immediate workup rather than observation 1, 2

The anterior cervical location (likely Level II nodes) is the most common site for metastatic squamous cell carcinoma from oropharyngeal primary tumors, papillary thyroid carcinoma, and lymphoma. 3

Critical First Steps: Imaging Before Any Intervention

Order contrast-enhanced CT neck or MRI with contrast immediately as the mandatory first diagnostic test. 1, 3 This imaging must be obtained before any tissue sampling to:

• Assess internal characteristics (solid vs cystic—cystic masses can still be malignant, especially HPV-positive oropharyngeal cancer metastases) 1, 3
• Identify additional pathologic lymph nodes 3
• Evaluate potential primary tumor sites 3
• Determine fixation to adjacent structures 3

What NOT to Do: Avoid These Critical Pitfalls

Do not prescribe empiric antibiotics. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine antibiotic therapy for neck masses unless there are clear signs of bacterial infection (fever, warmth, erythema, rapid onset). 1, 2 This patient has none of these features. Empiric antibiotics will:

• Delay diagnosis of malignancy 2
• Create false reassurance if partial resolution occurs (which may represent infection in underlying malignancy) 2
• Obscure the clinical picture 1

Do not perform open excisional biopsy before imaging and FNA. This worsens outcomes if malignancy is present and risks tumor spillage. 3

Mandatory Physical Examination Components

While awaiting imaging, perform a targeted examination including: 1, 2

• Skin and scalp examination (looking for primary skin malignancies)
• Complete oral cavity inspection (looking for mucosal lesions, ulcerations)
• Oropharynx visualization (tonsils, base of tongue—common HPV-positive cancer sites)
• Bimanual palpation of floor of mouth and entire neck
• Assessment for additional lymph nodes (supraclavicular, posterior cervical, contralateral)
• Cranial nerve examination (any deficits suggest advanced disease)
• Assessment for fixation to adjacent tissues (indicates locally advanced disease) 1

Historical Red Flags to Elicit

Ask specifically about: 1

• Tobacco use and alcohol consumption (traditional HNSCC risk factors)
• Sexual history (number of partners, oral sex—HPV-related oropharyngeal cancer risk)
• Constitutional symptoms (weight loss, night sweats—lymphoma)
• Hoarseness, otalgia, dysphagia, odynophagia (suggests primary head/neck malignancy)
• Prior head and neck malignancy including skin cancers
• Immunosuppression (HIV, transplant, immunomodulating medications)

Next Step After Imaging: Fine-Needle Aspiration

Perform FNA or refer to someone who can perform FNA instead of open biopsy. 1, 2, 3 If imaging shows cystic components, target the solid portions or cyst wall. 3 FNA provides:

• Cytologic diagnosis
• Material for culture if mycobacterial infection suspected
• Minimal morbidity compared to open biopsy 1

Special Consideration: Cystic Masses Are Not Benign

Do not assume a cystic mass is benign. Up to 80% of cystic neck masses in adults >40 years are malignant. 3 HPV-positive oropharyngeal cancer metastases commonly present as soft, cystic masses that can be mistaken for branchial cleft cysts. 1, 3 Continue evaluation until a definitive diagnosis is obtained. 1

If Malignancy is Confirmed or Suspected

Refer urgently to otolaryngology for: 1

• Examination under anesthesia of upper aerodigestive tract if no primary site identified
• Direct laryngoscopy, nasopharyngoscopy, and pharyngoscopy to identify occult primary tumor
• Multidisciplinary tumor board evaluation for treatment planning

Timeline for Action

• Imaging: Within 24-48 hours given the size and concerning features
• FNA: Within 1 week of imaging results
• Specialist referral: Immediately if imaging or FNA suggests malignancy 1