What is the appropriate evaluation and management approach for a 31-year-old female presenting with neck swelling?

Evaluation and Management of Neck Swelling in a 31-Year-Old Female

A 31-year-old female with neck swelling requires immediate risk stratification based on specific historical and physical examination features to determine if she is at increased risk for malignancy, which will dictate whether imaging and fine-needle aspiration are needed urgently versus watchful waiting with documented follow-up. 1, 2

Initial Risk Stratification

High-Risk Historical Features (Any One Triggers Aggressive Workup)

• Mass present ≥2 weeks without significant fluctuation or of uncertain duration 1, 2
• No history of recent infection or infectious symptoms 1, 2
• Tobacco and/or alcohol use 1
• Voice change or hoarseness 2
• Dysphagia or odynophagia 1, 2
• Ipsilateral ear pain with normal ear examination 1, 2
• Unilateral hearing loss 2
• Unexplained weight loss 2
• Hemoptysis or blood in saliva 2
• Fever >101°F 2

High-Risk Physical Examination Features (Any One Triggers Aggressive Workup)

• Size >1.5 cm 1, 2
• Firm consistency 1, 2
• Fixation to adjacent tissues (reduced mobility) 1, 2
• Ulceration of overlying skin 1, 2

Management Algorithm Based on Risk

If ANY High-Risk Feature Present:

Step 1: Order contrast-enhanced CT neck (or MRI) immediately 2

• Contrast administration is mandatory for proper evaluation 2
• Approximately half of all persistent neck masses in adults are malignant 2
• HPV-positive oropharyngeal cancer now represents over 70% of new oropharyngeal cancers and frequently presents as an isolated neck mass, even in younger patients without traditional risk factors 2

Step 2: Perform fine-needle aspiration (FNA) if diagnosis remains uncertain after imaging 2, 3

Step 3: If no primary site identified after CT and FNA, proceed to examination under anesthesia of the upper aerodigestive tract BEFORE any open biopsy 1, 2

• This identifies occult primary malignancies that would change surgical management 1
• Open biopsy should never be performed before endoscopic evaluation in high-risk patients 1

If NO High-Risk Features Present:

Document a specific follow-up plan to assess resolution or obtain final diagnosis 3

• Reassess in 2 weeks 1
• If mass persists, changes character, develops concerning features, or grows, immediately escalate to imaging and FNA 3
• Do NOT routinely prescribe antibiotics unless there are clear signs and symptoms of bacterial infection 3

Critical Pitfalls to Avoid

Never assume a cystic-appearing mass is benign 2

• Even if the mass appears cystic on CT or FNA, evaluation must continue until a definitive diagnosis is obtained 2
• Cystic neck masses have a high rate of malignancy and false-negative biopsies 1

Never perform open biopsy before endoscopic examination in high-risk patients 1

• This can miss the primary tumor site and compromise subsequent treatment 1

Do not provide false reassurance based on age alone 2

• While age >40 years increases risk, HPV-related oropharyngeal cancers occur in younger patients without traditional risk factors 2

Location-Specific Considerations

If the mass is clearly thyroid in origin and <1.5 cm with regular margins on ultrasound, the standard high-risk criteria may not apply 3. However, functional assessment with TSH should be obtained, and if the mass meets any other high-risk criteria (firm, fixed, duration ≥2 weeks), proceed with the aggressive workup pathway 3.