Is imaging appropriate for a cyst-like bump found on physical exam on the neck between C3 and C4 (cervical spine) in an adult patient with a history of migraines?

Imaging is Appropriate and Strongly Recommended

Yes, imaging with CT or MRI with contrast is strongly recommended for a cyst-like bump on the neck between C3 and C4, as this finding meets criteria for increased malignancy risk and requires definitive characterization before any invasive procedures. 1, 2

Why This Lesion Warrants Imaging

The American Academy of Otolaryngology-Head and Neck Surgery provides clear guidance that clinicians should order neck CT (or MRI) with contrast for patients with a neck mass deemed at increased risk for malignancy. 1 Your patient's cyst-like bump likely meets at least one of the following high-risk criteria:

• Duration ≥2 weeks or uncertain duration 2
• Size >1.5 cm (if applicable based on your exam) 2
• Firm consistency or fixation to adjacent tissues 2

Critical Warning About Cystic Neck Masses

Do not assume this cystic lesion is benign. 1 The AAO-HNS specifically warns that cystic neck masses in adults carry an 80% malignancy rate in patients over age 40, with up to 62% of metastases from oropharyngeal sites (tonsils, base of tongue) presenting as cystic masses. 1 These malignant cystic lesions—particularly HPV-positive oropharyngeal squamous cell carcinoma and papillary thyroid carcinoma metastases—can be radiologically and clinically indistinguishable from benign branchial cleft cysts. 1, 3, 4

Imaging Selection Algorithm

First-line imaging: CT neck with IV contrast 1

• Provides excellent characterization of cystic masses 5, 6
• Identifies concerning features: rim enhancement, central necrosis, multiple nodes, extracapsular spread, wall irregularity, nodularity 1
• Evaluates proximity to major vessels and deep extent 3, 5

Alternative: MRI with IV contrast 2

• Superior soft tissue contrast if CT contraindicated 2
• Particularly useful for evaluating deep-seated lesions 6

Critical ordering details: 2

• Specify "with IV contrast" (essential for characterization)
• Include anatomical location (C3-C4 level)
• Note clinical concern for cystic mass

What NOT to Do

Avoid these common pitfalls: 7, 2, 3

• Do not proceed directly to FNA or biopsy without imaging first—ultrasound and cross-sectional imaging provide superior diagnostic information and guide subsequent management 7
• Do not prescribe empiric antibiotics unless there are clear signs of bacterial infection (warmth, erythema, fever, acute tenderness)—this delays diagnosis of malignancy 1, 3
• Do not order CT without and with contrast—this doubles radiation exposure with minimal diagnostic benefit 2
• Do not omit contrast unless specifically contraindicated by severe renal insufficiency or contrast allergy 2

Next Steps After Imaging

If imaging confirms a cystic mass, continue evaluation until a definitive diagnosis is obtained: 1

1. Ultrasound-guided FNA targeting solid components or cyst wall (sensitivity 73% for cystic metastases vs. 90% for solid masses) 1
2. Core biopsy if FNA inadequate (95% adequacy rate, 94-96% accuracy) 1
3. Targeted physical examination including visualization of larynx, base of tongue, and pharynx to identify potential primary malignancy 1, 3
4. Ancillary tests (HPV testing, additional imaging) based on findings 3
5. Examination under anesthesia with panendoscopy if diagnosis remains uncertain after FNA and imaging 1, 3

Clinical Context Note

The patient's history of migraines is not relevant to the evaluation of this neck mass and should not influence the decision to obtain imaging. 1