What are the differential diagnoses for a mass on the cheek?

Differential Diagnosis of a Cheek Mass

A mass on the cheek requires systematic evaluation to distinguish between benign lesions (lipomas, accessory parotid tumors), infectious/inflammatory processes, and malignancies (cutaneous cancers, lymphoma, metastatic disease), with the primary goal of identifying features that indicate increased risk for malignancy requiring urgent workup.

Malignant Etiologies (Highest Priority)

Cutaneous Malignancy with Deep Extension

• Melanoma or other skin cancers of the face can present as cheek masses when there is direct invasion into deeper tissues 1
• Examine for changes in skin lesion symmetry, border irregularity, color variation, diameter >6mm, or ulceration overlying the mass 1
• Any ulceration of skin overlying a cheek mass suggests possible cutaneous malignancy with direct extension 1

Lymphoma

• B-cell lymphoma can present as a cheek mass, appearing as a slowly growing swelling resistant to NSAIDs and antibiotics 2
• Lymphoma may present with firm, non-tender masses, often with B-symptoms (fever, night sweats, weight loss) 3
• Extranodal marginal zone lymphoma with transformation to diffuse large B-cell lymphoma has been reported in accessory parotid tissue 4

Metastatic Disease

• Intraparotid or facial lymph node metastases from head and neck squamous cell carcinoma can manifest as cheek masses 1
• HPV-positive oropharyngeal cancer frequently presents with cystic metastatic lymphadenopathy that may be soft in texture 5

Salivary Gland Tumors

Accessory Parotid Gland Tumors

• Pleomorphic adenoma is the most common tumor of accessory parotid tissue, presenting as a mid-cheek or infrazygomatic mass 4
• These tumors are notorious for recurrence if adequate surgical margins are not achieved 4
• All pathological tumor types occurring in the main parotid gland can also occur in accessory parotid tissue 4

Benign Soft Tissue Tumors

Lipomatous Lesions

• Angiolipoma presents as a soft, mobile mass, typically 3-4 cm, palpable anterior to the masseter muscle 6
• Lipoblastoma in children presents as a painless, mobile cheek mass with heterogeneous solid and lipomatous components on imaging 7
• Lipomas represent 1-5% of all oral cavity neoplasms and are usually painless, soft, round, and mobile 6

Risk Stratification for Malignancy

High-Risk Features Requiring Urgent Workup

The following characteristics mandate immediate evaluation for malignancy:

• Mass characteristics: Firm texture, reduced mobility/fixation to adjacent tissues, size >1.5 cm, or ulceration of overlying skin 1
• Duration: Mass present ≥2 weeks without significant fluctuation or of uncertain duration 1
• Age and exposures: Patient >40 years, tobacco use, alcohol abuse 1
• Associated symptoms: New numbness in oral cavity or cheek, dysphagia, odynophagia, weight loss, ipsilateral otalgia with normal ear exam, voice changes 1
• Examination findings: Oral cavity or oropharyngeal ulceration, tonsil asymmetry, limited tongue mobility, facial skin lesions with concerning features 1

Lower-Risk Features

• Soft, mobile mass in a young patient without systemic symptoms suggests benign etiology like lipoma or angiolipoma 6
• Tender mass with signs of infection is less likely malignant than a nontender mass 1

Diagnostic Approach Algorithm

Step 1: Initial Assessment

• Document mass duration, growth pattern, associated symptoms (numbness, dysphagia, otalgia, voice changes, weight loss) 1
• Examine face and scalp for skin lesions with asymmetry, border irregularity, color changes, or ulceration 1
• Palpate the mass for size, consistency (firm vs soft), mobility (mobile vs fixed), and tenderness 1
• Perform complete oral cavity examination with dentures removed, palpating floor of mouth and tongue 1
• Examine oropharynx with mouth open but tongue NOT protruded (tongue protrusion obscures visualization) 1

Step 2: Imaging for High-Risk Patients

• CT neck with contrast (or MRI with contrast) is strongly recommended for patients with any high-risk features 1, 5
• Imaging should assess mass characteristics, identify solid vs cystic components, evaluate for multiple nodes, and search for primary tumor sites 5

Step 3: Tissue Diagnosis

• Fine-needle aspiration (FNA) is first-line for suspected malignancy, with image guidance directed at solid components 5
• Excisional biopsy is preferred for suspected lymphoma, with fresh tissue submitted in saline 1
• Never perform open excisional biopsy before imaging and FNA if malignancy is suspected, as this worsens outcomes and risks tumor spillage 5

Step 4: Examination Under Anesthesia

• For patients at increased risk for malignancy without diagnosis after FNA and imaging, recommend examination of upper aerodigestive tract under anesthesia before open biopsy 1

Critical Pitfalls to Avoid

• Do not assume soft texture equals benign: Cystic metastases from HPV-positive oropharyngeal cancer and papillary thyroid carcinoma frequently present as soft masses 5
• Do not prescribe empiric antibiotics for a fixed or firm cheek mass without clear infectious signs, as this delays cancer diagnosis and worsens prognosis 5
• Do not overlook accessory parotid tumors: These present as mid-cheek masses and require standard parotidectomy approach to prevent facial nerve damage 4
• In children, consider congenital lesions including dermoid cysts and vascular malformations in addition to malignancy 3