What is the recommended evaluation and management for a patient with a history of biopsy on a mass between the neck and jawline, now presenting with a new mass on the left temple, associated with lightheadedness, weakness, sweating, and intermittent pain rated 7-8/10, not relieved by acetaminophen (paracetamol)?

Urgent Evaluation Required for New Temple Mass with Systemic Symptoms

This patient requires immediate referral to an otolaryngologist (ENT surgeon) within 24-48 hours for comprehensive evaluation, as the combination of a new temple mass with severe pain, systemic symptoms (lightheadedness, weakness, sweating), and prior neck/jaw mass biopsy raises significant concern for malignancy or other serious pathology. 1, 2

Critical Red Flags Present

This patient demonstrates multiple high-risk features requiring urgent specialist evaluation:

• New mass on temple with severe pain (7-8/10) that is unresponsive to acetaminophen, suggesting a process beyond simple inflammation 2
• Systemic symptoms (lightheadedness, weakness, sweating) accompanying the mass indicate potential vascular involvement, infection, or metabolic derangement requiring immediate assessment 3
• Prior biopsy site with persistent soreness between neck and jawline suggests either incomplete resolution, recurrence, or new pathology in a patient already at elevated risk 1, 2
• Duration and progression of symptoms warrant urgent evaluation, as masses present ≥2 weeks without resolution require specialist assessment 1, 2

Immediate Diagnostic Workup Required

The ENT specialist should perform the following evaluation:

Targeted Physical Examination

• Complete head and neck examination including visualization of the larynx, base of tongue, and pharynx using flexible laryngoscopy 1
• Bilateral palpation of all cervical lymph node chains to assess for additional masses, fixation, or concerning features 4
• Assessment of cranial nerves to evaluate for neurologic involvement 1
• Examination of the oral cavity and oropharynx for mucosal lesions or asymmetry 1

Imaging Studies

• CT scan of the head and neck with IV contrast is the first-line imaging modality to characterize the temple mass, evaluate vascular structures (particularly temporal artery), assess the prior biopsy site, and identify any primary malignancy 2, 4
• MRI may be indicated if soft tissue characterization is needed or if vascular abnormality is suspected 4

Tissue Diagnosis

• Fine-needle aspiration (FNA) should be performed as the first-line biopsy technique if a mass is confirmed on imaging, as it has high diagnostic accuracy with minimal complications 1, 2, 4
• Ultrasound-guided FNA is preferred if the mass is difficult to palpate or if initial FNA is non-diagnostic 1, 2
• Core needle biopsy should be considered if FNA is inadequate or if lymphoma is suspected 1, 4

Critical Pitfalls to Avoid

Do NOT Prescribe Empiric Antibiotics

Empiric antibiotic therapy without clear signs of bacterial infection (fever >101°F, erythema, fluctuance, rapid onset after URI) will dangerously delay diagnosis of malignancy. 1, 2 The absence of infectious symptoms and the severity of pain unresponsive to acetaminophen argue strongly against an infectious etiology.

Do NOT Assume Benign Etiology

• The combination of systemic symptoms with a new mass in a patient with prior head/neck pathology requiring biopsy places this patient at significantly elevated risk for malignancy 1, 2
• Even if imaging suggests a cystic lesion, continued evaluation is mandatory as cystic neck masses have an 80% malignancy rate in adults over 40 years old 1, 2

Do NOT Perform Open Biopsy First

Open biopsy before imaging and specialist evaluation can disseminate tumor cells and worsen prognosis. 2, 4 The diagnostic sequence must be: imaging → FNA → core biopsy if needed → open biopsy only as last resort.

Specific Considerations for Temple Location

The temporal region mass with associated systemic symptoms raises additional concerns:

• Giant cell (temporal) arteritis must be considered, particularly if the patient is over 50 years old, though the prior neck mass history makes malignancy more likely 3
• Parotid tail involvement or temporal bone pathology requires specialized imaging and evaluation 2
• Vascular lesions (arteriovenous malformation, aneurysm) can present with pulsatile masses and systemic symptoms 2

Timeline for Action

• Contact patient immediately to schedule urgent ENT consultation within 24-48 hours 1, 2
• Communicate directly with ENT specialist about the urgent nature of the referral, emphasizing the combination of new mass, severe symptoms, and prior biopsy history 1
• Ensure patient understands the need for urgent evaluation and the potential seriousness of the presentation 1
• Document clear follow-up plan and confirm patient has contact information for immediate concerns 1

Pain Management Pending Evaluation

While acetaminophen has failed to provide relief, avoid prescribing stronger analgesics or anti-inflammatory medications until after specialist evaluation and imaging, as these may mask important diagnostic findings or complicate surgical planning if needed. 2 The severe, unresponsive pain itself is a concerning feature requiring urgent diagnostic workup rather than symptomatic management alone.