How should a neck lump be evaluated and managed?

Evaluation and Management of a Neck Lump in Adults

Any adult presenting with a neck lump requires immediate risk stratification for malignancy, as most adult neck masses are neoplastic rather than infectious, and early identification dramatically impacts outcomes. 1

Initial Risk Stratification for Malignancy

You must identify patients at increased risk for malignancy based on specific criteria. A patient is high-risk if they meet ANY of the following:

Historical Red Flags

• Mass present ≥2 weeks without significant fluctuation or of uncertain duration (even without other suspicious features) 1
• Prior head and neck malignancy (including skin, salivary gland, or aerodigestive sites) - places patient at risk for recurrence or second primary decades later 1
• Absence of infectious symptoms (no fever, no recent URI, no dental problems, no trauma, no odynophagia, no otalgia) 1

Physical Examination Red Flags

• Fixed to adjacent tissues 1, 2
• Firm or hard consistency (not soft or fluctuant) 1, 2
• Size >1.5 cm 1, 2
• Ulceration of overlying skin 1, 2
• Nontender mass (infectious masses are typically painful/tender) 1
• Tonsil asymmetry on oral examination 1
• Skin lesions on face, neck, or scalp (cutaneous malignancy can metastasize to cervical nodes) 1

Management Algorithm Based on Risk

For HIGH-RISK Patients (Any Red Flag Present)

1. Mandatory Imaging - STRONG RECOMMENDATION

• Order CT neck with IV contrast immediately (or MRI with contrast if CT contraindicated) 1, 2
• This is a strong recommendation (highest level) - imaging must be obtained before any tissue sampling 1, 2
• Specify "evaluation of neck mass" with exact anatomical location, duration, size, consistency, and associated symptoms in the order 3
• Never omit contrast unless specifically contraindicated (severe renal insufficiency or contrast allergy) - non-contrast studies provide significantly less diagnostic information 3

2. Targeted Physical Examination

• Perform or refer for direct visualization of larynx, base of tongue, and pharynx (flexible laryngoscopy) 1
• This identifies potential primary sites in the upper aerodigestive tract 1

3. Tissue Diagnosis Hierarchy

• Fine-needle aspiration (FNA) is the initial pathologic test - this is a strong recommendation with Grade A evidence 1, 2
• FNA should be performed (or patient referred to someone who can perform it) when diagnosis remains uncertain after imaging 1, 2
• Critical pitfall to avoid: Never proceed directly to open biopsy without FNA first 2
• For cystic masses: Continue evaluation until diagnosis obtained - never assume benign even if cystic on imaging or FNA 1, 2, 4

4. If Diagnosis Still Uncertain After FNA and Imaging

• Obtain ancillary tests based on history/physical (may include EBV titers, HIV, tuberculosis testing, etc.) 1
• Before any open biopsy: Patient must undergo examination of upper aerodigestive tract under anesthesia (panendoscopy) 1, 2
• This sequence prevents the catastrophic error of open biopsy before identifying a primary tumor 1, 2

5. Patient Education Requirements

• Explain the significance of being at increased risk for malignancy 1
• Explain all recommended diagnostic tests and their rationale 1

For LOW-RISK Patients (No Red Flags)

Only consider antibiotics if clear evidence of bacterial infection:

• Local signs: warmth, erythema, localized swelling, tenderness 1
• Systemic signs: fever, tachycardia 1
• Recent URI, dental problem, trauma, or insect bite 1

If prescribing antibiotics:

• Use single course of broad-spectrum antibiotic targeting Staphylococcus aureus and Group A Streptococcus 1, 5
• Mandatory reassessment within 2 weeks 1
• If mass has not completely resolved: Immediately proceed to high-risk workup (imaging, FNA) 1
• Partial resolution requires additional evaluation - may represent infection in underlying malignancy 1
• If completely resolved: Reassess once more in 2-4 weeks to monitor for recurrence 1

Patient Instructions for Self-Monitoring:

• Check size of mass weekly using fingertips 1, 6
• Contact provider immediately if: mass enlarges, does not completely resolve, or new symptoms develop 1, 6
• Document clear follow-up plan to assess resolution or obtain final diagnosis 1

Critical Pitfalls to Avoid

• Never use empiric antibiotics without clear infectious signs - this delays malignancy diagnosis 1
• Never assume cystic masses are benign - metastatic papillary thyroid cancer commonly presents as cystic cervical lymph nodes 1, 4
• Never perform open biopsy before panendoscopy in high-risk patients without diagnosis 1, 2
• Never skip contrast imaging unless contraindicated - dramatically reduces diagnostic accuracy 3, 2
• Never accept "partial resolution" with antibiotics as adequate - requires full malignancy workup 1