How should I evaluate and manage a patient presenting with a neck swelling?

Evaluation and Management of Neck Swelling in Adults

Begin by stratifying malignancy risk using specific historical and physical examination criteria, then proceed immediately to contrast-enhanced CT imaging and fine-needle aspiration for any high-risk patient—avoiding empiric antibiotics and open biopsy until the full diagnostic workup is complete. 1, 2

Risk Stratification: Identify High-Risk Features Immediately

Historical Red Flags for Malignancy

• Duration ≥2 weeks without significant fluctuation or uncertain duration triggers urgent evaluation 1, 2, 3
• Absence of infectious etiology: no recent upper respiratory infection, dental problem, fever, rapid onset within days, or trauma 2, 3
• Age >40 years combined with tobacco use (≥10 pack-years) or alcohol abuse 1, 3
• Prior head and neck malignancy including skin cancer of scalp, face, or neck, or prior radiation treatment 1, 3
• Immunocompromised status or immunomodulating medications 1, 3

Associated Symptoms Suggesting Malignancy

• Hoarseness or voice change (may indicate laryngeal involvement) 1, 3
• Dysphagia, odynophagia, or unexplained weight loss (suggests aerodigestive tract primary) 1, 3
• Otalgia with normal ear examination (referred pain from pharyngeal malignancy) 1
• Hemoptysis or blood in saliva 3
• Unilateral nasal obstruction or epistaxis (nasopharyngeal primary) 1

Physical Examination Red Flags

• Size >1.5 cm in greatest dimension 1, 2, 3
• Firm or hard consistency 1, 2, 3
• Fixation to adjacent tissues (suggests capsular invasion) 1, 2, 3
• Ulceration of overlying skin 1, 2, 3
• Nontender mass (infectious masses are typically tender) 1, 3
• Tonsil asymmetry on oropharyngeal examination 1
• Skin lesions on face, neck, or scalp (cutaneous malignancy can metastasize to cervical nodes) 1

Required Physical Examination Components

Perform a targeted head and neck examination, not just palpation of the mass itself: 1

• Scalp and face inspection for ulcerations, pigmented lesions, or asymmetry 1
• Oral cavity examination with dentures removed: palpate floor of mouth, inspect lateral tongue with gauze retraction, check for ulcers or masses 1
• Oropharynx visualization with mouth open but tongue NOT protruded (protrusion obscures the view): assess for tonsil asymmetry, masses, or ulcers 1
• Neck palpation documenting exact size in centimeters, consistency, mobility versus fixation, overlying skin changes, tenderness, and precise anatomic location 2
• Thyroid gland palpation 1

Be aware of normal structures often mistaken for pathologic masses: submandibular glands, hyoid bone, transverse process of C2, and carotid bulb 1

Diagnostic Algorithm for High-Risk Patients

Step 1: Targeted Endoscopic Examination

Visualize the larynx, base of tongue, and pharynx via flexible laryngoscopy or refer to a specialist who can perform this examination 1, 2, 3

• This identifies occult primary tumors before tissue sampling 2
• If you cannot perform a complete examination due to anatomic constraints, refer immediately 1

Step 2: Imaging

Obtain contrast-enhanced CT of the neck (or MRI with contrast if CT is contraindicated) without delay 1, 2, 3, 4

• This is mandatory for risk stratification and surgical planning 4
• Do not delay imaging in high-risk patients 4

Step 3: Tissue Diagnosis

Perform fine-needle aspiration (FNA) rather than open biopsy if the diagnosis remains uncertain after imaging 1, 2, 3, 5

• FNA offers high adequacy (~95%) and diagnostic accuracy (94-96%) 2
• If initial FNA is nondiagnostic, repeat under ultrasound guidance before considering open biopsy 2
• When lymphoma is suspected, core-needle biopsy provides greater sensitivity (92%) compared to FNA (74%) 2

Step 4: Examination Under Anesthesia Before Open Biopsy

If diagnosis remains uncertain after imaging and FNA, perform examination of the upper aerodigestive tract under anesthesia (panendoscopy) prior to any open surgical biopsy 1, 2, 3

• This locates the primary site and avoids compromising subsequent cancer treatment 2

Management of Low-Risk (Infectious-Appearing) Masses

For masses with clear infectious signs (warmth, erythema, tenderness, fever, tachycardia, recent URI or dental issue, rapid onset within days): 2, 3

• A single course of broad-spectrum antibiotics targeting Staphylococcus aureus and group A Streptococcus is reasonable 2
• Re-evaluate within 2 weeks: if the mass has not completely resolved, initiate full malignancy workup 2, 3
• Partial resolution should prompt additional evaluation because infection may coexist with underlying malignancy 2
• After complete resolution, follow up at 2-4 weeks to monitor for recurrence 2

When no infectious features are present, empiric antibiotics should be avoided and the malignancy workup should proceed directly 2, 3

Patient Education and Follow-Up for Low-Risk Masses

Advise patients to check the mass weekly using fingertips to assess size (one fingertip wide? two fingertips wide?) 1

Instruct patients to contact you if: 1

• The mass gets larger
• The mass does not go away completely within 2-3 weeks
• The mass goes away but then comes back

Document a specific follow-up plan to assess resolution or final diagnosis 1

Critical Pitfalls to Avoid

Do Not Assume Cystic Masses Are Benign

Cystic neck masses require definitive diagnostic confirmation because malignancies such as papillary thyroid carcinoma, lymphoma, oropharyngeal carcinoma, and salivary-gland cancers often present cystically 1, 2, 3, 4

• Continue evaluation until a diagnosis is obtained 1, 2

Do Not Perform Open Biopsy Prematurely

Open surgical biopsy should not be performed before completing imaging, FNA, and endoscopic evaluation 1, 2, 3, 4

• Premature biopsy disrupts tissue planes, impairs staging, and complicates subsequent surgery 2, 4

Do Not Give Empiric Antibiotics Without Clear Infection

Most adult neck masses are neoplastic, not infectious 2, 3, 4

• Unnecessary antibiotics delay diagnosis, foster antimicrobial resistance, and provide false reassurance 2, 3
• Reserve antibiotics for patients with fever, warmth, erythema, tenderness, and rapid onset 2

Ensure Urgent Specialist Referral for High-Risk Patients

When high-risk features are identified, refer urgently to otolaryngology or head and neck surgery with direct communication of urgency 2, 3, 4

• Document the referral timeline and ensure thorough evaluation within a short timeframe 3

Documentation Requirements

Record the following for every neck mass: 2

• Exact size in centimeters
• Consistency (soft, firm, hard)
• Mobility (mobile versus fixed to adjacent structures)
• Overlying skin changes (ulceration, erythema, warmth)
• Precise anatomic location
• Tenderness
• Duration and fluctuation pattern