What should I do for enlarged, tender lumps that are rapidly growing, painful, warm, or accompanied by systemic symptoms?

Evaluation and Management of Enlarged, Tender Lumps

For enlarged, tender lumps that are rapidly growing, painful, warm, or accompanied by systemic symptoms, you should immediately assess for signs of bacterial infection (warmth, erythema, localized swelling, fever) and prescribe antibiotics only if these features are present; otherwise, proceed urgently to rule out malignancy through physical examination, imaging, and tissue diagnosis, as most adult neck masses are neoplastic rather than infectious. 1

Initial Assessment: Infection vs. Malignancy

Signs Suggesting Bacterial Infection

• Local signs: Warmth, erythema of overlying skin, localized swelling, and tenderness to palpation 1
• Systemic signs: Fever, tachycardia, and symptoms specific to the anatomic region (rhinorrhea, odynophagia, otalgia, dental pain) 1
• Temporal relationship: Mass developed within days to weeks of upper respiratory infection, dental problem, trauma, insect bites, travel, or animal exposure 1

Critical pitfall: Most neck masses in adults are neoplastic, not infectious. Judicious antibiotic use minimizes side effects, bacterial resistance, unnecessary costs, and delayed cancer diagnosis. 1

High-Risk Features for Malignancy (Require Urgent Workup)

Mass characteristics:

• Present ≥2 weeks or uncertain duration 1
• Fixed to adjacent tissues 1
• Firm consistency 1
• Size >1.5 cm 1
• Ulceration of overlying skin 1
• Paradoxically, nontender masses are MORE suspicious for malignancy than tender ones 1

Patient demographics and history:

• Age >40 years (strongest demographic risk factor) 1, 2
• Tobacco and alcohol use (synergistic risk factors) 1, 2
• Prior head and neck malignancy 1, 2

Associated symptoms:

• Pharyngitis or persistent sore throat 1, 2
• Dysphagia 1, 2
• Ipsilateral otalgia with normal ear examination (referred pain) 1, 2
• Recent voice change 1, 2
• Unexplained weight loss 1, 2
• Unilateral hearing loss 1, 2
• Nasal obstruction and epistaxis 1, 2

Management Algorithm

Step 1: Determine Infection vs. Malignancy Risk

If clear signs of bacterial infection are present:

• Prescribe appropriate antibiotics 1
• Arrange follow-up within 1-2 weeks to ensure resolution 1
• If mass persists or enlarges despite antibiotics, immediately proceed to malignancy workup 1

If no clear infectious signs OR mass present ≥2 weeks:

• Do NOT prescribe antibiotics 1
• Proceed immediately to malignancy evaluation 1

Step 2: Malignancy Workup (for High-Risk Features)

Physical examination:

• Perform flexible fiberoptic endoscopy to visualize nasopharynx, base of tongue, hypopharynx, and larynx 1, 2
• Examine oral cavity, oropharynx for ulceration, masses, tonsillar asymmetry 1, 2
• Assess tongue mobility 1, 2
• Examine skin of face, neck, scalp for cutaneous malignancy 1

Imaging:

• Order neck CT with contrast (or MRI with contrast) 1
• Both modalities are equally effective; IV contrast is essential for detecting nodal necrosis 2

Tissue diagnosis:

• Perform fine-needle aspiration (FNA) instead of open biopsy when diagnosis remains uncertain after imaging 1
• For cystic masses, continue evaluation until diagnosis is obtained—do NOT assume benign 1
• Cystic neck masses in adults >40 years have up to 80% malignancy rate 2

If diagnosis still uncertain after FNA and imaging:

• Obtain ancillary tests based on history and physical examination 1
• Consider examination under anesthesia of upper aerodigestive tract before open biopsy 1

Step 3: Follow-Up for Lower-Risk Masses

For patients NOT at increased malignancy risk:

• Document a plan for follow-up to assess resolution or final diagnosis 1
• Advise patients of criteria triggering need for additional evaluation 1
• Reactive lymphadenopathy from respiratory infection typically resolves within days of completing treatment 1

Common Pitfalls to Avoid

1. Never prescribe multiple courses of antibiotics without tissue diagnosis—this is the most common cause of delayed cancer diagnosis 2
2. Never assume a cystic neck mass is benign in adults, particularly those >40 years 2
3. Do not rely on tenderness to exclude malignancy—nontender masses are actually MORE likely to be neoplastic 1
4. Do not perform open biopsy before FNA—FNA is preferred for initial tissue diagnosis 1
5. Do not skip endoscopic examination in high-risk patients—occult primary tumors are common 1, 2

Special Considerations

For chest wall lumps specifically:

• Ultrasound is first-line imaging for superficial masses 3
• CT chest determines bony involvement, chest wall invasion, or pleural space involvement 3
• Image-guided core biopsy is preferred over fine-needle aspiration when diagnosis remains uncertain 3

For breast lumps in women:

• Diagnostic mammogram/digital breast tomosynthesis plus axillary ultrasound should evaluate axillary lumps 3
• Risk of malignancy is low (7%) in women without personal breast cancer history but increases with age 3