How should a 24-year-old woman with a one-week history of a swollen neck be evaluated and managed?

Evaluation and Management of a One-Week Neck Swelling in a 24-Year-Old Woman

A 24-year-old woman with one week of neck swelling requires immediate risk stratification for malignancy based on specific historical and physical examination features, followed by either close observation with mandatory two-week reassessment or urgent diagnostic workup depending on the presence of high-risk characteristics. 1, 2

Initial Risk Stratification

High-Risk Features Requiring Urgent Malignancy Workup

The following features mandate immediate diagnostic evaluation rather than observation:

Historical red flags:

• Duration ≥2 weeks without fluctuation (this patient is at one week, approaching the threshold) 1, 2
• Absence of infectious etiology – no recent upper respiratory infection, dental problem, fever, or rapid onset within days 1, 2
• Age consideration – while traditional risk increases after age 40, HPV-positive oropharyngeal cancer now commonly presents in younger adults with neck masses as the only symptom 1

Physical examination red flags:

• Size >1.5 cm in any dimension 1, 2
• Firm or hard consistency (versus soft/rubbery texture) 1, 2
• Fixation to adjacent tissues – suggests capsular invasion by metastatic disease 1, 2
• Overlying skin ulceration 1, 2
• Non-tender mass – generally more suspicious for malignancy than tender masses 1

Essential Physical Examination Components

Perform a systematic head and neck examination documenting:

• Exact size in centimeters using calipers if available 1, 2
• Consistency (soft, firm, hard), mobility (mobile versus fixed), and tenderness 1, 2
• Overlying skin changes – warmth, erythema, ulceration 1, 2
• Scalp inspection for ulcerations or pigmented lesions 1
• Oral cavity examination – remove dentures, inspect all surfaces, palpate floor of mouth for masses or ulcers 1
• Oropharynx examination – assess for tonsillar asymmetry, masses, or ulcers (ask patient to open mouth without protruding tongue to optimize visualization) 1
• Thyroid gland palpation 1
• Bilateral neck palpation for additional masses or lymphadenopathy 1

Screen for associated symptoms that increase malignancy risk:

• Hoarseness, otalgia, hearing loss, intraoral swelling/ulceration, numbness in oral cavity or cheek, dysphagia, odynophagia, weight loss, hemoptysis, nasal congestion, unilateral epistaxis 1
• Systemic B symptoms (fever, night sweats, weight loss) suggest lymphoma 1

Management Algorithm

If ANY High-Risk Feature Is Present: Urgent Diagnostic Workup

Do not delay – initiate the following immediately:

1. Contrast-enhanced CT of the neck (or MRI with contrast if CT contraindicated) 1, 2

2. Targeted endoscopic examination of the larynx, base of tongue, and pharynx to identify occult primary tumors 1, 2

3. Fine-needle aspiration (FNA) – the preferred initial tissue sampling method with 95% adequacy and 94-96% diagnostic accuracy 2

   • If initial FNA is nondiagnostic, repeat under ultrasound guidance before considering open biopsy 2
   • For suspected lymphoma, core-needle biopsy provides higher sensitivity (92%) compared to FNA (74%) 2

4. Urgent specialist referral to otolaryngology or oncology within days 2

Critical: If malignancy remains uncertain after imaging and FNA, perform examination of the upper aerodigestive tract under anesthesia BEFORE any open surgical biopsy to avoid compromising staging and treatment. 2

If Low-Risk (Infectious-Appearing) Features Present

Signs suggesting infectious etiology:

• Warmth, erythema, localized tenderness 1, 3
• Fever, tachycardia 3
• Recent upper respiratory infection or dental problem 1, 2
• Rapid onset (days rather than weeks) 2

Management approach:

• A single course of broad-spectrum antibiotics is reasonable (e.g., amoxicillin-clavulanate) 1, 3
• Mandatory reassessment within 2 weeks 1, 4, 3
  • Complete resolution → schedule additional follow-up at 2-4 weeks to monitor for recurrence 1, 4
  • Persistence or partial resolution → immediately initiate full malignancy workup (imaging, FNA, specialist referral) because infection may coexist with underlying malignancy 1, 4, 2
  • Any new high-risk features → urgent malignancy workup 2

If No Clear Infectious Signs and No High-Risk Features

At one week duration without high-risk features:

• Avoid empiric antibiotics – unnecessary use delays diagnosis, promotes antimicrobial resistance, and provides false reassurance 1, 2
• Close observation with mandatory 2-week follow-up 1, 4
• Document explicit return criteria – instruct patient to return immediately if mass enlarges, becomes fixed, develops overlying skin changes, or new symptoms appear 2
• If mass persists at 2-week follow-up, initiate full malignancy workup 1, 4

Critical Pitfalls to Avoid

Do not assume cystic neck masses are benign – papillary thyroid carcinoma, lymphoma, HPV-positive oropharyngeal carcinoma, and salivary gland cancers frequently present as cystic lesions mimicking benign pathology. Definitive diagnosis is required. 2

Do not perform open surgical biopsy before completing imaging, FNA, and endoscopic evaluation – premature biopsy impairs staging and treatment planning. 2

Do not prescribe multiple courses of antibiotics without evidence of ongoing infection – this is a common cause of delayed cancer diagnosis. 1, 2

Do not assume tenderness equals infection – malignant nodes can be tender, especially with rapid growth or necrosis. 2

Do not underestimate risk in young patients – the HPV epidemic has shifted oropharyngeal cancer demographics, with many patients now presenting in their 20s-40s without traditional tobacco/alcohol risk factors. 1

Special Considerations for This 24-Year-Old Patient

• HPV-related oropharyngeal cancer now commonly presents in younger adults (20s-40s) with neck mass as the only symptom, often without traditional risk factors 1
• Thyroid cancer is particularly common in women under age 40 1
• While inflammatory and congenital causes are more common in young adults, approximately half of persistent adult neck masses are malignant, making thorough evaluation essential 1, 5
• Sexual history (number of partners, oral sex practices) is relevant for HPV risk stratification 1