Evaluation of the Neck Mass in Adults

Publication Date: September 1, 2017

Key Points

Key Points

Table 1. Summary of Guideline Key Action Statements (KAS)

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Statement Action Strength
1. Avoidance of antibiotic therapy Clinicians should NOT routinely prescribe antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection. R
2a. Standalone suspicious history Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has been present for 2 weeks or longer without significant fluctuation, or the mass is of uncertain duration. R
2b. Standalone suspicious physical examination Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on one or more of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size greater than 1.5 cm, and/or ulceration of overlying skin. R
2c. Additional suspicious signs and symptoms Clinicians should conduct an initial history and physical examination for adults with a neck mass to identify those patients with other suspicious findings that represent an increased risk for malignancy. R
3. Follow up of the patient not at increased risk For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow up to assess resolution or final diagnosis. R
4. Patient education For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk, and explain any recommended diagnostic tests. R
5. Targeted physical examination Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. R
6. Imaging Clinicians should order a neck CT (or MRI) with contrast for patients with a neck mass deemed at increased risk for malignancy. S
7. Fine needle aspiration Clinicians should perform fine needle aspiration (FNA) instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain. S
8. Cystic masses For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging studies, until a diagnosis is obtained and should not assume the mass is benign. R
9. Ancillary tests Clinician should obtain additional ancillary tests based on the patient's history and physical examination when a patient with a neck mass is at increased risk for malignancy and/or does not have a diagnosis after FNA and imaging. R
10. Examination under anesthesia of the upper aerodigestive tract before open biopsy Clinicians should recommend examination of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass who are at increased risk for malignancy and without a diagnosis or primary site identified, with FNA, imaging, and/or ancillary tests. R

Figure 1. Key Action Statement (KAS) Algorithm


Table 2. Essential Components of a Targeted Physical Examination in a Patient at Increased Risk for Head and Neck Malignancy

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Anatomic site Examination details
Skin and scalp May reveal a cutaneous malignancy
Otoscopy Unilateral serous otitis media may suggest a nasopharyngeal malignancy
Cranial nerves Itemized assessment of ocular motility, facial sensation and movement, hearing, palate elevation, presence of gag reflex, vocal fold movement, tongue mobility and shoulder elevation
Oral cavity Visual and digital exam of ventral and lateral surfaces of oral cavity, tongue and floor of mouth
Oropharynx Visual exam of soft palate, tonsillar fossae and posterior wall. Palpation of the tongue base and tonsillar fossae
Nasal cavity Visual exam of the septum, floor, and turbinates
Nasopharynx Visual exam of the eustachian tube orifices, superior and posterior walls
Hypopharynx Visual exam of pyriform sinuses and posterior pharyngeal wall
Larynx Visual exam of the epiglottis, vocal folds, and subglottis
Neck Assessment of the neck mass—firmness, size, fixation, location, and presence of additional lymphadenopathy
Bimanual palpation of floor of mouth and entire neck
Salivary glands Palpation of parotid and submandibular glands to assess for mass
Thyroid gland Palpation to assess for mass
  • Infections cause most of the neck masses in children. Most persistent neck masses in adults are neoplasms, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid or salivary gland cancer.
  • A neck mass in the adult patient should be considered malignant until proven otherwise.
  • Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly impacts tumor stage and worsens prognosis.
  • Recent decreases in HNSCC due to reduced tobacco use have been offset by an increasing prevalence of HPV infection — 225% from 1988 to 2004.
    • Patients with HPV-positive HNSCC are younger, mostly male, have more oral and vaginal sexual partners, better dentition, less or no tobacco exposure, less alcohol consumption, greater marijuana use, higher education level and higher socioeconomic status. This demographic is no longer at low risk.
  • Among patients with HNSCC who present with neck mass, diagnostic delays of 3–6 months are common, which is particularly disappointing since delays as short as 2 months are associated with worse functional outcomes, lower quality of life, cancer recurrence and death.
  • Fine needle aspiration (FNA), rather than open biopsy, is the preferred method for cancer diagnosis in a neck mass.

Diagnosis

...agnosis...

...idance Of Antibiotic Therapy Clinic...


...lone Suspicious History Clinicians...


...alone Suspicious Physical Examinat...


...ditional Suspicious Signs and Symptoms Clinicia...


...atient Not At Increased Risk Fo...


...ion For patients with a neck mass who are de...


...Physical Examination Clinicians should perform...


...ingClinicians should order a neck CT (or...


...piration Clinicians should perform FNA i...


...es For patients with a neck mass...


...cillary Tests Clinicians should obtain addit...


...nation Under Anesthesia of the Upper Aero...


...Characteristics Suspicious for Malignancy in t...


...Common Ancillary Tests for Evaluatio...


...re 2. Neck Exam: Palpation of the S...


...Lymph Node Levels of the Nec...


...lpation of the Tongue Base (Lateral View)...


...Palpation of the Tongue Base (Posterior View)...


...manual Palpation of the Floor of the Mouth...


...igure 7. Scope Exam...


Patient Information

...tient Informa...

...Follow Up...


...uently Asked Questions for Adults with a Neck...


Neck Mass Biopsy – What Should the Adult Patie...


...amination Under Anesthesia – What Sh...