Neck Masses in Adults

Aka: Neck Masses in Adults, Neck Mass in the Adult, Adult Neck Mass, Neck Mass

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II. Epidemiology

  1. Non-thyroid Neck Masses in Adults: 80% are neoplasms
    1. 80% malignant
    2. 80% of Salivary Gland Tumors in parotid
      1. 80% of Parotid Gland tumors benign
      2. 80% mixed tumors

III. Causes

  1. Causes of Neck Mass in Adults

IV. History

  1. Age over 45 is most important predictor of malignancy
  2. Size and duration of Neck Mass
  3. Symptom duration >2 weeks without signs of infectious cause
  4. Symptoms that help localize primary diagnosis
    1. Pharynx
      1. Pharyngitis
      2. Dysphagia
      3. Otalgia
    2. Larynx
      1. Hoarseness
      2. Voice quality change
    3. Otalgia (Referred via Cranial Nerves from Larynx)
      1. Cranial Nerve 9
      2. Cranial Nerve 10
  5. Habits with increased malignancy risk
    1. Tobacco Abuse
    2. Alcohol Abuse
  6. Miscellaneous symptoms
    1. Fever without obvious source
    2. Unexplained Weight Loss
    3. Night Sweats
    4. Neck Pain
    5. Cough
  7. Exposure history
    1. Tuberculosis exposure
    2. Foreign travel
    3. Occupation
    4. Sexual History
      1. Human Papilloma Virus is a risk for head and neck Squamous Cell Carcinoma (including cystic lesions)
      2. HIV Infection is associated with head and neck cancer (Kaposi's Sarcoma, Lymphoma)
    5. Head or neck Trauma
    6. Insect Bite
    7. Exposure to pets or farm animals
      1. See Pet-Borne Parasitic Zoonoses

V. Examination

  1. See Mouth Exam
  2. See Submandibular Exam

VI. Imaging

  1. CT Neck with contrast
    1. First-line imaging for most persistent Neck Masses in Adults (present >3-4 weeks)
    2. Confirm patient can tolerate supine position for CT (esp. Hoarseness in Emergency Department)
      1. Large airway mass may obstruct airway in flat, supine position
    3. Contraindications to CT contrast
      1. See CT Intravenous Contrast for a complete list of contraindications
      2. Salivary Gland mass (contrast obscures Sialolith identification)
      3. Thyroid mass or metastatic Thyroid Cancer (iodinated contrast may stimulate growth)
  2. Ultrasound
    1. First-line study for children with Neck Mass (reduces risk of CT-associated Radiation Exposure)
    2. Distinguishes cystic from solid lesions
    3. Evaluates Vascular Malformation flow rates
    4. Guides fine needle aspirate biopsy
  3. CT Angiography
    1. First line study for pulsatile Neck Mass

VII. Evaluation: Approach

  1. See Lymphadenopathy for other approach
  2. Congenital Anomaly suspected
    1. Obtain CT neck
    2. Consider ENT referral
  3. Neoplasm suspected
    1. Obtain CT neck with contrast
    2. Fine-needle aspiration of mass
  4. Inflammatory or infectious process suspected
    1. Consider testing for cause (e.g. EBV, CMV, HIV)
    2. Consider empiric trial of broad-spectrum Antibiotic (if Bacterial cause is suspected)
      1. Only pursue trial Antibiotics if specific Bacterial Infection diagnosis suspected
      2. AAO-HNS does not recommend routine trial of Antibiotics otherwise
        1. Delays diagnosis of malignancy in >20% of cases
    3. No improvement at re-evaluation in 3-4 weeks
      1. Obtain Chest XRay
      2. Place PPD Tuberculin Skin Test (or Quantiferon-TB)
      3. Consider CT neck with contrast
      4. Consider fine needle aspirate of mass

VIII. References

  1. Broder (2021) Crit Dec Emerg Med 35(10): 10-1
  2. Fedok in Noble (2001) Primary Care Medicine, p. 1767-73
  3. Haynes (2015) Am Fam Physician 91(10): 698-706 [PubMed]
  4. McGuirt (1999) Med Clin North Am 83(1):219-34 [PubMed]
  5. Schwetschenau (2002) Am Fam Physician 66(5):831-8 [PubMed]

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