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. Thyroid Nodules are among the most common Neck Masses and are benign in 95% of cases
  2. Non-thyroid Neck Masses in Adults: 80% of solid, persistent, lateral Neck Masses are neoplasms
    1. 80% malignant
      1. Of new head and neck cancers, 70% are HPV-related oropharyngeal Squamous Cell Carcinoma
    2. 80% of Salivary Gland Tumors are in the 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. Timing of onset
    1. Acute presentations are more likely due to infections or Trauma
    2. Subacute presentations are more likely to be neoplasms
      1. 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. Head or neck Trauma
      1. Neck Hematoma
      2. Pulsatile masses or vascular complications (e.g. pseudoaneurysm, AV fistula)
    5. Insect Bite
    6. 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)
    7. Exposure to pets or farm animals
      1. See Pet-Borne Parasitic Zoonoses

V. Exam

  1. Skin exam of the face, scalp and neck
  2. Oropharyngeal exam
    1. See Mouth Exam
  3. Neck Exam
    1. See Submandibular Exam
  4. Lymphadenopathy red flags
    1. See Lymphadenopathy of the Head and Neck
    2. Persistent Lymphadenopathy >6 weeks
    3. Fixed, firm non-mobile Lymph Nodes >1.5 cm
  5. Neck Mass
    1. Abnormal lesion, visible or palpable (or seen on imaging)
    2. Neck region includes between Mandible and clavicle
  6. Nasolaryngoscopy (if available)
    1. Nasal mucosa
    2. Tongue base
    3. Larynx

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
  4. MRI with contrast
    1. Consider when Cranial Nerve Involvement is present

VII. Evaluation: Approach

  1. See Lymphadenopathy for other approach
  2. Congenital Anomaly suspected
    1. Obtain CT neck with contrast
    2. Consider ENT referral
  3. Neoplasm suspected
    1. Cystic Neck Masses in age >40 years old are malignant in 80%
    2. Obtain CT neck with contrast
    3. Fine-needle aspiration of mass
  4. Cranial Nerve Involvement
    1. MRI with contrast
    2. Fine-needle aspiration of mass
  5. 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]
  6. Wilbur (2026) Am Fam Physician 113(2): 156-65 [PubMed]

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