NECK MASSES in ADULTS

• All neck masses should be considered malignant until proven otherwise
• If infectious symptoms – could treat – then need to review that has resolved
• First line investigations – CT and FNA
• Early referral ENT
• HPV associated
  • In recent years, the rates of human papillomavirus (HPV)–positive oropharyngeal cancer have risen markedly, with the prevalence more than tripling from 19% to 66% between 1987 and 2006.
  • The overall rate of oropharyngeal cancer is increasing despite lower rates of tobacco use
  • More likely asymptomatic, cystic nodes
  • Features suggestive of human papillomavirus–positive oropharyngeal cancer
    • Younger age
    • Male sex
    • Higher number of oral and vaginal sexual partners
    • Less or no tobacco exposure
    • Less alcohol consumption
    • Marijuana use
    • Higher education
    • Higher socioeconomic status
• Red flags
  • Mass present > 2 weeks
  • Recent voice change
  • Dysphagia or odynophagia
  • Ipsilateral otalgia, nasal obstruction, epistaxis
  • Unexplained weight loss or loss of appetite
• Risk factors
  • Smoking
  • Alcohol
  • Age > 40
  • History of previous head and neck skin lesions
  • History head or neck malignancy
• Clinical features
  • Note location carefully
  • Mobility – fixed more likely malignant
  • Size > 1.5cm
  • Firmness
  • Overlying skin ulceration
  • Also inspect other aspects head and neck
    • Skin cancers
    • Otoscopy – unilateral middle ear effusion nasopharyngeal carcinoma
    • Anterior rhinoscopy
    • Oral cavity, oropharynx
    • Tonsil enlargement or asymmetry
• Investigations
  • CT with contrast – first line to assist localize primary neoplasm
  • Fine needle aspiration
  • USS not first line as operator dependent – useful for guiding samples

Ancillary investigations for adult neck massesintended to assist clinicians when malignancy is unlikely or when initial investigations do notyield a diagnosis. If these tests are  undertaken, they should be based on clinical suspicion for specific diseases and should be obtained simultaneously to the malignancy work-up to prevent a delayed diagnosis.
Ancillary investigation	Rationale
Full blood examination	Elevated white cell count may indicate infection or lymphoma
Anti-neutrophil antibody (ANA)	Elevated ANA may indicate autoimmune diseases
Erythrocyte sedimentation rate (ESR)	Elevated ESR may indicate autoimmune diseases
Thyroid stimulating hormone (TSH)	TSH abnormalities may indicate thyroid pathology (eg multinodular goiter, Grave’s disease)
Parathyroid hormone (PTH)	Elevated PTH may indicate parathyroid adenoma
Thyroid ultrasonography	May reveal thyroid nodules, parathyroid adenomas
Computed tomography of the chest with contrast	May reveal lung malignancy, tuberculosis or sarcoidosis
Specific infection tests (eg human immunodeficiency virus, Epstein–Barr virus, cytomegalovirus, tuberculosis)	Positive tests may indicate infectious cause

Key points

• Head and neck malignancy is the most common cause of adult neck masses.
• It is recommended that all adult neck masses be considered malignant until proven otherwise.
• All patients presenting with a neck mass should have a thorough history taken and examination performed followed by targeted investigations.
• It is important to continue investigations until a clear and specific diagnosis has been reached.
• CT of the neck with contrast and FNA are the mainstay of investigation for all patients with a neck mass suspicious for malignancy.
• Further evaluation by an ENT specialist is required for any patient with a suspicious neck mass and normal contrast-enhanced CT of the neck.
• Ancillary testing may be performed, without delaying investigation for malignancy.
• The advice of an ENT specialist can be sought if there are any concerns or uncertainties