Neck Mass Referral Guidelines

Diagnosis/Definition

The general definition of a neck mass is any abnormal enlargement, swelling, or growth from the level of the base of skull to the clavicles.

A neck mass has a very long differential diagnosis that changes depending upon the patient’s age and risk factors.

Initial Diagnosis and Management

• History: Many times the etiology of a neck mass can be determined from a good history. Initially, the goal is to differentiate among inflammatory, infectious, neoplastic, congenital, and traumatic causes.
• One general rule of thumb is that a mass present for 7 days is infectious, 7 weeks is neoplastic, and 7 months is congenital.
• Besides duration, other important historical points include recent history of URI, travel outside the US, history of cat scratches, exposure to tuberculosis, HIV risk factors, and alcohol/tobacco use.
• Physical: A complete head and neck examination is indicated and is specifically directed to look for a site of infection and/or primary malignancy. Often overlooked on physical exam, the teeth are commonly a source of pathology. A characterization of the mass can sometimes be helpful for diagnosis. Specifically, examine the mass for location, firmness, mobility, skin involvement, size, number, and tenderness.
• Ancillary Tests: The following can help with diagnosis of a neck mass:
• Mono Spot
• Cat Scratch Disease Panel.
• CBC
• Throat cultures when indicated.
• TB test
• HIV testing if indicated.
• Toxoplasmosis titer if indicated.
• CXR
• Thyroid ultrasound, if a thyroid mass is suspected. IN THIS CASE, A CONTRAST CT SCAN SHOULD BE AVOIDED AS IODINATED CONTRAST CAN INTERFERE WITH RADIOACTIVE IODINE UPTAKE IN THE TREATMENT OF THYROID CANCER.

Initial Management

• The goal of initial management is to] ensure a diagnosis and treat the underlying problem.
• If an infectious etiology is considered, a trial of antibiotics is indicated for 2 weeks.
• Typically, appropriate doses of Augmentin or Clindamycin are given.
• If the patient has a newly positive TB test, referral to Infectious Diseases is warranted.

Ongoing Management and Objectives

The goal of ongoing management is to document resolution of the mass with treatment. Indications for Specialty Care Referral Patients with a neck mass should be referred to Otolaryngology for the following:

• A neck mass that persists without improvement for greater than 2 weeks duration despite initial therapy.
• Any suspicion of malignancy.
• Evidence of rapid growth, airway compromise, dysphagia, hoarseness, or globus.
• Progression of disease despite therapy.