Guideline sources The following summarized guidelines for the evaluation and management of neck mass are prepared by our editorial team based on guidelines from the American Academy of Otolaryngology- Head and Neck Surgery Foundation (AAO-HNSF 2017). 1 Guidelines 1. Classification and risk stratification Risk of malignancy: Classify patients with a neck mass as being at increased risk for malignancy if the patient lacks a history of infectious etiology and the mass has been present for 2 weeks without significant fluctuation, or if the mass is of uncertain duration. B Classify patients with a neck mass as being at increased risk for malignancy based if the mass is fixed to adjacent tissues, displays a firm consistency, has a size > 1.5 cm, and/or there is ulceration of overlying skin. B https://web.pathway.md/diseases/rec7WUbkm2KXXHJ1i 1/3 6/30/23, 1:15 AM Neck mass Pathway 2. Diagnostic investigations Clinical assessment: conduct a 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. B Show 3 more Diagnostic imaging: obtain a CT (or MRI) of the neck with contrast for patients with a neck mass who are deemed to be at increased risk for malignancy. B Ancillary tests: obtain 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. B 3. Diagnostic procedures Fine-needle aspiration: Perform FNA rather than open biopsy as the first-line method to obtain a tissue sample in patients with a neck mass deemed at increased risk for malignancy. B Complete a thorough and appropriate evaluation until a diagnosis is obtained in patients with a cystic neck mass who are deemed at high risk of malignancy. Avoid assuming prematurely that the mass is benign. B 4. Medical management Antibiotics: avoid routine antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection. D 5. Therapeutic procedures Examination under anesthesia: perform an examination of the upper aerodigestive tract under anesthesia prior to open biopsy for patients with a neck mass who are at increased risk for malignancy and in whom a primary site has not been identified via FNA, imaging, and/or ancillary tests. B 6. Patient education General counseling: counsel patients who are found to be at increased risk for malignancy regarding the significance of this finding, and any recommended diagnostic tests. B 7. Follow-up and surveillance https://web.pathway.md/diseases/rec7WUbkm2KXXHJ1i 2/3 6/30/23, 1:15 AM Neck mass Pathway General principles: advise patients with a neck mass who are not at increased risk for malignancy of criteria that would trigger the need for additional evaluation. Document a follow-up plan to discuss final diagnosis and/or assess resolution. B Clinical findings Symptoms Past medical history Difficulty breathing Allergic reactions Dysphagia Cancer Ear pain EBV infection Hoarseness HPV infection Sore throat HSV Swollen lymph nodes Hiv-1 infection Inflammation Social history Thyroglossal duct cyst Tuberculosis Alcohol consumption Current cigarette smoking Exposure to cat scratch References 1. Melissa A Pynnonen, M Boyd Gillespie, Benjamin Roman et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngol Head Neck Surg. 2017 Sep;157 2_suppl):S1 S30. Open 2. James Haynes, Kelly R Arnold, Christina Aguirre-Oskins et al. Evaluation of neck masses in adults. Am Fam Physician. 2015 May 15;91 10 698 706. Open 3. Tara L Rosenberg, Jimmy J Brown, Gina D Jefferson. Evaluating the adult patient with a neck mass. Med Clin North Am. 2010 Sep;94 5 1017 29. Open 4. M Gleeson, A Herbert, A Richards. Management of lateral neck masses in adults. BMJ. 2000 Jun 3;320 7248 1521 4. Open 5. Lei Qin, Tsung-Ming Chen, Yi-Wei Kao et al. Predicting 90 Day Mortality in Locoregionally Advanced Head and Neck Squamous Cell Carcinoma after Curative Surgery. Cancers Basel). 2018 Oct 22;10 10 392. Open 6. Expert Panel on Neurologic Imaging:, Joseph M Aulino, Claudia F E Kirsch et al. ACR Appropriateness Criteria Neck Mass-Adenopathy. J Am Coll Radiol. 2019 May;16 5S S150 S160. Open https://web.pathway.md/diseases/rec7WUbkm2KXXHJ1i 3/3