New guideline on evaluating neck masses offers imaging, biopsy advice

Among other recommendations, clinicians should order neck CT or MRI with contrast in patients with a neck mass who are thought to be at increased risk for malignancy.


The American Academy of Otolaryngology-Head and Neck Surgery issued a clinical practice guideline last week on evaluating neck masses in adult patients.

The guideline's goal is to assist diagnostic workup of neck masses and ensure prompt diagnosis and intervention to optimize outcomes in adults who have potentially malignant disease. It is intended for clinicians who are the first to encounter a patient with a neck mass, including primary care and emergency clinicians, dentists, pathologists, and radiologists.

The academy's Guideline Development Group strongly recommends that clinicians should order neck CT or MRI with contrast in patients with a neck mass who are thought to be at increased risk for malignancy. The guideline recommends against routine prescription of antibiotics in patients with a neck mass, except in cases where there are signs and symptoms of bacterial infection.

Other recommendations include the following:

  • Clinicians should identify patients who are at increased risk for malignancy because they have no history of infection and a neck mass that has been present for at least two weeks with no significant change or that has been present for an uncertain period of time. A mass that demonstrates fixation to adjacent tissues, firmness, a size greater than 1.5 cm, or ulceration of underlying skin is also more likely to be malignant.
  • Clinicians should advise patients with no increased risk of malignancy about criteria that would indicate a need for additional evaluation and should also document a follow-up plan for resolution or final diagnosis.
  • Clinicians should perform a targeted physical exam in patients at increased risk for malignancy, or refer patients to a clinician who can perform such an exam.
  • Clinicians should perform fine-needle aspiration rather than open biopsy in patients with a neck mass at increased risk for malignancy when the diagnosis remains uncertain, or refer patients to a clinician who can perform this procedure.

The guideline was published Sept. 10 by the Otolaryngology-Head and Neck Surgery and is available free of charge online.