Examqo › Examqo library › Otolaryngology – Head and Neck Surgery › Salivary glands and neck · IMLE
Neck mass in an adult
An adult neck mass present for two weeks or more without a clear infectious cause is malignant until proven otherwise; work-up is a full head and neck examination with laryngoscopy, contrast CT or MRI and fine-needle aspiration (FNA) — not a "trial" of antibiotics or an open biopsy.
Why it matters in the exam
Under the AAO-HNS 2017 guideline, a mass present for two weeks or more, or of unknown duration, without signs of infection requires assessment for malignancy. Worrying signs: a fixed hard mass, size over 1.5 cm, skin ulceration, weight loss, hoarseness, difficulty swallowing, referred ear pain, and smoking, alcohol or an HPV risk factor. Antibiotics are not given without signs of infection. In a cystic neck mass in an adult — especially over age 40 — think of a cystic metastasis of HPV-related oropharyngeal carcinoma, and do not diagnose a "branchial cyst" until it is fully excluded.
Work-up: full physical examination including endoscopy of the larynx and pharynx, contrast imaging (CT or MRI), and FNA (preferably ultrasound-guided). When FNA shows squamous cell carcinoma — test p16/HPV, and when the nasopharynx is suspected — EBV. When no primary is visible (unknown primary): PET-CT, then examination under anaesthesia including targeted biopsies, tonsillectomy and sometimes lingual tonsillectomy. When lymphoma is suspected, core biopsy or excision of a node is needed, because FNA is not enough for classification.
A pulsatile mass at level II to III that moves sideways but not up and down (Fontaine sign) is a carotid body tumour (paraganglioma) — no biopsy is done, but imaging (CT or MRI with angiography); the tumour splays the internal and external carotid arteries (lyre sign). The Shamblin classification describes the relation to the carotid arteries: I — localised, II — partly surrounding, III — fully encasing, and predicts surgical risk. SDH gene mutations should be tested, especially with multiple tumours or a family history. With a midline mass that rises on swallowing — think of the thyroid.
Key points
- Two weeks or more without infection — malignant until proven otherwise.
- Laryngoscopy, imaging and FNA.
- Cystic in an adult — HPV and the oropharynx.
- No primary — PET-CT and tonsillectomy.
- Pulsatile at level II to III — carotid body tumour.
Summary table
| Situation | Clue | Next step |
|---|---|---|
| Suspicious mass | Two weeks or more, hard, fixed, over 1.5 cm | Laryngoscopy, CT or MRI, FNA |
| Cystic mass in an adult | Over age 40, non-smoker | Suspect HPV and the oropharynx |
| Squamous carcinoma without a primary | Positive FNA, normal examination | PET-CT and examination under anaesthesia with tonsillectomy |
| Suspected lymphoma | Multiple nodes, systemic symptoms | Core biopsy or node excision |
| Pulsatile mass at level II to III | Moves sideways only | Imaging without biopsy; Shamblin |
| Clear signs of infection | Fever, pain, infectious source | Treat and reassess within two weeks |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: ENT and head and neck surgery, Medical licensing exam (IMLE), Family medicine, Oncology, General surgery.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AAO-HNS Clinical Practice Guideline: Evaluation of the Neck Mass in Adults, 2017 — Risk assessment, imaging and FNA
- NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers — Occult Primary, 2025 — Work-up of cervical metastasis of unknown primary
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Differential diagnosis of neck masses; paragangliomas
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.