The diagnostic flow chart

As a rule of thumb, every swelling in the neck in an adult patient should be considered as malignant as long as benign disease has not been established. However, the differential diagnosis of a neck mass is broad. The evaluation of the neck mass should be approached in a thorough and didactic manner. Therefore, a flowchart was developed which guides medical professionals through the diagnostic process.

Diagnostic flow chart

A thorough history and physical examination are essential in this evaluation. In this step, we will explain the steps on how to approach the neck mass in the neck. Previously, you have learned how to take a thorough patient history and the important anatomical structure of the head and neck region. Neck masses should be differentiated between benign and malignant masses.

As for physical examinations, the location of the neck mass is important. The neck is traditionally divided into the central and lateral neck. Knowledge of the localization of lymph nodes in the neck is essential, as patterns of lymphatic drainage may suggest the origin of a primary tumor in case of a neck metastasis. The localization of a mass can suggest specific aetiologies; masses in the central neck usually originate from the thyroid gland, and masses in the lateral neck usually present as lymph node metastases. Neck masses located in the preauricular area or under the angle of the jaw likely represent either salivary or lymphoid tissue.

The characteristics of the mass can usually differentiate between malignant and benign masses. Reactive lymph nodes that are usually discrete, mobile, firm or elastic. Soft, ballotable, mobile masses are often congenital cysts. Masses with size >1.5cm, firm texture to palpation, fixed or reduced mobility, ulceration of overlying skin are all suggestive for malignancies. Metastatic lymph nodes are typically slightly tender or rock hard.

The differential diagnoses based on the location is given in the diagnostic flow chart. In this chart, the first step is to differentiate if the mass originates from a lymph node or not. Based on the location of the mass, a refined differential diagnosis can be formulated.

The most important first diagnostic tool for patients suspected of having a malignant neck mass is fine-needle aspiration cytology. It is important to avoid open biopsy as long as we do not have a diagnosis.