Evaluating Neck Masses in Adult and Pediatric Patients

Gordon H. Sun, MD, MS


April 16, 2019

Initial Imaging Studies for Adults

In general, contrast-enhanced CT is the initial imaging study of choice for adults with persistent neck masses.1,2] CT is able to:

  • Capture dimensions, location, and consistency of the mass;

  • Identify malignant but nonenlarged lymph nodes;

  • Distinguish lymph nodes from blood vessels; and

  • Characterize surrounding structures and organs for potential sites of primary malignancy or other pathologies.

Although the American Academy of Otolaryngology-Head and Neck Cancer Foundation considers both CT and MRI effective for assessing neck masses, the advantages of CT over MRI include wider availability, lower cost, and decreased scanning time. Whereas the primary drawback to CT is exposure to ionizing radiation, MRI is contraindicated in patients with certain implantable medical devices (eg, pacemakers).[2]

PET/CT is typically performed in patients with a preexisting diagnosis of cancer, usually for cancer staging.[1,2]

Ultrasonography, though noninvasive and inexpensive, is inadequate for visualizing most portions of the upper aerodigestive tract—the site where primary tumors often arise. It is more valuable in evaluating thyroid and salivary gland tumors, as well as some other unique patient situations (eg, contraindication to use of contrast medium).[2]

Plain radiographs of the neck have little use in the workup of an adult neck mass.

A Child With a Neck Mass

A 10-year-old boy was brought by his parents to the pediatrician for evaluation of a right neck mass. His parents reported that the child had developed a tactile fever, productive cough, and rhinorrhea 3 days ago. They first noticed that the child's neck had become swollen, red, and tender to touch 2 days ago. They had not noted any recent weight loss or malaise, but their son told them that a few of his classmates had been absent from school because of illness.

The patient was otherwise healthy and had no surgical history or drug, food, or environmental allergies. His vaccination record was up to date.

Vital signs were temperature, 38.6°C (101.5°F); heart rate, 90 beats/min; respiratory rate, 18 breaths/min; and blood pressure, 110/68 mm Hg. Oxygen saturation was 99% on room air.

On physical examination, the patient appeared well nourished and comfortable, with no labored breathing. Pupils were equal and reactive to light, and there was no conjunctival injection. Nasal exam demonstrated congested and inflamed inferior turbinates with mild mucoid rhinorrhea. Otoscopic examination was unremarkable. Oral examination demonstrated 2+ erythematous tonsils without purulence; midline uvula; and a mobile, normal-appearing tongue. There was a mobile lateral right neck swelling measuring 2 cm, with overlying erythema and tenderness to palpation. Chest examination was clear to auscultation and percussion.


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