Malignant neoplasms are by far the most common cause of persistent neck masses in adults. An asymptomatic neck mass may be the first manifestation of head and neck cancer and should be considered malignant until proven otherwise. A new clinical practice guideline from the American Academy of Otolaryngology-Head and Neck Surgery was developed to promote the efficient and accurate diagnostic workup of neck masses in adults and to ensure that patients receive prompt diagnosis and intervention to optimize outcomes.

The guideline addresses the initial broad differential diagnosis of a neck mass in an adult and isn't intended to direct management. It comprises 10 key statements.

According to the guideline, antibiotics shouldn't be prescribed unless there are signs and symptoms of a bacterial infection. Patients with a neck mass are at increased risk for malignancy if there is no history of infectious etiology; the mass is fixed, firm, ulcerated, or greater than 1.5 cm in size; or the mass has been present for at least two weeks. Patients who aren't at increased risk for malignancy should be advised of the criteria that would indicate the need for further evaluation and be given a follow-up plan.

Patients at increased malignancy risk should be informed of the significance of the findings, and the clinician should explain the necessity for any recommended diagnostic tests. These patients should also undergo a targeted physical examination. Clinicians should order a computed tomography or magnetic resonance imaging scan of the neck with contrast for high-risk patients. If the diagnosis remains uncertain, clinicians should perform fine-needle aspiration rather than open biopsy.

For patients with a cystic neck mass, clinicians should continue the evaluation until a diagnosis is reached; they should not assume the mass is benign. When the patient is at increased risk for malignancy and/or has not received a diagnosis after diagnostic testing, ancillary tests should be performed based on the patient's history and physical examination. If the diagnosis remains uncertain, the upper aerodigestive tract should be examined before an open biopsy is performed.

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