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Essentials of Diagnosis

  • Primary neoplasms of the neck are rare.

  • Benign tumors include vascular tumors, neurogenic tumors, and lipomas.

  • The most common malignant neoplasm is metastatic cancers arising from the upper aerodigestive tract, skin, or thyroid.

  • Human papilloma virus (HPV)-positive oropharynx cancers often first present with metastatic lymphadenopathy.

  • Neck dissections may be performed in a therapeutic or elective setting. Elective neck dissection determines the presence of occult metastases for pathologic staging.

General Considerations

Neck masses are common and represent a wide range of pathologies. Neoplasms of the head and neck may be benign or malignant. Benign tumors can arise from soft tissue in the neck including fat, salivary tissue, lymph nodes, blood vessels, and nerves. Malignant tumors often represent metastatic disease from squamous cell carcinoma (SCC) of the skin or upper aerodigestive tract. Pain and symptoms including hoarseness, dysphasia, and odynophagia may suggest the location of a primary tumor setting of an unknown primary presenting with metastatic lymphadenopathy. A systematic approach is central in evaluation of neck masses including a detailed history and physical as well as a diagnostic evaluation to include imaging and tissue biopsy when appropriate.


History and Physical Exam

A complete head and neck examination should be performed when evaluating a neck mass. Fiberoptic laryngoscopy can be used to examine the upper aerodigestive tract for an occult malignancy when the primary site is unknown. Patency of the airway can be compromised in patients with neck neoplasms and should be evaluated at the time of fiberoptic laryngoscopy. Palpation of the floor of mouth, base of tongue, and tonsil should be included. For vascular lesions, auscultation of the neck mass may reveal a bruit. A painful neck mass may suggest a neurogenic tumor such as schwannoma or neuroma. Examination of the skin including the scalp and posterior neck may reveal a source of a metastatic unknown primary tumor from a cutaneous malignancy.

Neck masses are common and can represent a wide range of benign and malignant lesions. One important element in the diagnostic workup of the neck neoplasm is ruling out a malignant process. Physical exam, imaging, and tissue diagnosis are used to differentiate benign from malignant neck masses.


The imaging modality that is selected in the workup of a neck mass differs based on the differential diagnosis. Imaging modalities include neck ultrasound, computed tomography (CT) with contrast, magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT).


Ultrasound imaging is a valuable tool that can be used in an in-office examination of the neck with the physical exam, by an ultrasound radiologist, as well as to guide biopsy. This modality is commonly used for the thyroid to evaluate the thyroid nodule, identifying ...

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