Fever/Night sweats, Repetitive infections (?), Skin lesions or abrasions, Transfusion history, Weight loss, Appetite
changes, fatigue.
Diagnostic evaluation of cervical lymphadenitis. ASO, antistreptolysin titer; CXR, chest radiography; CBC,
complete blood cell count; CMV, cytomegalovirus; EBV, Epstein–Barr virus; ESR, erythrocyte sedimentation rate;
HIV, human immunodeficiency virus; PPD, purified protein derivative; VDRL, Venereal Disease Research
Laboratories.
Source: Adapted from Gosche and Vick (2006), with permission.
• Ultrasonography is useful in an acute setting in assessing whether a swelling is nodal in
origin, an infected cyst or other soft tissue mass. It may detect an abscess requiring
drainage.
• Lymph node biopsy is indicated if:
• Initial physical examination and history suggest malignancy.
• Lymph node size is greater than 2.5 cm in absence of signs of infection.
• Lymph node persists or enlarges.
• Appropriate antibiotics fail to shrink node within 2 weeks.
• Supraclavicular adenopathy
SORT: KEY RECOMMENDATIONS FOR PRACTICE
EVIDENCE
RATING
CLINICAL RECOMMENDATION
A persistent neck mass in an adult older than 40 years should
REFERENCES
C
1, 6, 8, 10
C
20
C
7, 13, 14, 21
prompt a search for a malignant source.
Contrast-enhanced computed tomography is the initial
diagnostic test of choice in an adult with a persistent neck mass.
Fine-needle aspiration biopsy is an effective tool to determine
the etiology of a neck mass.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C
= consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the
SORT evidence rating system, go to https://www.aafp.org/afpsort.
Table 3.
Preferred Imaging Modalities for Neck Masses or Adenopathy in Adults
SCENARIO
Nonpulsatile solitary mass or
multiple neck masses
RECOMMENDED TEST
Contrast-enhanced CT
COMMENTS
—
SCENARIO
Pulsatile neck mass
RECOMMENDED TEST
COMMENTS
Contrast-enhanced CT and contrast-
May be performed at the same
enhanced CT angiography
time
Patient with a neck mass and
Contrast-enhanced CT or CT with
Positron emission tomography is
history of cancer treatment
positron emission tomography
superior in this subset of patien
The clinician may proceed with FNAB, if indicated, once appropriate imaging has ruled out involvement of
underlying vital structures. FNAB can provide further information through cytology, Gram stain, and
bacterial and acid-fast bacilli cultures while avoiding complications of open biopsy. The sensitivity of
FNAB for detecting a malignancy ranges from 77% to 97%, and the specificity ranges from 93% to
100%.7,13,14,21 FNAB should never be performed on a pulsatile mass or a mass that appears to be
vascular in origin.
Patients with suspected infectious and inflammatory masses should be tested for HIV, Epstein-Barr virus,
cytomegalovirus, toxoplasmosis, tuberculosis, and B. henselae, when clinically appropriate. Endocrine
masses can be assessed further with blood work, including thyroid and parathyroid hormone panels.