A Clinical Study Evaluating the Diagnostic Challenges and Management Outcomes of Neck Masses in Adults with Special Reference to Occult Head and Neck Malignancies

Abstract

Background: Adult neck masses have a broad etiological spectrum ranging from inflammatory and infectious conditions to benign and malignant neoplasms. Cervical lymphadenopathy may occasionally represent metastatic head and neck malignancy without an identifiable primary tumour, creating significant diagnostic and therapeutic challenges. The present study was undertaken to evaluate the clinical profile, diagnostic evaluation, etiological spectrum, occult malignancies, management modalities, and short-term outcomes of adult patients presenting with neck masses.

Materials and Methods: A prospective observational study was conducted in the Department of Otorhinolaryngology, Kodagu Institute of Medical Sciences, Madikeri, Karnataka, over a period of 6 months. A total of 64 adult patients aged ≥18 years presenting with newly detected neck masses or cervical lymphadenopathy were enrolled consecutively. Detailed history and clinical examination were followed by appropriate investigations including ultrasonography, fine-needle aspiration cytology (FNAC), contrast-enhanced computed tomography (CECT), magnetic resonance imaging (MRI), endoscopic evaluation, biopsy, histopathological examination, and immunohistochemistry where indicated. Patients with suspected occult malignancy underwent systematic evaluation for identification of the primary site. Management and clinical outcomes were assessed at the end of the study period.

Results: Among 64 patients, 39 (60.9%) were males, and 25 (39.1%) were females, with a mean age of 48.2 ± 15.1 years. Painless neck swelling was the commonest presentation, observed in 48 (75.0%) patients. Cervical lymphadenopathy constituted the predominant anatomical presentation in 45 (70.3%) patients. Tobacco use was reported in 23 (35.9%) and alcohol consumption in 18 (28.1%) patients. FNAC was performed in 58 (90.6%) patients, ultrasonography in 51 (79.7%), and CECT neck in 39 (60.9%). Malignant lesions constituted the largest final diagnostic category, accounting for 25 (39.1%) patients. Of these, 20 (80.0%) had metastatic cervical malignancy and 5 (20.0%) had primary malignant lesions. The primary tumour was identified in 16 of the 20 metastatic cases, while 4 (20.0%) had an occult primary, representing 6.3% of the total study population. Major diagnostic challenges included difficulty identifying the primary site, inadequate or inconclusive FNAC, requirement for repeat tissue sampling, and clinical-radiological/cytological discordance. At the end of the study period, 36 (56.3%) patients showed complete or significant clinical improvement, while 10 (15.6%) had persistent disease and 12 (18.8%) required further treatment or oncological referral.

Conclusion: Adult neck masses have a diverse etiological spectrum, with malignancy constituting a substantial proportion of cases. Cervical lymphadenopathy was the predominant presentation, and metastatic malignancy accounted for most malignant lesions. Occult primary malignancy represented an important diagnostic challenge. A systematic approach incorporating clinical examination, FNAC, appropriate imaging, endoscopic evaluation, and histopathological assessment is essential for timely diagnosis and appropriate management. Multidisciplinary evaluation is particularly important in patients presenting with metastatic cervical disease without an identifiable primary tumour.