Condition		History/risk factors	Physical findings	Diagnosis	Management
Acute
Acute sialadenitis		Older, debilitated persons with dehydration or recent dental procedures	Rapid or gradual onset of pain and swelling; local edema, erythema, tenderness, or fluctuance consistent with an abscess	Contrast-enhanced CT	Sialagogues, gentle massage; abscess, express by compressing the gland
Hematoma		Trauma	Soft, possible overlying ecchymosis	Ultrasonography or contrast-enhanced CT	Monitor if small; surgical drainage if large or expanding
Pseudoaneurysm or arteriovenous fistula		Trauma with shearing forces	Lateral; soft, pulsatile mass with a thrill or bruit	CT with or without CT angiography	Surgical evaluation for ligation
Reactive lymphadenopathy
	Bartonella henselae infection	Kitten or flea exposure	Isolated, mobile, fluctuant, tender, warm, erythematous, > 2 cm near site of inoculation	Bartonella antibody titers	Azithromycin (Zithromax)
	Cytomegalovirus	URI symptoms	Rubbery, mobile, cervical, and generalized; > 2 cm	Cytomegalovirus titer	Biopsy if no resolution after 8 weeks
	Epstein-Barr virus infection	URI symptoms	Rubbery, mobile, cervical, and generalized; > 2 cm	Monospot, Epstein-Barr virus titer	Biopsy if no resolution after 8 weeks
	HIV infection	Blood/sexual contact	Rubbery, mobile, cervical, and generalized	HIV enzyme-linked immunoassay	Highly active antiretroviral therapy
	Mycobacterium tuberculosis (extrapulmonary)	Travel to or immigration from an endemic area, homelessness, immunocompromise	Diffuse, bilateral lymph nodes (multiple, fixed, firm, nontender)	Purified protein derivative test to rule out atypical mycobacteria infection; acid-fast bacilli culture	Antibiotics: rifampin and isoniazid; add pyrazinamide and ethambutol or streptomycin in endemic areas; refer to a head and neck surgeon if persistent after initial diagnosis and treatment
	Staphylococcal or streptococcal infection	Skin infections	Mobile, fluctuant, tender, warm, erythematous	Clinical	Antibiotics
	Toxoplasmosis	Cat feces exposure	Rubbery, mobile, cervical, and generalized	Toxoplasmosis antibody titer	Supportive care or treat with pyrimethamine and sulfadiazine
	Viral URI	URI symptoms	Mobile, rubbery, bilateral; subsides in 3 to 6 weeks	Clinical	Biopsy if no resolution 3 to 6 weeks after symptom resolution
Subacute (weeks to months)
Cancer
	Hodgkin lymphoma	15 to 34 years of age and > 55 years, constitutional symptoms, later splenomegaly	Painless, rapidly growing lymph node; rubbery, soft, mobile	Contrast-enhanced CT of the neck, chest, abdomen, pelvis; biopsy	Refer to oncology
	Human papillomavirus–related squamous cell carcinoma	35- to 55-year-old white men with a history of smoking, heavy alcohol use, and multiple sex partners (especially involving orogenital contact)	Rapidly enlarging, lateral, cystic lymph nodes; persistent cervical nodal hypertrophy; palatine or lingual tonsillar asymmetry; dysphagia; voice changes; pharyngeal bleeding	Nasal endoscopy, laryngoscopy, bronchoscopy with biopsies	2-week trial of antibiotics; refer for biopsy if no resolution
	Metastatic cancer	History of melanoma or lung, breast, colon, genitourinary cancer	Matted, firm, fixed lymph nodes	Contrast-enhanced CT of the neck, thorax, abdomen, pelvis	Refer to oncology
	Non-Hodgkin lymphoma	Older persons	Painless, rapidly growing lymph node; rubbery, soft, mobile; may involve the tonsillar ring in the pharynx	Contrast-enhanced CT of the neck, chest, abdomen, pelvis; biopsy	Refer to oncology
	Parotid tumors	Asymptomatic	Slow-growing, unilateral, mobile, asymptomatic; cranial nerve (often VII [facial]) involved if malignant	Contrast-enhanced CT and/or FNAB	Refer to ENT for excisional biopsy
	Upper aerodigestive tract squamous cell carcinoma	Male sex; use of tobacco, alcohol, betel nut	Nonhealing ulcers, dysarthria, dysphagia, odynophagia, loose or misaligned teeth, globus, hoarseness, hemoptysis, oropharyngeal paresthesias	Nasal endoscopy, laryngoscopy, bronchoscopy with biopsies	2-week trial of antibiotics; refer for biopsy if no resolution
Chronic sialadenitis		Mild to severe pain, often after meals	Firm gland	CT	Sialagogues, gentle massage, refer to ENT
Idiopathic diseases
	Castleman disease (angiofollicular lymphoproliferative disease)	Constitutional symptoms	Solitary lymph node	Contrast-enhanced CT (shows no enhancement, unlike lymphoma); FNAB	Refer to hematology
	Kikuchi disease (histiocytic necrotizing lymphadenitis)	Lymphadenopathy, fever, leukopenia	Posterior lymphadenopathy resolves in 3 months	FNAB	Refer to hematology
	Kimura disease	Endemic in Asia; painless subcutaneous mass, eosinophilia	Submandibular triangle, orbital, epicranial, periauricular; nontender, ill-defined	Eosinophilia, elevated immunoglobulin E level, biopsy	Refer to hematology
	Rosai-Dorfman disease	Occasional fever in healthy young adults	Matted lymphadenopathy	Elevated erythrocyte sedimentation rate, polyclonal hypergammaglobulinemia	Refer to hematology
Systemic diseases
	Amyloidosis	Asymptomatic or associated CHF, nephrotic syndrome, neuropathy	Painless systemic lymphadenopathy	FNAB or excisional biopsy	Refer to hematology
	Sarcoidosis	20- to 40-year-old black persons, variable presentation: persistent cough, skin rash/patch, joint pain, arrhythmias	Painless cervical, axillary, inguinal lymphadenopathy	FNAB or excisional biopsy; chest radiography or CT	Refer to pulmonary/rheumatology if necessary
	Sjögren syndrome	Xerophthalmia, xerostomia	Parotid gland enlargement	Antinuclear antibodies, SS-A and SS-B antibodies, FNAB	Symptomatic treatment with sialagogues, frequent water intake
Chronic (usually evident as long-standing)
Carotid body tumors		Flushing, palpitations, hypertension if hormonally active, dysphagia, dyspnea, eustachian tube dysfunction	Painless oropharyngeal or upper anterior triangle of the neck; pulsatile, compressible with a bruit or thrill, mobile from medial to lateral direction	CT, CT angiography (lyre sign); plasma and urine metanephrines, catecholamines	Refer to ENT
Congenital cysts
	Branchial cleft cyst	Often diagnosed as a child; slow or rapidly growing after URI; acute or subacute	Mandibular angle, anterior to sternocleidomastoid	Ultrasonography	Antibiotics; refer to ENT for excision after repeated infections
	Dermoid cyst	Children and young adults	Submental triangle; soft, doughy, painless	CT	Surgical excision
	Thyroglossal duct cyst	Often diagnosed in childhood; slow growing or may arise quickly after URI; may present as acute or subacute	Midline, adjacent to the hyoid bone; rises with deglutition	CT (assures no thyroid cancer calcifications)	Antibiotics; refer to ENT for excision after repeated infections
Glomus vagale, glomus jugulare tumors		Flushing, palpitations, hypertension if hormonally active, dysphagia, dyspnea, eustachian tube dysfunction	Similar to carotid body tumors; ipsilateral tonsil may pulsate and be deviated to midline	CT, plasma and urine metanephrines, catecholamines	Refer to ENT
Goiters (enlarged thyroid)
	Graves disease	Hyperthyroid symptoms	Associated exophthalmos, pretibial myxedema	TSH-receptor antibody; diffuse uptake on scintigraphy	Radioactive iodine ablation, thyroidectomy, methimazole (Tapazole) or propylthiouracil
	Hashimoto thyroiditis	Hypothyroid symptoms	Enlarged thyroid	Thyroid peroxidase antibody	Levothyroxine
	Iodine deficiency	Reduced dietary iodine; exposure to thiocyanate (cassava, various vegetables)	Diffusely enlarged thyroid	Dietary history	Increase iodine/decrease thiocyanate containing compounds
	Lithium use	Bipolar disease	Diffusely enlarged thyroid/rare nodular thyroid	History of exposure	Monitor thyroid function at 6 to 12 months, treat dysfunction, discontinuation not required
	Toxic multinodular	Hyperthyroid symptoms	Diffusely nodular	Multiple foci on scintigraphy	Radioactive iodine ablation, thyroidectomy, methimazole or propylthiouracil
Laryngocele		Repetitive nose blowing, coughing, or blowing into a musical instrument	Midline, superior to thyroid cartilage; resonant, intermittent, globus sensation	CT or laryngoscopy	Refer to ENT
Lipomas		Age > 35 years, possible history of trauma	Soft, mobile, discrete subcutaneous tumors	CT	Monitor or excise
Liposarcoma		Middle-aged	Slowly enlarging, painless, nonulcerated or rapidly growing and ulcerated	CT; excisional biopsy	Excision
Parathyroid cysts or cancer		Hypercalcemia symptoms, family history of multiple endocrine neoplasia	Anterior cervical triangle	Serum calcium, parathyroid hormone immunoassay	Refer to endocrinology, ENT
Thyroid nodules
	Cold thyroid nodule	Usually asymptomatic	Solitary nodules	TSH, FT4, thyroid ultrasonography, FNAB if > 1 cm	Refer to endocrinology, repeat ultrasonography in 6 to 18 months
	Thyroid cancer	Radiation, childhood lymphoma, family history, age < 45 years, hoarseness	Solitary nodules	TSH, FT4, thyroid ultrasonography, FNAB if > 1 cm	Refer for excision
	Toxic thyroid adenoma	Hyperthyroid symptoms	Solitary nodules	TSH, FT4, thyroid ultrasonography, FNAB if > 1 cm	Radioactive iodine or thyroidectomy