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Lateral Neck Mass Malignancy Exclusion — RACP Adult Medicine MCQ

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ModerateGeneral Internal MedicineLateral Neck Mass Malignancy ExclusionRACP Adult Medicine

A 35-year-old woman presents with a neck mass. Ultrasound shows a 4 cm cystic lateral neck mass anterior to the sternocleidomastoid at level II-III. FNA cytology shows squamous epithelium. She has no other symptoms. What should be excluded before accepting this as a branchial cleft cyst?

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Correct answer: C — Carotid body tumour

A cystic lateral neck mass with squamous epithelium in an adult should ALWAYS raise suspicion for cystic metastatic squamous cell carcinoma, particularly from an HPV-related oropharyngeal primary (base of tongue, tonsil). The historical diagnosis of 'branchial cleft cyst' in adults is being increasingly questioned – up to 30% of presumed branchial cleft cysts in adults over 40 harbour occult SCC. Evaluation should include ENT examination with nasopharyngoscopy, CT/MRI neck, and HPV testing on the FNA specimen. A true branchial cleft cyst is a diagnosis of exclusion after malignancy has been ruled out.

Reference: Cancer Council Australia – 2020 – Head and Neck Cancer OCP