Initial Imaging for Suspected Head and Neck Malignancy

Primary Neck Imaging

The American College of Radiology recommends contrast-enhanced CT neck as the preferred initial study for evaluating a palpable hard neck mass in an adult, particularly when head and neck cancer is suspected 1
Superior spatial resolution makes CT the optimal modality for initial evaluation of neck masses in adults at risk for head and neck cancer 1
IV contrast is essential for detecting nodal necrosis, identifying the primary tumor within the upper aerodigestive tract, and clarifying the relationship of masses to major neck vessels 1
CT neck with IV contrast provides anatomic delineation of both the primary site and nodal disease 4, 2
CT neck with IV contrast evaluates deep neck spaces that ultrasound cannot adequately assess 4

The American College of Radiology recommends CT chest imaging at the time of initial staging for patients with suspected head and neck malignancy, especially those with a significant smoking history 2, 5, 3, 6
A 25-year smoking history is a separate indication for chest CT at initial staging, as tobacco use increases risk for both head and neck squamous cell carcinoma and primary lung cancer 2, 5, 3, 6
7-14% of patients have a second lung primary at initial staging of head and neck squamous cell carcinoma 2, 3, 6
Patients with a significant smoking history qualify for lung cancer screening per U.S. Preventative Services Task Force guidelines 2, 5, 3
Screening for pulmonary metastases is appropriate given the likely advanced stage disease suggested by symptoms 2, 5, 3

FDG-PET/CT is not appropriate as an initial imaging study for a neck mass, but becomes a recommended complementary study once the diagnosis is established 1, 4, 2
Ultrasound has limited utility as a primary imaging modality in this clinical scenario, but may be appropriate as an adjunct for nodal evaluation and biopsy guidance 4, 1, 2
If vocal fold paralysis is found on laryngoscopy, imaging from skull base to thoracic inlet/aortic arch is indicated to evaluate the entire nerve course 8

Do not order plain chest radiography instead of CT chest, as sensitivity for detecting pulmonary metastases is only 28% compared to CT 3, 6
Do not skip chest imaging in smokers with head and neck cancer, as the dual risk for synchronous lung primary and metastatic disease makes this essential 2, 5, 3
Do not perform CT without IV contrast for the neck evaluation, as contrast is critical for distinguishing vessels from nodes and identifying nodal necrosis 1
Avoid dual-phase CT (without and with contrast) as it is not usually necessary and increases radiation exposure 1