Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary

Abstract

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Evaluation of the Neck Mass in Adults." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed emphasize reducing delays in diagnosis of head and neck squamous cell carcinoma; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected.

The current practice of open neck mass biopsy in the diagnosis of head and neck cancer: A retrospective cohort study

“…16,17 For this reason, diagnostic FNA is still recommended as the first diagnostic test before proceeding to open neck biopsy. 12 Fortunately, recent research confirms that FNA can accurately diagnose lymphoma when there is close coordination between the head and neck surgeon and an experienced cytopathologist and when cytomorphology is supplemented by modern flow cytometry. 18,19 While additional tissue collection in the form of core needle biopsy or open biopsy is often recommended after FNA results suggest lymphoma, 20 other pathologies must first be ruled out by the FNA, hence the emphasis on FNA as the first-line diagnostic measure.…”

“…In our regional cohort, we found that 31 of 50 or 62% of patients fall in this category. Despite patient care guidelines that advise against open neck mass biopsy, this procedure is still being used as a primary diagnostic test for some patients. In assessing clinical documentation stating why surgeons conducted an open biopsy, the majority (26/50 or 52%) use vague terms and cite non‐evidence–based findings, such as cystic neck mass, as indications.…”

“…Studies have attempted to delineate lymph node characteristics most defining between lymphoma and metastatic etiologies, but note that no imaging findings can be considered pathognomonic for either tumor type . For this reason, diagnostic FNA is still recommended as the first diagnostic test before proceeding to open neck biopsy . Fortunately, recent research confirms that FNA can accurately diagnose lymphoma when there is close coordination between the head and neck surgeon and an experienced cytopathologist and when cytomorphology is supplemented by modern flow cytometry .…”

“…Finally, in assessing which tests were performed on open neck biopsy patients in their work‐up as a whole, less than half of patients underwent a flexible laryngoscopy (18/50 or 36%), direct laryngoscopy (21/50 or 42%), or were evaluated for HPV status (21/50 or 42%). Although it is possible that evaluation of HPV status was intentionally deferred to the tertiary care center after diagnosis of HNSCC, flexible or direct laryngoscopy is standard of care prior to open neck mass biopsy . This indicates a lack of knowledge about the standardized work up of a neck mass and is an opportunity for education.…”

“…Although it is possible that evaluation of HPV status was intentionally deferred to the tertiary care center after diagnosis of HNSCC, flexible or direct laryngoscopy is standard of care prior to open neck mass biopsy. 12 This indicates a lack of knowledge about the standardized work up of a neck mass and is an opportunity for education.…”