Clinical Practice Guideline: Evaluation of the Neck Mass in Adults

Abstract

Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead,...

The diagnostic pathway of oropharyngeal squamous cell carcinoma in a large U.S. healthcare system

“…The American Family Physician , UptoDate (Wolters Kluwer Health, Waltham, MA), and others suggest antibiotic trial for acute and subacute cervical lymphadenopathy . This recommendation contrasts the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS) recently developed clinical practice guidelines for the evaluation of the adult neck mass, which specifically recommend against empiric antibiotics . Due to the difficulty in distinguishing reactive from metastatic lymph nodes, more research should be done to define the risk factors for malignancy.…”

“…The otolaryngologist performed flexible endoscopy in 82% of patients at the first visit, reflecting adherence to the new AAO–HNS guideline recommendation for a targeted physical examination “including visualizing the mucosa of the larynx, base of tongue, and pharynx.” 26(S‐2) A small number of patients underwent mirror exam, and these exams were not specifically analyzed in our study. The importance of adequate examination of the pharyngeal axis is underscored by the fact that 40% of OPSCC cases occurred in the base of the tongue, which cannot be visualized well transorally.…”

Accuracy of fine‐needle aspiration cytology of head and neck masses

“…It is a wide spectrum encompassing infectious to neoplastic conditions with various underlying etiologies. Many structures such as lymph nodes, salivary glands and thyroid are easily accessible and provide a specific set of lesions with possible differential diagnoses . FNAC is broadly adopted as a longstanding tool for the diagnosis and the planning of an effective treatment of head and neck masses .…”

“…Many structures such as lymph nodes, salivary glands and thyroid are easily accessible and provide a specific set of lesions with possible differential diagnoses. 1 FNAC is broadly adopted as a longstanding tool for the diagnosis and the planning of an effective treatment of head and neck masses. 2 Nevertheless, its sensitivity and specificity reporting in the literature are widely variable and mainly depend on the site of the mass.…”

Plain Language Summary: Evaluation of the Neck Mass in Adults

“…1 The purpose of the summary is to convey key concepts and recommendations from the guideline in clear, understandable, patientfriendly language. It was developed by consumers, clinicians, and AAO-HNSF staff.…”