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, this guideline is restricted
to addressing the appropriate work-up of an adult patient with a neck mass that may
be malignant in order to expedite diagnosis and referral to a head and neck cancer
specialist. The Guideline Development Group sought to craft a set of actionable statements
relevant to diagnostic decisions made by a clinician in the workup of an adult patient
with a neck mass. Furthermore, where possible, the Guideline Development Group incorporated
evidence to promote high-quality and cost-effective care. Action Statements The development
group made a strong recommendation that clinicians should order a neck computed tomography
(or magnetic resonance imaging) with contrast for patients with a neck mass deemed
at increased risk for malignancy. The development group made the following recommendations:
(1) Clinicians should identify patients with a neck mass who are at increased risk
for malignancy because the patient lacks a history of infectious etiology and the
mass has been present for ≥2 weeks without significant fluctuation or the mass is
of uncertain duration. (2) Clinicians should identify patients with a neck mass who
are at increased risk for malignancy based on ≥1 of these physical examination characteristics:
fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying
skin. (3) Clinicians should conduct an initial history and physical examination for
patients with a neck mass to identify those with other suspicious findings that represent
an increased risk for malignancy. (4) For patients with a neck mass who are not at
increased risk for malignancy, clinicians or their designees should advise patients
of criteria that would trigger the need for additional evaluation. Clinicians or their
designees should also document a plan for follow-up to assess resolution or final
diagnosis. (5) For patients with a neck mass who are deemed at increased risk for
malignancy, clinicians or their designees should explain to the patient the significance
of being at increased risk and explain any recommended diagnostic tests. (6) Clinicians
should perform, or refer the patient to a clinician who can perform, a targeted physical
examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx)
for patients with a neck mass deemed at increased risk for malignancy. (7) Clinicians
should perform fine-needle aspiration (FNA) instead of open biopsy, or refer the patient
to someone who can perform FNA, for patients with a neck mass deemed at increased
risk for malignancy when the diagnosis of the neck mass remains uncertain. (8) For
patients with a neck mass deemed at increased risk for malignancy, clinicians should
continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging
studies, until a diagnosis is obtained and should not assume that the mass is benign.
(9) Clinicians should obtain additional ancillary tests based on the patient's history
and physical examination when a patient with a neck mass is deemed at increased risk
for malignancy who does not have a diagnosis after FNA and imaging. (10) Clinicians
should recommend evaluation of the upper aerodigestive tract under anesthesia, before
open biopsy, for patients with a neck mass deemed at increased risk for malignancy
and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary
tests. The development group recommended against clinicians routinely prescribing
antibiotic therapy for patients with a neck mass unless there are signs and symptoms
of bacterial infection.