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Wednesday, September 20, 2017

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published the "Clinical Practice Guideline: Evaluation of the Neck Mass in Adults." These guidelines includes 12 recommendations how to reduce delays in diagnosis of head and neck squamous cell carcinoma; promote appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reduce inappropriate testing; and promote appropriate physical examination when cancer is suspected.

The recommendations include these statements:

·        Clinicians should not routinely prescribe antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.

·        Clinicians should identify patients with a neck mass who are at increased risk for malignancy when 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.
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·        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, and/or ulceration of overlying skin.
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·        Clinicians should conduct an initial history and physical examination for all adults with a neck mass to identify those patients with an increased risk for malignancy.

·        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.

·        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.

·        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.

·        Clinicians should order neck computed tomography (CT; or magnetic resonance imaging [MRI]) with contrast for patients with a neck mass deemed at increased risk for malignancy.

·        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.

·        For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation and perform additional ancillary tests 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.

Hopefully this guideline will 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.


Click here to read the executive summary of the guidelines, click here to read the guidelines and click here to read the plain language summary.