New clinical guideline for evaluating neck mass

Newswise
September 12, 2017
Written by Newswise
With the development of the Clinical Practice Guideline: Evaluation of the Neck Mass in Adults, published in Otolaryngology–Head and Neck Surgery and presented at the AAO-HNSF 2017 Annual Meeting and OTO Experience in Chicago, the appropriate testing and physical examination of an adult with a neck mass is addressed, with a specific goal to reduce delays in diagnosis of malignant disease and to optimize outcomes.

"Neck masses are common in adults, but the underlying cause is not always easily identified. This guideline is an important instrument for the early diagnosis and treatment of potentially malignant growths, especially with the rise of HPV-related head and neck cancer. A neck mass may indicate a serious medical problem. It does not mean the patient has cancer, but it does mean they need more medical evaluation to make a diagnosis," said Dr. M. Boyd Gillespie, guideline development group assistant chair.

Most persistent neck masses in adults are neoplasms, new and abnormal growths, and malignant growths far exceed any other. While the traditional patient profile for neck mass was an older adult, younger people infected with HPV are changing that expectation. If current trends continue, the incidence of HPV oropharyngeal (tonsil and base of tongue) head and neck squamous cell carcinoma will surpass HPV-positive cancer of the uterine cervix by 2020.

Forty years ago, patients with a neck mass experienced an average of a five- to six-month delay from the time of initial presentation to the diagnosis of malignancy. Today, studies continue to report delays as long as three to six months. The information in this guideline is targeted at anyone who may be the first clinician a patient with a neck mass encounters.

"In addition to crafting a set of actionable statements relevant to diagnostic decisions in the workup of an adult patient with a neck mass, the guideline also seeks to promote high quality and cost-effective care as well as educate patients about seeking medical attention when a neck mass presents," Gillespie said.

Fact sheet

What is the purpose of this guideline?
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 head and neck cancer
• Promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies
• Reducing inappropriate testing
• Promoting appropriate physical examination when cancer is suspected

What is a neck mass?
A neck mass is an abnormal lump in the neck. Neck lumps or masses may be any size. They can be large enough to see or feel or very small. They can be a sign of an infection or something more serious, such as cancer.

What causes a neck mass?
Neck masses are common in adults and can occur for many reasons. Adults may develop a neck mass due to a viral or bacterial infection. Ear or sinus infection, dental infection, strep throat, mumps, or a goiter may cause a neck mass. If a neck mass is from an infection, it should go away completely when the infection goes away. A neck mass could also be caused by a benign (noncancerous) tumor or a cancerous tumor. Cancerous, or malignant, neck masses in adults are most often due to head and neck squamous cell carcinoma. Other cancers such as lymphoma, thyroid or salivary gland cancer, skin cancer, or cancer that has spread from somewhere else in the body, may also cause a neck mass.

What is the prevalence of head and neck cancer?
• Head and neck squamous cell carcinoma has a worldwide annual incidence of 550,000 cases, representing five percent of all newly diagnosed cancers.
• From 1988 to 2004, the U.S. population experienced a 225 percent increase in HPV positive oropharyngeal (tonsil and base of tongue) head and neck squamous cell carcinoma.
• If current trends continue, the incidence of HPV-positive oropharyngeal (tonsil and base of tongue) head and neck squamous cell carcinoma will surpass that of HPV positive cancer of the uterine cervix by 2020 and constitute 50% percent of all head and neck cancer by 2030.

What are the common symptoms in patients with a neck mass at high risk for cancer?
• The mass lasts longer than two to three weeks
• The mass gets larger
• The mass gets smaller but does not completely go away
• Voice changes
• Trouble or pain with swallowing
• Trouble hearing or ear pain on the same side as the neck mass
• Neck or throat pain
• Unexplained weight loss
• Fever > 101 degrees Fahrenheit

Why is the guideline for evaluation of neck mass in adults important?
Currently, there is only one 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. The information in this guideline is targeted at 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.

Significant points made in the guideline:

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

2a. Stand-alone Suspicious History
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 two weeks or greater without significant fluctuation or the mass is of uncertain duration.

2b. Stand-alone Suspicious Physical Examination
Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on one or more of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size greater than 1.5 cm, and/or ulceration of overlying skin.

2c. Additional Suspicious Signs and Symptoms
Clinicians should conduct an initial history and physical examination for adults with a neck mass to identify those patients with other suspicious findings that represent an increased risk for malignancy.

3. Follow Up of the Patient Not at Increased Risk
For patients with a neck mass who are not at increased risk for malignancy, clinicians or the 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.

4. Patient Education
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.

5. Targeted Physical Examination
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.

6. Imaging
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.

7. Fine Needle Aspiration (FNA)
Clinicians should perform 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. Cystic Masses
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 the mass is benign.

9. Ancillary Tests
Clinician should obtain additional ancillary tests based on the patient's history and physical examination when a patient with a neck mass is at increased risk for malignancy and/or does not have a diagnosis after FNA and imaging.

10. Examination under Anesthesia of the Upper Aerodigestive Tract before Open Biopsy
Clinicians should recommend examination of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass who are at increased risk for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests.

Where can I get more information?
Patients and health-care providers should discuss all evaluation, testing, and follow-up options and find the best approach for the patient. There are printable patient handouts and materials that further explain neck mass evaluation in adults that can help with discussions between patients and providers. For more information on evaluation of the neck mass in adults, visit www.entnet.org/NeckMassCPG

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