Plain Language Summary Plain Language Summary: Evaluation of the Neck Mass in Adults Melissa A. Pynnonen, MD, MSc 1, Maria Colandrea, DNP 2,3, Sandra A. Finestone, PsyD 4, and Sarah S. O Connor 5 Otolaryngology Head and Neck Surgery 2017, Vol. 157(3) 372 382 Ó American Academy of Otolaryngology Head and Neck Surgery Foundation 2017 Reprints and permission: sagepub.com/journalspermissions.nav DOI: 10.1177/0194599817723610 http://otojournal.org Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Abstract This plain language summary serves as an overview in explaining the evaluation of the neck mass in adults. The summary applies to patients aged 18 years and is based on the 2017 Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. The evidence-based guideline includes research to support more effective evaluation and diagnosis of the neck mass in adults. The guideline was developed as a quality improvement opportunity for evaluation of the neck mass by creating clear recommendations to use in medical practice. Keywords neck mass, squamous cell carcinoma, neck cancer, plain language summary Received June 23, 2017; revised July 7, 2017; accepted July 11, 2017. How Was This Summary Developed? This plain language summary is based on the American Academy of Otolaryngology Head and Neck Surgery Foundation s (AAO-HNSF s) Clinical Practice Guideline: 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. The neck mass guideline was developed through the methods outlined in the third edition of the AAO-HNSF s guideline development manual. 2 A literature search from December 2015 through February 2016 was performed by an information specialist to identify research studies (systematic reviews, clinical practice guidelines, randomized controlled trials, and comparative studies). The AAO-HNSF assembled a guideline development group representing the disciplines of advanced practice nursing, clinical pathology, consumer advocacy, emergency medicine, general practice medicine, general surgery, head and neck surgery and oncology, otolaryngology, oral and maxillofacial surgery, physician assistants, and radiology. The group also included a staff member from the AAO-HNSF. Prior to publication, the guideline underwent extensive peer review, including open public comment. 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. You 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. 3 If your neck mass is from an infection, it should go away completely when the infection goes away. Your neck mass could also be caused by a benign (noncancerous) tumor or a cancerous tumor. Cancerous, or malignant (pronounced muh-lig-nent), neck masses in adults are most often due to head and neck squamous (pronounced SKWAY-muss) cell carcinoma (pronounced kahr-suh-nohmuh), abbreviated HNSCC. Other causes for a neck mass may be due to cancers such as lymphoma, thyroid or salivary gland cancer, skin cancer, or cancer that has spread from somewhere else in the body. I Have a Lump in My Neck: Should I See a Health Care Provider? See your health care provider if the lump in your neck lasts longerthan2to3weeks. Thisiscalled a persistent neck mass, which means that the lump has not gone away. You 1 University of Michigan, Ann Arbor, Michigan, USA 2 Veterans Affairs Medical Center, Durham, North Carolina, USA 3 Duke University School of Nursing, Durham, North Carolina, USA 4 Consumers United for Evidence-Based Healthcare, Baltimore, Maryland, USA 5 American Academy of Otolaryngology Head and Neck Surgery, Alexandria, Virginia, USA Corresponding Author: Melissa A. Pynnonen, MD, MSc, University of Michigan, 1500 E Medical Center Drive, SPC 5201, Ann Arbor, MI 48109-5201, USA. Email: pynnonen@umich.edu
Pynnonen et al 373 Figure 1. Patient information: adult neck mass follow-up.
374 Otolaryngology Head and Neck Surgery 157(3) (continued)
Pynnonen et al 375 (continued)
376 Otolaryngology Head and Neck Surgery 157(3) Figure 2. Patient information: frequently asked questions for adults with a neck mass.
Pynnonen et al 377 Figure 3. Adult scope examination. should see a health care provider if you are not sure how long you have had the neck mass. Your neck mass may mean that you have a serious medical problem. It may not be cancer (malignancy), but you need to be evaluated by a health care provider. Your provider will discuss any tests needed for diagnosing your neck mass and your follow-up care. Be sure that your neck mass goes away completely. Follow your provider s instructions and get any tests that have been ordered. Check your neck mass for any changes. Figure 1 explains how to monitor your neck mass. Keep your provider informed of your progress or any problems. Am I at Risk for Having a Malignant (Cancerous) Neck Mass? Common symptoms in patients with a neck mass at higher risk for malignancy (cancer) include the following: The mass lasts longer than 2 to 3 weeks The mass gets larger The mass gets smaller but does not completely go away Voice change 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 F Long-term tobacco use (cigarettes, cigars, chewing tobacco, or snuff) and alcohol use are the 2 most common causes of cancers of the mouth, throat, voice box, and tongue. 4 Another common risk factor for cancers of the neck, throat, and mouth is a human papilloma virus (HPV) infection. HPV infection is usually transmitted sexually. HPV found in the mouth and throat is called oral HPV. Some high-risk types of oral HPV infection can cause head and neck cancers. 5 HNSCC of the oropharynx (pronounced or-oh-fairinks), or tonsil and base of the tongue, has gone up because of the increase in HPV infections. HPV-related cancers often lack the common risk factors of tobacco use and drinking and tend to affect younger adults. Patients with HPV-positive HNSCC may have some of the aforementioned symptoms. But, many times, a neck mass will be the only sign of this type of cancer. How Is a Neck Mass Diagnosed? Your provider will ask about your medical history. See Figure 2 for questions that your provider may ask you. Your provider will also examine your head and neck. He or she may perform endoscopy (pronounced en-dah-skuhpee). Endoscopy can be performed in the office or in the operating room. When endoscopy is done in the office, a small tube with an attached camera is inserted through your nose. Your provider can then examine your throat, voice box, and the opening of your esophagus. Figure 3 shows a scope examination. Sometimes you may need a more detailed examination. If so, endoscopy is performed in the operating room. Figure 4 explains what you can expect if you have this procedure done. Your provider may order tests to help diagnose your neck mass. Figure 2 explains some of the tests. A biopsy is one type of test that involves taking a sample of tissue from your neck mass. Figure 5 (biopsy handout) explains different types of biopsies and what to expect if you have this procedure. Your provider will explain next steps once a diagnosis has been made. This guideline offers recommendations about diagnosis and treatment for adults with a neck mass. The recommendations are based on the best research evidence and are intended to improve the quality of care. The recommendations, also called key action statements, are summarized in Table 1. These recommendations are meant to improve the quality of care for most patients with a neck mass, but they do not provide comprehensive advice on diagnosing all neck masses. You may use the guideline recommendations for discussion with your provider, but your provider will offer care that is customized to you.
378 Otolaryngology Head and Neck Surgery 157(3) Figure 4. Patient information: examination under anesthesia. What should the adult patient expect?
Pynnonen et al 379 (continued)
380 Otolaryngology Head and Neck Surgery 157(3) Figure 5. Patient information: neck mass biopsy. What should the adult patient expect?
Pynnonen et al 381 Table 1. Summary of Guideline Key Action Statements. Statement Action Strength 1. Avoidance of antibiotic therapy 2a. Stand-alone suspicious history 2b. Stand-alone suspicious physical examination 2c. Additional suspicious signs and symptoms 3. Follow-up of the patient not at increased risk 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 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. 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. 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. 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. 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 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 that the mass is benign. 9. Ancillary tests Clinicians 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. Strong recommendation Strong recommendation
382 Otolaryngology Head and Neck Surgery 157(3) Why Is Follow-up So Important? You and your provider should discuss a follow-up plan if you have a neck mass. Some neck masses may be thought to be benign (not cancerous) at first but are later found to be cancer, which is why a follow-up plan is so important. You and your provider need to discuss the method for follow-up that works best for you. 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. About the AAO-HNS The American Academy of Otolaryngology Head and Neck Surgery (www.entnet.org), one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology head and neck surgery through education, research, and lifelong learning. The organization s vision: Empowering otolaryngologist head and neck surgeons to deliver the best patient care. Author Contributions Melissa A. Pynnonen, writer, chair; Maria Colandrea, writer, panel member; Sandra A. Finestone, writer, panel member; Sarah S. O Connor, writer, American Academy of Otolaryngology Head and Neck Surgery Foundation staff. Disclosures Competing interests: Sarah S. O Connor, salaried employee of American Academy of Otolaryngology Head and Neck Surgery Foundation. Sponsorships: American Academy of Otolaryngology Head and Neck Surgery Foundation. Funding source: American Academy of Otolaryngology Head and Neck Surgery Foundation. References 1. Pynnonen MA, Gillespie MB, Rosenfeld RM, et al. Clinical practice guideline: evaluation of the neck mass in adults. Otolaryngol Head Neck Surg. 2017;157(suppl 2):S1-S30. 2. Rosenfeld RM, Shiffman RN, Robertson P. Clinical practice guideline development manual, 3rd edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg. 2013;148(suppl 1):S1-S55. 3. Lights V, Kinman T. What s causing this lump on my neck? http://www.healthline.com/health/neck-lump. Published October 14, 2015. 4. American Academy of Otolaryngology Head and Neck Surgery. Head and neck cancer. http://www.entnet.org/content/ head-and-neck-cancer. Published 2017. 5. Centers for Disease Control and Prevention. HPV and oropharyngeal cancer fact sheet. https://www.cdc.gov/std/hpv/stdfacthpvandoropharyngealcancer.htm. Published January 3, 2017.