From the Guidelines
Management of a geriatric patient with two movable, painless neck lumps should begin with a thorough evaluation to rule out malignancy, following the recommendations of the clinical practice guideline for evaluation of the neck mass in adults 1. The initial approach includes a complete history and physical examination to identify patients at increased risk for malignancy, as outlined in the guideline's key action statements, particularly statements 2a, 2b, and 2c 1. Key points to consider in the history and physical examination include:
- The presence of a history of infectious etiology and the duration of the mass
- Physical examination characteristics such as fixation to adjacent tissues, firm consistency, size >1.5 cm, and/or ulceration of overlying skin
- The presence of other suspicious findings that represent an increased risk for malignancy
Imaging studies, such as neck computed tomography (CT) or magnetic resonance imaging (MRI) with contrast, should be ordered for patients deemed at increased risk for malignancy, as recommended in statement 6 of the guideline 1. Fine needle aspiration biopsy (FNAB) is typically recommended as the next diagnostic step to determine the nature of the lumps, as stated in statement 7 of the guideline 1. While awaiting diagnosis, no specific treatment should be initiated. If the lumps are determined to be benign (such as lipomas or sebaceous cysts), observation may be appropriate, especially in elderly patients with comorbidities. For confirmed benign lesions causing discomfort or cosmetic concerns, surgical excision under local anesthesia can be considered. However, if malignancy is suspected or confirmed (such as lymphoma or metastatic disease), prompt referral to an oncologist and otolaryngologist is essential for staging and treatment planning, as recommended in the guideline 1. The management approach should be tailored to the patient's overall health status, considering age-related factors such as reduced physiological reserve, multiple comorbidities, and potential medication interactions that may affect treatment decisions.
From the Research
Management and Treatment of Neck Lumps
The management and treatment of a geriatric patient presenting with two movable lumps on the neck, with no reported pain, can be approached as follows:
- Initial investigations can be performed on an outpatient basis, whereas for further examinations, the patient should be referred to a unit specialized in the treatment of head and neck tumors 2.
- The diagnosis should always be confirmed before devising a treatment plan, and ultrasonic imaging and microscopy of a fine needle sample constitute the first-line investigations 2.
- Fine-needle aspiration cytology (FNAC) is a riskless, easy, and fast tool that can be used in forming a diagnosis and appropriate management of neck masses 3.
- For patients with solitary or even multiple posterior neck lumps alone, regardless of size, routine investigation or reassurance may be considered, depending on other clinical examination characteristics 4.
- A careful medical history should be obtained, and a thorough physical examination should be performed to guide the need for follow-up examination with imaging, biopsies, and specialist referrals 5.
Diagnostic Techniques
- Caliper measurement can be used to improve clinical assessment of palpable neck lumps, as it is more accurate than clinical palpation in estimating the size of clinically palpable neck lumps 6.
- Ultrasonography is a useful adjunct in the evaluation of neck lumps, and can be used to confirm the diagnosis and guide further management 2, 3, 4.
- Open biopsy is generally not recommended, as it can hamper further treatment of the tumor, and is only considered in special cases 2.