Laura J. Bontempo

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults:

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.

The Internship Preparation Camp at the University of Maryland

Background Specialty-specific ‘boot camps’ boost the competence and confidence of medical school graduates as they prepare to enter a residency programme. Objective We sought to evaluate the efficacy of a specialty-neutral Internship Preparation Camp (IPC) that we developed and made available to senior medical students at our medical school. The primary goal of the IPC is to educate students in the cognitive and procedural skills that are applicable to postgraduate year 1 trainees in all fields of specialisation. Methods The curriculum was developed through input from senior medical students and faculty from multiple specialties. The course used small-group sessions and skills labs led by distinguished speakers from various professions (medicine, nursing and pharmacy) to teach senior medical students the information and skills common to the needs of all new physicians, regardless of the specialty they have chosen. The course was presented across 3 half-days and was offered just prior to graduation. Results Of 166 possible participants, 65 attended the course; 39 (60%) of them completed evaluations immediately following the course and 29 (45%) of participants completed a follow-up evaluation 3u2005months later. All respondents reported increased confidence in caring for patients in all subject areas taught. In the follow-up survey, 82% of respondents reported using information learned during the course on an hourly, daily or weekly basis in their care of patients. Conclusions A specialty-neutral IPC is of benefit to its attendees, regardless of the medical specialty in which they train.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary

The American Academy of Otolaryngology—Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology–Head and Neck Surgery featuring the “Clinical Practice Guideline: Evaluation of the Neck Mass in Adults.” To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed emphasize reducing delays in diagnosis of head and neck squamous cell carcinoma; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected.

Family Medical History

“Is there a family history?” n nAs I stood there watching her cry from pain and fear, that question shattered my soul like a bullet entering a thorax. n n“Yes, there is a family history. A strong one.” n nThis article is protected by copyright. All rights reserved.

54-Year-Old Female with a Syncopal Episode

Author(s): Cimino-Fiallos, Nicole; Chang, Wan-Tsu W.; Bontempo, Laura J.; Dezman, Zachary D.W.

65-year-old Female with Cardiac Arrest and Return of Spontaneous Circulation

CASE PRESENTATION A 65-year-old female was transported to the emergency department (ED) at approximately 2:00 AM following a witnessed cardiac arrest. According to the patient’s husband, she had been asleep in bed when she awoke suddenly, sat upright, and reached for her albuterol inhaler before “collapsing.” He found her to be pulseless and initiated cardiopulmonary resuscitation (CPR) while placing a call to emergency medical services (EMS). On EMS arrival, the patient was unresponsive and continued to receive CPR. She was intubated in the field using a size 7.0 endotracheal tube. Her initial rhythm was pulseless electrical activity (PEA), but she converted to normal sinus rhythm after receiving 1mg of epinephrine intravenously and 15 total minutes of CPR. No further history was available. Per her husband, her past medical history was notable for “thyroid problems.” Her only medications were an albuterol inhaler, recently prescribed by her primary physician, and a multivitamin. She had no known drug allergies. On social history, the patient was not known to drink alcohol, smoke cigarettes, or use other substances. A family medical history and review of systems could not be obtained due to the acuity of her condition. On examination, the patient was an obese female, intubated, and unresponsive. Her temperature was 37.1 degrees Celsius, blood pressure was 97/65 millimeters Hg, heart rate was 75 beats per minute (bpm). Her body mass index was estimated at 32. She was initially receiving assisted ventilation by EMS, but on examination in the ED she was found to have a spontaneous respiratory rate of 12 breaths per minute with an oxygen saturation of 98% on 40% fraction of inspired oxygen. Her head was atraumatic and normocephalic. Her pupillary exam showed mid-dilated symmetric pupils with sluggish reactivity to light. There was no hemotympanium or Battle’s sign. She had no apparent facial droop. An oral endotracheal tube was in place, confirmed with radiography University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland *

52-Year-Old Jehovah’s Witness Female with Weakness

CASE PRESENTATION A 52-year-old woman came to the emergency department (ED) for hemodialysis (HD) due to end-stage renal disease (ESRD). She had spent the preceding several weeks in an outside hospital being treated for pneumonia and bacteremia with daptomycin. She subsequently left against medical advice (AMA) after having her dialysis access catheter removed. She presented to our ED because she needed HD vascular access placement and re-initiation of dialysis treatments. Her medical history included chronic kidney disease secondary to hypertensive nephrosclerosis, anemia, hypertension, deep venous thromboses (DVT), systemic lupus erythematosus, and a seizure disorder of unknown etiology. The patient, a Jehovah’s Witness, refused blood transfusions; therefore, her anemia was being treated with intravenous (IV) administration of iron, epoetin alfa, and folate. Other medications included nifedipine, clonidine, metoprolol, sevelamer, and prednisone. She was allergic to amoxicillin, azithromycin, hydralazine, labetolol, linezolid, morphine, and vancomycin. She reported previous IV heroin use many years earlier and previous cigarette smoking. She denied alcohol use or any current drug or tobacco use. Upon arrival, she was alert and in no acute distress with a fever of 38.3° Celsius, heart rate of 87 beats per minute (bpm), blood pressure of 110/65 millimeters mercury (mmHg), respiratory rate of 17 breaths per minute, and pulse oximetry of 99% while breathing room air. She weighed 80 kilograms and was 5 feet 6 inches tall. Her head was normocephalic and atraumatic with moist mucous membranes. Pupils were anicteric, equal, round, and reactive to light and accommodation. The neck was supple and without lymphadenopathy or tenderness. Her lungs had coarse breath sounds with mild bibasilar crackles but no wheezes or rhonchi. There were no retractions or increased work of breathing. Her heart was of regular rate and rhythm without murmurs, rubs, or gallops. Her abdomen was soft with normal bowel sounds and without distention, tenderness, rebound, or guarding. University of Maryland Medical Center, Baltimore, Maryland University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland * †

18-year-old Female with a Change in Mental Status

CASE PRESENTATION An 18-year-old female presented to the emergency department (ED) with confusion and “abnormal behavior.” Her family stated that she’d had increasingly abnormal speech for one week, word-finding difficulties, and then required frequent redirection to complete tasks. Two weeks prior to presentation, the patient was involved in a motor vehicle crash (MVC). The vehicles were moving slowly and sustained little damage. The airbags did not deploy and the patient was belted. She subsequently developed a series of headaches that persisted for a week and then resolved. Two days before presenting to our ED, she was seen at another ED for intermittent, crampy abdominal pain accompanied by vomiting, fevers to 38.9°C, and headache. She was diagnosed with a urinary tract infection (UTI) and discharged, but she did not take the nitrofurantoin she was prescribed. These symptoms continued on the day of presentation to our ED. She had a past medical history of sickle cell trait. She did not take any medications and she had no drug allergies. Her family history was notable for epilepsy and systemic lupus erythematosus. She denied any tobacco, alcohol, or illicit drug use. She was a recent high school graduate. She was alert and in no acute distress on physical exam. She was afebrile (37.1°C) with a heart rate of 90 beats/ minute, blood pressure 135/85 mmHg, and her oxygen saturation was 99% while breathing room air. She weighed 100.5 kg and was five feet, six inches in height, had a body mass index of 36.9 kg/m2, and was well developed and well nourished. Her head was normocephalic and atraumatic, and mucus membranes were dry. Pupils were equal, round and reactive to light and accommodation; the extra ocular movements were normal. Sclera were anicteric and fundi were without papilledema. The neck was supple and without lymphadenopathy or carotid bruits. Her lungs had coarse breath sounds bilaterally but no wheezes, crackles, or rhonchi. There were no retractions or increased work University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, MD University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, MD *

55-year-old Male with Bilateral Lower Extremity Weakness

CASE PRESENTATION A 55-year-old male presented to a Level I trauma center via ambulance with a complaint of bilateral lower extremity weakness after falling. He stated he had slipped and fallen on his buttocks while showering. He discovered he was unable to stand, so he crawled to his bedroom and dialed 911. By the time the paramedics arrived to his home, he had no sensation or motor function below his knees bilaterally. A cervical collar was placed by the paramedics and the patient was transported to the hospital. Upon arrival, he continued to complain of pain to his buttocks. He denied any chest pain, shortness of breath, headache, syncope, abdominal pain, nausea, vomiting, or upper extremity weakness. He denied any past medical history or surgeries. He was not taking any medications and did not have any allergies. His family history was noncontributory. He denied smoking, alcohol, or any drug use. Initial evaluation showed a well-developed, well-nourished male in no acute distress with a cervical collar in place. Triage vital signs were a temperature of 36.9° Celsius, heart rate of 77 beats per minute, respiratory rate of 23 breaths per minute, blood pressure of 139/95 millimeters mercury and pulse oximetry of 100% on room air. His body mass index was 23.79 kg/m2. His head was normocephalic and atraumatic. His pupils were equally reactive to light bilaterally with normal conjunctiva and sclera. His extraocular movements were intact. On cardiovascular exam, he had a regular rate and rhythm with normal heart sounds; specifically, no murmurs were auscultated. His upper extremity pulses were 2+ bilaterally, femoral pulses were 1+ bilaterally, and no dorsalis pedis or posterior tibial pulses were appreciated by palpation or with Doppler ultrasound. The patient was in no respiratory distress and his lungs were without wheezes, rhonchi or rales. His abdomen was soft and nontender with normal bowel sounds and no rebound or guarding. He had normal rectal tone but was not able to contract his anal sphincter on command. Musculoskeletal exam had no cervical, thoracic or lumbar midline tenderness and no step-offs were palpated. University of Maryland Medical Center, Baltimore, Maryland University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland * †

29-year-old Woman with Dyspnea

CASE PRESENTATION A 29-year-old female presented to the emergency department (ED) with a chief complaint of worsening dyspnea over the prior three weeks. Her shortness of breath was exacerbated by exertion and lying down. It was also worse at night. Over the same time, she had developed a dry, raspy, nonproductive cough, bilateral leg swelling, and chest tightness. She denied any fevers, chest or abdominal pain, recent travel, or viral illness. She had no medical problems or past surgical history. Her only home medication was ibuprofen and she had no known drug allergies. She denied any family history of sudden death, myocardial infarction, or heart failure. She denied tobacco or illicit drug use. She reported occasionally drinking alcohol. She had been employed as a welder for the past three years and had recently increased her work hours. The patient had an initial blood pressure of 138/108 mmHg, heart rate of 126 beats per minute, respiratory rate of 18 breaths per minute, temperature of 36.70 Celsius, and an oxygen saturation of 99% on room air. Shortly after being placed in a room, the patient desaturated to 88% on room air. She was placed on two liters per minute of oxygen by nasal cannula, with improvement of her saturation to 95%. On physical exam, the patient was well developed, well nourished, and appeared to be her stated age. She was in no acute distress. Her head, eye, ear, nose and throat exams were all unremarkable. Neck exam showed no jugular vein distention and no goiter. On cardiac exam, she was found to be tachycardic with a regular rhythm and an audible s3 gallop. She was tachypneic without accessory muscle use. Rales were heard in all lung fields. Abdominal exam was unremarkable. She was noted to have trace pedal edema with normal range of motion of her joints and limbs. She was awake, alert and appropriately interactive without focality to her neurological examination. Skin examination showed no rashes or erythema. Her laboratory results are shown in Tables 1-3. Her electrocardiogram (ECG) and chest radiography are shown in Images 1 and 2. A bedside ultrasound (US) was performed University of Maryland Medical Center, Baltimore, Maryland University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland * †