Benign Head and Neck Tumors: Clinical Guidelines

List of Abbreviations

WHO - World Health Organization

MRI - Magnetic resonance imaging

FNAB — Fine-Needle Aspiration Biopsy (cytological examination of fine-needle aspiration microspecimen)

US — Ultrasound

MRA — Magnetic Resonance Angiography (single region)

ICD-10 — International Classification of Diseases, 10th Revision

MFR — maxillofacial region

Terms and Definitions

Excisional biopsy — removal of the entire pathological lesion for examination.

Incisional biopsy — sampling of a part of a pathological lesion or diffusely altered organ for examination.

Removal of soft tissue tumors of the head and neck using video-endoscopic technologies (endoscopically assisted surgical interventions) is a surgical intervention using endoscopic visualization.

Cytological examination of a fine-needle aspiration biopsy smear involves tissue sampling for study (usually using a single-use disposable injection syringe with a needle) followed by cytological examination.

Organ-specific tumors are tumors characteristic of a specific organ and its specific structures.

Organ-nonspecific tumors are tumors that lack a typical organ localization (e.g., adenocarcinoma, squamous cell carcinoma).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Tumor is an abnormal mass of tissue that arises as a result of excessive, uncontrolled cellular growth which persists even after the cessation of the stimuli that evoked the change (R. Willis) [35].

Benign tumor is a neoplasm characterized by slow growth, absence of metastasis and recurrence after complete removal, highly differentiated cells, and radioresistance [35,37].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Due to the large number of types of benign lesions in the head and neck localization, the etiology and pathogenesis can be quite diverse, and in some cases, not fully understood [1].

In benign tumors, the pathogenesis of the disease is based on impaired mechanisms of cell division and growth control, as well as apoptosis pathways. There are also several predisposing factors that significantly increase the risk of developing this disease (mechanical or thermal trauma, viruses, endocrine disorders) [2,3].

Also, tumor-like lesions and malformations can form as a result of impaired normal development of the first and second branchial arches and clefts, pharyngeal pouches, and other parts of the branchial apparatus, or complex embryogenetic disorders of the vascular or lymphatic system [4].

1.3 Epidemiology of the Disease or Condition

According to statistical data, neoplasms and tumor-like processes of the oral cavity and maxillofacial region account for about 20–25% of tumor diseases of other localizations [36,37]. Benign neoplasms and tumor-like lesions of the oral mucosa account for 26.6% of all benign neoplasms of the maxillofacial region. Among benign tumors of the oral mucosa, papilloma is the most common (41.3%), frequently localized on the tongue (35%) and buccal mucosa (25%) [5,6]. Congenital cysts and fistulas are relatively rare, accounting for about 5% of all neoplasms of the face and jaws. Branchial cleft anomalies are observed more frequently than thyroglossal duct cysts (61% and 39% of cases, respectively). Dermoid cysts of the floor of the mouth account for 1.6–6.5% of all dermoid cysts and 23–34% of head and neck cysts [7].

1.4 Features of Coding the Disease or Condition

D10 - Benign neoplasm of mouth and pharynx:

D10.0 Benign neoplasm of lip

D10.1 Benign neoplasm of tongue

D10.2 Benign neoplasm of floor of mouth

D10.3 Benign neoplasm of other and unspecified parts of mouth

D11 - Benign neoplasm of major salivary glands:

D11.0 Benign neoplasm of parotid gland

D11.7 Benign neoplasm of other major salivary glands

D11.9 Benign neoplasm of major salivary gland, unspecified

D13.0 Benign neoplasm of other and ill-defined parts of digestive system

D14.0 Benign neoplasm of middle ear and respiratory system

D16.0 Benign neoplasm of bone and articular cartilage

D17.0 Benign neoplasm of lipomatous tissue of skin and subcutaneous tissue of head, face and neck

D18 - Haemangioma and lymphangioma, any site:

D18.0 Hemangioma of any site

D18.1 Lymphangioma of any site

D19.0 Benign neoplasm of mesothelial tissue

D21.0 Other benign neoplasms of connective and other soft tissue

D22.0 Melanocytic naevi

D23 - Other benign neoplasms of skin:

D23.0 Other benign neoplasms of skin of lip

D23.1 Other benign neoplasms of skin of eyelid, including canthus

D23.2 Other benign neoplasms of skin of ear and external auditory canal

D23.3 Other benign neoplasms of skin of other and unspecified parts of face

D23.4 Other benign neoplasms of skin of scalp and neck

D36 - Benign neoplasm of other and unspecified sites:

D36.0 Benign neoplasm of lymph nodes

D36.7 Benign neoplasm of other specified sites

D36.9 Benign neoplasm of unspecified site

1.5 Classification of the disease or condition

I. Types of benign neoplasms:

1. True neoplasms,

2. Tumor-like lesions,

3. Cysts.

II. International Histological Classification of Tumours [40].

1. Organ-specific

1) Odontogenic:

• ameloblastoma,

• odontoma,

• odontogenic fibroma,

• epulis,

• cementoma,

• osteoblastoclastoma.

2) Salivary gland:

• adenoma,

• mixed tumor,

• cyst,

• mucoepidermoid tumor,

• angioma,

• lymphangioma,

• lipoma,

• schwannoma,

• neurofibromatosis.

3) Oral mucosa:

• papilloma,

• fibroma,

• fibromatosis,

• myxoma,

• hemangioma,

• lymphangioma,

• lipoma,

• neurofibroma.

2. Organ-nonspecific

1) Osteogenic:

• osteoma,

• chondroma,

• ossifying fibroma.

2) Non-odontogenic.

3) Non-osteogenic:

• hemangioma,

• hemangioendothelioma,

• chondroma,

• myxoma,

• neurofibroma,

• neurofibromatosis

III. International Histological Classification of Tumours of the Oral Cavity and Oropharynx (1974) [8].

1. Tumours arising from stratified squamous epithelium:

• squamous cell papilloma.

2. Tumours arising from glandular epithelium:

• adenoma.

3. Tumours arising from soft tissues:

• fibroma,

• lipoma,

• leiomyoma,

• rhabdomyoma,

• chondroma,

• osteochondroma,

• hemangioma,

• lymphangioma (cavernous, cystic),

• benign hemangioendothelioma,

• benign hemangiopericytoma,

• neurofibroma,

• neurilemoma.

4. Tumours arising from the melanogenic system:

• pigmented and non-pigmented nevus.

5. Tumours of disputed and uncertain origin:

• myxoma,

• granular cell tumour,

• congenital "myoblastoma".

6. Unclassified tumours.

7. Tumour-like conditions:

• common wart,

• papillary hyperplasia,

• benign lymphoepithelial lesions.

IV. Histological classification of extraorgan neck tumours (G.V. Falileev, 1970), including only benign formations [38].

1. Of neuroectodermal origin:

• neurinoma (neurilemoma),

• neurofibroma,

• ganglioneuroma,

• meningioma,

• carotid chemodectoma,

• vagus nerve tumour.

2. From mesenchymal derivatives and unclassified:

1) Fibrous:

• fibroma,

• desmoid.

2) Adipose:

• lipoma.

3) Synovial:

• synovioma.

4) Vascular:

• hemangioma,

• lymphangioma.

5) Muscular:

• myoma,

• leiomyoma,

• rhabdomyoma.

6) Unclassified tumours.

3. Dysembryonic tumours:

• median cervical cyst,

• lateral cervical cyst,

• chordoma,

• thymoma,

• teratoma, etc.

V. International Classification of Diseases, 10th Revision (ICD-10), 1997, WHO, Geneva [39].

1. Benign formations of the skin of the face, head, and neck:

• squamous cell papilloma,

• fibroma,

• dermatofibroma,

• lipoma,

• hemangioma,

• lymphangioma,

• senile keratoma,

• trichoepithelioma, pigmented nevus,

• leiomyoma, xanthoma,

• epidermal cyst,

• keloid.

2. Benign tumors of the red border of the lips and oral cavity organs:

• squamous cell papilloma,

• fibroma,

• neurilemoma (schwannoma),

• neurofibromatosis (Recklinghausen's disease),

• hemangioma,

• lipoma,

• minor salivary gland adenoma,

• minor salivary gland cyst,

• sublingual salivary gland cyst,

• lip fissure.

VI. World Health Organization (WHO), classification of head and neck tumors. Current edition, part of the 4th edition of the WHO series, 2017 (benign formations highlighted only) [11]

1. Tumors of the nasal cavity, paranasal sinuses, and skull base:

• various types of paranasal sinus papillomas,

• hamartoma.

2. Salivary gland tumors:

• pleomorphic adenoma,

• epithelioid hemangioendothelioma.

3. Benign soft tissue tumors:

• leiomyoma,

• hemangioma,

• schwannoma,

• neurofibroma.

4. Other tumors:

• meningioma,

• ameloblastoma

• of the paranasal sinuses,

• chondromesenchymal hamartoma,

• hematolymphoid tumors.

5. Nasopharyngeal tumors:

• hairy polyp,

• ectopic pituitary adenoma,

• craniopharyngioma,

• nasopharyngeal angiofibroma,

• hematolymphoid tumors,

• chordoma.

6. Tumors of the hypopharynx, larynx, trachea, and parapharyngeal space:

• oral mucosal epithelial dysplasia,

• verrucous leukoplakia,

• papillomas,

• squamous cell papilloma,

• condyloma,

• common wart,

• multifocal epithelial hyperplasia,

• epulis,

• ectomesenchymal chondromyxoid tumor.

7. Soft tissue and nervous system tumors:

• granular cell tumor,

• rhabdomyoma,

• lymphangioma,

• hemangioma,

• schwannoma,

• neurofibroma.

8. Cysts and cyst-like lesions:

• branchial cleft cysts,

• thyroglossal duct cyst,

• ranula,

• dermoid and teratoid cysts.

1.6 Clinical presentation of the disease or condition

Due to the large number of types of benign head and neck formations, symptoms may vary. Symptoms may also depend on the location and size of the tumor.

When small in size, the disease may be asymptomatic for a long time. When the formation is superficially located, the patient complains of an aesthetic defect, facial asymmetry, or the presence of the formation itself.

With an increase in the size of the formation or at a specific location, the patient may complain of a foreign body sensation, dysphagia, limited tongue or neck mobility, or difficulty opening the mouth or swallowing.

Basically, patients present with local complaints; their general condition is unaffected.

However, in inflammatory processes (cysts and cyst-like formations), patients may experience pain, as well as general inflammatory symptoms such as elevated body temperature and fever.

In certain types of formations, periodic bleeding is possible.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The criteria for diagnosing a benign head and neck mass include detecting a head or neck mass via physical and instrumental examinations undertaken as a result of analyzing the patient's complaints, ruling out other pathologies with a similar clinical presentation, and a histological examination report.

2.1 Complaints and Anamnesis

Comments: Assessing the rate of disease progression may indicate potential malignant transformation of the mass. This is necessary for an adequate prognosis of further disease development, choosing the correct treatment tactics for the patient, and determining postoperative rehabilitation algorithms if surgical treatment is required

Comment: when inflammatory complications develop with the spread of the inflammatory process to surrounding tissues, general inflammatory symptoms may appear, which subsequently complicates diagnosis and implies a change in the treatment algorithm.

Comment: When taking a history from a patient with a suspected diagnosis of benign head and neck masses, it is extremely important not only to find out how the clinical picture of the disease developed, but also to identify the main factors that could have contributed to the development of the disease, assess their current severity, and the possibility of their correction.

2.2 Physical Examination

Comments: the examination is performed in a dental chair, assessing the size, shape, clarity of edges, color and adhesion to surrounding tissues, density, and tenderness upon palpation. It is also necessary to assess the presence of infiltration in the underlying tissues, as well as the location relative to vessels and nerves.

Comments: In various types of benign masses, functional changes can be a pathognomonic sign of the disease; for example, one of the signs of a thyroglossal duct cyst is its displacement along the midline during swallowing. Also, in case of functional impairment, difficulties with anesthesia may arise, and it is necessary to address the issue of involving specialists from related disciplines in the treatment and surgical intervention.

2.3 Laboratory Diagnostics

2.4 Instrumental Diagnostics

Comments: The efficacy of ultrasound in detecting a pathological neck mass ranged from 70% to 90% [14]. The ultrasound pattern of cystic formations of the soft tissues of the neck and head depends on their nosological form. Typical ultrasound signs of tumor diseases of the soft tissues, lymph nodes, and major salivary glands include the state of layered differentiation of soft tissues, the echostructure of the mass, as well as the characteristics and type of blood flow. In the case of vascular tumors, duplex scanning of the maxillofacial vessels is performed.

Comments: These diagnostic tests must be performed prior to FNA to prevent changes in the appearance of the mass relative to other anatomical regions. Based on the assessment of homogeneity, tumor structure, and contour characteristics on MRI, it is possible to differentiate benign and malignant tumor growth in 90% of cases. It is advisable to use CT angiography (computed tomographic angiography of one anatomical area) for large arteriovenous, capillary, and venous forms of lesions. The combination of MRI and MRA makes it possible to differentiate low-flow and high-flow vascular malformations, and in extensive lesions, allows ruling out or confirming the involvement of intracranial structures, which is essential for planning the treatment strategy.

Comments: According to modern data, 80% of studies are successful, but a cytological conclusion of no tumor cannot be considered definitive, as FNA may yield a small volume of material. At the same time, a conclusion regarding the presence of a tumor should always be considered definitive

Comments: Pathomorphological examination of biopsy (surgical) material from tumors and tumor-like soft tissue formations includes: macroscopic examination, morphological study of tissues using a medical laboratory light microscope with staining using various reagents, including histochemical methods.

2.5 Other Procedures

Information is not available.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Surgical Treatment

Evaluation of all patients prior to treatment should be performed by a maxillofacial surgeon, who must take the following steps: determine the size of the lesion and assess its relationship to surrounding organs, review the results of the biopsy material and tumor imaging (CT, MRI) to determine the extent of tumor spread, and evaluate the current functional status and the feasibility of surgical treatment.

Comments: A clinical study (n=65) demonstrated that the implementation of minimally invasive endoscopically assisted surgical techniques in clinical practice can significantly improve aesthetic and functional outcomes of surgeries in aesthetically sensitive areas.

Comments: Types of reconstructive surgical interventions in the maxillofacial region according to surgical and technical techniques:

Group I – local plastic surgeries.

In this case, tissues immediately adjacent to the defect or deformity are used to eliminate relatively small-sized defects or deformations of the maxillofacial region and neck.

Group II – transplantation of a musculocutaneous complex (pedicled flap plastic surgery).

Pedicled flap plastic surgery is used in the presence of extensive and voluminous defects and deformations of the maxillofacial region and neck, which cannot be eliminated using local tissues, and free tissue transfer is deemed inexpedient.

Group III – autotransplantation of a myocutaneous-osseous complex, free flap autotransplantation with the formation of vascular anastomoses (free tissue and organ transplantation).

It is indicated for the elimination of complex extensive defects and deformations of the maxillofacial region and neck and can be combined with both pedicled flap plastic surgery and local plastic surgeries. Practically any tissue can be used in the maxillofacial region during transplantation to replace various defects and deformations, taking into account the principle of organotypicity (skin, fascia, adipose tissue, nerves, blood vessels, cartilage, bone, mucous membrane, hair follicles, etc.).

Group IV – bone lengthening (distraction osteogenesis).

Distraction osteogenesis is indicated for defects and underdevelopment of the facial skull bones.

Group V – introduction of bone matrix implants, synthetics*** into soft tissues (facial endoprosthetics with silicone or titanium implants [polymeric endoprostheses for reconstructive surgery, custom-made implants made of titanium alloy, etc.]). It allows the correction of bone and soft tissue defects of the maxillofacial region as an alternative method to auto- and allotransplantation.

Group VI – bone reconstruction (ectoprosthetics [oral and extraoral prostheses (prostheses for cranio-maxillofacial surgery, endoprostheses for lower jaw defects, external implantable ear prosthesis, external nose prosthesis]). A procedure that allows the prompt elimination of maxillofacial defects in cases where reconstructive surgery is impossible for various reasons.

Comments: removal of the vascular neoplasm is the primary radical treatment method, especially for small-sized angiomas. Their removal followed by wound edge approximation rarely leads to recurrence and is the most accessible and rapid treatment method. With an increase in the size of the lesion, the following procedures are performed: ligation of vessels (afferent and efferent), removal of the vascular neoplasm with defect plasty. In cases of significant tissue infiltration, complex reconstructive-plastic surgeries must sometimes be performed: free flap autotransplantation with vascular anastomosis creation, facial bone resection, bone reconstruction (defect replacement with a bone allograft).

3.2. Conservative treatment

Comment: It consists of standard anti-inflammatory and symptomatic therapy [39, 45].

3.3 Other Treatment

Treatments other than surgery are possible only in the group of benign vascular lesions [33, 34]:

1. sclerotherapy

2. cryodestruction for vascular neoplasms

3. laser therapy

4. electrochemical lysis

5. endovascular therapy

A comparative evaluation of various treatment methods was performed using statistical methods. It was proven that a multidisciplinary approach using multiple methods provides high treatment efficacy. The relative frequency of positive results reached 84.2% for surgical treatment, 81.8% for endovascular therapy, and 96.9% for combined treatment, respectively.

Comments: The administration of a sclerosant (drugs for the treatment of varicose veins) is carried out by transcutaneous injection into the vascular lumen, monitoring the correct positioning of the needle tip within the vessel by simultaneous fluoroscopy (skull X-ray) with the injection of a water-soluble nephrotropic low-osmolar radiopaque agent. The administration of a venosclerosing drug (drugs for the treatment of varicose veins) results in vascular endothelial damage, leading to the obliteration of the latter and a decrease in blood flow velocity and volume within the lesion.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comment: The need for patient rehabilitation is due to surgical trauma to the soft tissues of the head and neck and postoperative sutures. The presence of postoperative wounds in the specified anatomical areas, their healing by primary intention, and sutures at vessel ligation sites entail the risk of purulent-septic complications and postoperative bleeding in the event of suture failure. Pain syndrome of varying severity and potential impairments in swallowing, facial expression, mouth opening, tongue movement, and speech in the postoperative period can lead to significant social maladjustment and reduce the quality of life of this category of patients.

Stages of patient rehabilitation after surgical treatment:

Stage 1 – early rehabilitation after surgical intervention. During this period, the patient is in a rehabilitation inpatient unit.

Stage 2, from day 15 to 45 after surgery, aims to accelerate reparative processes and restore functional and aesthetic properties.

5. Prevention and Dispensary Observation

6. Organization of Medical Care

Indications for hospital admission to a medical organization:

1. Emergency hospitalization is indicated if an inflammatory process develops (cystic lesions), as well as in cases of heavy, profuse, and ongoing bleeding (vascular tumors).

2. Elective hospitalization is indicated in the presence of a mass without inflammation of the surrounding tissues.

Diagnostic procedures in an elective setting at the stage of establishing a diagnosis may be performed on an outpatient basis. Surgical treatment is recommended to be performed in specialized hospital departments equipped for minimally invasive interventions. Some types of surgical treatment may also be performed on an outpatient basis or in a day hospital.

Indications for discharging a patient from a medical organization:

1. In case of emergency hospitalization for an inflammatory process, indications for discharge are the relief of acute disease manifestations and positive dynamics in the patient's condition: reduction of local inflammatory manifestations; decrease in pain severity with the possibility of management using outpatient medications; absence of signs of bleeding with the possibility of correcting posthemorrhagic anemia (if present) on an outpatient basis;

2. In case of elective hospitalization for a benign head and neck mass, indications for discharge are: an uncomplicated course of the early postoperative period; absence of purulent-septic complications of the wound healing process; controlled pain syndrome with the possibility of management using oral medications on an outpatient basis; the patient's ability to independently continue conservative therapy at home under the supervision of a local physician.

7. Additional Information

Negative factors affecting treatment outcomes include:

1. Development of infectious complications;

2. Impairment of functional and aesthetic qualities;

3. Non-compliance with the postoperative regimen and recommendations.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kulakov A.A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgeons.

2. Yaremenko A.I. – MD, Professor, Vice-President of the Association of Maxillofacial Surgeons.

3. Belchenko V.A. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

4. Braylovskaya T.V. – MD, Professor, Executive Secretary of the Association of Maxillofacial Surgeons.

5. Kutukova S.I. – MD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

6. Razumova A.Ya. – PhD in Medicine, Associate Professor, Member of the Association of Maxillofacial Surgeons.

7. Lopatin A.S. – MD, Professor, President of the Russian Rhinologic Society.

8. Semenov M.G. – MD, Professor, Head of the Department of Maxillofacial Surgery and Surgical Dentistry named after A.A. Limberg, North-Western State Medical University named after I.I. Mechnikov, Member of the Association of Maxillofacial Surgeons.

9. Sysolyatin P.G. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

9. Bayrikov I.M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgeons.

10. Ivanov S.Yu. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

11. Drobyshev A.Yu. – MD, Professor, Vice-President of the Association of Maxillofacial Surgeons.

12. Tarasenko S.V. (Head of the Department of Surgical Dentistry, E.V. Borovsky Institute of Dentistry, Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University)).

13. Topolnitsky O.Z. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

14. Durnovo E.A. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

15. Epifanov S.A. – MD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

16. Bagnenko A.S. – PhD in Medicine, Associate Professor, Member of the Association of Maxillofacial Surgeons.

No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Methods used for the collection/selection of evidence:

• search for publications in peer-reviewed specialized periodicals with an impact factor > 0.3;

• electronic database searching.

Databases used for the collection/selection of evidence:

• PUBMED, MEDLINE, ELIBRARY, and ClinicalKey databases. The search depth was 25 years.

Target audience for these clinical guidelines:

• Dentists

• Maxillofacial surgeons

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions).

Table 2. Levels of Evidence (LE) grading scale for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions).

Table 3. Grades of Recommendation (GR) scale for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision — at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Ministry of Health and Social Development of the Russian Federation No. 422n dated August 30, 2019, "On approval of the procedure for providing medical care in the field of maxillofacial surgery";

2. Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 25, 2023) "The Fundamentals of Healthcare Legislation in the Russian Federation" (with rev. and add., effective April 1, 2024);

3. Decree of the Government of the Russian Federation No. 1387 dated November 5, 1997, "On measures to stabilize and develop healthcare and medical science in the Russian Federation" (Collected Legislation of the Russian Federation, 1997, No. 46, Art. 5312).

4. Order of the Russian Ministry of Health No. 804n dated October 13, 2017 (as amended on September 24, 2020, with amendments dated October 26, 2022) "On Approval of the Nomenclature of Medical Services" (Registered with the Ministry of Justice of Russia on November 7, 2017, No. 48808)

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

1. Benign head and neck masses require surgical treatment.

2. Preoperative evaluation of both local and general status is necessary.

3. Any mass requires morphological examination.

4. Dispensary observation every 6 months for 1 year with ultrasound examination is required.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.