Head and neck masses constitute a significant proportion of cases encountered in outpatient departments and tertiary care centres, involving patients across a wide age range and both genders. These masses arise from a variety of anatomical structures including lymph nodes, thyroid gland, salivary glands, skin, subcutaneous tissue, and embryological remnants.1,2 The etiological spectrum of head and neck swellings is broad, ranging from inflammatory and infectious conditions to benign neoplastic lesions and malignant tumours, including both primary malignancies and metastatic deposits.3,4 As a result of this wide differential diagnosis, evaluation of head and neck masses remains a diagnostic challenge and requires a systematic approach to achieve early and accurate diagnosis.4,5

Clinically, many head and neck swellings present as painless enlargements, often with overlapping features that make differentiation between benign and malignant lesions difficult. Although a large proportion of these swellings are inflammatory or benign in nature, the possibility of malignancy must always be considered, particularly in adult patients and those with established risk factors such as tobacco use, alcohol consumption, chronic infections, or a prior history of malignancy.4,5 Contemporary clinical practice guidelines emphasize that any persistent neck mass in an adult warrants thorough evaluation, as delays in diagnosis may lead to presentation at an advanced stage and result in poorer treatment outcomes.4,8 These recommendations highlight the need for diagnostic methods that are accurate, safe, cost-effective, and acceptable to patients.

Fine Needle Aspiration Cytology (FNAC) has emerged as one of the most widely accepted initial diagnostic techniques for the evaluation of head and neck masses.5,6 FNAC is a minimally invasive procedure that involves aspiration of cellular material using a fine needle, followed by cytological examination of the obtained smears.6 The technique offers several advantages, including simplicity, rapidity, low cost, minimal complications, and the ability to provide a preliminary diagnosis without the need for open surgical biopsy. Because of these attributes, FNAC has gained widespread acceptance as a first-line investigation in the diagnostic workup of superficial head and neck lesions.1,3

The present study was designed as a hospital-based, descriptive observational study undertaken to evaluate the diagnostic utility and accuracy of Fine Needle Aspiration Cytology (FNAC) in the evaluation of head and neck masses. The study involved prospective collection of clinical and cytological data, with histopathological correlation wherever available, which was considered the reference (gold) standard.

This design permitted estimation of diagnostic accuracy parameters and assessment of FNAC as a first-line diagnostic investigation in routine clinical practice.

1. Inclusion Criteria

• Patients of age groups above 12 years and both genders
• Patients presenting with head and neck masses requiring FNAC
• Patients who provided informed written consent
• Patients with available histopathological reports (for diagnostic accuracy analysis)

1. Exclusion Criteria

• Patients of age groups below 12 years
• Patients who refused consent for FNAC
• Patients with known bleeding disorders contraindicating FNAC
• Lesions inaccessible to FNAC due to anatomical constraints
• Repeatedly inadequate or non-diagnostic smears where repeat aspiration was not feasible

The primary study method employed was Fine Needle Aspiration Cytology (FNAC) for the evaluation of head and neck masses. FNAC was utilized as a minimally invasive diagnostic technique for cytological assessment. Rapid On-Site Evaluation (ROSE) was used as an adjunct tool to assess specimen adequacy.

TABLE 1: FNAC REPORT OF ALL PATIENTS STUDIED:

Thyroid gland lesions (n = 514)

Thyroid gland lesions constituted a significant proportion of cases, with colloid goiter (294 cases; 20.45%) being the most frequent diagnosis. This was followed by autoimmune thyroiditis (133 cases; 9.26%) and colloid cysts (62 cases; 4.8%). Hashimoto’s thyroiditis (21 cases; 1.46%) and granulomatous thyroiditis (4 cases; 0.28%) were less common.

Miscellaneous lesions – skin and soft tissue (n = 612)

Miscellaneous lesions formed the largest group in the study. Abscesses (318 cases; 22.13%) were the most common diagnosis, followed by lipomas (159 cases; 11.06%) and epidermal inclusion cysts (104 cases; 7.24%). Other diagnoses included acute on chronic inflammation (14 cases; 0.97%), acute suppurative pathology (6 cases; 0.42%), and benign cystic lesions (4 cases; 0.28%). Rare lesions included tubercular abscess (1 case; 0.07%), benign spindle cell lesion (1 case; 0.07%), and benign mesenchymal lesion (2 cases; 0.14%). Malignancy was rare in this group, with 2 cases of squamous cell carcinoma (0.14%), while 1 case (0.07%) was reported as suspicious for malignancy.

Salivary gland lesions (n = 13)

Salivary gland lesions were infrequent. Pleomorphic adenoma (10 cases; 0.7%) was the most common diagnosis, followed by Warthin’s tumor (2 cases; 0.14%). A benign cystic lesion was reported in 1 case (0.07%).

Inconclusive FNAC reports (n = 3)

Only 3 cases (0.21%) were reported as inconclusive, indicating a high overall adequacy rate of FNAC in the present study.

Overall, the findings demonstrate that the majority of FNAC diagnoses were benign or inflammatory, with malignant lesions forming a very small proportion, emphasizing the usefulness of FNAC as a first-line diagnostic modality for head and neck swellings.

Table 2: Clinical Symptom among study population:

All 1,438 patients (100%) presented with swelling, which was the primary clinical indication for FNAC. Among these, 678 patients (54.10%) reported no symptom other than swelling, indicating that more than half of the lesions were asymptomatic apart from the mass itself.

Pain was the most common associated symptom, observed in 714 patients (49.65%), followed by fever in 543 patients (37.76%), suggesting a significant proportion of inflammatory or infectious lesions. Fatigue was reported by 45 patients (3.13%), while upper respiratory tract infection was present in 20 patients (1.39%).

Table 3: Anatomical sites of the swellings:

Out of a total of 1,438 swellings, the neck region was the most commonly involved site, accounting for 912 cases (63.4%). Within the neck region, neck swellings were the most frequent, seen in 592 cases (41.13%), followed by cervical swellings in 314 cases (21.85%). Submandibular swellings were infrequent, with 6 cases (0.42%).

The head region accounted for 526 cases (36.6%). These included head swellings in 2 cases (0.14%), forehead swellings in 242 cases (16.84%), ear swellings in 193 cases (13.43%), and face swellings in 62 cases (4.31%). Less commonly involved sites were the mandible (12 cases; 0.83%), parotid region (9 cases; 0.63%), scalp (5 cases; 0.35%), and occipital region (1 case; 0.07%). Overall, the distribution shows a clear predominance of swellings in the neck region, followed by the head region, reflecting the common anatomical sites evaluated by FNAC in the present study.

Table 4: Distribution of FNAC Findings Among Patients (n=1438)

Out of a total of 1,438 patients evaluated by FNAC, inflammatory lesions constituted the largest diagnostic category, accounting for 794 cases (55.22%). This high proportion reflects the significant burden of inflammatory and infectious conditions presenting as head and neck swellings, particularly lymphadenitis and soft tissue infections, in the study population.

Benign lesions formed the second most common group, with 638 cases (44.33%). These included a wide spectrum of non-neoplastic conditions such as colloid goiter, benign cystic lesions, lipomas, and benign salivary gland tumours. The substantial proportion of benign diagnoses highlights the usefulness of FNAC in confidently identifying non-malignant lesions and thereby avoiding unnecessary surgical interventions.

Table 5: Distribution of Histopathology Findings (n=11)

Histopathology is considered the gold standard for definitive diagnosis of head and neck lesions. Out of the total 1438 cases included in the study, histopathological confirmation was available for 11 cases (0.7%), and these were used to assess the diagnostic accuracy of FNAC.

FNAC has emerged as one of the most accessible diagnostic techniques for head and neck swellings, mainly due to its simplicity and excellent patient acceptance.7 It is particularly useful because a large proportion of head and neck masses arise from superficial structures such as cervical lymph nodes, thyroid gland, and salivary glands, which are easily approachable by aspiration.8
Early studies established FNAC as an effective diagnostic modality in head and neck lesions. Young et al. described needle aspiration cytologic biopsy in head and neck masses and highlighted its diagnostic importance in clinical practice. Lever et al. also provided foundational evidence on fine needle aspiration cytology and emphasized its value in routine clinical diagnosis.
Several later studies have reinforced FNAC as an effective first-line test in head and neck swellings. Banstola et al., Khokle et al., Khetrapal et al., and Valiya et al. consistently reported FNAC as a useful tool in evaluating head and neck lesions with high diagnostic relevance across multiple lesion types. In addition, larger descriptive series by Savant et al. and Bandyopadhyay et al. further strengthen evidence that FNAC can reliably diagnose lesions in lymph nodes, thyroid, salivary glands, and soft tissues.9
The anatomical distribution of lesions showed that neck swellings (63.4%) were more common than head region swellings (36.6%). This is expected because the neck contains a large number of lymph nodes, thyroid gland, and major salivary glands.7
Cervical lymphadenopathy remains one of the most frequent clinical presentations in outpatient practice. FNAC plays a key role in evaluating cervical  lymphadenopathy  by  differentiating  reactive  lymphadenitis, granulomatous inflammation, suppurative lesions, and metastatic deposits.10-11
Several studies have shown variable site distribution depending on population characteristics. Ishar et al. reported lymph nodes as the most common aspirated site in non-thyroidal head and neck lesions. Gupta et al. reported lymph nodes as the predominant category in their study, followed by thyroid lesions.12 Rathod et al. reported thyroid lesions as the most common site, followed by lymph nodes.13 This variation is influenced by demographic factors and regional burden of infectious disease or thyroid pathology.14
The present study’s clinical distribution supports FNAC as a versatile method applicable to multiple anatomical sites, including lymph nodes, thyroid gland, salivary glands, and superficial soft tissues.
Cytological Spectrum of FNAC Findings
The cytological evaluation in the present study demonstrated that the majority of lesions were non-neoplastic, with inflammatory lesions forming the largest category (55.22%), followed by benign lesions (44.33%), while malignant lesions were rare (0.42%). This finding highlights that most palpable head and neck swellings in the study population were related to inflammatory or benign conditions rather than malignancy. Such a trend has been reported consistently across multiple regional studies evaluating head and neck lesions using FNAC.15

The predominance of inflammatory lesions reflects the high prevalence of reactive and infective lymphadenitis, including granulomatous (tuberculous) lymphadenitis, particularly in developing countries. FNAC plays a significant role in these settings because it enables early diagnosis and initiation of treatment, thereby decreasing morbidity and reducing unnecessary surgical procedures. 

In conclusion, FNAC should continue to be regarded as a key diagnostic modality in the evaluation of head and neck swellings. When used in conjunction with clinical examination, imaging, and histopathological confirmation where indicated, FNAC contributes significantly to early diagnosis and appropriate treatment planning. Histopathology remains essential for definitive diagnosis in selected and discordant cases; however, FNAC remains an indispensable initial diagnostic and screening tool in head and neck pathology.

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