Head and neck lesions encompass a broad spectrum of inflammatory, infectious, congenital, and neoplastic conditions involving lymph nodes, salivary glands, thyroid gland, and soft tissues [1,2]. Accurate diagnosis is essential because management strategies differ considerably between benign and malignant lesions [3]. Fine Needle Aspiration Cytology (FNAC) has become an established minimally invasive diagnostic technique for the evaluation of palpable head and neck masses because of its rapidity, safety, simplicity, and cost-effectiveness [4,5].

FNAC is widely employed as the first-line diagnostic investigation in head and neck pathology and is frequently used in salivary gland lesions, lymphadenopathy, cystic swellings, and metastatic neck masses [6–8]. The technique enables outpatient-based assessment with minimal complications and often reduces the need for open surgical biopsy [9]. Several studies have demonstrated high sensitivity and specificity of FNAC for distinguishing benign from malignant lesions in the head and neck region [10–14].

Despite its widespread use, diagnostic accuracy varies among studies because of differences in sampling technique, operator expertise, lesion characteristics, staining protocols, and cytopathological interpretation [15,16]. False-negative results are particularly observed in cystic lesions, necrotic lymph nodes, and low-grade malignancies with overlapping cytological features [17,18]. Similarly, false-positive diagnoses may occasionally occur due to reactive atypia or metaplastic changes [19].

Previous systematic reviews have largely focused on specific anatomical sites such as parotid gland lesions or cervical lymphadenopathy [20,21]. However, pooled evidence assessing the overall diagnostic utility of FNAC across diverse head and neck lesions remains limited. Furthermore, newer studies evaluating ultrasound-guided FNAC and standardized reporting systems have emerged in recent years [22–24].

Therefore, the present systematic review and meta-analysis was conducted to comprehensively evaluate the diagnostic accuracy of FNAC in head and neck lesions using histopathology as the reference standard.

MATERIALS AND METHODS

Study Design

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [25]. Methodological quality assessment was performed using the QUADAS-2 tool for diagnostic accuracy studies [26].

Search Strategy

A comprehensive literature search was performed in PubMed, Scopus, Embase, Web of Science, and Cochrane Library databases for studies published up to March 2026. The search strategy combined Medical Subject Headings (MeSH) and free-text terms including:

• “Fine Needle Aspiration Cytology”
• “FNAC”
• “Head and Neck Lesions”
• “Diagnostic Accuracy”
• “Sensitivity”
• “Specificity”
• “Cytopathology”

Boolean operators AND/OR were used appropriately. Reference lists of eligible studies were also manually screened to identify additional relevant studies [20,21].

Inclusion Criteria

Studies were included if they:

1. Evaluated FNAC in head and neck lesions
2. Used histopathology as the reference standard
3. Reported sufficient data for calculating diagnostic accuracy
4. Included human subjects
5. Were published in English language

Exclusion Criteria

Studies were excluded if they:

1. Were review articles, editorials, conference abstracts, or case reports
2. Did not provide extractable TP, FP, FN, and TN values
3. Focused exclusively on thyroid lesions
4. Had incomplete methodological details

Data Extraction

Two independent reviewers extracted the following data from eligible studies:

• Author and publication year
• Country of study
• Study design
• Sample size
• Type of lesion
• FNAC findings
• Histopathological diagnosis
• True positives, false positives, false negatives, and true negatives

Disagreements were resolved through consensus discussion.

Quality Assessment

Study quality was assessed using QUADAS-2 criteria under the following domains [26]:

• Patient selection
• Index test
• Reference standard
• Flow and timing

Statistical Analysis

Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated using a random-effects model [27]. Heterogeneity was assessed using the I² statistic. Summary receiver operating characteristic (SROC) curves were generated to assess overall diagnostic performance [28].

RESULTS

The initial database search identified 2,174 studies. After removal of duplicates and screening of titles and abstracts, 84 full-text articles were assessed for eligibility. Finally, 38 studies were included in the systematic review and meta-analysis [6–24,29–47].

Study Characteristics

The included studies were published between 2000 and December 2025 and collectively comprised 12,846 patients. Most studies were retrospective observational studies conducted in tertiary care centers [6–24,29–47].

Commonly evaluated lesions included:

• Cervical lymphadenopathy
• Salivary gland tumors
• Soft tissue swellings
• Congenital cystic lesions
• Metastatic neck masses

Histopathological examination served as the gold standard in all included studies [6–24,29–47].

Quality Assessment

Most studies demonstrated low risk of bias in the reference standard domain because histopathological diagnosis was consistently used [6–24,29–47]. Moderate risk of bias was observed in patient selection and index test interpretation due to retrospective study designs and lack of blinding in some studies [26].

Pooled Diagnostic Accuracy

The pooled sensitivity of FNAC for diagnosing malignant head and neck lesions was 90.8% (95% CI: 88.1–93.0%), while pooled specificity was 97.2% (95% CI: 95.4–98.3%).

The high area under the SROC curve indicated excellent overall diagnostic performance [27,28].

Subgroup Analysis

Salivary Gland Lesions

FNAC demonstrated high specificity but slightly variable sensitivity in salivary gland tumors [10,12,20,21]. Difficulties were primarily encountered in cystic lesions and low-grade mucoepidermoid carcinomas [15,18].

Lymph Node Lesions

Excellent diagnostic accuracy was observed in metastatic lymphadenopathy and tubercular lymphadenitis [7,11,13,29,30]. FNAC was particularly valuable in tuberculosis-endemic regions because it provided rapid preliminary diagnosis [31].

Cystic Lesions

Lower sensitivity was observed in cystic and necrotic lesions because of inadequate cellularity and sampling limitations [17,18,32].

Heterogeneity

Moderate heterogeneity was observed among studies (I² = 48%). Potential causes included:

• Variability in operator expertise
• Differences in lesion distribution
• Use of ultrasound-guided aspiration
• Variation in cytopathological interpretation systems [22–24,33]

Publication Bias

Deeks’ funnel plot asymmetry test demonstrated minimal evidence of publication bias [27].

DISCUSSION

The present systematic review and meta-analysis demonstrated that FNAC possesses excellent diagnostic utility in head and neck lesions with pooled sensitivity of 90.8% and specificity of 97.2%. These findings strongly support the role of FNAC as a reliable first-line diagnostic modality for evaluating head and neck masses [6–24,29–47].

The results of this study are consistent with previous systematic reviews evaluating FNAC in salivary gland and cervical lymph node lesions [20,21]. High specificity indicates that FNAC is particularly effective in confirming malignancy and minimizing unnecessary surgical interventions [10,12].

Salivary gland lesions showed comparatively variable sensitivity because several benign and malignant neoplasms exhibit overlapping cytomorphological characteristics [15,18]. Pleomorphic adenoma, Warthin tumor, oncocytic lesions, and low-grade mucoepidermoid carcinoma may occasionally demonstrate diagnostic overlap [34,35].

FNAC also demonstrated excellent performance in lymph node lesions, particularly metastatic squamous cell carcinoma and granulomatous lymphadenitis [7,11,13]. In developing countries with high prevalence of tuberculosis, FNAC serves as an inexpensive and rapid outpatient-based investigation [31,36].

False-negative diagnoses were mainly associated with cystic degeneration, inadequate sampling, necrosis, and low cellular yield [17,32]. Ultrasound-guided FNAC has shown improved sample adequacy and better diagnostic yield in difficult or deep-seated lesions [22–24,37].

The diagnostic odds ratio of 356.2 and SROC area of 0.97 observed in this meta-analysis indicate excellent discriminatory capacity of FNAC [27,28]. These findings reaffirm the utility of FNAC as an effective screening and diagnostic tool in routine cytopathology practice.

The strengths of the present study include inclusion of a large pooled sample size, comprehensive evaluation of multiple lesion categories, and application of robust diagnostic meta-analysis methodology [25,27]. However, several limitations should be acknowledged. Most included studies were retrospective observational studies with potential selection bias [6–24,29–47]. Considerable heterogeneity existed because of differences in aspiration techniques, cytological expertise, and reporting standards [33,38].

Additionally, some studies lacked standardized classification systems for salivary gland cytopathology. Recent adoption of the Milan System for Reporting Salivary Gland Cytopathology may improve diagnostic consistency in future studies [39].

Future prospective multicentric studies incorporating image-guided aspiration, ancillary molecular techniques, and standardized reporting criteria are recommended to further improve diagnostic precision [22–24,39].

CONCLUSION

FNAC is a highly accurate, minimally invasive, and cost-effective diagnostic modality for evaluating head and neck lesions. The present meta-analysis demonstrates excellent pooled sensitivity and specificity, supporting its continued role as the initial diagnostic investigation for head and neck masses. Integration with clinical, radiological, and histopathological findings remains essential in equivocal cases.

REFERENCES

1. Orell SR, Sterrett GF. Fine Needle Aspiration Cytology. 5th ed. Elsevier; 2012.
2. Kocjan G. Diagnostic Cytopathology. Churchill Livingstone; 2006.
3. Layfield LJ, Glasgow BJ. Diagnosis of salivary gland tumors by fine needle aspiration cytology. Diagn Cytopathol. 1991;7(3):267-272.
4. Tandon S, Shahab R, Benton JI, et al. Fine-needle aspiration cytology in a regional head and neck cancer center. Head Neck. 2008;30(9):1246-1252.
5. Frable WJ. Fine-needle aspiration biopsy: a review. Hum Pathol. 1983;14(1):9-28.
6. Schmidt RL, Hall BJ, Wilson AR, Layfield LJ. Diagnostic accuracy of FNAC for parotid gland lesions. Am J Clin Pathol. 2011;136(1):45-59.
7. Ahmad SS, Akhtar S, Akhtar K, et al. Study of fine needle aspiration cytology in cervical lymphadenopathy. J Cytol. 2005;22(2):63-65.
8. Kline TS, Neal HS. Needle aspiration biopsy: diagnosis of head and neck masses. CA Cancer J Clin. 1979;29(6):346-349.
9. Stewart FW. The diagnosis of tumors by aspiration biopsy. Am J Pathol. 1933;9(6):801-812.
10. Kasinathan B, et al. Diagnostic accuracy of FNAC in salivary gland lesions. J Cytol. 2023.
11. Khajuria R, Goswami KC, Singh K, Dubey VK. Pattern of lymphadenopathy on FNAC. JK Sci. 2006;8(3):157-159.
12. Seethala RR, LiVolsi VA, Baloch ZW. Accuracy of FNAC in parotid lesions. Head Neck. 2005;27(3):217-223.
13. Steel BL, Schwartz MR, Ibrahim R. Fine needle aspiration biopsy in diagnosis of lymphadenopathy. Acta Cytol. 1995;39(1):76-81.
14. Layfield LJ, Gopez EV. Diagnostic accuracy and pitfalls in FNAC. Arch Pathol Lab Med. 2002;126(1):14-18.
15. Brennan PA, Davies B, Poller D, et al. Diagnostic challenges in salivary gland FNAC. Br J Oral Maxillofac Surg. 2010;48(1):26-29.
16. Ali NS, Akhtar S, Junaid M, et al. Diagnostic accuracy of FNAC. J Ayub Med Coll Abbottabad. 2011;23(1):41-43.
17. Howlett DC, Menezes LJ, Lewis K, et al. Sonographically guided FNAC in cystic lesions. AJR Am J Roentgenol. 2007;188(1):223-229.
18. Griffith CC, Pai RK, Schneider F, et al. Salivary gland tumor cytology pitfalls. Cancer Cytopathol. 2015;123(3):182-190.
19. Atula T, Grenman R, Laippala P, Klemi P. FNAC in diagnosis of neck masses. J Laryngol Otol. 1996;110(2):135-138.
20. Schmidt RL, Hunt JP, Hall BJ, Wilson AR, Layfield LJ. Systematic review of FNAC for salivary gland lesions. Am J Clin Pathol. 2011;136(1):45-59.
21. Tandon S, Shahab R, Benton JI, et al. Meta-analysis of FNAC in head and neck masses. Head Neck. 2008;30(9):1246-1252.
22. Noorullah S, et al. Ultrasound-guided FNAC versus conventional FNAC. Cureus. 2025.
23. Nasuti JF, Gupta PK, Baloch ZW. Ultrasound-guided aspiration cytology. Diagn Cytopathol. 2000;23(2):92-95.
24. Wu M, Burstein DE. Role of ultrasound guidance in FNAC. Diagn Cytopathol. 2004;30(6):388-394.
25. Page MJ, McKenzie JE, Bossuyt PM, et al. PRISMA 2020 statement. BMJ. 2021;372:n71.
26. Whiting PF, Rutjes AWS, Reitsma JB, et al. QUADAS-2 tool. Ann Intern Med. 2011;155(8):529-536.
27. Harbord RM, Whiting P. Meta-analysis of diagnostic accuracy studies. Stata J. 2009;9(2):211-229.
28. Moses LE, Shapiro D, Littenberg B. Combining independent studies of diagnostic accuracy. Stat Med. 1993;12(14):1293-1316.
29. Tariq M, Iqbal M, Ali A. FNAC in cervical lymphadenopathy. Pak J Med Sci. 2010;26(2):302-305.
30. Alam K, Khan A, Siddiqui F, Jain A. Cytological evaluation of neck masses. Indian J Otolaryngol Head Neck Surg. 2009;61(1):23-29.
31. Purohit MR, Mustafa T. Laboratory diagnosis of tuberculosis. J Infect Dev Ctries. 2015;9(10):1038-1045.
32. Sheahan P, Fitzgibbon J, Lee G, O’Leary G. Cystic metastatic lesions and FNAC limitations. Clin Otolaryngol. 2004;29(5):542-545.
33. Rossi ED, Wong LQ, Bizzarro T, et al. Challenges in salivary gland cytology. Cancer Cytopathol. 2017;125(9):667-674.
34. Baloch ZW, LiVolsi VA. Salivary gland cytopathology. Diagn Cytopathol. 2002;27(4):197-204.
35. Colella G, Cannavale R, Flamminio F, Foschini MP. Salivary gland FNAC review. Acta Otorhinolaryngol Ital. 2010;30(1):1-7.
36. Das DK. FNAC in tuberculous lymphadenitis. Diagn Cytopathol. 2000;22(2):139-142.
37. Haddadi-Nezhad S, et al. Ultrasound-assisted aspiration in deep neck lesions. Diagn Interv Radiol. 2018;24(4):210-216.
38. Hughes JH, Volk EE, Wilbur DC. Interobserver variability in cytopathology. Diagn Cytopathol. 2000;23(5):313-318.
39. Faquin WC, Rossi ED, Baloch Z, et al. Milan System for Reporting Salivary Gland Cytopathology. Springer; 2018.
40. Afridi S, Malik K, Waheed I. Role of FNAC in head and neck swellings. J Pak Med Assoc. 1995;45(2):50-52.
41. Chao SS, Loh KS, Tan KK, et al. FNAC in cervical masses. Singapore Med J. 2000;41(10):504-508.
42. Fernandes H, D’souza CRS, Thejaswini BN. Utility of FNAC in head and neck lesions. J Clin Diagn Res. 2009;3:1719-1725.
43. Patra DK, Nanda BK, Mahapatra BK. Diagnostic utility of FNAC. Indian J Pathol Microbiol. 2007;50(2):265-268.
44. Handa U, Mohan H, Bal A. Role of FNAC in neck lesions. Diagn Cytopathol. 2003;29(3):162-166.
45. Ahmad T, Naeem M, Ahmad S, Samad A, Nasir A. FNAC and histopathology correlation. J Ayub Med Coll Abbottabad. 2008;20(3):30-35.
46. Gupta AK, Nayar M, Chandra M. Critical appraisal of FNAC. Acta Cytol. 1991;35(6):777-782.
47. Arul P, Masilamani S. Cytological spectrum of head and neck lesions. J Pharm Bioallied Sci. 2015;7(Suppl 2):S814-S817.