We read with great interest the study by Celik et al.,[1] which examined the diagnostic profiles of cervical lymphadenopathy using cervical ultrasonography, fine needle aspiration biopsy, and excisional lymph node biopsy. The authors' use of multimodal diagnostic comparison and age-stratified outcome evaluation provides a useful dataset for refining biopsy decision thresholds in head and neck surgery. However, several aspects warrant closer scrutiny in light of their clinical implications. The study's finding that 66 of 137 patients were ultimately diagnosed with malignant pathology raises important questions about preoperative triage efficiency. Despite a majority of these malignancies being associated with fine needle aspiration biopsy results classified as non-diagnostic or suspicious, the absence of a statistically significant association between fine needle aspiration biopsy classification and excisional biopsy results (p>0.05) suggests possible limitations in discriminatory power. This pattern may reflect classification ambiguity at the cytological level rather than true diagnostic neutrality. Clinically, this has the potential to delay appropriate hematopathological sub-typing in lymphoproliferative disease and emphasizes the need for integrated cytology-radiology review protocols before escalation to surgical biopsy. Another concern is the decision logic surrounding the performance of fine needle aspiration biopsy prior to excisional biopsy, especially in patients later confirmed to have reactive follicular hyperplasia. Of the 46 patients with reactive follicular hyperplasia, 39 had either non-diagnostic or suspicious fine needle aspiration biopsy results, prompting surgery that may have been avoidable. Without a stratified analysis correlating lymph node size, vascularity pattern, and fine needle aspiration biopsy outcome with final diagnosis, it is difficult to determine whether excision was warranted in these benign cases.[2] The risk here is dual: overtreatment of benign pathology and resource diversion from higher-yield surgical diagnostics. The study also reports that ultrasonography findings showed no statistically significant correlation with excisional biopsy results. However, this finding merits reevaluation through multivariable modeling or receiver operating characteristic curve analysis to quantify the predictive contribution of features such as loss of hilum or intranodal necrosis. In its current form, the analysis treats ultrasonography as a binary predictor, which may obscure the additive diagnostic value of pattern recognition when interpreted alongside age, clinical context, and cytology.[3] This simplification may hinder the development of more nuanced triage algorithms that could prioritize or defer excisional biopsy. The observed malignancy prevalence of 48.2% in this cohort, particularly in patients aged >=41 years, supports the clinical intuition to lower biopsy thresholds in older adults. However, given that the study was conducted in a tertiary referral setting with an enriched high-risk population, the translational applicability of these age thresholds to general practice or community settings may be limited. A counterfactual analysis comparing malignancy rates in patients who did not undergo biopsy could clarify the extent of selection bias and refine age-based biopsy criteria. Clarifying the roles of fine needle aspiration biopsy, ultrasonography, and excisional lymph node biopsy in cervical lymphadenopathy evaluation remains a critical challenge. We commend the authors for their comprehensive tri-modal comparison and for stratifying malignancy outcomes by age group, which adds clinically actionable nuance to biopsy selection strategies. This study supports the continued use of excisional lymph node biopsy in lymphoproliferative disease and in patients aged over 40 with persistent suspicion. However, improving triage specificity through refined ultrasonographic scoring systems and cytology-validated algorithms may reduce unnecessary surgeries while preserving diagnostic sensitivity for malignancy.