Neck Masses: Evaluation and Diagnostic Approach

Oral and maxillofacial surgeons frequently history and physical. In stressing the importance
deal with patients who present with an unknown of history-taking, Sir William Osler said: ‘‘If you
neck mass. Formulation of a differential diagnosis listen to your patient, they will tell you their
is essential and requires that the surgeon bring to diagnosis’’ [1].
bear a host of skills to systematically arrive at
a definitive diagnosis and ensure that the correct
History and review of systems
treatment is rendered. This article highlights some
of the skills needed in the workup of neck masses The chief complaint provides the foundation
and reviews some of the available techniques that for the evaluation of the patient and directs the
aid in achieving the correct diagnosis. examination. Once this data have been obtained,
the history of the present illness should be
examined further because it is valuable for the
Clinical evaluation
development of the initial diagnostic impressions.
The way you talk with a patient while taking Characteristics of the mass, such as the location,
a history lays the foundation for good care. By growth rate, and presence of pain, provide clues to
listening and responding skillfully and empathic- the nature of the problem. For example, a long-
ally, you learn what is bothering the patient and standing nonpainful mass with slow or insignifi-
what symptoms he or she has experienced. You cant changes points toward a benign process.
also may learn what the patient thinks the trouble Associated symptoms, such as referred pain,
may be, how or why it happened, and what
changes in voice quality, difficulty swallowing,
outcome is hoped for or feared. As you listen to
the story of an illness, moreover, you begin to
and epistaxis, should be discussed with the patient
formulate a range of possible diagnoses. By and can give clues to the origin of the mass. The
asking additional questions, you can fill in the surgeon should also question the patient regard-
gaps in the patient’s initial account and test some ing systemic symptoms. Although such symptoms
of your diagnostic hypotheses. [1]. may be uncommon, they can suggest metastatic
disease, especially if neurologic and pulmonary
The history and physical examination is the
complaints are present. The classic ‘‘B signs’’ of
cornerstone of medicine. The surgeon must
lymphoma are fever, night sweats, and weight
continually strive to improve on this skill through
loss.
deliberate and systematic manipulation of the
The clinician not only has to consider the
present illness, but the patient’s sex, age, social
history, occupational exposure, travel history, and
* Corresponding author. Department of Surgery,
past surgical and medical history. For example, it
University of Florida College of Medicine, 653-1 West is not too uncommon for patients to present to
8th Street, Jacksonville, FL 32246 a surgeon with a neck mass only a few months
E-mail address: after another physician removed a skin cancer
[email protected]fl.edu (R. Fernandes) from the patient’s face or neck.
1042-3699/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2008.04.001 oralmaxsurgery.theclinics.com
 3 LEE &

Physical examination The lymphatic system of the neck is a network

The physical examination should be performed of channels connecting both superficial and deep
in a systematic fashion. The temptation to focus lymph nodes. Although no physical or anatomic
on the problem area should be resisted. The separation exists between lymph node groups,
clinician should carry out a standard, detailed nodal groups have been subdivided into six to
head and neck examination with emphasis in this seven groups for practical reasons that mostly
case on the neck. A detailed skin examination relate to treatment. Suen and Goepfert [2] in 1987
should be done with attention directed to the suggested this classification, which is based on the
ipsilateral scalp in cases where parotid swelling is Memorial-Sloan Kettering classification [3]. It
present. Cranial nerve examination is also impor- was then accepted by the Union International
tant because abnormal findings can indicate nerve Contre le Cancer, the American Joint Committee
involvement by tumor and a poorer prognosis. on Cancer, and the American Academy of
These facts serve as guides in the differential Otolaryn- gology-Head and Neck Surgery for the
diagnosis. A thorough examination of the oral standard- ization of clinical and surgical reports
cavity, nasopharynx, and the larynx is crucial. The [4,5].
lateral pharyngeal walls can also be involved and
ipsilateral bulging of the tonsilar area is com-
monly seen in dumbbell tumors of the parotid. Endoscopy
The detailed examination of these subsites is often Endoscopy should be part of the oral and
facilitated by the use of an endoscope or mirrors, maxillofacial surgeon’s armamentarium when
which is discussed later in this article. evaluating patients with head and neck masses,
During the physical examination of a neck especially if malignancy is suspected. For
mass, the clinician should seek to determine the example, supraglottic carcinomas can present as
location, size, and character of the lesion. One an unexplained mass in the neck and are often
should determine if the mass is tender to missed on initial examination [6]. Endoscopy can
palpation, if the mass is fixed, if there is be divided into indirect and direct endoscopy,
pulsation, and if there is fixation to the overlying with the latter performed with a rigid or flexible
skin. Palpation of the thyroid should be done to scope. Indirect mirror laryngoscopy is one of the
assess for the presence of thyroid nodules or most useful techniques and has several advan-
enlargement. Some patients with large substernal tages. It is inexpensive and, when properly
goiters produce a positive Pemberton’s sign (ie, performed on a cooperative patient, can bring
elevated arms above the head results in superior into view all the necessary structures. The prob-
vena cava syndrome). Such findings as rubbery lem with the indirect technique is that even with
nodes may suggest a lymphoma, whereas a large, the aid of topical anesthesia, a strong gag reflex
firm, fixed node may point to a metastatic can be observed. Areas that are difficult to visual-
malignancy. Presence of a mass isolated to the ize with indirect laryngoscopy include the anterior
supraclavicular region should trigger thoughts of commissure, portions of the epiglottis, the pyri-
a primary abdominal malignancy or malignancy form sinus, the ventricle, and the lateral base of
at other sites beyond the head and neck. When the tongue. Indirect mirror nasopharyngoscopy
evaluating children, it is important to determine also offers good visualization, but is technique-
the timing of the appearance of the mass because sensitive. Also, the soft palate can obstruct visual-
this timing is critical in the formu- lation of the ization or biopsy. Direct flexible fiber-optic
differential diagnosis. The differential for a mass nasopharynscopy/laryngoscopy is the method
present at birth is different from those that preferred by the authors. It is simple, relatively
originated later, such as lymphangioma, well tolerated by patients, and can be easily and
vascular malformation, and hemangioma. comfortably performed in the office with topical
A thorough working knowledge of the anesthesia.
lymphatics of the head and neck is essential for The classic ‘‘panendoscopy’’ of direct laryn-
the practicing oral and maxillofacial surgeon. goscopy, rigid esophagoscopy, and bronchoscopy
Regard- less of the nature of the primary disease can also be performed, but has lost favor as
and the involvement of any nodal groups should a routine means of evaluation of the unknown
be reported using the accepted nomenclature. The primary patient. Several different scopes are
patterns of drainage can give clues for finding a avail- able, but all use the same basic approach: a
primary source in a patient presenting with a neck peroral route, supine positioning, and general
mass. anesthesia
 NECK 3
in the operating room. The role of panendoscopy (FNAB) has become the gold standard for the
is controversial, especially with modern histologic evaluation of a patient with a neck
radiographic techniques, and might best be mass. FNAB is an inexpensive, rapid, and rela-
reserved for symptom-directed evaluation. tively accurate diagnostic tool for evaluating
neoplastic and nonneoplastic lesions, especially
Differential diagnosis in superficial or easily palpable masses. Imaging
techniques, such as ultrasound, CT, and MRI,
Formulating your diagnostic possibilities
have also been described and proven safe in
should begin at the time of the first encounter
deep-seated lesions [9]. In the head and neck,
and evolve through to the final diagnosis. The
FNAB can be used in the thyroid, skull base,
formulation of a good differential diagnosis is
salivary glands, paraspinal lesions, cervical
based on a thorough understanding of head and
masses, and nodules. It also can aid in preopera-
neck pathology. However, a complete review of
tive planning and patient counseling. This is espe-
possible lesions in the head and neck goes beyond
cially true in patients with malignant versus
the scope of this article. The differential list is
benign disease or patients who are poor surgical
arranged from the most probable diagnosis to the
candidates. There has been some controversy in
least likely, usually including the five most likely
the use of FNAB because of its potential
diagnoses. The differential serves as the ‘‘game
pitfalls, such as tumor seeding, nerve damage,
plan’’ for the arriving at the final diagnosis. The
and salivary fistulas. Experience has shown that
differential list is based on the clinical and
these prob- lems rarely occur when FNAB is
imaging information gathered, which can later be
properly per- formed and that complications are
‘‘ruled in’’ or ‘‘ruled out’’ based on additional
almost nonexistent. For example, Smith [10]
informa- tion. The clinician also has to develop a
reported an incidence of 0.005% of tumor
priority list within each of the most likely
seeding, all of which were abdominal, pelvic, or
categories. This may ultimately reflect your
retroperitoneal lesions.
treatment or next diagnostic step (Fig. 1). Box 1
If the clinician chooses to use FNAB in clinical
contains a list of commonly occurring pathology
practice, he or she must have an understanding of
in the head and neck subclassified based on
its limitations. A variety of lesions in the neck are
congenital, infectious, benign, and malignant
investigated by aspirates. These can range from
tumors.
reactive changes, lymphomas, and malignancies
to congenital/developmental cysts. Each presents
Pathologic assessment with its own diagnostic challenges, which go
Histologic assessment of neck masses should beyond the scope of this article. The diagnostic
rarely require open biopsies. The routine use of accuracy is variable in the literature, with sensi-
open biopsies can lead to tumor seeding and can tivities ranging from 77% to 95% and specificities
ultimately require a more extensive resection. from 93% to 100% [11]. Squamous cell
Currently, cytologic diagnoses of neck masses carcinoma (SCCA) represents the most common
are often obtained through the use of fine needle malignancy in the cervical lymph chains. A
aspiration, while minimizing the stated negatives. common diagnos- tic problem is to distinguish it
Hayes Martin recognized this during the infancy from benign squa- mous lesions, including cysts
of modern head and neck surgery: [12–15]. The clinician and patient must
understand that the FNAB can be ‘‘positive’’ for
Incisional biopsy for the removal of a portion or
SCCA or for other solid tumors, but a FNAB that
of the whole of a cervical tumor should never be
does not show cancer cells is never ‘‘negative’’
made until other methods have been unsuccess-
ful. One of the most reprehensible surgical and does not rule out cancer. Another area in
practices is the immediate incision or excision of which FNAB has been questioned is in its
a cervical mass for diagnosis without preliminary inability to accurately diagnose primary
investigation for a possible primary growth. lymphadenopathies and lym- phomas [16]. The
There can be no better example of ill-advised culmination of a cervical lymphoma workup may
and needless surgery [7]. still require open biopsy for histopathology and
flow cytometry.
Fine needle aspiration biopsy The differential diagnosis of a neck mass in the
pediatric population is quite expansive, the most
Since Hayes Martin [8] first used the technique common being reactive lymphadenopathy. How-
in the 1930s, fine needle aspiration biopsy ever, the patient that fails to respond to an initial
 3 LEE &

Patient with Neck Mass

Clinical History and ROS

- Determine characteristics of mass
- Symptoms of infection
- Symptoms of cancer

Physical Examination
- Examine skin, cervical nodes,
thyroid, oral and nasal cavity, larynx
and pharynx
- endoscopy direct vs indirect

Formulate Diagnostic Impression/Differential

Probable Diagnosis
-e.g. uncomplicated infection Diagnosis Unclear
- Inadequate information

Treat Accordingly
Fine needle Biopsy Imaging Studies
- CT, MRI, US,
Angiography, plain film, PET

Non-diagnostic

Repeat 1-2 times Consider Open Biopsy

- consider CT, US guided -perform with oncologic principles for prudence

Diagnostic

Treat Accordingly

Fig. 1. Algorithm for assessment of a neck mass. Abbreviations: PET, positron emission tomography; ROS, review of
system; US, ultrasound.

course of antibiotic therapy poses a treatment FNAB in the pediatric population [19,20]. The
dilemma to the clinician. The incidence of malig- psychologic trauma of an FNAB to the patient
nancy is lower in children than in adults, with and the parents has to be weighed against the risks
mesenchymal tumors representing 90% of the and benefits of traditional open biopsy under gen-
lesions found in children [17]. Torsiglieri and eral anesthesia.
colleagues [18] reviewed 455 pediatric FNABs FNAB is a valuable diagnostic tool in the
and found 55% congenital lesions, 27% inflam- evaluation of a neck mass in both the pediatric
matory, 5% noninflammatory benign lesions, and adult patient. Its low overall cost, low
3% benign neoplasms, and 11% malignancies, associated morbidity, and high accuracy put it at
the most common being lymphoma. Several the top of the diagnostic algorithm. However,
studies have reported the efficacy and safety despite their positive attributes, FNABs are not
of
 NECK 3
CT and MRI studies can also complement one
Box 1. Limited differential for a another. An important consideration is context
neck mass of the study (eg, after-operation, following
earlier procedures).
Nonneoplastic The use of imaging in the determination of
Congenital head and neck malignancies is vital for
Thyroglossal duct cyst determining the origin, extent, and thus
Branchial cleft cyst resectability of the mass. Imaging of the cervical
Hemangiomas lymphatics alters the esti- mated clinical stage in
Lymphangioma (cystic hygroma) 20% to 30% of patients [21].
Layngoceole
Dermo CT scan
id CT is probably the most widely used imaging
Infectiou study in the head and neck, outside the neuro-
s cranium. It has the advantages of wide availabil-
Acute lymphadenitis ity, speed, relatively low cost, and good spatial
Abscess resolution. It is excellent at separating fat from
Tuberculosis muscle, and bone is well imaged. However, its
Cat scratch disease ability to separate muscle and tumor is not as
Neoplastic good. Spiral (helical) CT is quickly becoming the
Benign mainstay in many medical centers [22]. The
Lipom advantages of spiral CT are a result of the contin-
a uous rotation of the x-ray tube and the detector as
Saliva the patient moves through the gantry. This allows
ry rapid scanning of large volumes of tissue during
Pleomorphic adenoma quiet respiration; a reduction in the amount of in-
Warthin’s tumor travenous contrast needed, as well as the amount
Thyroid goiter of motion artifact; and multiplanar and three-
Paragangliomas (eg, carotid body dimensional reconstruction [23–25]. CT can be
tumors) particularly valuable in the head and neck pathol-
Maligna ogy patient because many of these patients have
nt significant comorbidities, such as chronic
Saliva obstructive pulmonary disease, and cannot handle
ry their secretions. Therefore, breath-holding and
Mucoepidermoid long scanning time are not well tolerated.

MRI
infallible and should never replace sound clinical
judgment. Although MRI has several favorable charac-
teristics for the evaluation of the head and neck,
Imaging studies its superiority compared with CT has not been
established [26,27]. There is, however, a distinct
Imaging is frequently employed to help advantage in its soft tissue capabilities and it is
determine the exact location and other character- useful when the distinction between the mass
istics of the disease process among patients who and surrounding soft tissue is poor. Metallic
present with a neck mass. The only exception may dental restorations do not significantly degrade
be someone with an obvious inflammatory or the MRI image. Many different techniques are
infective process where empiric treatment may be available for image enhancement on MRI. In gen-
started, followed by re-evaluation. CT and MRI eral, T1-weighed images relate to how quickly
have proven to be indispensable tools in evaluat- nuclei return to their base state. This type of
ing a patient with a neck mass and can be used to image takes less time to produce and fat appears
complement one another. In principle, imaging bright and cerebrospinal fluid dark. T2-weighted
complements the physical examination, and axial images relate to the loss of phase coherence and
and coronal sectional studies are based on anat- typically take longer to acquire. These images
omy and the changes that occur with pathology. pro- duce cerebrospinal fluid that is bright and fat
that
 3 LEE &

is darker. Gadolinium-enhanced images can also on the differential. PET is a functional study
improve the clarity of margins of many lesions based on the uptake of 18-fluorodeoxyglucose in
and, because gadolinium is a noniodinated cells proportional to their rate of glycolysis [37].
medium, it is considered safer in patients with PET scans have the ability to survey the whole
renal impairment and a history of allergic reac- body and detect primary tumors that would not
tions [28,29]. Additional techniques, such as fast- otherwise be visualized. It routinely is used to
spin echo and fat suppression, produce sharper detect an occult primary and in the evaluation
images in shorter times and allow for better delin- of recurrent disease after treatment [38,39]. Tradi-
eation of tissues. For example, in fast spin echo tionally, the widespread use of PET has been
T2 images, fat does not appear dark, and limited because of its expense, its poor spatial res-
distinguish- ing between fat and fluid (eg, olution, and its limited availability. Other limita-
hemorrhage) is difficult. Fat suppression tions are its inability to detect lesions smaller
techniques obliterate the signal from fat, than 5 to 10 mm and the physiologic uptake of
producing an image where fluid is bright and fat laryngeal and oropharyngeal muscles, resulting
is dark. This technique can also be applied to in unwanted false positives [40,41]. Recently,
gadolinium-enhanced T1 images where the PET has been combined with other modalities,
lesion abuts fatty tissues and the extent of the such as CT, providing anatomic and functional
mass is obscured because both are bright [30]. information. Several studies have reported
In patients with cancer of the head and neck, improved detection of primary and metastatic dis-
nodal involvement has significant prognostic ease when PET combined with CT was compared
value. Studies in the late 80s by Mancuso and with PET, CT, and MRI alone [42,43].
colleagues [31] and Som [32] illustrated the use of
CT in detection of nodal metastasis. Radio- Ultrasound
graphic abnormalities that may indicate a patho-
logic process include nodal enlargement beyond Ultrasound is another study that is readily
maximal normal size, clusters of ill-defined nodes, available, inexpensive, noninvasive, and accurate.
and distinctive nodal shapes. Although shape and Conventional B-mode ultrasound has been used
size are no longer considered reliable, round no- with success as an examination tool in the
des tend to be neoplastic and elliptic nodes tend evaluation of benign, inflammatory, vascular,
to be normal or hyperplastic [33]. Contrast- and malignant lesions, as well as in the evaluation
enhanced CT is thought to be superior to MRI and surveillance of thyroid nodules [44–47]. It
in the detection of central nodal necrosis [27]. also can be used in both the pre- and
With the development of fat suppression tech- postoperative phases of treatment. Other
niques, gadolinium enhancement, field strength, techniques, such as contrast-enhanced color
high-resolution microimaging, and stylized sur- Doppler sonography, have also been
face coils, MRI has been reported to be compara- investigated to give information about blood
ble to CT in central nodal necrosis detection flow to lymph nodes. Moritz and col- leagues [48]
[26,34]. MRI is also preferred for targeted imag- showed that characterization of hilar vessels with
ing of a primary site, such as base of tongue, sal- branching indicated lymphadenitis and
ivary glands, and the base of the skull, especially predominately peripheral vessels indicated
when perineural extension is a concern [35]. An- malignancy with very high sensitivities and speci-
other recent advance is that of the use of MRI ficities. The limitation of ultrasound is that it is
imaging to identify pathologic nodes using super- highly operator-dependent and many radiologists
magnetic iron oxide nanoparticles that accumu- inexperienced in ultrasound prefer CT or MRI.
late in normal functioning nodes, giving an Ultrasound is commonly used to direct FNAB
intense signal. The goal is to improve sensitivity techniques to improve the diagnostic yield
in detecting smaller metastatic nodes from reac- [49,50]. Ultrasound is widely used in Europe
tive nodes [36]. for neck mass evaluation and many European
oral- maxillofacial surgery clinics employ
ultrasound as an adjunct to physical
Positron emission tomography
examination.
Positron emission tomography (PET) is
another modality for evaluating the patient with Angiography
a neck mass, especially if metastatic disease is Vascular lesions should be considered when
high dealing with a mass in the head and neck,
especially in the pediatric population [51].
Clinical
 NECK 3
examination is often sufficient for diagnosis when Lymphangiomas (cystic hygromas)
all or a portion of the lesion is superficial. How- The old term for cervical lymphangioma is
ever, the extent of the lesion is often underesti- cystic hygroma. This entity results from a malfor-
mated [52,53]. Deeper lesions of the neck require mation of the lymphatic system in the cervical
imaging and sometimes the study itself can diag- region that leads to proliferation of the vessels in
nose the lesion. For example, angiography of the region and a subsequent mass. These masses
carotid body tumors demonstrates their patho- may encompass a large area of the neck without
gnomonic lyre signs (bowing of the external and true localization to a specific site. Lymphangio-
internal carotid arteries) [54]. Imaging can also mas may be subdivided into macrocystic versus
be essential for treatment feasibility, preoperative microcystic. This distinction is based on the pre-
planning, and sometimes diagnosis. The combined dominant size of the cystic spaces within the
use of angiography, CT, and MRI has been lesion and may impact on the treatment and
described for evaluating hemangiomas, lymphan- resolution of the lesion. Macrocystic lesions are
giomas, arteriovenous malformations, and para- more sus- ceptible to the sclerosing agent OK432
gangliomas. In general, MRI is considered to (picibanil).
give the most diagnostic information regarding
tissue characterization and extension of vascular Branchial cleft cysts
lesions [54,55]. CT and plain radiographic studies Branchial cleft cysts originate from entrapped
are valuable when intraosseous involvement is squamous epithelium and lymphoid tissues during
suspected. However, care must be taken with development of the branchial grooves. There are
lesions involving the mandible because on plain multiple types of branchial cleft cysts ranging
radiography vascular malformations are difficult from type I to type IV. The most common
to distinguish from benign odontogenic tumors, branchial cleft cyst is the type II (second brachial
such as ameloblastomas or myxomas [56]. Both cleft). The location of the second branchial cleft
CT and magnetic resonance angiography can be cyst is in the upper neck deep to the sternocleido-
used for three-dimensional reconstruction. These mastoid muscle with its anterior sinus often
can be helpful in preoperative planning and in exiting anterior to the muscle. These cysts often
some situations can eliminate the need for angiog- present during the younger years of development
raphy [57,58]. Catheter angiography is valuable with the majority presenting before 10 years of
when large vascular connections are suspected or age. One can occasionally see these cysts in
when preoperative delineation of feeding and adults, often after an infection resulting in a rapid
draining vessels for surgery and embolization is enlargement of the cyst and pain. These cysts
needed. Catheter angiography does not, however, are often confused with large necrotic cystic
demonstrate the involvement of the lesion with nodes from tonsilar cancer.
the surrounding tissue [59,60].
Thyroglosal duct cysts
The most common developmental cyst found
Common neck masses in the neck is the thyroglossal duct cyst [61]. This
The following is a short list of common neck cyst originates from a lack of degeneration of the
masses that may be encountered by the surgeon. cystic track from the migration of the thyroid
gland in the neck during development. As such,
Nonneoplastic masses the track may be found anywhere from the fora-
men cecum up to the pyramidal lobe of the
Nonneoplastic masses in the neck may be thyroid. During development, as the thyroid
separated into two broad categories: congenital descends in the neck, it is close to the developing
or infectious. The following is a brief description hyoid bone (Reichert’s cartilage). Given this
of entities that may be placed in the di fferential of fact, the track of the cyst may be present in front,
neck masses. back, or through the central portion of the hyoid
bone. The typical presentation of the thyroglossal
Congenital duct cyst is a large mass in the midline of the neck
Congenital masses are those that were present that moves with swallowing or protrusion of the
since birth. They may have enlarged over a period tongue. The lesion may also present as a lateral
of time but the common thread is the presentation or paramedian mass. A common clinical scenario
at birth. is that of a young person with a recent upper
respiratory track infection and a new neck mass.
 3 LEE &

The resection of these cysts entails the complete 40% to 50% of these have residual telangectasias,
removal of the mass and its track along with the scarring, or atrophic skin that needs treatment.
central portion of the hyoid bone as described Immediate therapeutic intervention is necessary
by Sistrunk [62] (Fig. 2). in patients with lesions that compromise the air-
Vascular lesions way, visual or auditory function, and feeding
Virchow [63] described the first anatomic path- [67]. Many different treatment modalities have
ologic classification of vascular lesions. Our cur- been described, including steroids, cryotherapy,
rent understanding was greatly expanded by the embolization, sclerotherapy, laser, and surgery
work of Mulliken and Glowacki [64], who classi- [68]. Vascular lesions are classified by the type of
fied vascular lesions as hemangiomas and vessel involved and their intravascular flow (ie,
vascular malformations. Hemangiomas are high versus low). Capillary, lymphatic, and ve-
present at birth and rapidly proliferate in the first nous malformations are classified as ‘‘low flow.’’
years of life, fol- lowed by a slow involution. Arterial, arteriovenous malformations and arte-
Vascular malforma- tions are present at birth but riovenous fistulas are considered ‘‘high flow’’
may not be evident and show proportionate [64]. Generally, treatment consists of laser, or em-
growth. Hemangiomas typically are classified as bolization, or both, followed by surgery [68].
capillary, cavernous, and capillary-cavernous.
These lesions are more common in females (3:1) Infectious
and 60% are located in the head and neck [65,66]. Infectious processes may also account for
A large majority of these lesions are not treated enlargement/masses in the neck. These lesions
because of their ten- dency for spontaneously may appear as localized or diffuse. Other causes,
involution. However

Fig. 2. (A) Adult male with enlarging neck mass. (B) CT scan of the central neck mass revealing the large cystic mass in
the central neck consistent with a thyroglossal duct cyst. (C) Surgical resection of the mass via a Sistrunk procedure. (D)
Surgical specimen.
 NECK 3
aside from the routine abscesses originating from may present in the neck as large isolated masses
odontogenic sources or folliculitis, include tuber- present for long periods of time without much
culosis and cat scratch disease (CSD). change over the years. The treatment of these
Tuberculosis benign tumors is a simple excision. Recurrence
During the past 2 decades, tuberculosis was of these tumors is rare (Figs. 3 and 4).
a relatively rare disease. However, with the
continued progression of the HIV and AIDS, Carotid body tumors
a rise in the number of cases has been noted in the A carotid body tumor is a type of a para-
western hemisphere. Tuberculosis has and con- ganglioma. Paragangliomas represent vascular
tinues to be a major health problem for the neoplastic tumors that arise from chemoreceptors
developing world. When present in the neck, this located in the walls of blood vessels or are
disease is referred to as scrofula. associated with specific nerves [73]. The tissue of
origin of these tumors denotes the name given
Cat scratch disease to the tumors. They range from carotid body
The causative organism of CSD is the gram- tumors to jugular paragangliomas. The common
negative bacterium Bartonella henselae. CSD is presen- tation of a carotid body tumor is a neck
one of the common reasons for infectious cervical mass that does not move in a superior-inferior
lymphadenopathy both in adults and children. direction but does in the anterior-posterior
Usually 3 to 10 days after contact with an infected direction. The mass may be pulsatile or present
cat, often a newly acquired kitten, a small papule with a bruit. Angiography used to be the
appears followed by a prolonged period of primary imaging modality for carotid body
regional lymphadenopathy [69]. The workup for tumors. This study would give a characteristic
CSD includes a thorough history and physical appearance referred to as the lyre sign. Today
examination and can be confirmed by serology MR or CT scans may be used to obtain this
(IgG or IgM antibodies against Bartonella) or information. The treatment for these tumors is
bartonella DNA. The treatment for CSD is sup- surgical resection whenever possible,
portive care. A course of antibiotic, often a cepha- depending on tumor size and patient
losporin, may be employed for patients with comorbidities (Fig. 5).
painful or abscessed lymph nodes.
Thyroid nodules and goiters
Neoplastic masses Goiter, the Latin term for throat, describes an
enlargement of the thyroid gland. The type of
Benign lesions goiter can be classified based on its
Tumors in the neck may originate from any epidemiologic, etiologic, functional, or
tissues present in the neck. As such, the tumors morphologic factors. Iodine deficiency is the most
include salivary gland tumors (originating from common factor contributing to the development of
the submandibular gland or tail of the parotid goiter. How- ever, other factors that can play a
gland), nerve sheath and nerve tumors, lipomas, role include elevated thyrotropin, advanced age,
vascular tumors, and others. This simple but often pregnancy, and exposure to lithium. Also, a
forgotten fact will aid in the formulation of a good variant of Hashimoto’s thryoiditis is associated
differential diagnosis for the surgical trainee. with goiters, as is Graves’ disease, and nutritional
goitrogens (eg, cassava) [74]. The World Health
Lipomas Organization has also graded goiters from 0 to 2
Benign lipomatous tumors have been subclas- or 3, based on palpation and size of the goiter.
sified according to their histologic features and Treatment is based on functional disease or
growth pattern into classic lipomas (solitary or compressive symp- toms (to surrounding nerves,
multiple), fibrolipoma, angiolipoma, infiltrating vessels, or organs). Goiters also can be
lipoma, intramuscular lipoma, hibernoma, pleo- substernal, graded from I to III, depending on
morphic lipoma, lipoblastomatosis, and diffuse the position in the mediastinum, necessitating the
lipoblastomatosis [70,71]. Further classification appropriate presurgical planning [75]. In the
has also been done according to either size or United States, surgery is the mainstay of treatment
weight. A tumor is classified as a giant lipoma if but radioactive iodine can be used instead [76,77]
the size is greater than 10 cm in one dimension (Fig. 6).
or the weight greater than 1000 g [72]. Lipomas Thyroid nodules can also present a challenge
to the clinician. Although most thyroid nodules
are benign, evaluation needs to be done to rule out
 3 LEE &

Fig. 3. (A) Patient with a right neck mass in level V. (B) CT scan of the mass revealed a large mass consistent with
a lipoma. (C) Surgical exposure and delivery of the mass. (D) Surgical specimen.

cancer. The workup varies depending on the plasms that can present in the neck.
surgeon and the patient’s presentation. Such
Upper aerodigestive tract cancer
factors as stability and size of nodule, age, sex,
Upper aerodigestive tract cancers include
and history of irradiation all influence the risk of
lesions arising from the oral cavity, nasopharynx,
malignancy [78]. The workup generally consists
hypopharynx, and the larynx. These cancers
of fine needle aspiration (principal tool),
represent about 3% of all cancers. It is predicted
ultrasound, thyroid function tests, and
that in 2008, 47,560 men and women will be
scintigraphy.
diagnosed with this disease. About 90% of these
will be epithelial in nature [81]. Alcohol and
tobacco are the common etiologic factors in the
Malignant neoplasms
development of this disease. Recent studies have
Much like benign tumors of the neck, malig- shown that there is also a link with the human
nant neoplasms can originate from any tissues in papilloma virus. The oral cavity is the most com-
the region, or may present secondary to metastasis mon site for primary tumors of the head and neck,
from distant sites. The possibilities range from with the tongue and floor of the mouth predomi-
metastatic carcinomas (eg, lung, colon, breast) to nating. Several factors influence the presence of
salivary gland malignancies (Fig. 7). An regional metastasis, such as depth of invasion
asymmet- ric, asymptomatic mass in the neck, (O2 mm), site, and stage. As many as 30% of
especially in adults, is always considered a patients present with cervical involvement and
malignancy until proven otherwise. The
occurrence of a malignant process in these lesions
is approximately 30%
[79,80]. We present a short list of malignant neo-
 NECK 3

Fig. 4. (A) A young woman with a long-standing, enlarging neck mass consistent with a lipoma. (B) Surgical delivery of
the mass. Note the superficial location of the mass. (C) Surgical mass.

up to 45% of patients harbor occult metastasis, hypopharynx extends from the hyoid to the post-
usually in levels I, II, or III [82,83]. Nasopharyn- cricoid area and is divided into three subsites: (1)
geal carcinoma is relatively rare in the United the pyriform sinus (the most common site), (2) the
States. However, because of the propensity of lateral/posterior pharyngeal walls, and (3), the
nasopharyngeal carcinoma for cervical metastasis, postcricoid area. Cervical involvement is high
which has been reported as high as 87%, it should and the prognosis is quite poor with these tumors.
not be overlooked [82,83]. Oropharyngeal carci- Laryngeal tumors are divided into (1) supraglot-
nomas most commonly arise at the tonsil and tic, (2) glottic, and (3) subglottic categories. Can-
base of tongue and, because of the abundant lym- cers of the glottis are most common and have the
phoid tissue in this subsite (Waldeyer’s ring), best prognosis. Cervical involvement varies with
lym- phomas often present here as well. the subsite and is highest with supraglottic carci-
Depending on the subsite, there is a 15% to 75% nomas. Supraglottic cancers tend to present later
rate of cervical node involvement and bilateral because the area is difficult to examine and symp-
metastasis is com- mon [82,83]. Large cystic toms (eg, voice hoarseness) don’t arise as early
metastasis from this sub- site is common and can as with glottic cancers. Treatment of upper aero-
be mistakenly diagnosed and treated as a digestive tract cancers depends on the subsite
branchial cleft cyst. As a result, high-risk and involves multimodality therapy consisting of
‘‘unknown primary’’ patients should un- dergo surgery, radiation, and chemotherapy.
tonsillectomy and blind biopsy. The
 3 LEE &

Fig. 5. (A) Elderly patient with a symptomatic right neck mass that, on workup, was found to be a carotid body tumor.
(B) CT of the tumor showed the characteristic displacement of the tumor between the internal and external carotid
branch. (C) Exposure of the tumor taking care to have superior and inferior control of the vessels. (D) Near-complete
removal of the tumor without ligation of the vessels and preservation of the nerves.

Skin cancer multiple local recurrences. The risk of regional

Skin cancers are the most common malignancy nodal involvement for SCCA increases with mul-
in the United States, where basal cell carcinoma tiple recurrences, increased thickness, increased
(BCCA) and squamous cell carcinoma (SCCA) size (larger than 2 cm), more poorly differentiated
represent the majority of lesions treated. These tumors, perineural invasion, and tumor locations
malignancies are highly curable and rarely metas- in scars, burns, and certain sites (eg, temple, ear,
tasize: 0.1% for BCCA and 2% to 5% for SCCA lips) [84–87].
[84,85]. However, specific pathologic features Melanoma, although less common than the
represent an increased likelihood of cervical aforementioned skin cancers, has a mortality rate
spread that should be respected by the clinician. that far surpasses that of SCCA and BCCA. In
Like other head and neck malignancies, lymphatic 2008, 62,480 new cases will be diagnosed and 8420
spread is associated with decreased survival [85]. men and women will die of melanoma [81]. Sev-
For BCCA, most patients with metastatic disease eral staging factors, including depth of invasion,
have the morphea or basosquamous form, dem- site, ulceration, macrometastasis, and number of
onstrate perineural invasion, and are prone to positive nodes, should be considered when
 NECK 3

Fig. 6. (A) Patient with large anterior neck mass with greater extension to the right neck. ( B) Coronal CT of the neck
reveals a large thyroid goiter with significant deviation of the great vessels and the airway. (C) Surgical specimen of the
goiter. Note the large lobulated mass. (D) Neck surgical bed after removal of the goiter.

Fig. 7. (A) Patient with multiple bilateral lower neck nodes. Workup consisting of fine needle aspiration and CT scan
revealed the neck nodes to be metastatic lung carcinoma. (B) Young man with known carcinoid tumor developed nu-
merous neck nodes, which were found to be metastatic nodes on open biopsy.
 3 LEE &

choosing the appropriate therapy [88]. Mucosal the following interventions: total or subtotal
melanoma in the head and neck is rare but highly thyroidectomy, neck dissection, radioiodine
aggressive and lethal. The most common sites are ablation, chemotherapy, and radiation therapy.
the nose, paranasal sinuses, oral cavity, and naso- A detailed discussion thyroid nodule evaluation is
pharynx. These areas should be evaluated in pa- presented in another article of this volume.
tients with cervical lymphadenopathy and no
primary skin lesions. Lymphoma
Salivary gland tumors Cervical adenopathy is among the most com-
The clinician should be familiar with several mon presenting symptoms in lymphoma, occur-
malignant tumors that occur in the salivary ring in 75% of Hodgkin’s and 30% to 40% of
glands. The most common that present as a pri- non-Hodgkin’s patients. It is the most common
mary or metastatic lesion in the neck are mucoe- malignancy in childhood, representing 10% of all
pidermoid carcinoma (MEC) and adenoid cystic malignancies [90]. Hodgkin’s lymphomas are
carcinoma (ACC). MEC is the most common more frequent between 5 and 30 years of age,
salivary gland malignancy and the second most whereas the non-Hodgkin’s forms occur later in
common malignancy of the submandibular gland. life [91]. The nodes tend to be softer, more rub-
MEC is divided into low, intermediate, and high bery, and more mobile than those associated
grades, depending on the ratio of mucin, interme- with metastatic carcinoma. Extranodal involve-
diate, or epithelial cells. Compared to low-grade ment is seen in the head and neck most often in
MEC, high-grade lesions tend to present at a later Waldeyer’s ring and tends to be the non-Hodg-
stage; have higher incidence of nodal kin’s type. Diagnosis is usually achieved by fine
involvement, recurrence, and distant metastasis; needle aspiration followed by open biopsy confir-
and promise lower chances of survival [89]. ACC mation. Therapy depends on the type and stage
is the second most common salivary gland tumor and consists of chemotherapy, or radiation, or
and the most common in the submandibular both.
gland. Most pa- tients present between 30 and 70
years of age. Three histologic subtypes exist: Unknown primaries
cribiform, tubu- lar, and solid. ACC has a
tendency for perineural spread, most often Carcinomas from an unknown primary repre-
affecting the facial nerve or V2 or V3 of the sent a small group of malignancies that pose
trigeminal nerve. Perineural spread can be a significant challenge to the clinician. Patients
centripetal (toward brain) or centrifugal with malignant cervical adenopathy with no
(peripheral), the former making resection immediately apparent primary represent 3% to
difficult. Lymphatic spread is uncommon in ACC. 10% of all head and neck cancers [92]. Most of
There- fore, a mass in the neck would likely the primary tumors occur in the upper
represent the primary lesion. Prognosis is time- aerodigestive tract, but primary sites in the lungs,
dependent and survival does not plateau at 5 abdomen, skin, and urinary tract are possible [93].
years. Even after 20 years mortality continues to Gener- ally, if a patient presents with mid- to
increase. high-jugular nodes, the clinician should suspect a
head and neck origin versus an isolated
Thyroid cancer supraclavicular node, which may be indicative of
a primary below the clavicles, such as in the lungs
In general, thyroid cancer presenting as a neck or gastrointesti- nal tract. The literature reports
mass is uncommon and the prognosis is good, that the primary tumor is found in 10% to 40% of
with the notable exception of anaplastic carci- patients. The most common site for the origin of
noma. The typical cancers of the thyroid are the the primary tu- mor is the palatine tonsil (35%),
well-differentiated carcinomas (WDTCs), medul- base of tongue (26%), lung (17%), and
lary carcinoma, anaplastic carcinoma, and lym- nasopharynx (9%). Other sites, such as the
phoma. The WDTCs are papillary and follicular esophagus, skin, and larynx, con- tribute between
carcinoma. Follicular carcinoma also includes 1% and 4% [94–97]. However, approximately 1%
Hurthle cell and insular carcinomas. Patients to 2% of primary tumors elude diagnosis despite
diagnosed with medullary carcinoma should be repeated FNAB, imaging, and directed
screened for multiple endocrine neoplasia 2A, oropharyngeal biopsies [96]. Generally, the
multiple endocrine neoplasia 2B, and familial workup consists of physical examination; im-
medullary carcinoma. Treatment depends on the aging, including PET scan; biopsy of an affected
cancer and the institution and involves some or all
 NECK 3
node; directed biopsy of the upper aerodigestive [18] Torsiglieri AJ, Tom LW, Ross AJ 3rd, et al. Pediat-
tract; at least ipsilateral tonsillectomy; and ric neck masses: guidelines for evaluation. Int J
panendoscopy. Pediatr Otorhinolaryngol 1988;16(3):199–210.
[19] Ramadan HH, Wax MK, Boyd CB. Fine needle
aspiration of head and neck masses in children.
References Am J Otolaryngol 1997;18(6):400–4.
[20] Liu ES, Bernstien JM, Sculerati N, et al. Fine
[1] Bates B. A guide to physical examination and his- needle aspiration biopsy of pediatric head and neck
tory taking. 6th edition. Philadelphia: J.B. Lippin- masses. Int J Pediatr Otorhinolaryngol
cott Company; 1995. p. 1. 2001;60:135–40.
[2] Suen JY, Goepfert H. Standardization of neck [21] Stevens MH, Harnsberger HR, Mancuso AA, et al.
dissection nomenclature. Head Neck Surg 1987;10: Computer tomography of cervical lymph nodes.
75–7. Staging and management of head and neck cancer.
[3] Shah JP, Strong E, Spiro RH, et al. Surgical grand Arch Otolaryngol 1985;111:735–9.
rounds. Neck dissection: current status and future [22] Kerbele M, Kenn W, Hahn D. Current concepts in
possibilities. Clin Bull 1981;11:25–33. imaging laryngeal and hypolaryngeal cancer. Eur
[4] Fleming ID, Cooper JS, Henson DE, et al. AJCC Radiol 2002;12:1672–83.
cancer staging manual. Philadelphia: Lippincott- [23] Spreer J, Krahe T, Jung G, et al. Spiral versus con-
Raven, 1997. ventional CT in routine examinations of the neck.
[5] Robbins KT, Medina JE, Wolf GT. Standardizing J Comput Assist Tomogr 1995;19:905–10.
neck dissection terminology. Arch Otolaryngol [24] Mukherji SK, Castillo M, Huda W, et al. Compari-
Head Neck Surg 1991;117:601–5. son of dynamic and spiral CT for imaging the
[6] Petrivic Z, Arsovic N, Trivic A. Selective neck dis- glottic larynx. J Comput Assist Tomogr
section for N0 neck supraglottic carcinoma. Int 1995;19:899–904.
Congr Ser 2003;1240:853–8. [25] Suojanen JN, Mukherji SK, wippold FJ. Spiral CT
[7] Martin H, Morfit HM. Cervical node metastases as of the larynx. AJNR Am J Neuroradiol
the first symptom of cancer. Surg Gynecol Obstet 1994;15:1579–82.
1944;78:133–59. [26] King AD, Tse GM, Yeun EH, et al. Necrosis in
[8] Martin HE, Ellis EB. Biopsy of needle puncture met- astatic neck nodes: diagnosis accuracy of CT,
and aspiration. Ann Surg 1930;92:160–81. MR imaging and US. Radiology 2004;230:720–6.
[9] Spearman M, Curtin H, Dusenbury D, et al. [27] Yousem DM, Som PM, Hackney DB, et al. Central
Com- puted tomographyddirected fine needle nodal necrosis and extracapsular neoplastic spread
aspiration of the skull base parapharyngeal and in cervical lymph nodes: MR versus CT imaging.
infratemporal fossa masses. Skull Base Surg Radiology 1992;182:753–9.
1995;5(4):199–205. [28] Vogl T, Dresel S, Juergens M, et al. MR imaging
[10] Smith EH. The hazards of fine-needle aspiration with Gd-DTPA in lesions of the head and neck.
biopsy. Ultrasound Med Biol 1984;10:629–34. J Otolaryngol 1993;22:220–30.
[11] Smallman LA, Young JA, Oates J, et al. Fine [29] Hudgins PA, Gussack GS. MR imaging in the man-
needle aspiration cytology in the management of agement of extracranial malignant tumors of the
ENT patients. J Laryngol Otol 1988;102:909–13. head and neck. Am J Roentgenol 1992;159:161–9.
[12] Engzell U, Zajicek J. Aspiration biopsy of tumors [30] Lewin JS, Curtin HD, Ross JS, et al. Fast spin echo
of the neck. I. Aspiration biopsy and cytologic imaging of the neck: comparison with conventional
findings in 100 cases of congenital cysts. Acta spin echo, utility of fat suppression, and evaluation
Cytol 1970;14: 51–75. of tissue contrast characteristics. AJNR Am J Neu-
[13] Ramzy I, Rone R, Shantz HD. Squamous cells in roradiol 1994;15:1351–7.
needle aspirates of subcutaneous lesions: a [31] Mancuso AA, Harnsberger HR, Muraki AS, et al.
diagnostic problem. Am J Clin Pathol Computed tomography of cervical and retrophar-
1986;85:319–24. yngeal lymph nodes: normal anatomy, variants of
[14] Burgess KL, Hurtwick RWJ, Bedard YC. Metastas- normal, and applications in staging of head and
tic squamous carcinoma presenting as a neck cyst. neck cancers. Radiology 1984;152:749–53.
Differential diagnosis from inflamed branchial cleft [32] Som PM. Lymph nodes of the neck. Radiology
cyst in fine needle aspirates. Acta Cytol 1993;37: 1987; 165:593–600.
494–8. [33] Atula T, Varpula MJ, Kurki TJI, et al. Assessment
[15] Warson F, Blommaert D, DeRoy G. Inflamed bran- of cervical lymph node status in head and neck can-
chial cyst: a potential pitfall is aspiration cytology. cer patients: palpation, computed tomography, and
Acta Cytol 1986;30:201–2. low field magnetic resonance imaging compared
[16] Hehn ST, Grogen TM, Miller TP. Utility of fine with ultra-sound guided fine-needle aspiration
nee- dle aspiration as a diagnostic technique in cytol- ogy. Eur J Radiol 1997;25(2):152–61.
lym- phoma. J Clin Oncol 2004;22:3046–52. [34] King AD, Tse GMK, Yuen EH, et al. Comparison
[17] May M. Neck masses in children: diagnosis and of CT and MR imaging for the detection of extrano-
treatment. Ear Nose Throat J 1978;7:136–58. dal neoplastic spread in metastatic neck nodes. Eur
J Radiol 2004;230:720–6.
 3 LEE &

[35] Wippold FJ 2nd. Head and neck imaging: the role cervical metastases. Arch Otolaryngol Head Neck
of CT and MRI. J Magn Reson Imaging 2007;25: Surg 2000;126:1091–6.
453–65. [50] Sack MJ, Weber RS, Weinstein GS, et al. Image-
[36] Mack MG, Balzer JO, Straub R, et al. Superpara- guided fine-needle aspiration of the head and neck:
magnetic iron oxidedenhanced MR imaging of five years’ experience. Arch Otolaryngol Head
head and neck lymph nodes. Radiology 2002;222: Neck Surg 1998;124:1155–61.
239–44. [51] Watson WL, McCarthy WD. Blood and lymph
[37] Phelps ME. Inaugural article: positron emission to- vessel tumor: a report of 1056. Surg Gynecol Obstet
mography provides molecular imaging of biological 1940;71(5):569–88.
processes. Proc Natl Acad Sci U S A 2000;97: [52] Kaban LB, Mulliken JB. Vascular lesions of the
9226–33. maxillofacial region. J Oral Maxillofac Surg 1986;
[38] Rege SD, Maass A, Chaiken L, et al. Use of 4(3):163–6.
positron emission tomography with fluoro- [53] Gelbert F, Riche MC, Reizine D, et al. MR imaging
deoxyglucose in patients with extracranial head and of head and neck vascular malformations. J Magn
neck cancers. Cancer 1994;73:3047–58. Reson Imaging 1991;1(5):579–84.
[39] Greven KM, Williams DW 3rd, Keyes JW Jr, et al. [54] Westerband A, Hunter GC, Cintora I, et al. Current
Can positron emission tomography distinguish tu- trends in the detection and management of carotid
mor recurrence from irradiation sequelae in patients body tumors. J Vasc Surg 1998;28:84–92.
treated for larynx cancer? Cancer J Sci Am 1997;3: [55] Yonetsu K, Nakayama E, Miwa K, et al. Magnetic
353–7. resonance imaging of oral and maxillofacial angi-
[40] Blodgett TM, Fukui MB, Snyderman CH, et al. omas. Oral Surg Oral Med Oral Pathol 1993;76(6):
Combined PET-CT in the head and neck: part1. 783–9.
Physiologic, altered physiologic and artifactual [56] Flis CM, Connor SE. Imaging of head and neck
FDG uptake. Radiographics 2005;25:897–912. venous malformations. Eur Radiol 2005;15:2185–93.
[41] Fukui MB, Blodgett TM, Snyderman CH, et al. [57] Randoux B, Marro B, Koskas F, et al. Carotid
Combined PET-CT in the head and neck: part 2. artery stenosis: prospective comparison of CT,
Diagnostic uses and pitfalls of oncologic imaging. three- dimensional gadolinium-enhanced MR, and
Radiographics 2005;25:897–912. conven- tional angioagraphy. Radiology
[42] Ng SH, Yen TC, Chang JTC, et al. Prospective 2002;223(2):586–7.
study of [18] fluorodeoxyglucose positron emission [58] Perkins JA, Sidhu M, Manning SC, et al. Three-
tomography and computed tomography and mag- dimensional CT angiography of vascular tumors of
netic resonance imaging in oral cavity squamous the head and neck. Int J Pediatr Otorhinolaryngol
cell carcinoma with palpably negative neck. J Clin 2004;69(3):319–25.
Oncol 2006;24(27):4371–6. [59] Welsh D, Hengerer AS. The diagnosis and
[43] Branstetter BF 4th, Blodgett TM, Zimmer LA, et al. treatment of intramuscular hemangioma of the
Head and neck malignancy: Is PET/CT more accu- masseter muscle. Am J Otolaryngol 1980;1:186–90.
rate than PT or CT alone? Radiology 2005;235: [60] Stanley RJ, Cubillo E. Nonsurgical treatment of ar-
580–6. teriovenous malformations of the trunk and limb by
[44] Quraishi MS, O’Halpin DR, Blayney AW. Ultraso- transcatheter arterial embolization. Radiology 1975;
nography in the evaluation of neck abscesses in chil- 115(3):609–12.
dren. Clin Otolaryngol Allied Sci 1997;22(1):30–3. [61] Al-Khateeb TH, Al Zoubi F. Congenital neck
[45] Bruneton JN, Normand FN, Balu-Maesro C, et al. masses: a descriptive retrospective study of 252
Lymphomatous superficial lymph nodes: US detec- cases. J Oral Maxillofac Surg 2007;65:2242–7.
tion. Radiology 1987;165:233–5. [62] Sistrunk WE. The surgical treatment of cysts of the
[46] Cooper DS, Doherty GM, Haugen BR, et al. Man- thyroglossal tract. Ann Surg 1920;71:121–4.
agement guidelines for patients with thyroid [63] Virchow R. Angiome. In: Virchow R, editor. Die
nodules nad differentiated thyroid cancer. Thyroid krankheiten geschwulste. Berlin: August Hirswald;
2006;16: 109–42. 1863. p. 306–425.
[47] Ahuja AT, Richards P, Wong KT, et al. Accuracy [64] Mulliken JB, Glowacki J. Hemangiomas and vascu-
of high resolution sonography compared with lar malformations of infants and children: a classifi-
magnetic resonance imaging in the diagnosis of cation based on endothelial characteristics. Plast
head and neck venous vascular malformations. Reconstr Surg 1988;69:412–22.
Clin Radiol 2003;58:869–75. [65] Bowers RE, Graham EA, Tomlinson KM. The nat-
[48] Moritz JD, Ludwig A, Oestmann JW. Contrast-en- ural history of the strawberry nevus. Arch Dermatol
hanced color Doppler sonography for evaluation 1960;82:667–80.
of enlarged cervical lymph nodes in head and neck [66] Enjolras O, Riche MC, Merland JJ, et al. Manage-
tumors. Am J Roentgenol 2000;174:1279–84. ment of alarming hemangiomas in infancy: a
[49] Knappe M, Louw M, Gregor RT. Ultrasonography- review of 25 cases. Pediatrics 1990;85:491–8.
guided fine-needle aspiration for the assessment of [67] Low DW. Hemangiomas and vascular malforma-
tions. Semin Pediatr Surg 1994;3(2):40–61.
 NECK 3
[68] Werner JA, Dunne AA, Folz BJ, et al. Current con- [83] Shah JP. Patterns of cervical lymph node metastasis
cepts in the classification, diagnosis, and treatment from squamous cell carcinomas of the upper aerodi-
of hemangiomas and vascular malformations of gestive tract. Am J Surg 1990;160(4):405–6.
the head and neck. Eur Arch Otorhinolaryngol [84] Lo JS, Snow SN, Reizner GT, et al. Metastatic
2001;258:141–9. basal cell carcinoma: report of 12 cases with a review
[69] Ridder GJ, Boedeker CC, Technau-Ihling K, et al. of the literature. J Am Acad Dermatol
Cat-scratch disease: otolaryngologic manifestations 1991;24:715–9.
and management. Otolaryngol Head Neck Surg [85] Rowe DE, Carroll RJ, Day CL Jr. Prognostic fac-
2005;132:353–8. tors for local recurrence, metastasis, and survival
[70] Salvatore C, Antonio B, Del Vecchio W, et al. Gi- rates in squamous cell carcinoma of the skin, ear,
ant infiltrating lipoma of the face: CT and MR im- and lip. Implications for treatment modality selec-
aging findings. AJNR Am J Neuroradiol 2003;24: tion. J Am Acad Dermatol 1992;26:976–90.
283–6. [86] Randle HW. Basal cell carcinoma. Identification
[71] Copcu E, Sivrioglu N. Posterior cervical giant lipo- and treatment of the high-risk patient. Dermatol
mas. Plast Reconstr Surg 2005;115:2156–7. Surg 1996;22:255–61.
[72] Sanchez MR, Golomb FM, Moy JA, et al. Giant li- [87] Barksdale SK, O’Connor N, Barnhill R. Prognostic
poma: case report and review of the literature. J Am factors for cutaneous squamous cell and basal cell
Acad Dermatol 1993;28:266–8. carcinoma. Determinants of risk of recurrence, me-
[73] Perskey MS, Setton A, Niimi Y, et al. Combined tastasis, and development of subsequent skin can-
endovascular and surgical treatment of head and cers. Surg Oncol Clin N Am 1997;6:625–38.
neck paragangliomasda team approach. Head [88] Balch CM, Buzaid AC, Soong SJ, et al. Final
Neck 2002;24:423–31. version of the American Joint Committee on
[74] Meier C. Non toxic goiters. In: Randolph GW, edi- Cancer staging system for cutaneous melanoma. J
tor. Surgery of the thyroid and parathyroid glands. Clin Oncol 2001; 19:3635–48.
Philadelphia: Saunders; 2003. [89] Hicks MJ, el-Naggar AK, Flaitz CM, et al. His-
[75] Shahian DM, Rossi RL. Posterior mediastinal tocytologic grading of mucoepidermoid carcinoma
goiter. Chest 1988;94:599–602. of major salivary glands in prognosis and
[76] Hermus AR, Huysmans DA. Treatment of benign survival: a clinicopathologic and flow cytometric
nodular thyroid disease. N Engl J Med 1998;338: investigation. Head Neck 1995;17:89–95.
1438–47. [90] Bonilla JA, Healy GB. Management of malignant
[77] Maurer AH, Charles ND. Radioiodine treatment head and neck tumors in children. Pediatr Clin
for non-toxic multinodular goiter. J Nucl Med North Am 1989;36:1443–50.
1999;40:1313–6. [91] Dailey SH, Sataloff RT. Lymphoma. An update on
[78] Ross SR. Evaluation and nonsurgical management evolving trends in staging and management. Ear
of the thyroid nodule. In: Randolph GW, editor. Nose Throat J 2001;80:164–70.
Surgery of the thyroid and parathyroid glands. Phil- [92] Adams JR, O’Brien CJ. Unknown primary squa-
adelphia: Saunders; 2003. mous cell carcinoma of the head and neck: a review
[79] Jereczek-Fossa BA, Jassem J, Orecchia R. Cervical of diagnosis, treatment and outcomes. Asian J Surg
lymph node metastasis of squamous cell carcinoma 2002;25:188–93.
from and unknown primary. Cancer Treat Rev [93] Talmi YP, Wolf GT, Hazuka M, et al. Unknown
2003;30:135–64. primary of the head and neck. J Laryngol Otol
[80] Koivunen P, Laranne J, Virtaniemi J, et al. Cervical 1996;110:353–6.
metastasis of unknown origin: a series of 72 [94] Altman E, Cadman E. An analysis of 1539 patients
patients. Acta Otolaryngol 2002;122:569–74. with cancer of unknown primary site. Cancer 1986;
[81] Ries LAG, Melbert D, Kraphcho M, et al, editors. 57:120–4.
SEER cancer statistics review 1975–2005. [95] Chepeha D, Koch W, Pitman K. Management of
Bethesda (MD): National Cancer Institute; based on un- known primary tumor. Head Neck
Novem- ber 2007 SEER data submission, posted to 2003;25:499–504.
the SEER website, 2008. Available at: [96] Gunthinas-Linhius O, Klussman P, Dinh S, et al.
http://seer.can- cer.gov/csr/1975_2005/. Diagnostic work-up and outcome of cervical metas-
[82] Lindberg R. Distribution of cervical lymph node tasis from an unknown primary. Acta Otolaryngol
metastasis from squamous cell of the upper re- 2006;126:536–44.
spiratory and digestive tract. Cancer 1972;29: [97] Hass I, Hoffman TK, Engers R, et al. Diagnostic
1446–9. strategies in cervical carcinoma of an uknown
primary (CUP). Eur Arch Otorhinolaryngol 2002;
259:325–33.