If the patient is aged < 40 years and lymph nodes have been present for less than 2 to 4 weeks, are tender, or are associated with fever or poor dental hygiene, then an infection may instead be the cause. Dentistry referral and/or an antibiotic trial should be considered. Lymphomas, also common in the neck, may be accompanied by “B symptoms” (fever, night sweats, unintentional weight loss of > 10%). 24 If lymphoma is suspected, fine-needle aspiration (FNA) for cytology and flow cytometry should be performed. If lymphoma is confirmed, the GP should refer the patient to an appropriate medical oncologist for further evaluation, which may include referral to Oto-HNS for core or open biopsy. Contraindications to FNA of a neck mass include paragangliomas, such as a carotid body tumor.
Other cancers of the upper aerodigestive tract also often spread to the neck nodes and may initially present as a neck mass. A thorough examination can usually point to the primary cancer, and FNA will provide the diagnosis with high specificity and sensitivity. 25 Midline cystic neck masses in close proximity to the hyoid bone are likely thyroglossal duct cysts. If these cysts grow, they likely require removal.
Salivary glands. The submandibular, sublingual, and parotid are the major salivary glands. There also are hundreds of small salivary glands scattered through the oral and pharyngeal mucosa. Tumors arising from the salivary glands represent about 6% of all head and neck masses; these tumors are nearly 3 times more common in men than in women. 26 About 80% of salivary gland tumors originate in the parotid gland; patients with such tumors typically present with a painless parotid mass. 26 In advanced cases, patients may present with skin infiltration and facial paralysis secondary to involvement of
the facial nerve that courses through the parotid gland after it exits the temporal bone near the mastoid tip.
Salivary gland tumors are most commonly benign, and pleomorphic adenomas are the most common benign parotid neoplasm. 27 The incidence of malignancy is highest in submandibular, sublingual, and minor salivary glands. There are numerous primary salivary gland malignancies, such as mucoepidermoid carcinoma, adenocarcinoma, and adenoid cystic carcinoma. Facial skin SCC may metastasize to periparotid nodes. There are also multiple nonneoplastic causes of salivary gland inflammation. Recurrent diffuse, painful gland enlargement may be suggestive of recurrent sialadenitis and may be
secondary to a stone or xerostomia associated with dehydration or use of diuretics, antidepressants, or lithium. Multiple lymphoepithelial cysts may be associated with HIV and do not require resection. 28
Management
After taking a thorough history and performing a physical examination, the physician evaluating a patient for HNC should proceed with diagnostic testing followed by referral to a specialist.
Diagnostic Testing
Laboratory values. Although laboratory values are unlikely to help in evaluation of a malignancy, elevated white blood cell count, erythrocyte sedimentation
rate, and C-reactive protein level are markers of a general inflammatory process that may support a clinically suspected diagnosis of infection. Values that decrease over time may represent progress toward disease resolution. 29
