West Visayas State University – College of Medicine – Batch 2020

Block XX
Module 3 Head and Neck Tumors
Lecture 1
04/ 22/ 19
Dr. J.P. Ambos

TOPIC OUTLINE
I. Objectives
II. Anatomic Considerations
III. General Considerations
IV. Diagnostic Evaluation
V. Tests
VI. Congenital and Developmental Disorders
VII. Primary Tumors
Supplementary Notes
Review Questions
References

LECTURER BOOK REFERENCE OLD TRANS

I. OBJECTIVES
• Review the anatomy of head and neck Figure 2. The triangles of the neck is divided by the
• To know the different head and neck masses sternocleidomastoid into anterior and posterior triangles. Source: Doc’s
Lecture
• To know the different Diagnostic modalities
• Management of Head and Neck Masses A. ANTERIOR TRIANGLES
• Boundaries:
II. ANATOMIC CONSIDERATIONS Superiorly: Body of the mandible
• Disclaimer: doc was mainly showing images for this Posteriorly: Sternocleidomastoid Muscle
part of the lecture and briefly mentioning general terms Anteriorly: Midline of the neck
and to take note of the following – prominent Subdivided:
landmarks, triangles of the neck, and lymphatic vessels ─ Carotid triangle
• Boundaries of the Neck ─ Digastric triangle
Superiorly: Pericraniocervical line ─ Submental triangle
Inferiorly: Level of the clavicle, scapula and thoracic ─ Muscular triangle
inlet (first rib and superior manubrium)
The spines of the second and seventh cervical CAROTID TRIANGLE
vertebrae are the most prominent • Covered by the skin, superficial fascia, platysma and
deep fascia containing branches of the facial and
cutaneous cervical nerves.
• Limited by:
Posteriorly: Sternocleidomastoid
Anteroinferiorly: Superior belly of omohyoid
Superiorly: Stylohyoid and the posterior belly of
digastric.
Floor: Parts of thyrohyoid, hypoglossus and inferior
and middle pharyngeal constrictor muscles
• Contains:
Upper part of the common carotid artery and its
division into
─ External and internal carotid arteries
─ Internal Jugular Vein
─ Hypoglossal Nerve, Vagus Nerve

Figure 1. Note the prominent landmarks, the triangles of the neck and
the lymphatic levels. Source: Doc’s Lecture
What is present in your carotid triangle?
Jugular vein, carotid artery and vagus nerve
DIGASTRIC TRIANGLE
• Covered by the skin, superficial fascia, platysma and
deep fascia, which contain branches of the facial and
transverse cutaneous cervical nerves

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• Limited by: SUPRACLAVICULAR TRIANGLE
Superiorly: the lower border of the mandible and its • Shares the same boundaries, except that superiorly it
projection to the mastoid process is limited by the omohyoid.
Posteroinferiorly: posterior belly of digastric and by • It corresponds to the greater supraclavicular fossa.
stylohyoid • Its floor contains the first rib, scalenus medius and the
Anteroinferiorly: anterior belly of digastric first slip of serratus anterior.
Floor: formed by mylohyoid and hyoglossus • The trunks of the brachial plexus may easily be
• Contains: palpated here if the neck is contralaterally flexed
Anterior region:
─ Submandibular gland, which has the facial vein
superficial to it and the facial artery deep to it.
─ Submental and mylohyoid arteries and nerves
Posterior region:
─ Lower part of the parotid gland.
─ External carotid artery
─ internal carotid artery, internal jugular vein and
vagus nerve

SUBMENTAL TRIANGLE
• Demarcated by:
Anterior bellies of both digastric muscles
Apex is at the chin,
Base is the body of the hyoid bone
Floor is formed by both mylohyoid muscle
• Contains lymph nodes and small veins that unite to Figure 3. The anterior and posterior triangles of the neck. Source:
form the anterior jugular vein. Doc’s Lecture.

C. CAROTID SHEATH
MUSCULAR TRIANGLE
• The carotid sheath is a local condensation of the
• Bounded by:
prevertebral, the pretracheal, and the investing layers
Anteriorly: median line of the neck from the hyoid
of the deep fascia that surround the common and
bone to the sternum,
internal carotid arteries, the internal jugular vein, the
Inferoposteriorly: the anterior margin of
vagus nerve, and the deep cervical lymph nodes.
sternocleidomastoid
posterosuperiorly by the superior belly of omohyoid
D. ARTERIAL SUPPLY
• Contains:
Omohyoid, sternohyoid, sternothyroid and
thyrohyoid

B. POSTERIOR TRIANGLES
• Boundaries:
Posteriorly: Trapezius muscle
Anteriorly: Sternocleidomastoid muscle
Inferiorly: Clavicle
• Subdivided by the inferior belly of the omohyoid muscle
into
Occipital triangle
Supraclavicular triangle

OCCIPITAL TRIANGLE
• Same boundaries with posterior triangle except that Figure 4. The major arterial supply of the neck. Source: Doc’s Lecture
inferiorly it is limited by the inferior belly of omohyoid
RIGHT SUBCLAVIAN ARTERY
• Floor, is formed by splenius capitis, levator scapulae,
• For description, divided into:
and scalene medius and posterior; semispinalis capitis
First part, from its origin to the medial border of
occasionally appears at the apex.
scalenus anterior;
Second Part, behind scalenus anterior

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 third part from the lateral margin of scalenus
anterior to the outer border of the first rib, where
the artery becomes the axillary artery.

VERTEBRAL ARTERY
• Arises from the superoposterior aspect of the 1st part
of subclavian artery.

INTERNAL THORACIC ARTERY

• Arises inferiorly from the first part of the subclavian
artery.

THYROCERVICAL TRUNK
• It is a short, wide artery that arises from the front of the
first part of the subclavian artery and divides almost at
into the inferior thyroid, suprascapular and superficial
cervical arteries.
Cervical portion of the common carotid artery at the
level of the upper border of the thyroid cartilage (C4),
the common carotid artery bifurcates into external
and internal carotid arteries
Figure 6. The major arteries that supply the head and neck region.
Source: Doc’s lecture.
E. VENOUS DRAINAGE
• The veins of the neck lie superficial or deep to the deep
investing fascia.
• Superficial veins ultimately drain into either the
external, anterior or posterior external jugular veins
• Deep veins tend to drain into either the internal jugular
vein or the subclavian vein.

F. NERVE SUPPLY

Figure 5. The common carotid artery bifurcates into internal carotid

artery and external carotid artery at the level of thyroid cartilage.
Source: Doc’s lecture.
Figure 7. Cutaneous nerves of the head and neck. Source: Doc’s
EXTERNAL CAROTID ARTERY Lecture.
• External Carotid Artery gives off the ascending
pharyngeal, superior thyroid, lingual, facial, occipital
and posterior auricular arteries, and then enters the
parotid salivary gland where it divides into its terminal
branches, the superficial temporal and maxillary.
• It supplies the face, scalp, tongue, upper and lower
teeth and gingivae, palatine tonsil, paranasal sinuses
and nasopharyngeal tube, external and middle ears,
pharynx, larynx and superior pole of the thyroid gland

Figure 8. The branches of the cervical plexus. Source: Doc’s lecture.

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 G. LYMPHATIC DRAINAGE
• Lymph node levels of the neck:
Level I – submental and submandibular
Level II – upper jugular chain nodes
Level III – middle jugular chain
Level IV – lower jugular chain
Level V – posterior triangle nodes
Level VI – anterior compartment nodes – includes
the precricoid (Delphian) node
Level VII – paratracheal nodes
Figure 9. Swollen lymph nodes in the neck are a common source of
neck pain. Source: Doc’s Lecture.
Figure 10. Lymph vessels and nodes of the oral and pharyngeal
regions. Source: Gray’s Anatomy.
From Gray’s:
• Level I nodes
Lie in the Submandibular triangle
The group includes the pre and post glandular
nodes, and the pre- and post-vascular nodes. The
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Submandibular gland is included in the specimen
when the lymph nodes within this triangle are
removed.
• Level II (upper jugular) nodes
lie around the upper portion of the internal jugular
vein and the upper part of the accessory nerve.
• Level III (middle jugular) nodes
lie around the middle third of the internal jugular
vein from the inferior border of level II to the
superior belly of omohyoid or cricothyroid
membrane.
• Level IV (lower jugular) nodes
lie around the lower third of the internal jugular vein
from the inferior border of level III to the clavicle.
• Level V (posterior triangle) nodes
lie around the lower part of the accessory nerve
and the transverse cervical vessels.
• Level VI Anterior (Central) Compartment Group-lymph
nodes in this compartment
Includes the pre- and paratracheal nodes, the
precricoid (Delphian) node, and the perithyroidal
nodes, including the lymph nodes along the
recurrent laryngeal nerves.
The superior boundary is the hyoid bone, the
inferior boundary is the suprasternal notch, and the
lateral boundaries are the common carotid arteries.
LYMPH NODE DISSECTION (NOT DISCUSSED)
• The classic radical neck dissection involved a thorough
clearance of levels I–V, including the sacrifice of
sternocleidomastoid, the internal jugular vein and the
accessory nerve.
• Modified radical neck dissections (so-called functional
neck dissections) still remove level I–V nodes but
spare either or all of sternocleidomastoid, the internal
jugular vein and the accessory nerve.
• Selective neck dissections remove selected groups of
nodes, e.g. the supra-omohyoid neck dissection
removes level I–III nodes,
• Lateral neck dissection removes level II–IV nodes
• Posterolateral neck dissection removes level II–V
nodes.
• The location and incidence of metastasis vary
according to the primary site.
• Primary tumors within the oral cavity and lip
metastasize to the nodes in levels I, II, and III.
• Skip metastases may occur with oral tongue cancers
such that involvement of nodes in level III or IV may
occur without involvement of higher echelon nodes
(levels I & II). T
• Tumors arising in the oropharynx, hypopharynx, and
larynx most commonly spread to the lymph nodes of
the lateral neck in levels II, III, and IV.
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• Malignancies of the nasopharynx and thyroid
commonly spread to level V nodes in addition to the
jugular chain nodes
• Retropharyngeal lymph nodes are sites for metastasis
from tumors of the nasopharynx, soft palate, and
lateral and posterior walls of the oropharynx and
hypopharynx.
• Tumors of the hypopharynx, cervical esophagus, and
thyroid frequently involve the paratracheal nodal
compartment, and may extend to the lymphatics in the
upper mediastinum (level VII).
• The delphian node, a pretracheal lymph node, may
become involved by advanced tumors of the glottis
with subglottic spread.
Figure 11. Prominent landmarks. Source: Doc’s Lecture
Figure 12. Prominent landmarks in relation to the vessels. Source:
Doc’s lecture
PROMINENT LANDMARKS
Hyoid Bone
Hyoid bone body- felt in the midline neck a few
centimeters below and behind the chin, at the
junction of the skin of the anterior neck and the floor
of the mouth. Sits level with the fourth cervical
vertebra (range C3–C5/6) it is higher in children.
The greater horns may be palpated between a finger
and thumb, and moved from side to side
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Thyroid Cartilage
The upper border lies between the fourth and fifth
cervical vertebrae
The laryngeal prominence (Adam’s apple) of the
thyroid cartilage is palpable in the midline neck
Prominent in Males
Thyroid laminae can be felt passing posterolaterally
Cricoid Cartilage
The firm, smooth anterior arch of the cricoid cartilage
is palpable below the inferior border of the thyroid
cartilage
The inferior border of the Cricoid commonly sits at
the level of the seventh cervical vertebra (rangeC5–
T1); the posterior cricoid overlaps the sixth cervical
vertebra.
The indentation between the thyroid and cricoid
cartilages is covered by the anterior/median
cricothyroid ligament, punctured during cricothyroid
puncture or cricothyroidotomy.
The clavicle - palpable in all except the morbidly
obese
The suprasternal (jugular) notch lies between the
expanded medial ends of the clavicles
The posterior end of the first rib may be felt
indistinctly within the floor of the posterior triangle of
the neck.
III. GENERAL CONSIDERATIONS
• Patient’s age group
• Location of neck mass
• Associated manifestations
A. PEDIATRIC AGE GROUP
• 0-15 years old
• Common location – midline and anterior neck
• Inflammatory – most common in this age group
Adenitis (bacterial, viral granulomatous) 
Granulomatous could be TB which presents with
primary complex
• Congenital/ Developmental – 2nd in incidence
Thyroglossal duct cyst, Dermoid, Laryngocoele
• Neoplastic – Thyroid Lymphoma
only seldom
B. YOUNG ADULT GROUP
• 16-40 years old
• Common location – Anterior Triangle
• Inflammatory
Adenitis (bacterial, viral granulomatous)
Most common in this age group
• Sialadenitis (parotid, submaxillary)
• Congenital/Developmental
Branchial Cyst, Thymic Cyst
• Sialadenopathy (parotid, submaxillary)
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 Submaxillary aka submandibular B. PHYSICAL EXAMINATION
• Neoplastic
Thyroid, Lymphoma, Metastatic (upper jugular,
oropharynx oral cavity larynx, lower jugular,
submaxillary)
• Primary vascular

C. OLDER ADULT GROUP

• 40 years old and up
• Common location – Posterior Triangle Figure 14. Physical Examination. Source: Dr lecture
• Inflammatory – Adenitis
• Congenital – lymphangioma, cystic hygroma • Visualization and palpation of mass
May present at this age because those that are not Most important
prominent before are slow growing and may Location
accumulate fluid Size and number
• Neoplastic – most common in this age group Relationship to surrounding structures
Thyroid, Lymphoma, Metastatic Consistency – e.g. rubbery, firm
Presence of pulsations and thrills
Due to AV malformations
Associated tenderness
Drainage/Bleeding
• Auscultation for bruits
• Detection of unusual smells
Abscesses smells like death (refers to anaerobes)
• Evidence of source of infection or malignancy
elsewhere in the head and neck
If tender may be benign, due to infection
• Pan Endoscopy
Figure 13. Common lesions involving the neck. Source: Doc’s Lecture

IV. DIAGNOSTIC EVALUATION

• History
• Physical examination
• Tests:
CT
MRI
Biopsy

A. HISTORY
• Age
• Rate of growth
If fast may be malignant Figure 15. Neck Mass. Source: Dr lecture

• Previous malignancy of head and neck V. TESTS

• Episode of infection/inflammation A. ULTRASOUND
• Previous radiation to the head and neck • Differentiate solid from cystic masses
• Associated symptoms related to the upper • Increasing use in guided fine-needle aspiration biopsy
aerodigestive tract • Operator-dependent results
Will present with dyspnea, paralysis or hoarseness
B. ANGIOGRAPHY
• Injection of dye
• Useful to evaluate vascularity, specific blood supply

C. CT
• Provides information on physical characteristics and
vascularity
• Defines relationship to surrounding structures
• Provides information in bony abnormalities

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 Maxillofacial trauma, sinuses VI. CONGENITAL AND DEVELOPMENTAL
May also inject dye DISORDERS
A. BRANCHIAL CLEFT CYST
D. MRI
• Provide information on physical characteristics and
vascularity
• Define relationship to surrounding structures
• Provides information on soft tissue abnormalities
• Better delineation of submucosal diseases
Usually mucous secretion

E. BIOPSY
Figure 17. Brachial cleft cyst. Source: Dr lecture
• Definitive diagnostic test of preference
Fine-Needle Aspiration Biopsy • Vestigial remnants of fetal branchial apparatus from
Punch Biopsy which all neck structures are derived
Open (incision, excision) • Present as smooth, painless, slowly enlarging masses
along the anterior border of the sternocleidomastoid
Table 1. FNAB. Source: Doc’s lecture • Usually present between ages 20-30
Internal tracts open into the tonsil (2nd) or pyriform
sinus (3rd or 4th) or ear (1st)
Inflammation treated prior to removal
2nd branchial cleft cyst most common
These benign cysts usually appear on the upper
lateral aspect of the neck along the
sternocleidomastoid muscle. Contents of the cyst
Standard of care for initial biopsy
maybe clear and watery or mucinous and may
• For confirmation of cervical metastasis for staging and
contain desquamated, granular cellular debris. Cysts
decision-making in treatment
enlarge slowly, are rarely site of malignant
• For histologic diagnosis prior to non-surgical treatment
transformation, and generally readily excised
• In patients with unknown neck mass
• To allay fears in overly anxious patients and allow time
Treatment
for observation
• Initial Control of infection and Complete surgical
excision
Open Biopsy
• More invasive
B. THYROID GLOSSAL DUCT CYST
• Higher risk of seeding
More frequent distant metastasis
More regional recurrences
Increased local wound complications

Figure 18. Thyroid glossal duct cyst. Source: Dr lecture

• Vestigial remnants of tract migration of thyroid gland

from foramen cecum to the anterior neck
• Present as midline cysts anywhere from the base of the
tongue to superior border of the thyroid gland
• Adherent to hyoid bone
• Onset: Childhood and follows an upper respiratory
Figure 16. Flexible laryngoscopy. Source: Dr lecture infection
• Location: Midline of the neck
• Test: Tongue protrusion
• Scans: Ultrasound

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 The diagnosis usually is established by observing a
1- to 2- cm, smooth, well-defined midline neck mass
that moves upward with protrusion of the tongue.
Review: Thyroid gland
Arises from a ventral midline diverticulum of floor of
the pharynx
Migrates caudally along a path ventral to hyoid,
curves beneath and behind it and down to cricoid
area
Treatment
• Complete excision of cyst and tract with removal of
the central portion of the hyoid
What is the procedure called?
Sistrunk procedure – decreased recurrence
Treatment involves the “Sistrunk operation” which
consists of en bloc cystectomy and excision of the
central hyoid bone to minimize recurrence.
Approximately 1% of thyroglossal duct cysts are
found to contain cancer, which is usually papillary
(85%).
Squamous, Hürthle cell, and anaplastic cancers also
have been reported but are rare. Medullary thyroid
cancers (MTCs) are, however, not found in
thyroglossal duct cysts.
C. LYMPHANGIOMA
Figure 19. Lymphangioma. Source: Dr lecture
• Lymphatic malformation: Usually presents by age 2
• Present as painless cysts in the posterior triangle,
transilluminate
• Sudden increase in size with upper respiratory
infections, infections of the mass itself, hemorrhage
Arise from incomplete development and obstruction
of lymphatic system
80% present in the posterior triangle
>90% evident by 1st year of life
May be treated expectantly in absence of pressure
symptoms or gross deformity because spontaneous
regression has been known to occur.
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Treatment
• Expectant management (if without infection) and
Complete surgical excision
Same with cystic hygroma due to lymphatics
D. CERVICAL LYMPHADENOPATHY
• Most common type of neck masses encountered
• May arise from acute infections, chronic infections and
cervical metastasis
Acute infections - lymphadenitis
Common in 1st decade of life
From mouth or pharynx
Fever, malaise, sore throat
Antibiotics (penicillin)
Chronic infections
Tuberculosis, fungal disease, syphilis, sarcoidosis,
cat scratch fever, AIDS
Skin tests and serology more useful than biopsy
Medically managed
E. CERVICAL MALIGNANCY
• Suspected in a firm, non-tender, enlarging mass in an
older individual
• Primarily usually located in the head and neck,
especially for nodes in the upper 2/3 of the neck
• Primary may be occult in up to 15% of cases
Usually malignant
Hazards: radiation and chemicals
• Oral Cavity and oropharynx– (lymphadenopathy)
submandibular node
• Nasopharynx – high jugular posterolateral node
• Larynx & hypopharynx – Jugular & Delphian nodes
• Ears and Parotid – pre or post-auricular node
• Sentinel nodes/Virchow’s node – GIT
F. UNKNOWN PRIMARY
• Histologic evidence of malignance in the neck without
an apparent site of origin.
• Any unknown neck mass in adults must be considered
metastatic until proven otherwise
• Primary cervical malignance is rare
Diagnosis is made after a thorough physical
examination and a complete diagnostic evaluation.
Early detection  early management  good
prognosis
Accounts for only 5% of all head and neck cancers
5-year survival rate has been reported to be as high
86% (Fermont, 1980) depending on: Stage of
Disease
Histology
Source of metastases (if from the head and neck vs.
an infraclavicular origin)
• Squamous cell carcinoma (74-81%)
74% from head and neck primaries
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 11% from outside the head and neck Table 3. Location of Node and probable primary sites.
15% remained unknown Source: Doc’s lecture.
• Adenocarcinoma (7-22%) Location of Node Possible Primary Site
• Undifferentiated Carcinoma (10%) High in the neck Nasopharynx
• Melanoma (8%) Posterior triangle -do nasophryngoscopy
SCC – most common cancer with cervical Jugulodigastric
Tonsil, base of tongue, supraglottis
metastases muscle
Adenocarcinoma – 65% with primaries outside the Upper aerodigestive tract, trachea,
Supraclavicular area
bronchus, breast, genitourinary tract,
head and neck, from thyroid, salivary glands, GIT in Level IV
thyroid
women, breast or pelvic tumors
Tonsillectomy
Diagnostics • Advised in absence of suspicious lesions 19-25% of
• Fine needle aspiration occult primaries eventually detected in tonsils
• Open biopsy • Bilateral tonsillectomy correlated with significant
• Computed tomography improvement in survival rate
• Magnetic resonance imaging
G. SQUAMOUS CELL CARCINOMA
Endoscopy with guided biopsy
• 16% identification rate
• Most common sources for SCC: pyriform sinus,
tonsils, base of tongue, nasopharynx
Obvious lesions must be biopsied
Directed biopsies toward most common sources

Table 2. Unknown primary tumor probable sites. Source: Dr

lecture.
Level Possible Primary Site
I Oral cavity, submandibular
Nasopharynx, oropharynx, parotid,
II
supraglottic larynx Figure 20. Squamous cell carcinoma. Source: Dr lecture

III Orophayrnx, hypopharynx, supraglottic larynx

UNKNOWN PRIMARY LESIONS
Subglottic larynx, hypopharynx, esophagus, Squamous Cell Carcinoma
IV
thyroid • N1 – surgery or radiation alone
V Nasopharynx, Oropharynx • N2 – previous excisional biopsy surgery with post-
operative radiation
VI and VII Thyroid, larynx, lung

Bilateral Soft palate, tongue, epiglottis, nasopharynx Adenocarcinoma

• Neck dissection +/- radiation

Positron Emission Tomography Poorly Differentiated Carcinoma

• Not of any significant advantage primary versus CT or
MRI
• No benefit in detecting additional tumors over
conventional work-up
• Fused PET/CT able to detect more tumors than CT or
PET alone, but not significantly
• Detected 24.5 % of tumors undetected by conventional
work-up
• Intensive chemotherapy
KNOWN PRIMARY LESIONS
• Managed according to principles for primary site
• Complete cervical lymphadenectomy
Radical neck dissection: lymph nodes, fats, internal
jugular vein and sternocleidomastoid
May also do modified neck dissection
• Search for secondary primary in
Larynx — Lung
Tonsils — Esophagus
Oral cavity — Oral Cavity

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 VII. PRIMARY TUMORS
A. THYROID NEOPLASMS/MALIGNANCIES
Figure 21. Thyroid neoplasm. Source: Doc’s lecture
• Leading cause of masses in the anterior neck in all age
groups
• Lymph node metastases – initial symptom in 15% of
papillary carcinoma
• Treatment: Thyroidectomy
EPIDEMIOLOGY
• Increasing incidence is almost completely attributable
to papillary thyroid cancer
• Increasing incidence is also due largely to
improved/increased detection methods
• Only 5% of thyroid nodules are malignant
• Younger and older patients are more likely to have a
malignant thyroid nodule
• Patients younger than age 20 years have 20-50%
incidence of malignancy when presenting with a single
thyroid nodule
HISTOLOGY OF THYROID MALIGNANCIES
• Papillary (79%)
• Follicular (13%)
• Hurthle cell (3%)
• Medullary (4%)
• Anaplastic thyroid cancer – very aggressive; patient will
last for 6 months
RISK FACTORS FOR THYROID CANCER
• Age
• Sex (female) – 3x more likely to develop papillary
thyroid carcinoma (PTC)
• Exposure to radiation – the only established
environmental risk for thyroid cancer
Thyroid nodules with radiation history have 50%
incidence of malignancy
Higher risk in exposure to children compared with
adults
1986 Chernobyl accident conferred a 60-fold
increased risk in children
• Family history of thyroid cancer – approximately 6% of
patient with papillary thyroid CA have familial disease
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PAPILLARY THYROID CA MANAGEMENT
• Thyroglobulin level monitoring
• Routine neck ultrasound monitoring
• Neck management – elective lateral neck dissection is
not recommended unless N+ disease is documented
Central neck dissection
Level VI boundaries: carotid to carotid and hyoid to
innominate artery
Recommended for N+ disease
Recommended for palpable or visualized disease
during surgery
Controversial for N0 disease
Compartmental dissection (not selective node
plucking) is recommended
Incidence of recurrence over years
• Thyroid bed recurrence: 5-6%
• Regional lymphatic recurrence: 8-9%
• Distant site recurrence: 4-11%
Recommendation for Radioactive Iodine (RAI)
depends on risk profile and risk of recurrence
Adjuvant treatment
• Thyroid stimulating hormone (TSH) suppression
Long-term levothyroxine administration to suppress
TSH and therefore possible recurrence or
progression of thyroid cancer
Goal TSH of <0.1 for intermediate to high risk
patients
Goal TSH of 0.1 – 0.5 for low risk patients
Radioactive Iodine (RAI)
Dosage:
• Typically 100 mCi for residual thyroid bed uptake
• Typically 100-200 mCi for regional or distant disease or
aggressive subtypes
• No clear evidence on whether fixed amounts versus
quantitative tumor dosimetry tailored to patient is
superior
B. LYMPHOMAS
• Occur in all age groups
• Large percentage of neoplasms in the pediatric and
young age groups
• Present as cervical lymphadenopathy
• Treatment: Radiotherapy and/or chemotherapy
C. SALIVARY NEOPLASMS
• Present as solid mass in front of or below the ear, at
angle of the mandible, or in the submandibular triangle
• Pain, rapid growth, facial nerve symptoms suggest
malignancy
Most common is pleomorphic adenoma
These tumors are relatively uncommon and represent
less than 20% of all tumors in humans.
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 About 65 to 80% arise from the parotid, 10% in
submandibular, and remainder in minor salivary
glands.
• Treatment: Complete excision of submandibular
gland and superficial parotidectomy
Distribution of Salivary Neoplasms
• Parotid: 70% (75% benign and 25% malignant)
• Submandibular: 22% (57% benign and 43% malignant)
• Minor salivary: 8% (18% benign and 85% malignant)
Histology
Benign
• Pleomorphic adenoma (45%)
• Warthin tumor (6%)
• Benign cyst (1.0%)
Malignant
• Mucoepidermoid carcinoma (15.7%)
• Adenoid cystic carcinoma (10.0%)
• Adenocarcinoma (8.0%)
• Malignant mixed tumor (5.7%)
• Acinic cell carcinoma (3.0%)
• Present as firm, round, pulsatile, slowly-growing
masses at carotid bifurcation
• Treatment: Excision, expectant treatment,
Angiography with embolization
PARAGANGLIOMA
Paraganglia are clusters of neuroendocrine cells
associated with the sympathetic and parasympathetic
nervous systems.
Carotid body tumor is a prototype of a
parasympathetic paraganglioma. Chiefly composed
of nests (zellballen) of round to oval chief cells
(neuroectodermal in origin) that are surrounded by
delicate vascular septae.
E. SCHWANNOMAS
• Arise from neurilemmal (Schwann) cells of myelinated
nerves
• Present as painless, slowly enlarging masses in the
lateral neck
• Treatment for Schwannomas: Excision
SUMMARY

Symptoms suggestive of malignancy

• Most malignant salivary tumors present only with a
painless mass
• Pain
• Facial nerve paresis or paralysis
• Tongue weakness or numbness (submandibular
malignancies)
• Fixation of mass to overlying skin or underlying
structures

PLEOMORPHIC ADENOMA
• The tumor is well circumscribed by a fibrous capsule
and is sharply demarcated from the adjacent parotid
gland tissue
• The tumor consists of a combination of myoepithelial
cells and small ducts within a chondromyxoid stroma
• Pleomorphic adenoma is the most common benign
salivary gland tumor

BASAL CELL ADENOMA

• The tumor is well circumscribed and is composed of
variably shaped nests of cytologically bland basaloid
cells arranged in a “jigsaw puzzle” pattern
• The tumor cell nests are surrounded by an acellular
eosinophilic basement-membrane-like material
• Nuclear palisading is noted at the periphery of tumor
Figure 22. Algorithm for Neck Mass and its Management. Source:
cell nests Doc’s lecture.

D. CAROTID BODY TUMORS

• Derived from chemoreceptive tissues

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 SUPPLEMENTARY NOTES FROM UPCLASS
A. SKELETAL STRUCTURES
Paired
• Arytenoid cartilage
• Corniculate cartilage
• Cuneiform cartilage
Laryngectomy – remove along with first few tracheal
rings
Significance of cricoid – only complete ring

B. LARYNGEAL MUSCULATURE
EXTRINSIC – ACTS ON THE LARYNX AS A WHOLE
• Suprahyoid group - elevates the larynx
• Infrahyoid group - depresses the larynx

Strap Muscles
• Omohyoid and thyrohyoid are elevators
• Sternohyoid and sternothyroid are depressors

Elevators
• Mylohyoid
• Geniohyoid
• Genoglossus
• Hypoglossus
• Digastric
• Styloglossus

INTRINSIC - MOVEMENT BETWEEN THE

LARYNGEAL STRUCTURES
Usually act on the voice, main function

Abductors
• Posterior Cricoarytenoid
If vocal cord stays in the midline, airway will be
closed – severe dyspnea

Adductors
• Interarytenoid
• Lateral cricoarytenoid
• Cricothyroid

Tensors
• Cricothyroid (external)
• Vocalis
• Thyroarytenoid
Be careful in thyroidectomy. If you hit the recurrent
laryngeal nerve, a branch of vagus nerve, tenth
cranial nerve – patient cannot breathe
Superior laryngeal nerve - not totally hoarse but
cannot hit the high notes
CARTILAGES
C. MALIGNANT NEOPLASMS
Unpaired
SQUAMOUS CELL CARCINOMA
• Thyroid cartilage
• 85-95%
• Cricoid cartilage
• Most frequent malignancy involving the larynx
• Epiglottic cartilage
• Biologic behavior is closely related to their site of origin
within the larynx
• Arises from stratified squamous epithelium
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 Glottic (51%) ADENOSQAUMOUS CARCINOMA
True vocal cords • A rare neoplasm
Supraglottic (33%) • Histologic features: Both squamous cell CA and
Subglottic (2%) adenocarcinoma
5.5 cm from your true vocal cords • Larynx is the most common site
Uncategorized (14%) • 3% develop distant metastasis
• Male: Female ratio of 3.8:1  because of smoking • Treatment: Radical laryngeal surgery with neck
• 90% >40 years old dissection
• Risk factors: • Prognosis is poor
Tobacco and alcohol • Survival: 15-25%
Synergistic, will increase risk 2-3 times Adeno is gland + squamous – gland with squamous
Laryngopharyngeal reflux cell lining
HPV
Genetic susceptibility CHONDROSARCOMA
Diet • Rare
Nitrosamines, preserved, grilled • Most frequent non-epithelial laryngeal neoplasm
• Presentation: • 0.1 to 1% of all laryngeal tumors
Glottic: Dysphonia • Ages to 50-80 years old
─ Few lymphatic channels • Males > Females (3.4:1 ratio)
─ Nodal metastases are rare • Cricoid cartilage is most common site
─ Produce hoarseness early in their course • SSx: Dyspnea, stridor, dysphonia
Vocal fold cannot appose Dyspnea if laryngeal introitus is already affected -
Supraglottic: Dysphagia with dysphonia severe
─ Region rich in lymphatics • Treatment: Surgery (only to a small number of
─ Primary tumor can enlarge substantially before cases)
it causes any bothersome symptoms • Chemotherapy is not effective
─ Neck nodal metastases are common Sarcoma – malignancy of soft tissue
Dysphagia first
Subglottic: Dyspnea and stridor ADENOID CYSTIC CARCINOMA
inspiratory stridor • Rare
─ Rarely the site of origin of a laryngeal primary • Propensity for perineural invasion
carcinoma • Men = Female
─ Lymphatics are abundant (lateral neck nodes • Subglottis = most common 60%
and paratracheal neck nodes) • Uncommon cervical LN metastases
• Treatment: Surgery
Diagnosis: • Radio-resistant tumor
• History and Physical Examination • Has tendency for late recurrence
• Imaging
Best: CT scan with contrast D. TYPES OF NECK DISSECTION
• Endoscopic examination • Radical Neck Dissection
Flexible laryngoscopy • Modified Neck Dissection
• Biopsy • Selective Neck Dissection
Using rigid laryngoscopy • Salvage Neck Dissection

Treatment: RADICAL NECK DISSECTION

• Surgery and radiotherapy
Early Stage (Stage I and II)
• Single modality (RT or Surgery)
Approximately the same prognosis
Advanced Stage (Stage III and IV)
• Combined modality (either primary surgery followed by
radiotherapy, or Chemotherapy +RT)
• Resection of nodes levels I-V with sacrifice of internal
jugular vein, sternocleidomastoid muscle, and spinal
accessory nerve
MODIFIED NECK DISSECTION
• Resection of nodes levels I-V with sparing of at least
one of the non-lymphatic structures taken in a radical
neck dissection such as: internal jugular vein,
sternocleidomastoid muscle, and spinal accessory
nerve

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SELECTIVE NECK DISSECTION 3. What is the most definitive modality used?
• Supraomohyoid neck dissection Biopsy
• Lateral neck dissection 4. What is the most common etiology for
• Posterolateral neck dissection pediatric age group? Inflammatory
• Central neck dissection 5. What is the most common etiology for the
• Extended neck dissection – removal of an additional older adult group? Neoplastic
lymphatic group or non-lymphatic structure (e.g. 6. Give 2 common sources of SCC? pyriform
retropharyngeal node dissection, supraclavicular node sinus, tonsils, base of tongue, nasopharynx
dissection) 7. What is the difference between the right and
left bronchus that makes the right more
SALVAGE NECK DISSECTION prone to FBA? The right is more vertical and
• Removal of metastatic disease of the neck that was wider
previously treated 8. Most common site of foreign body aspiration:
cricopharyngeus

REVIEW QUESTIONS REFERENCES

1. Most common source of squamous cell • Upclass notes
carcinoma except: • Doctor’s lecture
a. Tonsils
b. Nasopharynx
c. Plexiform sinus
d. Base of the tongue
2. A 25-year old male patient presented with a
smooth, painless, slowly enlarging mass along
the anterior border of the sternocleidomastoid
muscle. What is the most likely management of
this condition?
a. Radiotherapy
b. Treat inflammation if present and do complete
surgical excision
c. Chemotherapy
d. No necessary treatment because it is painless
3. Most common histology of thyroid malignancy?
a. Hurthle cell
b. Medullary
c. Follicular
d. Papillary
4. It is at the level between the C3-C6 (range) and
may be higher in children.
a. Hyoid bone
b. Cricoid cartilage
c. Thyroid Cartilage
d. None of the above
5. Lymph Node level of the Delphian node:
a. Level IV
b. Level V
c. Level VI
d. Level VII

Answers: CBDAC

QUIZ
1. Best modality used to differentiate cystic and
solid masses? Ultrasound
2. What is used to identify bony abnormalities?
CT scan

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