PAROTID TUMOR OLD

A A parotid neoplasm must be differentiated from diffuse or discrete

enlargement due to a systemic disease such as mumps, Sjogren’s
syndrome, alcoholism, sarcoidosis (66%), lymphoma or AIDS
lymphadenopathy.
B Malignancy is suggested by a fixed, hard mass, facial nerve deficit and
palpable regional lymph nodes; however, most malignant neoplasms
present as solitary, firm, asymptomatic nodules.
C Facial nerve weakness accompanies 8-33% of malignant parotid
tumors. Pain occurs in 5.1%. Both are signs of poor prognosis.
D Parotid tumors of deep lobe, particularly large pleomorphic adenomas,
may present as oropharyngeal masses. Inspection and palpation of the
oropharynx is important.
E Tumors of the tail of the parotid may simulate neck masses.
F Sialography may be helpful in detecting parotid stones.
G Warthin’s tumor and oncocytoma concentrate technetium 99m.
H Fine needle aspiration (FNA) cytology may be useful in distinguishing
between benign and malignant masses. In a recent series, 32 of 33
benign masses and 11 of 13 malignant masses were correctly predicted.
I Transverse and coronal magnetic resonance imaging (MRI) cuts are the
most useful images for anatomic staging and can demonstrate the
relationship of the tumor to the facial nerve.
J Preoperative clinical evaluation is about 70% accurate in predicting a
benign lesion. About 80% of parotid tumors are benign and of theses,
75% are in the superficial lobe. Benign tumors include pleomorphic
adenomas (80%), monomorphic adenomas (1-4%(, Warthin’s tumors
(10%) and oncocytoma (1%)
K Eighty percent of malignant tumors are in the superficial lobe.
L Tumors of low grade malignancy include acinic cell adenocarcinoma
and mucoepidermoid carcinoma, low or intermediate grade.
M Tumors of high grade include mucoepidermoid carcinomas (high-
grade), undifferentiated tumors, squamous cell carcinoma, malignant
mixed tumors, adenocarcinomas (high-grade) and adenoid cystic
carcinomas.
N Treatment for all benign tumors is parotidectomy preserving the facial
nerve. Since 75% are in the superficial lobectomy is adequate for
these. Conservative total parotidectomy should be performed for the
20% in the deep lobe. Simple enucleation is inadequate because of high
incidence of recurrence except in Warthin’s tumor of the tail of the
parotid. Superficial parotidectomy with facial nerve preservation is
curative in 95-99% of. Cases of benign mixed tumors of the superficial
lobe and is the first step in excision of questionably malignant tumors.
Frozen section examination is very accurate in differentiating malignant
 from benign tumors. The risk of temporary damage to nerve VII is 20%;
the risk of permanent injury is 2%. With temporary nerve damage,
function usually returns within 3 months.
O Treatment of low grade-malignant neoplasm is conservative total
parotidectomy, or superficial parotidectomy if the tumor is localized to
the superficial lobe and the frozen section shows clear margins.
P Operative treatment is total or conservative parotidectomy and cervical
lymphadenectomy for all high grade tumors except adenocarcinoma
and adenoid cystic carcinomas, both of which commonly metastasize to
the lung. Facial nerve branches should be left intact unless encased in
tumor.
Q High grade tumors warrant adjuvant radiotherapy. Adjuvant
radiotherapy of the parotid bed and skull base is important in the
treatment of adenoid cystic carcinoma because of the high incidence of
perineural invasion. The negligible survival rate associated with
recurrent parotic neoplasm recommends adjuvant radiotherapy for all
adenoid cystic, undifferentiated and adenocarcinoma and for high
grade mucoepidermoid tumors. Histologic evidence of perineural
invasion, facial nerve weakness and cervical metastases are indication
for adjuvant radiotherapy, although no well-controlled, prospective
trials have been carried out. Radiotherapy is not effective as definitive
treatment for parotid neoplasm.
R Survival after recurrence is rare, but the course of the disease may be
prolonged. Recurrence is usually manifested by both local and distant
disease (80%). In the occasional patient who has a resectable local
recurrence alone, operation and irradiation should be used. Radiation
alone may be palliative but rarely cures recurrence.
S A benign tumor that recurs locally should be excised again and its
histological makeup confirmed with frozen and permanent sections.
The facial nerve should be preserved when possible. Re-excision of all
gross tumor has an 80% success rate.
T Invasion of the base of the skull with concomitant pain may be treated
by trigeminal nerve section and tarsorrhaphy for exposure keratitis.
Although an occasional parotid neoplasm responds to chemotherapy,
the inexorable course of the recurrent disease make significant
palliation unlikely. At present, there is no good indication for
chemotherapy.

NECK MASS OLD

A Age is an important consideration in neck mass evaluation. Neck
masses in children and young adults are benign 90% of the time,
whereas the “rule of 80” can be applied after age 40. This state that
 80%. Of nonthyroid neck masses in adults are neoplastic and that 80%
of the neoplastic masses are malignant. While 80% of neck
malignancies in adults are epidermoid (squamous cell) carcinomas. 90%
of neck cancers in children are mesenchymal in origin.
B Persistent lump in the neck of an adult is usually metastatic cancer and
originates from a primary tumor above clavicle. At least 50% of patient
seen with a neck mass diagnosed as cancer by node biopsy will be
found to have an obvious primary lesion of the head or neck at initial
exam.
C CT scan of the neck is the radiologic procedure of choice for neck mass
evaluation. It is most useful when evaluation masses that are difficult to
assess by physical exam, such as those in a deep lobe of the parotid
gland or the parapharyngeal space. CT and MRI are not reliable in
predicting the presence or absence of malignancy in enlarging cervical
nodes.
D All mucosal surfaces of the pharynx, oral cavity and larynx should be
examined before performing an open node biopsy in a patient with a
neck mass. Biopsy should be performed for suspicious primary lesions
in the upper aerodigestive tract. If results are positive for cancer, the
neck mass should be considered a metastatic node biopsy of the
metastasis then is not needed.
E Cervical lymphadenopathy in HIV positive patients is a common finding.
The most common malignant neck mass in HIV patient is lymphoma.
These lymphomas are generally high grade of B-cell origin and often
involve extranodal sites such as the parotic gland. Kaposis’s sarcoma is
the most common neoplastic process in patient infected with HIV. It
usually presents as a cutaneous or mucosal lesion, not as a neck mass.
F A tender neck mass strongly suggest infection. A neck abscess should
be drained and cultures obtained. If no abscess is present but
inflammation or infection is still suspected, antibiotics should be
administered. If the mass persists for 4 weeks despite antibiotic
treatment, it should be excised.
G Differential diagnosis of midline neck mass include: Thyroglossal duct
cyst, Dermoid cyst, Pyramidal lobe of thyroid and Sebaceous cyst
Most midline neck masses in children are congenital and benign.
Thyroglossal duct cyst is the most common midline neck mass in
children. It most frequently arises just inferior to the level of the hyoid
bone. In thyroid hypoplasia, a small area of aberrant ectopic thyroid
tissue may be mistaken for a thyroglossal duct cyst. The incidence of
such aberrant tissue is low (about 1% of all thyroglossal abnormalities).
Whether preoperative isotope scanning or ultrasound should or should
not be performed on patients with thyroglossal duct cyst is
controversial.
H Brachial cleft cyst or sinuses are frequently associated with a small pit
in the skin anterior to the sternocleidomastoid muscle. The patient may
report recurrent swelling or infection of the mass. Other lateral neck
masses may be represent inflammatory lymph nodes from chronic
infections or metastatic cancer from the head and neck.
I Supraclavicular nodes are usually either lymphoma or metastases from
cancer of the breast, lung, pancreas or stomach (Virchow’s node).
Biopsy is indicated if the primary is not evident.
J Fine needle aspiration (FNA) biopsy for cytologic diagnosis is the single
most important test in the workup of a neck mass. FNA should be
performed on all persistent neck masses unless physical exam reveals
an obvious primary tumor. If cells are examined by an experienced
pathologist, the sensitivity for the presence of neoplasm is 92% and the
specificity for the absence of tumor is 98%.
K Panendoscopy of the upper aerodigestive tract includes direct
laryngoscopy, rigid esophagoscopy and rigid bronchoscopy. The
purpose of panendoscopy is to stage and biopsy the primary tumor and
to screen for a second primary cancer at a separate site, such as
esophagus.
L The nasopharynx, base of tongue, and pyriform sinus are notorious
sites for squamous cancer in the neck with no evident primary. Directed
biopsy of these sites is done even when the mucosa appears normal
under direct exam.
M When the primary cancer is in the neck and the mass is a local
metastasis, excision of the primary tumor with enbloc resection of the
regional nodes can be curative. Adjunctive radiation is usually
advisable.
N In 5-8% of patient with squamous cell cancer is a neck node, no primary
tumor site is found. Treatment remains controversial and may consist
of neck dissection alone, radiation alone or a combination of the two.
O Excision of parotid and submandibular salivary gland masses is often
recommended. Regardless of preoperative cytologic determination of
malignancy. A salivary gland mass yielding a nonneoplastic diagnosis on
FNA may be observed rather than excised with the expectation that it
will resolve over time. If a salivary gland mass persists it should be
excised, regardless of the FNA findings. When FNA is performed by
experienced pathologist for the evaluation of a salivary
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NECK MASSES

A Neck masses should first be considered according to their location,

duration, and onset. Lesions between the carotid arteries (the central
compartment) are usually referable to the thyroid gland. Is this a lesion
of rapid onset and short duration (likely a manifestation of infection),
subacute, and persisting more than 2 weeks (often malignant) or chronic
(chiefly benign or of thyroid origin)? Age is another important
consideration in evaluating a neck mass. Neck masses in children and
young adults are benign 90% of the time, whereas the “rule of 80”
applies after age 40. Eighty percent of persistent nonthyroid neck masses
are neoplastic, and 80% of the neoplastic masses are malignant. Hence, a
neck mass in someone 40 or older should be considered cancer until
proven otherwise.

B A persistent lump in the neck of an adult is usually metastatic cancer that

originates from a primary tumor above the clavicles. At least 70% of
patients seen with a neck mass diagnosed as cancer by a node biopsy will
be found to have an obvious primary tumor after complete head and
neck examination. However, persistent neck masses may also represent
benign problems, such as laryngocele, lipoma, or branchial cleft cysts. In
children, serological testing may identify a specific cause and obviate the
need for biopsy in about 10% of cases.

C Computed tomography (CT) of the neck with contrast is the radiologic

study of choice for the initial evaluation of most neck masses. The
greatest utility of CT is in the evaluation of lesions that are difficult to
define by physical examination, such as those in a deep lobe of the
parotid gland or the para- pharyngeal space. In addition, CT may also be
helpful in identify- ing primary cancers that are not readily apparent on
initial physical examination, such as human papillomavirus (HPV)–
initiated oropharynx cancers, which are often small despite presenting
with nodal metastases. Ultrasonography is useful for the initial
assessment of thyroid masses (within the central compartment and
moving with deglutition), in pediatric patients to avoid radiation, and in
guiding fine-needle aspiration (FNA). Magnetic resonance imaging (MRI)
is a useful adjunct modality for neck masses that may involve
surrounding structures, such as the brachial plexus, and for suspected
salivary neoplasms. Positron emission tomography (PET) should not be
employed as the initial imaging study for a patient with a neck mass,
even if it is proven to be malignant. A CT scan with contrast or MRI with
gadolinium should always be undertaken before a PET because even
 PET/CT lacks sufficient anatomic detail to plan treatment of a primary
tumor.

D A complete head and neck examination, including the skin and all
mucosal surfaces of the pharynx, oral cavity, and larynx, should be
examined before performing a node biopsy in a patient with a neck
mass. Biopsy of suspicious primary lesions should be performed, either in
the office or in the operating room, depending on accessibility and
patient-related factors. If biopsy of the primary site reveals cancer, the
neck mass should be considered to represent metastatic disease, and its
biopsy is seldom necessary. However, FNA of a neck mass should be
undertaken if no likely primary tumor is found after a complete head and
neck examination.
E Cervical lymphadenopathy can be seen in early HIV infection and is the
chief head and neck manifestation of HIV infec- tion; this typically
reflects lymphoid hyperplasia rather than a neoplastic process. The most
common malignant neck mass in patients with HIV is lymphoma. These
are generally high grade, are of B-cell origin, and often involve
extranodal sites such as the parotid gland or soft tissue of the neck.
Atypical infections, including mycobacteria, Actinomyces, and Nocardia,
should also be considered when evaluating a neck mass in a patient with
HIV.
F A tender neck mass strongly suggests infection. Fluctuance suggests a
neck abscess. Needle aspiration may confirm the presence of pus. A neck
abscess should be treated by incision and drainage; cultures should be
obtained. A CT scan with contrast may be helpful in differentiating an
abscess from other infectious responses, such as a phlegmon or reactive
adenopathy. If no abscess is present and infection is suspected,
antibiotics should be administered. If the mass persists for 2 weeks
despite adequate antibiotic therapy, biopsy should be performed.
G Differential diagnosis of a central neck mass includes thyroglossal duct
cyst, dermoid cyst, pyramidal lobe of thyroid, sebaceous cyst, lipoma,
and plunging ranula. Most midline neck masses in children are congenital
and benign. Thyroglossal duct cyst is the most common midline neck
mass in children. It most frequently arises just inferior to the hyoid bone.
In thyroid hypoplasia, a small mass of ectopic thyroid tissue may be
mistaken for a thyroglossal duct remnant. Such aberrant tissue
represents only 1% to 2% of all thyroglossal abnormalities. Despite its
rarity, preoperative ultrasound has been advocated for patients with
thyroglossal duct cysts to avoid excising the only functioning thyroid
tissue.
H Branchial cleft cysts or sinuses are frequently associated with a small pit
in the skin along the anterior border of the sternocleidomastoid muscle,
 but the absence of a pit does not preclude the diagnosis. The patient
may report recurrent swelling or infection of the mass. Some 15% of
branchial cleft cysts present in adulthood. Other lateral neck masses may
represent inflammatory lymph nodes from infections, enlargement of
salivary glands, carotid body tumors, neurogenic tumors, lymphoma, and
metastatic cancer.
I Cancer in supraclavicular nodes is usually either lymphoma or metastatic
from tumors of the breast, lung, abdomen, or pelvis. Needle aspiration
should be performed if a complete head and neck examination reveals
no primary tumor.
J FNA for cytologic diagnosis is the single most important test in the
evaluation of a neck mass. FNA of all persistent neck masses should be
undertaken unless an obvious primary tumor is identified. The use of
ultrasound to guide FNA is often helpful. The sensitivity and specificity of
FNA in the diagnosis of malignant neck masses have been reported by
various studies to range from 70% to 100%. Molecular studies may
augment routine analysis of FNA specimens when the diagnosis is uncer-
tain. Flow cytometry is useful in detecting non-Hodgkin’s lymphoma on
FNA specimens. It is important to perform immunohistochemical stain
for p16 status on the specimen if squamous cell carcinoma is confirmed.
HPV-initiated oropharynx cancer is a different disease from squamous
cell carcinoma with other causes, such as substance abuse.
K “Panendoscopy” of the upper aerodigestive tract includes direct
laryngoscopy, esophagoscopy, and bronchoscopy. Historically, the
purpose of panendoscopy was to stage and biopsy a known primary
tumor, identify a primary tumor not detected on office examination, and
screen for a second primary cancer at a separate site, such as the
esophagus. The incidence of a synchronous second primary tumor is
approximately 3%. Modern imaging and understanding of lymphatic
drainage have limited the role of panendoscopy. CT of the chest is more
sensitive than bronchoscopy for detecting primary or metastatic disease
in the lungs. Esophageal cancer seldom metastasizes to upper neck
nodes. Hence, few patients with a neck mass will benefit from
“panendoscopy.”

L A subset of patients will have metastatic carcinoma to a neck lymph

node in the absence of any known primary malignancy. This is often
referred to as carcinoma of unknown primary (CUP). “True” CUP refers
to metastases for which the primary tumor cannot be located after an
exhaustive clinical, radiographic, and surgical evaluation has been
performed, the latter often including biopsies and/or resection of
suspected primary sites. Today, for many patients who initially present
with metastasis of an unknown or occult primary site, the primary tumor
can eventually be located. The most common site of origin of head and
 neck squamous cell carcinomas (SCCs) that initially present as an
unknown primary is the oropharynx, and most of these tumors are HPV
related. The traditional clinical approach is to perform an examination
under anesthesia with targeted biopsies, based on clinical suspicion
and/or PET imaging, from the most likely primary sites. If a primary
tumor is not found by this initial approach, ipsilateral tonsillectomy and
resection of the base of tongue, by either transoral robotic surgery
(TORS) or transoral laser surgery (TLM), is associated with an increased
rate of primary tumor detection and is now increasingly advocated.
M When the primary cancer is found and the neck mass represents a
regional metastasis, resection of the primary tumor with formal neck
dissection may prove curative. Pre- operative studies often include a CT
scan of the chest. A PET/ CT, although sensitive to the presence of
metastatic disease, is of little benefit unless the risk for such distant
disease is high; this is seldom true with upper neck nodal disease. Risk-
based postoperative adjuvant treatment should be considered. Histology
of the primary cancer, surgical margin, number of involved nodes, and
presence of extranodal extension influence recommendations.
N “True” CUP accounts for only 1% to 2% of head and neck cancers and
may be decreasing because of improved detection methods. Neck
dissection or radiation alone is often adequate therapy for a single small
lymph node. The treatment of a large single node or multifocal disease is
controversial and may involve combined-modality therapy.
O Excision of parotid and submandibular salivary gland neoplasms is
usually warranted. Such lesions arise in proximity to named motor and
sensory nerves. Thus, whether benign or malignant, a salivary gland
tumor is no easier to treat as it grows. A salivary gland mass that does
not disclose a neoplasm with FNA may be observed rather than excised
because they often resolve with time. However, a persistent salivary
gland mass should often be excised, regardless of FNA findings.
P When a diagnosis of malignancy has been assigned and evaluation
completed, then multidisciplinary treatment planning is usually
appropriate for patients whose cancer presents with a neck mass.
Lymphoma, of course, should be referred to specialists in its
management. Cancers of cutaneous origin, the thyroid, and of the oral
cavity are chiefly addressed with resection and consideration of risk-
based postoperative adjuvant therapy. Cancers of the pharynx and larynx
are often appropriately treated without an operation through
appropriate use of radiation or chemotherapy in conjunction with
radiation, but resection is an important consideration. Planning
treatment for patients presenting with a malignant neck mass is
complex.