Management of the Neck Mass
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About 5% of all cancer patients will present with neck masses. About 12% of head and neck cancer patients present with neck masses. So it is a fairly common presenting symptom.Unfortunately it just about has your prognosis for almost any site when you see a neck mass, but it is frequently the first symptom that we will see. Especially for head and neck cancers. If at all possible you should avoid an open biopsy of a neck mass. There are a lot of reasons oncologically. It does compromise where we can put our incisions if you have an incision in the neck. It does obstruct the lymphatics and it may indicate a poor prognosis for the patient who has had an open neck biopsy. It usually is not necessary. We almost always can find a primary site or we almost always can do it either with a fine needle aspiration or something like that, prior to an open neck biopsy. So try to do all these other things first, prior to an open neck biopsy.
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Any neck mass in an adult is malignant until proven otherwise. Some of the statistics as we go through them are really kind of shocking, at least they were to me. At what a high percentage of malignancies you will find in your adult patients. At biopsy, the primary site is always best and before we launch on any type of treatment, whether it’s chemotherapy, radiation or surgical approach, we have to have a diagnosis. So that patient is going to have to have a biopsy at some point. Again, the history and physical directs what we do. It really is the way that you go through it. And I won’t insult you by going through how to do a history and physical, but I will just emphasize those points that I think it is so tempting to overlook when you see somebody walk through the door with a 10 cm mass in their neck. You want to get that diagnosis, and we do the same thing too. We find primary sites in the oral cavity all the time in patients who have had open neck biopsies. It’s really best to avoid.
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The jugular nodes along the internal jugular vein, especially the junctional nodes up here are the most important nodes that you are going to find in them, and really from a head/neck oncologists standpoint, those nodes are involved in almost all cancers that we treat up there. Also lots of lymphomas as well. Submandibular nodes and then posterior triangle nodes, supraclavicular nodes and that’s the way I would break them down. Remember, when you get that patient in the chair when you are examining for a neck mass, those nodes lie right underneath the sternocleidomastoid muscle so I always keep my hand on the top of their head and kind of turn their head so that you kind of loosen up that muscle. You can really feel those nodes, in most patients, down to about a centimeter. That’s probably the point at which they become significant. When you start picking up nodes smaller than that we don’t know what to do with them anyway and they are frequently not significant. Don’t forget your bimanual palpation for anyplace that you can do it. When we put the patient to sleep for our direct laryngoscopes, you can get your hand clear down to the vallecula and you can feel, you can bimanually palpate nodes all the way down. It’s really a good technique and an easy way to feel them. Of course, it’s not too easy in the clinic but when you do feel the base of the tongue and those things, make sure it’s the last thing you do for the patient because they won’t let you do much else after you do that. Canadian pharmacy news