When you look at all comers with nodes in the neck
When you look at all comers with nodes in the neck, you’ll find that about 90% of nodes in children are going to be benign. Vast, vast majority and that may even be an understatement. Almost always they are benign. Malignancy is the second thought when they don’t respond to antibiotics, when they don’t respond to all these other things that you are doing. But in adults that’s basically reversed. When you take all lymph nodes, and if you eliminate some of the younger adults, it’s probably higher than that. When you are talking about a unilateral node in a smoker, it’s probably in the mid 90%. So very, very high percentage of these are going to be malignant. So I think that you are going to be much less inclined to treat these people with several courses of antibiotics and probably quicker to go to a fine needle aspiration if you can’t find a primary in the mouth or oropharynx.
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Risk factors, of course, the number one risk factor that you have to know when a patient walks through the door with a neck mass, the first question that we ask them other than how long has I been there and these kind of things, is “Are you a cigarette smoker?” because then that increases the likelihood of that being cancer by a very very high percentage. And of course alcohol is synergistic with tobacco. The duration of the mass is also important. If the mass has been there for a couple of days, it may not be quite so significant as a mass that’s been there for a couple of months. Anything over a couple of weeks is probably significant. Something that’s been there for 10 years, 15 years, then of course that takes on a different significance. Then the size also. We talked about the size being relative. A mass greater than 2 cm is unlikely to be inflammatory. Some chronic infections – TB, histoplasmosis, toxoplasmosis – you’ll see bigger nodes in those patients but they are very very rare. For the most part, any node over 2 cm is significant. If it’s a family that you are taking care of and you know that other members have had melanomas, have had cancers, I think that raises your suspicion too. Certainly there are a number of syndromes that you see, and those are very very rare.
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Obviously associated symptoms, weight loss being the biggest one, but hoarseness, dysphasia, hemoptysis, those things guide you how you are going to look at that neck mass and also always ask them about fullness. Do they have fullness of the ear or pain in the ear, especially unilaterally. If it happens to be on the same side as the neck mass then those people are invariably going to have a cancer that you need to find. Visual changes for sinus cancers. Of course if you find those, they are in trouble. Fevers, chills that go along with your lymphomas can be important.
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A good history is going to outline what most of these people have if you just listen to the patients. Of course, you’ve heard that. Location, size, consistency, we’ll go through all these things in just a little more detail. Whether it’s fixed or not. A fixed mass is extremely ominous, with the exception of some infections, that’s going to mean malignancy in almost every patient. Variation in size. Although certain larger tumors, especially those that are necrotic, necrotic lymph nodes can respond to antibiotics, can get smaller, can fluctuate to some extent. For the most part, if they are fluctuating in size then that kind of goes away from malignancy and you may be looking at salivary glands and some of the other things. Then also whether they have associated masses or what color it is. If it blushes, if it looks like it might be fluid-filled close to the surface then of course those are all going to send you off on another tangent. Duration: less than … short period of time. Seven days is inflammatory, seven months is neoplastic, seven years is congenital.