While the majority of malignant adult neck masses are metastatic squamous pathology, other sources of metastatic disease and primary malignancy must be considered in the differential diagnosis and workup.
Workup starts with a careful history including risk factors such as smoking and alcohol use. Physical exam provides clues by location and feel (pulsation, firmness). Panendoscopy including assessment of vocal cord mobility is a necessity. The mainstay of diagnosis is fine needle aspiration (FNA) which is highly reliable in experienced hands. If FNA is non-diagnostic, excisional biopsy (or incisional if large) with preparation for neck dissection is the next step (see radical neck dissection). The bottom line is that surgical treatment for most head and neck cancers is highly effective and initial treatment should be aggressive.
Shah JP in Cameron JL, Current Surgical Therapy, 5th ed, Mosby, 1995: 902-906
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