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1 Continuing Education Column Differential Diagnosis of Head and Neck Mass Lesions Hang Seok Chang, M.D. Department of General Surgery Yonsei University College of Medicine Yongdong Severance Hospital E mail : surghsc@yumc.yonsei.ac.kr Abstract For the differential diagnosis of head and neck mass lesions, the age and presenting locations should be the primary considerations. The characteristic patterns of age and site predilection allow a diagnostic work up and treatment plans for the patients with head and neck mass lesions. In children and young adults, the underlying causes are; inflammatory, congenital and developmental, and neoplastic masses in decreasing frequency. By contrast, neoplastic diseases are most frequent in the elderly. Because of the characteristic lymphatic spread patterns of head and neck diseases, the location of the mass in the cervical lymphatic nodal chain may be the key for the identification and differential diagnosis of the primary disease site. Besides, the evaluation of specific historical and physical findings is mandatory for the accurate diagnosis. When the signs of inflammation are associated, conservative treatment and observation is first considered. On the other hand, for persistent or progressively enlarging masses and those with suspicious findings of malignancy, surgical intervention should be considered. Keywords : Head and neck masses; Differential Diagnosis; Age group; Location 239

2 Continuing Education Column Classification of neck masses Inflammatory neck masses Abscess Cervical lymphadenitis Bacterial Granulomatous: tuberculosis, actinomycosis, sarcoidosis Viral: infectious mononucleosis Non inflammatory neck masses Congenital thyroglossal duct anomalies branchiogenic anomalies lymphangioma dermoid cyst, sebaceous cyst hemangioma cervical thymic arrest teratoma laryngocele Neoplastic Benign tumors: thyroid tumors, salivary gland tumors, paragangliomas, carotid body tumors Malignant tumors Primary: from thyroid, salivary glands, cervical soft tissue Metastatic: from original sites head and neck: 60~70% other than head and neck: 10~20% no primary site found: 5~10% Lymphoreticular neoplasm Traumatic Distribution of disease categories by age (in order to frequency) 15 years 16~40 years 41 years Inflammatory Inflammatory Neoplastic Congenital Congenital Malignant Neoplastic Neoplastic Benign Malignant Benign Inflammatory Benign Malignant Congenital Trauma Trauma Trauma 240

3 A Clinical description of the location in neck Classification of neck nodes group in neck: A) Classification of MD Anderson Cancer Center B) Classification of Memorial Sloan Kettering Cancer Center B 241

4 Continuing Education Column Distribution of disease categories by location Location Midline and Anterior Neck Anterior Triangle Posterior Triangle Congenital / developmental Thyroglossal duct cyst Branchial cyst Lymphangioma Dermoid Thymic cyst Laryngocele Inflammatory Adenitis Adenitis Adenitis Bacterial Bacterial Bacterial Viral Viral Viral Granulomatous Granulomatous Granulomatous Sialadenitis Parotid Submaxillary Thorotrast Granuloma Neoplastic Thyroid Lymphoma Piimary vascular Lymphoma Lymphoma Metastatic Carotid body Metastatic Upper jugular Glomus Superior Oropharynx Hemangioma Nasopharynx Oral cavity Neurogenic Scalp Lower Jugular Neurilemoma Supraclavicular Hypopharynx Salivary Breast Larynx Parotid Lung Submaxillary Submaxillary Gastrointestinal Oral cavity Genitourinary Nasal Gynecological Face Trauma Sternocleidomastoid False aneurysm Neuroma Hematoma / fibroma 242

5 Location of primary tumor associated with lymph node metastasis in neck Location Primary sites Preauricular Ear, scalp, skin Submental Lip, skin, anterior oral cavity Submaxillary triangle Submandibular gland, oral cavity, skin, lip, paranasal sinus External jugular Parotid gland, skin, ear Suboccipital Scalp, postauricular skin Jugulodigastric Oral cavity, oropharynx, paranasal sinus, nasopharynx, hypopharynx, larynx, parotid gland Midjugular Hypopharynx, larynx, thyroid, oral cavity, oropharynx Lower jugular Thyroid, larynx, cervical esophagus Upper posterior Nasopharynx, paranasal sinus, oropha rynx, sin, scalp Prelaryngeal Larynx, thyroid Supracalvicular Thyroid, cervical esophagus, infracla vicular primary 243

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11 ; 27: McGuit WF. Neck Masses: Differential Diagnosis and Therapeutic Approach. In: Shockley WW, Pillsbury HC III, eds. THE NECK Diagnosis and Surgery. St. Louis: Mosby Year Book, 1994: Altman RP, Margileth AM. Cervical lymphadenopathy from atypical mycobacteria: Diagnosis and surgical treatment. J Pediatr Surg 1975; 10: Coker DD, Casterline PF, Chambers RG, Jaques DA. Metastases to lymph nodes of the head and neck from an unknown primary site. Am J Surg 1977; 134: Lee D J, Rostock RA, Harris A, Kashima H, Johns M. Clinical evaluation of patients with occult primary tumor. South Med J 1986; 79: Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tract. Cancer 1972; 29: Knight PJ, Mulne AF, Vassy LE. When is lymph node biopsy indicated in children with enlarged peripheral nodes? Pediatrics 1982; 69: DeVita VT Jr, Jaffe ES, Hellman S. Hodgkin s disease and the non Hodgkin s lymphomas. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds. Cancer. Principles and Practice of Oncology. 2nd ed. Philadelphia: JB Lippincott Co, 1985: Skandalakis JE, Godwin JT, Androulakis JA, Gray SW. The differential diagnosis of tumors of the neck. Prog Clin cancer 1970; 4: MacComb WS. Diagnosis and treatment of metastatic cervical cancerous nodes from unknown primary site. Am J Surg 1972; 124: Parsons JT, Million RR, Cassisi NJ. The influence of excisional or incisional biopsy of metastatic neck nodes on the manage- 249

12 ment of head and neck cancer. Int J Radiat Oncol Biol Phys 1985; 11: Shapiro AL, Pincus RC. Fine needle aspiration of diffuse cervical lymphadenopathy in patients with acquired immunodeficiency syndrome. Otolaryngol Head Neck Surg 1991; 105: McGuirt WF. Panendoscopy as a screening examination for simultaneous primary tumors in head and neck cancer: A prospective sequential study and review of the literature. Laryngoscope 1982; 92: Drake AF, Hulka GF. Congenital Neck Masses. In: Shockley WW, Pillsbury HC III, eds. THE NECK Diagnosis and Surgery. St. Louis: Mosby Year Book, 1994: Sistrunk WE. Technique of removal of cysts and sinuses of the thyroglossal duct. Surg Gynecol Obstet 1928; 46: Maddox PR, Malcolm HW. Approach to thyroid nodules. In: Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia: Elsevier Saunders, 2005: Fujimoto Y, Obara T, Okamoto T. Papillary thyroid carcinoma: Rationale for hemithyroidectomy. In: Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia: Elsevier Saunders, 2005: Clark OH. Papillary thyroid carcinoma: Rationale for total thyroidectomy. In: Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia: Elsevier Saunders, 2005: Hamming JF, Roukema JA. Management of regional lymph nodes in papullary, follicular, and medullary thyroid cancer. In: Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia: Elsevier Saunders, 2005: ; 47: Moley JF, Shervin N. Medullary thyroid carcinoma. In: Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia: Elsevier Saunders, 2005: ,,,,. 2003; 19: ,,,,, ; 21: Peer Reviewer Commentary 250

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<B0E6C8F1B4EBB3BBB0FA20C0D3BBF3B0ADC1C E687770> 2012 개원의와함께하는임상강좌 경희대학교의과대학감염내과학교실 문수연 F/29 CC: fever, headache, multiple cervical lymph node onset) 5 days ago 1 cm sized Bilateral, mild tender, movable, soft Reactive LN with viral infection 2012 개원의와함께하는임상강좌