What is Head and Neck Masses?
Differential diagnosis of neck masses requires detailed knowledge of the diagnosis and treatment of a wide spectrum of diseases. The aim of the diagnostic approach to patients presenting with a mass in the neck is to reach a diagnosis as quickly and accurately as possible and to avoid harming the patient while doing so.
Unfortunately, there are many wrong practices regarding the approach to neck masses in our country. These patients usually apply to ENT physicians with a biopsy report diagnosis of metastatic squamous cell carcinoma. Unfortunately, the habit of ‘taking a biopsy immediately from a neck mass’, which was abandoned many years ago abroad, is still very common in our country. Another very common mistake is that patients presenting with a mass in the neck are given antibiotics for weeks, and when the mass does not disappear after a few months and often grows (almost too late), the patient is referred to an ENT physician.
However, patients presenting with complaints of a mass in the neck should first be referred to an ENT physician. After completing a detailed head and neck examination, further examinations, FNAB and, if necessary, open biopsies, these patients should be referred by an ENT physician if they have a disease that concerns other disciplines. The necessity of this approach is based on the following reasons:
A significant proportion of late adult patients over the age of 40 who complain of a neck mass only have a primary head and neck tumor. In a study conducted by Martin and Morfit in 1944, it was determined that 65% of 218 patients who underwent direct lymph node biopsy without any research and were diagnosed with cervical carcinoma had an obvious primary tumor in the head and neck at the time of biopsy. In a study conducted by Martin and Romieu in 1952, it was determined that in a group of 1300 patients with primary head and neck tumors, the presenting complaint of 12.4% of the patients was an asymptomatic neck mass. In another study conducted by Lee and Helmus in 1970, it was stated that the biopsy results of 163 patients over the age of 40 who presented with a neck mass were reported as metastatic carcinoma in 29.4% and lymphoma in 21.4%. These results confirm the fact that “asymmetric lymph node enlargement in the neck in late adulthood should be considered metastatic until proven otherwise.”
Performing a lymph node biopsy without detailed investigation negatively affects the prognosis of the patient in the presence of metastatic carcinoma. In these patients, even with appropriate treatment, the risk of local recurrence and distant metastasis is almost twice as high as in patients who have never had a biopsy. The biopsy incision may be contaminated with tumor or the tumor may spread to surrounding soft tissues. It has been shown by lymphoscintigraphy that biopsy disrupts the lymphatic circulation in the neck. If the biopsy incision is not made from a suitable location, it may make the neck dissection that may be required later on technically difficult. In addition, possible problems such as wound infection and wound necrosis also delay the start of the necessary treatment.
Since the swelling disappears after the biopsy is taken, the patient may believe that he is cured and refuse treatment.
All of these explain why the patient’s first application should be an ENT physician. Only in this way can patient care be provided accurately, quickly and with the lowest morbidity.
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Kenan Selçuk TUNCAY
Otolaryngologist