Otolaryngology: Head & Neck Cancer

Head & Neck Cancer

Pathology

  • Squamous Cell Carcinoma (SCC) – Most Common (90-95%)
  • Verrucous Carcinoma – Variant of Squamous Cell Carcinoma
    • Not Aggressive; Good Prognosis
  • Adenocarcinoma
  • Adenoid Cystic Carcinoma
  • Mucoepidermoid Carcinoma
  • Lymphoma

Risk Factors

  • Tobacco – Most Common Risk Factor
  • Alcohol
  • Chewing Betel Nut Quid (Asia & India)
  • Radiation
  • Periodontal Disease
  • Immunosuppression
  • HPV

Sites

Cervical Lymph Node Metastasis – Radiographic Characteristics

  • Increased Size
    • Short-Axis Diameter ≥ 10 mm
    • Level II Short-Axis Diameter ≥ 11 mm
    • Retropharyngeal Short-Axis Diameter:
      • Lateral Group: ≥ 5 mm
      • Medial Group: Any Visible Size
  • Round Shape (Long:Short Axis Ratio < 2)
  • Evidence of Extra-Nodal Extension (ENE)
    • Ill-Defined Margins
    • Irregular Capsule Enhancement
    • Invasion of Surrounding Fat/Muscle
  • Hilum Thinning and Loss of Central Fat
  • Microcalcifications
  • Peripheral/Mixed Vascularity
  • Central/Cystic Necrosis

Most Common Primary Site of Head & Neck Metastases

  • Mets in Cervical Lymph Nodes: Tonsil (#1) & Base of Tongue (#2)
  • Mets in Larynx or Salivary Glands: Lung
  • Mets in Mouth or Pharynx: Esophagus

Cervical Mass Evaluation

Primary Mass Evaluation

  • *If Infectious Etiology Suspected: Broad-Spectrum Antibiotics & Reevaluate in 2 Weeks
  • Initial Evaluation: Fine-Needle Aspiration (FNA)
    • Avoid FNA if Pulsatile or Vascular in Nature (Concern for Carotid Body Tumor)
  • If Nondiagnostic: Panendoscopy & Imaging (CT/MRI/US)
    • Panendoscopy (“Triple Endoscopy”):
      • Laryngoscopy
      • Bronchoscopy
      • Esophagoscopy
    • Also Consider Core Needle Biopsy (CNB)
      • FNA is Generally Preferred Initially (Maintains Surgical Planes & Low Risk of Spread)
  • If Still Nondiagnostic: Excisional Biopsy (EBx)

Epidermoid Tumor (SCC) with “Unknown Primary”

  • Initial Evaluation: Panendoscopy with Random Biopsy
  • If Nondiagnostic: Imaging (CT, MRI and/or PET)
  • If Still Nondiagnostic: Ipsilateral Surgery (Palatine Tonsillectomy)
    • Frozen Section:
      • Positive: Staged Resection & Neck Dissection
      • Negative: Ipsilateral Base-of-Tongue Resection

Pediatric Lymphadenopathy – Management

  • Generally Benign & Self-Limited
  • “Red Flag” Features:
    • Age < 12 Months
    • Nontender, Fixed & Hard Nodes
    • Diameter > 2-3 cm
    • Supraclavicular Location
    • Persistent Generalized Lymphadenopathy
    • Mediastinal/Abdominal Mass
    • Persistent Systemic Symptoms (Fever, Weight Loss, Fatigue, etc.)
  • Management:
    • No “Red Flag” Features: Observe for 2-3 Weeks
      • Consider Empiric Antibiotics
      • If Persistent: Excisional Biopsy
    • “Red Flag” Features: Early Excisional Biopsy
      • Excisional Biopsy Preferred Over FNA (High False-Negative Rate)
      • Also Consider Chest X-Ray & Labs

Other Tumors

 “Lateral Aberrant Thyroid Tissue”

  • Definition: Appearance of Ectopic Thyroid Tissue in the Neck/Lymph Node
  • Most Common Cause: Metastatic Papillary Thyroid Cancer

Melanoma

  • *See Skin & Soft Tissue: Melanoma
  • Head & Neck Account for 15-30% of All Primary Melanomas
  • Higher Risk of Recurrence or Regional Lymph Node Metastases
    • Most Common Sites: Parotid Gland & Cervical Lymphatics
  • Primary Treatment: Wide Local Excision (WLE)
    • Normal Margins Preferred but Can Alter if Near Critical Structures (Facial Nerve, etc.)
    • Consider Sentinel Lymph Node Biopsy (SLNB)
    • May Require Superficial Parotidectomy if Lesion is on the Anterior Scalp/Face or Ear Above the Level of the Lip
      • Not Required for Lesions of the Chin, Neck or Posterior to Ear