11
Head and Neck Lesions
James J. Chandler and Doreen M. Agnese
Objectives
1. To provide a survey of head and neck surgery, designed as an introduction to this field.
2. To help the physician, surgical resident, or medical student develop an understanding of the diagnosis and treatment of primary cancers of various head and neck sites.
3. To enable the reader to develop an approach to a neck mass and to be able to discuss diagnostic methods and treatment.
4. To be able to answer such questions as: What are the more common neck masses in children and their embryonic origins? What is the relationship of alcohol and tobacco products to cancer? How is the risk of cancer of the thyroid assessed?
5. To develop an understanding of thyroid malig- nancies and their cells of origin.
6. To be able to develop a plan for diagnosis and treatment of salivary gland tumors and of primary hyperparathyroidism.
7. To develop an understanding of thyroiditis.
Case
A 48-year-old man is seen at your office. He noted a lump in the ante- rior neck while shaving a week ago; the lump is not painful or tender and has not changed. He has been completely well. On examination, you find a 2-cm-diameter lump just to the left of the midline, at the anterior margin of the sternocleidomastoid muscle. The lump is mod- erately firm, and it moves up when he swallows. The lump seems to be in the edge of the thyroid lobe. See Algorithms 11.1 and 11.2.
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Introduction
Problems presented that are centered in the region of the head and neck are best addressed while simultaneously considering the regional anatomy (which is reliable, with minimal anatomic varia- tion between patients) and the patient’s medical and social history.
For example, the patient in the case presented above stated that he never smoked and that he drank only an occasional glass of wine.
There is a close relationship of high alcohol intake or the use of smokeless tobacco with cancers of the oral cavity and pharynx, and there is a close relationship of tobacco smoking and alcohol intake with cancers of the esophagus and the entire respiratory tract.
The patient in our case would not be expected to have a cancer primary in any of these areas, given his social history.
Risk Factors
Tobacco, in its various forms, is a risk factor for the development of head and neck cancer. These forms include inhaled tobacco, chewing
History and physical exam
Upper neck
Neck
Mid-neck
Thyroid see Algorithm 11.2
Thyroid cancer See Algorithm 11.4
See Algorithms 11.2 and 11.3
See Algorithm 11.3
Supraclavicular
See Algorithm 11.3
Scalp Longtime lump
nontender superfacial, just under skin
Brown lesion
? Melanoma
Surgery consult derm oncology It's a wen
Excise, local anesthesia
Embedded tick?
send to ER Intraoral,
pharyngeal, nasal
Biopsy±
Refer to surgical oncology, oral surgery,
head and neck surgery, plastic surgery
Algorithm 11.1. Algorithm for approach to a patient with a mass in the head or neck.
tobacco, and snuff (often referred to as “snoose” in the western states), which is held against the cheek or gums. Betel nut chewing, common in the western Pacific basin and South Asia, also is associated with increased risk. Most cases of head and neck cancer are associated with a significant history of alcohol consumption coupled with a history of tobacco use. Marijuana use and some viruses have been implicated to play a causative role in the development of head and neck malig-
Physical Exam of Thyroid Nodule
Fine-needle aspiration (FNA) biopsy Cold
Hot Surgery or observe Ultrasound
Multiple
Symptomatic?
Total or subtotal thyroidectomy
2 a) “Suspicious”
b) “Malignant”
c) Many follicular cells little or no colloid d) Hürthle cells
Surgery
a) Female with 4-cm single nodule and
“follicular neoplasm”
b) Male with 2.5-cm nodule and “follicular neoplasm”
c) “Highly suspicious” for cancer d) “Malignant”
“Total,” 98+% thyroidectomy Alternative approach—now less common:
Total lobe on one side and
“near-total lobectomy” other side
Cancer? See Algorithm 11.4 FNA for largest FNA: an enlarging nodule
Single Scan or Observe
Abundant colloid and many lymphocytes few follicular cells
Symptomatic Total or subtotal thyroidectomy
Indeterminate cells Insufficient for diagnosis
Re-biopsy
“Follicular neoplasm” (smaller)
Total lobectomy
Final diagnosis: malignant
Return patient to O.R. in next 2–3 days and complete a total thyroidectomy, or wait 6 weeks
Observe 1
Algorithm 11.2. Algorithm for the evaluation and diagnosis of a thyroid nodule.
nancies. Radiation therapy for acne or skin warts can be followed by skin or thyroid cancers years later.
History
Important points to elicit in the history of the patient presenting with a mass in the head and neck region are:
• the exact location of the lesion
• the length of time the lesion has been present
• the rate of growth of the lesion: rapid enlargement implies infec- tion or malignancy
• the presence of pain or tenderness: cancer usually is not painful unless there is a superimposed infection or nerve invasion
• the presence of an unpleasant odor: bacterial tonsillitis, a foreign body in a child’s nasal passage, and squamous cell carcinoma of the tonsil or base of tongue with superimposed bacterial infection all are noteworthy for the associated odor
• history of difficulty swallowing
• painful or tender persistent lesion in the mouth
• referred pain to the ear
• hoarseness
• weight loss
• history of radiation exposure.
A thorough family history can be helpful. Specific questions regard- ing family members with goiter, multiple endocrine neoplasia syn- drome, or a high incidence of skin cancers should be asked.
In addition to a history of the use of tobacco and alcohol, a history of the use of other nonprescription substances should be sought. For example, cocaine use may result in intranasal lesions.
A complete sexual history should be obtained. Oropharyngeal sex- ually transmitted diseases have been reported. Risk factors for HIV and AIDS may be identified that may alter the differential diagnosis.
The patient in our case was asked about these points, but nothing contributory was found. This was a neck lump without symptoms, dis- covered suddenly during a morning shave.
Head and Neck Examination
Inspection (see Algorithm 11.3)
Many lesions in the head and neck can be identified using simple inspection. On the scalp, epidermal inclusion cysts (known as “wens”) easily can be appreciated; a puncta often is not visible, and skin color is normal. The external ear protrudes and especially is prone to damage from sun exposure. A horn-like, hard little lesion that can be torn off, producing a shallow ulcer, is referred to as actinic keratosis. This lesion is a precursor of squamous cell carcinoma. Patients with these lesions are managed appropriately by referral to a dermatologist or head and neck surgeon for treatment. Any ulcerated skin lesion demands
Superior to hyoid Probably a lymph node Follows infection Observe X months Or FNA
AT/near midline At hyoid Elevates when tongue protrudes No infection history Surgery referral
It, s a th
yroglossal duct cyst Surgery
At or below thyroid cartilage Moves with thyroid cartilage Likely thyroid See A11.2 Lateral middle neck and nonpulsatile FNA BX "Thyroid"cells Likely cancer Surgery referral (See A11.4)
Supraclavicular Hard? Patient >40 Cancer diagnosis? FNA Biopsy TB? Referral Infection, Disease or pulmonary medicine Brown cloudy fluid Branchial cleft cyst Surgery referral
Rubbery patient <40 Lymphoma CXR CT chest
Lateral upper neck Pulsatile Refer vascular surgery Just below ext. ear Nontender Parotid Refer surgeryLateral neck ? Met. cancer FNA BX Just under mandible Node vs. submaxillary gland FNA BX and check mouth
CXR-open biopsy consider Algorithm 11.3.Algorithm for the evaluation and management of a neck mass.
biopsy so that a diagnosis can be made and appropriate treatment given. Skin lesions that have changed during a period of observa- tion, have irregular borders, display variegated pigmentation, or bleed when rubbed must be referred for excision or biopsy.
These may be melanomas, requiring complete removal with curative intent.
Gray-white plaques on the lower lip may be seen. These lesions are called leukoplakia, and a small percentage subsequently develop cancer. Squamous cell carcinomas of the tongue usually are firm, tender, and painful. They often are raised and on the side of the tongue.
Cancers of the gums, tonsillar pillars, and inner surfaces of the cheeksgenerally are redder than the adjacent surfaces. A patient who seems sick and shows a swollen tonsil near the midline may have a peritonsillar abscess, which requires urgent drainage. A bluish cyst in the floor of a child’s mouth is rare and is a ranula.
Brown patches on the lips signal Peutz-Jeghers syndrome, associ- ated with intestinal polyps that can bleed or obstruct. Skin tumors of various size consisting of tiny blood vessels, hemangiomas, can be found anywhere in the head and neck region. Epidermal inclusion cystsor sebaceous cysts commonly are found behind the lower exter- nal ear, in areas of acne activity, the posterior neck, and the earlobes (especially at the site of skin or ear piercing). The pink or red skin blotches on sun-exposed skin may be malignant or premalignant and generally require diagnosis and possible treatment from a specialist in skin conditions. Darkly pigmented spots or skin blotches that leave a gray, roughened zone when the surface is lightly scraped are sebor- rheic keratoses, related to skin aging.
Cervical lymph nodes that are obvious on inspection or palpation mandate a complete examination of the head and neck. A firm uni- lateral neck mass in an adult is cancer until proven otherwise (see Algorithm 11.3).Many of these are cervical metastases from squamous cell carcinoma of the head and neck. Deviation of the tongue to the side of the lesion may be appreciated when the patient protrudes the tongue, suggesting 12th cranial nerve invasion by cancer.
A painless, hard mass in the lower neck in a patient who lives in crowded conditions or is immunocompromised, with or without another known to have tuberculosis, may be scrofula, a tuberculosis lymph nodal mass.
A lump in the upper midline of the anterior neck may be a thy- roglossal duct cyst (see Algorithm 11.3). If located further up, under the chin, it will be an enlarged submental lymph node. If you stand to the side and ask that the tongue be put out, elevation of this lump with tongue protrusion is diagnostic of a thyroglossal duct cyst.
Branchial cleft cystpresents at the anterior border of the sternoclei- domastoid muscle or just in front of the external ear’s tragus. Thyroid enlargement, diffuse or nodular, has been termed goiter. The swelling in the thyroid often is easily visible, as in our case.
When inspecting the thyroid, try sitting lower than the patient, with your eyes at the level of her/his midneck, using some light from the side. Ask the patient to swallow. When the patient swallows, the
thyroid slides up and down and the thyroid nodule or multinodular goitereasily is seen.
Palpation
A thyroid nodule often can be appreciated moving up and down under the sternocleidomastoid muscle, as you palpate more deeply lateral to the trachea. Lipomas may present in the supraclavicular areas. These lesions have well-defined borders and are relatively soft. Masses in the neck may represent malignant or inflammatory disease. Enlarged lymph nodes tend to be found along the course of the jugular vein and are termed high-jugular lymph nodes when located in the upper neck, below the angle of the jaw. Firm, nontender masses in the neck that are not easily moved are likely cancer metastatic to cervical lymph nodes.
Infections of the tonsils or teeth also can result in enlargement of neck lymph nodes, but these nodes are tender. When cancer metasta- sizes to the upper jugular nodes, the most common primary sites are the base of the tongue, the nasopharynx, and the tonsillar areas.
Cancer metastatic to mid-jugular nodes—lymph nodes in the central lateral neck under the muscle—most commonly originates from the thyroid lobe on that side. Supraclavicular lymph node metastases generally are from cancer sites below the clavicles. Keep in mind, however, that lung cancer can and does spread anywhere (see Algorithm 11.3).
Palpation of the thyroid gland is best performed by facing the patient, placing the index finger on the thyroid cartilage (Adam’s apple) to stabilize it while curling the fingers of the opposite hand around the sternocleidomastoid muscle, resting the thumb on the thyroid isthmus. The neck muscles should be relaxed. When the patient is asked to swallow, the thyroid lobe slips up and down between your fingers and thumb, allowing you to appreciate a nodule in that thyroid lobe. The neck lump in our case patient was firm. It moved up with the thyroid lobe when he swallowed.
Examination of the oral cavity requires palpation for completeness.
A moistened, gloved finger gently sweeps over the gum surfaces, the floor of the mouth, and the tongue, searching for rough or tender areas.
With the patient breathing through the mouth, one quickly can sweep across the base of the tongue to the epiglottis. Bimanual examination especially is useful for the floor of the mouth and can be used for cheek surfaces and for the tongue.
Special Examination Techniques
Special examination techniques are performed by surgical oncologists and head and neck surgical specialists. Fiberoptic laryngoscopes are passed through the nose for direct examination of the vocal cords and nearby areas. Pediatric (3.6 mm in diameter) and anesthesia (4.0 mm) bronchoscopes, both fiberoptic, also are useful for this examination. A complete examination, searching for a primary cancer site, requires general anesthesia. The examination relies on the use of fiberoptic instruments to look into and at all surfaces that can be reached,
including the nasopharynx and sinuses, and the performance of appropriate biopsies. Esophagoscopy and bronchoscopy are added when the primary cancer site has not been found: about 3% of patients with metastatic cancer found in a cervical lymph node will have a final unknown primary classification.
Imaging studiesalso play an important diagnostic role. Computed tomography (CT) scan with contrast is most useful in evaluating sus- picious cervical lymph nodes. For suspected or known supraclavicu- lar nodes involved with cancer or for lymphoma anywhere above the clavicles, CT of the chest with contrast is used.Adenocarcinoma diag- nosed by cervical lymph node biopsy indicates the need for further studies, possibly including mammography and endoscopy. Magnetic resonance imaging (MRI) is superior to CT for evaluating neural ele- ments. Positron emission tomography (PET) scanning may supplant the use of some modalities, but currently the cost factor argues against its use except in special circumstances. Ultrasound is used to assess the entire thyroid gland (see Algorithm 11.2).Ultrasound can deter- mine whether a lesion is cystic or solid: a thyroid lesion demonstrated on ultrasound is benign if it is entirely cystic. Radioisotope scanning also may be useful; nodules that take up less isotope than the sur- rounding thyroid tissue are termed “cold” and have a much higher chance of being malignant than “hot” nodules (1% incidence of cancer in “hot” nodules). Sestamibi scan often is able to locate a parathyroid benign tumor (adenoma).
Biopsy Techniques
Fine-needle aspiration (FNA) is the initial biopsy technique used for the diagnosis of thyroid lesions and neck masses, with few excep- tions (see Algorithm 11.2).In the case presented, FNA was the first step chosen by the thyroid surgeon to whom this 48-year-old healthy man with a suspected thyroid nodule was referred. Using local anes- thetic, the lump (nonpulsatile) is fixed between fingers of the non- dominant hand, and a needle attached to a small syringe (for best suction) is passed into the lesion, then quickly passed in and part way out of the mass, “chopping” firm tissue to free cells to be aspirated. An experienced cytopathologist should evaluate this specimen.
Fine-needle aspiration for diagnosis of a thyroid nodule may not be definitive. If the material is deemed “insufficient for diagnosis,” a repeat FNA should be performed. The presence of abundant colloid or lymphocytes suggests benign disease, with the indication for surgery resting on factors other than suspicion of malignancy. “Pap- illary cancer,” “suspicious for papillary cancer,” and “follicular neo- plasm” are phrases in the pathology report that argue for surgical removal, since a significant number of these patients will have a malignancy.
Biopsy of an intraoral lesion can be taken with a scalpel or using a dermal “punch” biopsy technique. Biopsy for suspected lymphoma (see Algorithm 11.3) requires open surgical biopsy of some or all of the lymph node.The complete diagnosis requires more tissue than can
be obtained with needle aspiration or needle core biopsy. An open biopsy in the neck always is done by a surgeon familiar with the plan- ning for possible neck dissection, because a diagnosis of squamous cell cancer in a node mandates the excision of the biopsy incision site as part of a curative operation.
On the face, surgeons plan to take a little normal-appearing skin with the biopsy, while cosmetically planning the best approaches for removal of a suspected cancer. In assessing a pigmented lesion anywhere on the skin, a possible melanoma, “shave” biopsy is never appropriate because the depth of invasion determines the plan for surgical cure. Punch biopsy at the thickest part of the lesion or exci- sional biopsy with a tiny margin is preferred as the initial diagnos- tic biopsy when melanoma is suspected.
The case patient’s biopsy was sufficient for diagnosis. The patholo- gist described the cytology as “follicular neoplasm,” and an operation was recommended to the patient. He concurred, after learning about the options, the procedure, and the significant risks. A preoperative ultrasound study of the neck revealed no abnormality except for a left thyroid lobe solid nodule, 1.8 cm in diameter.
Benign Lesions of the Head and Neck
Congenital
Thyroglossal duct cystsare in the midline, may enlarge quickly with infection, and elevate with tongue protrusion (see Algorithm 11.3).
These lesions are removed completely (including the central portion of the hyoid bone) with general anesthesia. A midline mass in a baby or young child may be lingual thyroid tissue. These masses may require excision if they cause obstruction. It is important to recognize that this might be the only functional thyroid tissue present; this means that normal thyroid must be identified by scanning technique before any surgical intervention is planned.
Dermoid cysts, consisting of elements from all three germ cell layers, are rare in the head and neck.
First branchial cleft sinus or cystpresents in the preauricular skin, lying close to the parotid gland. This lesion always is deep and diffi- cult to remove completely. Incomplete removal is followed by recur- rence. Second branchial cleft cyst presents at the anterior border of the sternocleidomastoid muscle in the middle or lower neck or as a large tender infected mass under the muscle. Diagnosis is made by aspirat- ing brown turbid fluid. After treatment of the acute infection, the child or young adult returns for elective surgical removal. A cystic hygroma is a large, soft mass in the side of the neck above the clavicle. These complex, cystic lesions present in infancy and are difficult to remove;
suspected cases should be referred to a pediatric surgeon for definitive management.
In older patients, the differential diagnosis of a mass presenting in the upper neck must be considered: metastatic cancer, carotid body
tumor, carotid artery aneurysm, branchial cleft cyst, or a primary cancer (see Algorithm 11.3).
Salivary gland tumorsare most common in the parotid gland, and the majority of these are benign (75–85%). Most parotid tumors are
“mixed tumors” or pleomorphic adenomas. All parotid tumors are removed by surgeons experienced in dissecting parotid tissue off the seventh cranial nerve. In the case of malignant tumors of the parotid, the nerve is no longer sacrificed (unless it is grossly involved with cancer), and the area is treated by irradiation after surgery. Tumors of other salivary glands are more likely to be malignant.
Infections
In a child or teenager, upper neck masses usually are enlarged lymph nodes draining an infected area. In the posterolateral neck, lateral to the sternocleidomastoid, and in the posterior triangle, these lumps almost always are inflamed nodes draining a zone of scalp infection.
However, thyroid cancer in a node can present here. A mass in the thyroid or adjacent to the thyroid is relatively common in all ages with the exception of infancy. Malignancy always must be considered.
Consider doing an FNA.
Scrofula (tuberculous lymphadenitis in the neck) is treated medically after diagnosis has been made. One actually might avoid the usual skin test in this case because the intermediate tuberculin test could result in a huge reaction, with skin slough of the forearm. Chest x-ray, CT of the neck and chest, sputum, or, better yet, early morning gastric washings for tuberculosis (TB) smear and culture should result in a positive diagnosis in a patient with a tuberculous infection severe enough to result in scrofula.
Ludwig’s anginais a severe, spreading, acute infection that arises from mixed mouth bacterial flora. It involves the floor of the mouth and produces pain and tenderness under the jaw in the midline. Imme- diate referral is essential because some patients require emergency drainage in addition to antibiotics to protect the airway.
Vincent’s angina(“trench mouth”) develops from poor hygiene and ulcerations in the gums, and is noted by fetid odor, acute infection, and rapid spreading. This condition is managed with antibiotics as well.
Referral usually is indicated, because differentiation from Ludwig’s angina is important.
Vascular (see Algorithm 11.3)
A carotid body tumor easily can be mistaken for a low, lateral parotid gland tumor. If a hard lump is right over the likely site of the carotid bulb, Doppler color flow study and possibly CT should precede any needle biopsy or surgical removal. Aneurysms of the carotid artery and a tortuous innominate artery present as pulsatile masses in the lateral neck. While color flow Doppler clarifies these diagnoses, con- sultation with a vascular surgeon should be strongly considered.
Parathyroid
The two superior parathyroid glands arise from the fourth branchial pouches, along with the lateral thyroid lobes. The two inferior glands arise from the third branchial pouches and normally lie more anterior than the superior two. Primary hyperparathyroidism (pHPT) results in elevated serum calcium (Ca2+) levels and usually is picked up on a routine blood serum laboratory study. Confirmation of pHPT comes from finding elevated serum Ca2+with elevated parathyroid hormone (PTH). This condition can result in bone demineralization, fractures, severe arthritis, renal failure, ureteral stones, acute pancreatitis, peptic ulcer, and mental changes. However, most patients are asymptomatic at the time of diagnosis.
Cure for pHPT is surgical. Since the majority of cases are caused by a single parathyoid adenoma, identification of the site of the adenoma, if possible, allows a more rapid procedure that usually requires only a short stay after surgery. Thus, with pHPT diagnosed with a radioiso- tope scan (sestamibi scan) demonstrating the site of the single adenoma, the surgeon can remove the enlarged gland and check the probability of cure with a rapid PTH level intraoperatively. Bloods for this test are drawn before and after removal of the adenoma. The PTH level falls within 5 minutes to a level consistent with cure after removing the single adenoma responsible for pHPT. In about 4% of cases there are two adenomas; in about 15% the cause of pHPT is hyperplasia, which usually involves all four glands. In the event that the sestamibi scan is not able to find a single adenoma or rapid PTH assay is not helpful or available, the surgeon plans a more elaborate procedure, requiring finding all parathyroids before removing any. To aid in locating these glands, some use intravenous methylene blue dye preoperatively. To aid locating a single adenoma, one can use a ses- tamibi scan preoperatively and then use a gamma-detecting probe to pick up the radioactive emissions in the operating room.
Thyroid
Diffuse enlargement and nodular masses of the thyroid are the most common neck masses. History and physical examination should be done first, before laboratory evaluation, imaging studies, or biopsy (see Algorithm 11.2).
Thyroiditis
Chronic lymphocytic (Hashimoto’s) thyroiditisis found virtually only in women, can be nodular, and leads to hypothyroidism. Surgery is reserved for those with the late fibrosis that can develop, causing tra- cheal or esophageal compression symptoms, and for cases in which cancer is suspected. Subacute thyroiditis produces a swollen and tender thyroid. Medical endocrinologists treat these cases with antiin- flammatory medication.
Hyperthyroidism
A diffuse goiter with signs and symptoms of hypermetabolic activity, elevated thyroxine, and low thyroid stimulating hormone levels is con-
sistent with primary hyperthyroidism—Graves’ disease. The treat- ment for this condition is medical, with an antithyroid agent used initially, sometimes with a beta-blocker added, and radioactive iodine used for recurrence. Women who are pregnant or anticipate the pos- sibility of pregnancy should not receive antithyroid drugs or radia- tion therapy due to the risk of resultant fetal hypothyroidism. In these cases and some others, surgical intervention may be warranted.
Medical follow-up is necessary, both to assess thyroid function and to decide on hormone replacement therapy.
Before any surgery on the thyroid, one must be certain either that the patient is euthyroid or that the hyperthyroid state is controlled to avoid the potentially lethal complication of “thyroid storm.”This dangerous condition is caused by release of thyroid hormone from the thyroid gland during surgical manipulation and results in severe tachy- cardia, fever, and other signs of hypermetabolism. For this reason, antithyroid drug plus a beta-blocker are given to “cool off” the thyroid and stop the symptoms and signs of Graves’ disease before surgery. If the thyroxine level in the serum has not fallen to a safe level for surgery, beta-blockers are continued for 4 or 5 days postoperatively. Iodine usually is given in an oral form for a week before operating on a hyper- active thyroid so as to block the release of thyroid hormone and to make the gland firmer and less vascular.
Thyroid Nodules (see Algorithm 11.2)
Multinodular goitersusually are benign, with nodules composed of colloid. These goiters may enlarge and compress the trachea and/or esophagus. It is important to remember that an individual nodule in a multinodular goiter may be malignant.If a nodule is notably larger than others or enlarges during a period of observation, biopsy is rec- ommended. Finding a “follicular” lesion indicates the need for surgi- cal referral. Finding a solitary thyroid nodule indicates the need for further evaluation if the diameter is greater than 0.8 cm on ultrasound.
Fine-needle aspiration, often with guidance by ultrasound, is the best initial diagnostic modality. Radioisotope scan then may be indicated to discover a “cold” nodule. If a nodule is large enough to be seen easily or if symptoms are present, surgical intervention is considered, regard- less of the results of FNA. If the biopsy yields primarily thyroid folli- cle cells, surgical referral is indicated.
While attempted “suppression” of a possibly malignant thyroid nodule through the administration of oral thyroid hormone formerly was a popular first step, the recommendation by a majority of medical and surgical endocrinologists today is surgical removal and evaluation by the pathologist.Some simple rules of thumb indicate the risk of malignancy in a thyroid nodule:
1. Most thyroid lesions and problems occur in women; a woman with a single nodule at age 40 is least likely, compared with women of other ages, to have a malignancy (about 10% likelihood in the surgical literature).
2. The chance of cancer increases as the age of the patient increases or decreases from age 40.A woman at age 20 or age 60 with a single
nodule has about a 25% chance of having cancer in the single nodule.
3. A male, for reasons unknown, has a two to three times greater like- lihood of thyroid cancer as compared with a female of the same agewith the same size thyroid nodule.
4. The larger the follicular neoplasm of the thyroid, the more likely it is cancer. A 4-cm thyroid tumor composed of thyroid follicular cells has a more than 50% likelihood of being cancer.
5. Firm neck lymph node, hoarse voice, lung nodule, bone pain or lesion, and hard and fixed thyroid mass are some of the signs of aggressive cancer.
The patient in our case had a left thyroid lobe resection. This tissue was sent to the pathologist with request for rapid section diagnosis.
The pathologist, via intercom into the operating room, reported that there was a 1.8-cm-diameter follicular lesion in the left thyroid lobe.
She could not see any definite sign of malignancy in the sections studied. The surgeon closed the neck, and the patient went home 6 hours later; he was able to swallow and felt only some mild discomfort.
Salivary Glands
Parotid tumors are much more frequent than tumors in the other salivary glands, and most are benign. All tumors are removed under general anesthesia, dissecting the gland containing the tumor off the facial nerve. The tumor is never just lifted out of the glandular tissue because doing so leads to a high rate of recurrence, with difficulty of cure thereafter. Pleomorphic adenoma, the most common benign parotid tumor, can become very large, and removal should be under- taken early when cure and safe removal are much easier. Sub- mandibular (also termed “submaxillary”) gland enlargementis less common. Fine-needle aspiration is useful. Tumors of submandibular, sublingual, and minor salivary glandsare more likely malignant, and all are treated by complete removal of the gland.
Be warned—the submandibular gland can be enlarged because of blockage of the orifice of Stensen’s duct by a “stone” or by cancer of the floor of the mouth. Check the area behind the teeth, below the tongue.
Sites of Head and Neck Cancer
Skin
Premalignant and low-grade skin cancers are common, but melanoma is the more feared lesion, and we constantly must be on the lookout for it. Therefore, plan biopsy for any pigmented lesion that has changed, is asymmetric, has irregular borders, has variegated color pattern, or is ulcerated. Seborrheic keratosesare the “age spots”
seen on the skin; some of these are difficult to differentiate from melanoma. The scalp may be hiding a malignancy, a wen, a buried tick, or the site of a Lyme disease–carrying tick bite. Check for these.
Oral Cavity
The oral cavity includes the lips, buccal mucosa, oral tongue (ante- rior two thirds), floor of mouth, hard palate, upper and lower alveo- lar ridges, and retromolar trigone (Fig. 11.1).Virtually all malignancies here are squamous cell in origin. They often are painful, generally raised or ulcerated, and firmer to the touch than surrounding tissue.
The pain from superficial infection often can be relieved through antibi- otic treatment. A patient with a suspected lesion is referred immedi- ately for early biopsy, and, if necessary, a multidisciplinary treatment plan for cancer cure can be instituted. Cancers of this region affect speech and swallowing patterns. A new onset of hoarseness or painful or difficult swallowing, especially when coupled with a history of tobacco or alcohol use, should prompt a thorough evaluation to iden- tify a primary cancer. The therapy for oral cavity cancers is dependent on the site and cancer stage at presentation.
Squamous cell carcinoma of the lip, almost always the lower lip, is the most common oral cavity malignancy. Early lesions are treated with wide excision. Neck dissection is indicated when neck metastases are present or when the primary cancer is large. Additional treatment is given in cases in which a margin is involved, if there is perineural, vascular, or lymphatic invasion, and for large primary tumors (>3 cm).
Carcinoma of the buccal mucosa is rare, often arising from areas of leukoplakia. Early-stage lesions not involving bony structures are well treated with radiation therapy. More advanced lesions are treated with resection, followed by radiation.
Figure 11.1. Oral Cavity includes lips, floor of mouth, anterior two thirds of tongue, buccal mucosa, hard palate, upper and lower alveolar ridge, and retro- molar trigone. (Reprinted from Bradford CR. Head and neck malignancies.
In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)
Cancers of the oral tongue often are associated with occult cervical lymph node metastases. Selective neck dissection is combined with primary resection (usually hemiglossectomy) in all but the most super- ficial lesions. Forty percent to 70% of patients with cancers of the floor of the mouth larger than 2 cm have occult lymph node metastases.
Because of this, surgical resection includes selective neck dissection or cervical lymph node irradiation. Early cancers of the retromolar trigone or alveolar ridge are treated effectively by transoral resection. More advanced lesions may require mandibulectomy and neck dissection, followed by postoperative radiation. Lesions of the palate and all abnormal-appearing lesions need biopsy.
Pharynx
The pharynx is a muscular tube that extends from the base of the skull to the cervical esophagus. It consists of three subdivisions—the nasopharynx, the oropharynx, and the hypopharynx (Fig. 11.2). The nasopharynx extends from the nose openings to the soft palate, and about 2% of the squamous cell cancers of the head and neck begin in this part of the pharynx. These may present with nose bleed, nasal obstruction, headache, or unilateral hearing loss. The majority of these cancers are associated with enlarged cervical lymph nodes at the time of presentation. Due to the difficulties of surgery in this region, early
Figure 11.2. Sagittal view of the face and neck depicting the subdivisions of the pharynx as described in the text. (Reprinted from Bradford CR. Head and neck malignancies. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery:
Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)
cancers are treated most appropriately with primary radiation therapy.
In more advanced lesions, chemotherapy is added.
The oropharynx includes the tonsillar fossa and anterior and poste- rior tonsillar pillars, tongue base, uvula, and lateral and posterior pharyngeal walls. Cancers of the oropharynx commonly present with chronic sore throat and ear pain, and later-stage patients may notice voice change, difficulty swallowing, or pain upon opening the mouth.
Small cancers without cervical lymph node involvement can be treated equally well with surgical excision or primary radiation therapy.
Advanced cancers require multimodality therapy. Cancers of the base of the tongue are very challenging. These often are diagnosed late, metastases are more common, and there is significant morbidity asso- ciated with treatment. Early cancers are treated best with radiation in order to preserve function.
The hypopharynx extends from the hyoid bone to the level of the cricoid cartilage. Cancers in this zone are very aggressive and gener- ally have poor outcome irrespective of the therapy chosen.
Larynx
The larynx is composed of three parts—the supraglottis, the glottis, and the subglottis (Figs. 11.3 and 11.4). The supraglottic larynx con- sists of the epiglottis, the aryepiglottic folds, the arytenoids, and the false vocal cords. The glottis includes the true vocal cords and the ante- rior and posterior commissures. The subglottic larynx extends from the lower portion of the glottic larynx to the hyoid bone. The primary symptom associated with laryngeal cancer is hoarseness, but airway obstruction, painful swallowing, neck mass, and weight loss may occur. In general, early-stage disease can be managed with radiation therapy or conservation surgery. More advanced cancers require laryn- gectomy, with or without neck dissection, and postoperative radiation therapy or induction (“neoadjuvant”) chemotherapy plus radiation therapy.
Sinuses and Nasal Cavity
These cancers are rare, and most are squamous cell cancers. Multiple other cell types, including melanoma, occur. Most cancers present late and all suspected cases should be referred early. Biopsy and careful staging studies by CT, MRI, and possibly PET are essential for plan- ning treatment.
Salivary Glands
Cancers of the salivary glands can arise in major glands (including the parotid, submandibular, and sublingual) and minor glands.
Surgery is the main form of treatment. Malignant tumors of the parotid gland are treated with total parotidectomy with preservation of the facial nerve, unless the nerve is involved directly. If the cancer is “high grade,” selective or modified radical neck dissection is added, then usually followed by postoperative radiation therapy.
Figure 11.3. Sagittal view of the larynx depicting the subdivisions of the larynx. The preepiglottic space is that area anterior to the epiglottis bordered by the hyoid bone superiorly and the thyrohyoid membrane and superior rim of the thyroid cartilage anteriorly. (Reprinted from Bradford CR. Head and neck malignancies. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery:
Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)
Figure 11.4. Laryngoscopic view of endolarynx. Relevant structures are iden- tified. (Reprinted from Bradford CR. Head and neck malignancies. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)
Thyroid (see Algorithm 11.4)
Because intraoperative frozen section analysis of thyroid tissue cannot always distinguish benign from malignant follicular lesions, the expe- rienced thyroid surgeon must plan the surgical procedure based on the operative findings, size of the tumor, and all of the factors noted earlier indicating the risk of cancer. Whether to remove all or most of the thyroid gland has been controversial (Tables 11.1 and 11.2). An excel- lent discussion of the evidence for these approaches is found inR.J.
Weigel’s chapter on thyroid surgery in Surgery: Basic Science and Clin- ical Evidence, edited by J.A. Norton et al, published by Springer-Verlag,
THYROID CANCER
Cancer (Papillary/Follicular Types) Medullary cancer:
total thyroidectomy and central neck complete node dissection Hürthle cell cancer:
(do not take up iodine, produce much thyroglobulin) Total thyroidectomy
Node dissection if node is positive Lifetime suppression of TSH Follow thyroglobulin level
In “low-risk” patients:
Node(s) positive?
Modified neck dissection on affected side, along with total thyroidectomy Total thyroidectomy
Lifetime T4 suppression Surgical follow-up Endocrine follow-up
In “high-risk” patients:
Total thyroidectomy
For papillary and non-Hürthle cell cell follicular cancer
Six weeks off thyroid hormone and iodine
Radioactive iodine Rx
Lifetime suppression of TSH with p.o. T4
Papillary cancer, thyroglobulin
less than 5, scan probably unnecesary
Consider whole body scan in 1–2 years
Surgical follow-up Endocrine follow-up
Lymphoma:
chemotherapy
± radiotherapy
Algorithm 11.4. Algorithm for the treatment of thyroid cancer.
Table 11.1.Proponents supporting less than total thyroidectomy (level II evidence). Mean TotalRisk stratificationfollow-up Authorspatients(basis)(years)OutcomeConclusions Nguyen and155(AMES)9Mortality TT vs. <TT;For low-risk patients, conservative Dilawari 1995a141 low2.3% vs. 1.85% (NS)resection is adequate Shaha et al 1038(AMES)20Local recurrence, Lob vs. Avoid less than lobectomy; for 1997b465 low<Lob; 27% vs. 4% (p=.005)low-risk patients, no advantage Local recurrence, TT vs. Lob;in recurrence or survival for total 1% vs. 4% (p=.1)thyroidectomy vs. lobectomy Overall failure, TT vs. Lob; 8% vs. 13% (p=.06) Sanders and1019(AMES)13Recurrence TT vs. Lob:For low-risk (AMES) patients, Cady 1998c790 lowLow risk; 5% vs. 5%lobectomy is adequate High risk; 29% vs. 34% (NS) Wanebo et al347(Age)10-yr mortality TT vs. Lob:No benefit of total thyroidectomy 1998d216 lowLow; 16.5% vs. 12.4% (NS)in any risk group 103 intermediateIntermediate; 75.4% vs. 33.5% (NS) 28 highHigh; 65% vs. 20% (NS) TT, total thyroidectomy; Lob, lobectomy. aNguyen KV, Dilawari RA. Predictive value of AMES scoring system in selection of extent of surgery in well differentiated carcinoma of thyroid. Am Surg 1995;61:151–155. bShaha AR, Shah JP, Loree TR. Low-risk differentiated thyroid cancer: the need for selective treatment. Ann Surg Oncol 1997;4:328–333. cSanders LE, Cady B. Differentiated thyroid cancer: reexamination of risk groups and outcome of treatment. Arch Surg 1988;133:419–425. dWanebo H, Coburn M, Teates D, Cole B. Total thyroidectomy does not enhance disease control or survival even in high-risk patients with differentiated thyroid cancer. Ann Surg 1998;227:912–921. Source:Reprinted from Weigel RJ. Thyroid. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.
Table 11.2.Proponents supporting total thyroidectomy (level II evidence). Mean TotalRisk stratificationfollow-up Authorspatients(basis)(years)OutcomeConclusions DeGroot et al269I: 12812Recurrence TT/NT vs. ST/Lob;Decreased risk of recurrence for TT/NT 1990aII: 89(p<.016)vs. ST/Lob III: 2920-yr mortality TT/NT vs. ST/Lob;Decreased mortality for tumors >1.0cm IV: 2010% vs. 20% (p<.004)for TT/NT vs. ST/Lob (class)(tumors>1.0cm) Samaan et al1599I: 67011Mortality TT vs. Lob vs. <Lob; 9%In patients not receiving RAI, decreased 1992bII: 563vs. 15% vs. 19% (p<.003)recurrence and mortality for TT III: 271Trend for improved outcome with TT IV: 95for patients receiving RAI (class) Mazafferi and1355I: 17015.730-yr recurrence (class II, III) TTTotal thyroidectomy results in lower Jhiang 1994cII: 948vs. Lob; 26% vs. 40% (p<.002)recurrence and mortality compared to III: 20430-yr mortality TT vs. Lob; 6% vs.lesser resections IV: 339% (p=.02) (class) Loh et al 1997d700I: 51611.310-yr recurrence TT vs. Lob; 23%Patients undergoing less than total II: 57vs. 46% (p<.0001)thyroidectomy had higher recurrence III: 10410-yr mortality TT vs. Lob; 5% vs.and mortality IV: 2311% (p<.01) (TNM) TT, total thyroidectomy; Lob, lobectomy; ST/Lob, subtotal thyroid lobectomy; NT, near-total thyroidectomy; RAI, radioactive iodine. aDeGroot LJ, Kaplan EL, McCormick M, Straus FH. Natural history, treatment and course of papillary thyroid carcinoma. J Clin Endocrinol Metab 1990;71:414–424. bSamaan NA, Schultz PN, Hickey RC, et al. The results of various modalities of treatment of well differentiated thyroid carcinoma: a retrospective review of 1599 patients. J Clin Endocrinol Metab 1992;75:714–720. cMazzaferri EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med 1994;97:418–428. dLoh K-C, Greenspan FS, Gee L, Miller TR, Yeo PPB. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospec- tive analysis of 700 patients. J Clin Endocrinol Metab 1997;82:3553–3562. Source:Reprinted from Weigel RJ. Thyroid. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.
2001. The majority of thyroid cancers are the papillary type, Even those lesions classified as “follicular” will behave similar to “papillary”
lesions if papillary elements are identified.
The final pathology report for our patient was available in the after- noon of the first postoperative day. The diagnosis was papillary carci- noma of the thyroid. The surgeon discussed the case with you and advised returning the patient to the operating room for completion total thyroidectomy. The patient had been forewarned about this pos- sibility and reentered the hospital for the procedure, which was carried out without complication 72 hours after the first operation. No abnormal lymph nodes were found during the procedure; none were biopsied.
Papillary thyroid carcinomasare highly curable, spreading locally and into nearby lymph nodes before becoming blood-borne and metastatic to lung, bone, or other sites. Residual disease or metastases usually can be controlled using radioactive iodine (131I); chemotherapy is not effective. Most often, the surgeon does a total thyroidectomy, per- forming a lymph node dissection only when metastases are identified;
modified radical neck dissection preserves the sternocleidomastoid muscle, spinal accessory nerve, and jugular vein while cleaning out the lymph nodes lateral to the thyroid and along the trachea.
For follicular cancers, the surgical approach is similar; however, these lesions are more likely to spread via the bloodstream and are not as easily controlled with 131I when metastatic. Anaplastic carcinomas are rare thyroid neoplasms that are highly aggressive, extensive (almost impossible to remove), and resistant to therapy. The surgical approach is to try to clear the anterior wall of the trachea and remove all cancer locally, if possible; tracheostomy may be necessary. The rare thyroid lymphomaresponds to chemotherapy or radiotherapy. Rarely, emergency operation is necessary to free the trachea.
Medullary thyroid cancerexists in “sporadic” and familial forms—
part of the multiple endocrine neoplasia (MEN) syndrome, an autosomal-dominant disease. Early diagnosis through calcitonin deter- mination is very important, because in the MEN syndrome this cancer may cause death before age 25. More recently, the ret proto-oncogene has been used to determine the presence of this cancer prior to changes in the calcitonin levels, allowing even earlier surgical intervention. The surgical approach is aggressive, consisting of total thyroidectomy with meticulous “central compartment” dissection and ipsilateral modified radical neck dissection.
In determining the management of papillary and follicular thyroid cancer, the relative risk of recurrence and death is evaluated so as to plan the most effective treatment. In patients with thyroid cancer, a man over 40, a woman over 50, and anyone with distant metastases or cancer involving both lobes or invading adjacent tissues is classified as “high risk.” If all other factors are “low risk,”
the size of the primary cancer can increase the risk of recurrence;
recurrence carries a significant possibility of death from the thyroid cancer in 10 years. Involvement of one or two nearby lymph nodes may increase the risk slightly but does not have the same significance
as in breast or colon cancer. Most physicians treating high-risk thyroid cancer and cancer with any node positive advocate total thyroidec- tomy, ablation of remaining viable thyroid cells with radioactive iodine, followed by lifelong suppression of the thyroid-stimulating hormone (TSH), giving enough oral thyroid hormone to accomplish that. This was the treatment program planned for our case patient.
In a lower risk patient, the 131I may not be necessary, but the TSH suppression is thought to be essential. These patients should be fol- lowed with periodic neck examinations and determination of the serum thyroglobulin levels. A very low thyroglobulin level is evidence against papillary cancer (or “Hürthle cell cancer”) recurrence.
Parathyroid
Parathyroid cancer is rare. This is fortunate, because cure may be dif- ficult to obtain. Surgery is the only treatment for a patient with this cancer. These patients present with high serum calcium levels and usually a hard mass in the neck.
Perils and Pitfalls
In any surgery of or near the thyroid, there is a risk of temporary or permanent injury to the recurrent laryngeal nerve and to the exter- nal branch of the superior laryngeal nerve. Removing or destroying too much parathyroid tissue carries the risk of producing severe hypoparathyroidism, which is difficult to manage and very unpleas- ant for the patient.An extremely important complication, because it is life threatening, is an unrecognized postoperative compression of the trachea from an expanding hematoma after thyroid surgery. All sur- geons must be aware of this possibility. When called to see a postop- erative thyroid patient who has difficulty breathing, the responding physician must not hesitate to open the incision and spread the closed muscles to relieve the pressure on the trachea by releasing the trapped blood.
Summary
An overview of this complex topic has stressed diagnostic techniques, lesions, and cancers most frequently encountered in the head and neck.
Appropriate referral, careful evaluation, and biopsy of suspicious lesions has been encouraged.
We have stressed the need for careful, logical progression from detailed history-taking to choice of appropriate diagnostic testing, only after careful physical examination. Referral to those with special train- ing and experience often is needed. Oropharyngeal and neck lesions, in smokers, are especially worrisome because of the greatly increased risk of cancer in these individuals. Thyroid conditions, nodules, and cancer have been discussed in greater detail. Abnormalities of the thyroid cause most lumps of the neck that trigger a visit to a physician’s office.
Selected Readings
Bradford CR, Head and neck malignancies. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York:
Springer-Verlag, 2001, 1179–1794.
Dackiw AP, Sussman JJ, Fritsche HA Jr, et al. Relative contribution of tech- netium-99 m sestamibi scintigraphy, intraoperative gamma probe detection, and the rapid parathyroid hormone assay to the surgical management of hyperparathyroidism. Arch Surg 2000;135:550–557.
Le HN, Norton JA. Parathyroid. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer- Verlag, 2001, 857–877.
Levin KE, Clark OH. The reasons for failure in parathyroid operations. Arch Surg 1989;124:911–915.
Potter DD Jr, Kendrick ML. An elderly woman with recurrent hyperparathy- roidism. Contemp Surg 2002;58(11):555–559.
Stojadinovic A, et al. Thyroid carcinoma: biological implications of age, method of detection, and site and extent of recurrence. Ann Surg Oncol 2002;9(8);789–798.
Weigel RJ. Thyroid. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery:
Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, 879–895.
Wise RA, Baker HW. Surgery of the Head and Neck, 3rd ed. Chicago: Year Book Medical Publishers, 1968.
