Neoplastic Neck Masses

Benign lesions in the head and neck include lipomas and fibromas and require no treatment unless they cause significant functional or cosmetic deformity. Sebaceous cysts and epidermal inclusion cysts are also common and usually need to be excised because of the high incidence of recurrent infection.

All neck masses in adults should be presumed to be malignant until proved otherwise. The most common malignant neck mass in adults is metastatic squamous cell carcinoma. Primary tumors are usually found in the upper aerodiges-tive tract or skin. Smoking and alcohol abuse are etiologic factors. Careful examination of all mucosal surfaces of the head and neck is crucial to identify the primary tumor site. Endoscopy with biopsies is the first step in the diagnosis; surgical treatment of the primary site involves neck dissection, radiation, or both.

Lymphomas are one of the most common malignancies of the neck in children but can occur at any age. Patients can present with lymphadenopathy associated with constitutional symptoms (night sweats, fever, weight loss), hilar adenopathy, or hepatosplenomegaly. Diagnosis is confirmed by excisional biopsy. Most head and neck lymphomas are treated with a combination of radiation and chemotherapy.

Rhabdomyosarcoma is a common childhood neoplasm with peak incidence at age 5 years. Early symptoms include a painless, enlarging mass or symptoms related to obstruction by tumor. Approximately 35% of rhabdomyosarcomas manifest in the head, neck, and orbit. Embryonal rhabdo-myosarcoma and botryoid sarcoma (a variety of embryonal rhabdomyosarcoma) are most common in the head and neck, accounting for 75% of cases. Other forms include alveolar and pleomorphic. Diagnosis is made by excisional biopsy, and treatment is multimodal, including surgery, radiation, and chemotherapy.

Carotid body tumors are paragangliomas that arise from the adventitia of the common carotid bifurcation. They are thought to arise from derivatives of neural crest cells and are members of the diffuse neuroendocrine system. They can be associated with other tumors of similar origin, including medullary thyroid carcinoma, parathyroid adenoma, and pheochromocytoma, in up to 7% of cases. Familial incidence is 8% to 10%, and inheritance is autosomal dominant. A high incidence of bilateral carotid body tumors occurs in familial paraganglioma syndromes, and 1% to 3% of these tumors actively secrete substances such as catecholamines or serotonin. Symptoms of catecholamine secretion include headache, perspiration, palpitations, pallor, and nausea. Screening for blood and urinary catecholamines should be performed to rule out a secreting tumor or pheochromocy-toma. Symptoms of serotonin secretion are carcinoid syndrome, including diarrhea, flushing, severe headaches, and hypertension.

Other tumors of the head and neck arise from neurogenic tissue. These include schwannomas, neurofibromas, neurofibrosarcomas, and neuroblastomas. These tumors can manifest with associated cranial nerve deficits. Treatment is surgical excision.

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