Please note that the following is a general guideline only.
Epidemiology
> 40 Yr neck node is a malignancy Unless proven otherwise, M>F
>40 Yr Cystic mass in the neck is a degenerated cancer node, not a branchial cyst until proven otherwise
In the young -Inflammatory more likely, if cystic- branchial cyst
Aetiology
Most common mets are SCC > others ie thyroid/ adeno Ca/ melanoma
SCC=Primary sites nasopharynx > tonsil > retromolar trigone > tongue base > piriform sinus Then outside head and neck
Primary lymphoma-less common
Inflammatory; bacterial/ viral/ TB should be considered)
Signs and Symptoms
Hx suggestive more of an inflammatory node are : acute onset, painful, resolving, younger patient
Hx suggestive of a neoplasm- progressive enlargement, generally non tender, SCC hard, may get cystic degeneration Lymphoma rubbery.
Ask about symptoms of a possible primary site;
-upper aerodigestive tract: Dysphagia, Otalgia due to referred pain
-Skin CA
-Thyroid cancer/risk of cancer
Examination
Node or nodes: what is the consistency, is it very tender(inflammatory)
Look for a primary site (oral cavity, oropharynx, Flexible scope: nsopharynx, Hypopharynx, larynx, skin, thyroid, melanoma)
If a low neck node look for a primary breast/ chest/ GI/ testicular origin
Investigation
If acute onset may observe/ do blood work up check for EBV, CMV etc
US guided FNAC: (if any possibility of neoplasm) : do all the stains-Cytokeration-SCC, Lukocyte antigens-lymphoma, HMB45, s 100-melanoma, Thyroid AB
Also consider TB culture on FNA
If non diagnostic need and excisional biopsy and through look for a primary site i.e. Panendoscopy & blind biopsies of the nasopharynx, tongue base, tonsillectomy (wide resection)
Cystic mets have poor FNA diagnostic yield and do need an excisional biopsy (cystic node in an adult is cancer unless proven otherwise; NOT a branchial cyst!)
If low cervical nodes/ adeno CA on FNA: work up for non-head and neck primary (chest/ prostate/ renal/ GI/ breast)
Treatment
Metastatic SCC; Neck dissection, treatment of the primary site and XRT +/- Chemotherapy
If Thyroid: need total thyroidectomy, neck dissection and post op radioactive treatment
if Lymphoma -CHOP etc