Management of lateral cystic swellings of the neck, in the over 40s’ age group

Abstract

We present a series of three case reports of patients over the age of 40 with cystic swellings in the lateral neck. Clinically they masqueraded as branchial cysts, but subsequently were diagnosed as being squamous cell carcinoma cystic lymph node metastasis arising from an occult tonsillar primary. Currently there is an absence of national guidelines for the treatment of lateral neck cysts in the over 40s' age group that subsequently prove to be cystic metastases from occult tonsillar primaries. This disease process is more common than thought, with up to 80 per cent of so-called branchial cysts in the over 40s' age group being malignant. We recommend that patients over the age of 40 presenting with lateral cystic swellings in the neck should have a high suspicion of malignancy and require a panendoscopy, ipsilateral tonsillectomy and blind biopsies of Waldeyer's ring. This avoids inadvertent excision of a possible cystic lymph node metastasis. If the panendoscopy histology proves to be benign, then proceed to excision of the cyst with frozen section analysis of it. If this confirms it to be benign then that is all that is necessary; if the frozen section is however positive for carcinoma then the surgeon can proceed at that time to a formal neck dissection and therefore avoid a further procedure. In the event of an occult tonsillar malignancy, excision of the cyst as part of a neck dissection with post-operative radiotherapy is recommended. It is our aim to treat a cystic lymph node metastasis as you would a solid lymph node metastasis.

Cystic metastasis from head and neck squamous cell cancer: A distinct disease variant?

“…May not be associated with the usual risk factors of smoking and alcohol abuse 10 Patient population frequently younger than those with solid metastatic SCC 11 Primary tumors are often occult 12 Prognosis better than with noncystic lymph node metastasis 13,14 Site of origin [15][16][17][18] Waldeyer's ring: 33%-62% Faucil tonsil: 43%-64% Tongue base: 37%-60% Nasopharyx: tonsil cancer. The unique features of this subtype of tonsil cancer are its propensity for moderately large cystic metastasis in lymph nodes of the jugulodigastric region coupled with relatively small or occult primary tumors.…”

Role of fine needle aspiration cytology in the preoperative investigation of branchial cysts

“…Accordingly, a thorough assessment of the skin of the head and neck, other nodes in the head and neck and a visual examination of the upper aero‐digestive tract as far as practicable is important. If there are any other suspicious features, a full examination of the upper aero‐digestive tract by endoscopy will be required 4 …”

“…The generality of triple assessment of any mass lesion, as commonly utilized by the surgical oncologist, for example, in the investigation of breast lumps or soft tissue lumps, is equally applicable to lateral neck masses 3–7 . Appropriate investigation will allow identification of alternate diagnoses such as a cystic squamous cell carcinoma (SCC) metastasis to a lymph node or a cystic inferior pole parotid tumour such as a Warthin's tumour.…”

Torbiel boczna szyi czy przerzut raka płaskonabłonkowego

“…U pacjentów powyżej 40. roku życia zaleca się dodatkowo wykonanie badania TK lub MRI [18]. Jeśli wynik biopsji wskazuje na obecność przerzutu raka płaskonabłonkowego lub jest niejednoznaczny, dalsze postępowanie powinno polegać na usunięciu torbieli oraz wykonaniu panendoskopii.…”