Aspiration cytology of head and neck masses

Fine needle aspiration biopsy and cytologic examination of the aspirate were performed on 203 masses involving glandular and nodal structures of the head and neck: thyroid gland (85); salivary glands (31); and lymph nodes (87). Overall cytologic-histologic correlation was 91 per cent, with a 10 per cent false-negative rate. The ease of the procedure coupled with the rapidity of obtaining a pathologic diagnosis allows a more intelligent therapeutic approach.     

Irradiation induced salivary gland neoplasia.

Twenty-six patients with a prior history of irradiation for benign conditions of the head and neck and salivary gland abnormalities are reported. All the patients had preoperative physical findings suggestive of tumor, not glandular infection. Forty-six per cent of the patients had one carcinoma and 11% had two carcinomas within the irradiated field. Eight of the 11 malignant tumors in these 26 patients were in the parotid gland. The nonmalignant salivery changes were similar to those previously reported in glands receiving therapeutic irradiation for carcinoma.     

Tumors of the submaxillary gland.

This study reviews a thirty year experience with 217 patients who had a tumor of the submaxillary gland, comprising about 9 per cent of all patients with salivary neoplasms seen during the same period. Most of the tumors were malignant (56 per cent), with adenoid cystic carcinoma predominating, but the histologic type most frequently encountered was benign mixed tumor (43 per cent). Median age was fifty-four years in patients with malignant tumors compared with forty-six years in those with benign tumors, and 58 per cent were women. Asymptomatic swelling was the usual presenting complaint, and the clinical findings are summarized using a staging system recently proposed for patients with parotid tumors. Cervical lymph node metastasis occurred in at least 50 per cent of patients who had an adenocarcinoma or epidermoid, mucoepidermoid, or anaplastic carcinoma. Treatment was surgical and complete gland excision proved adequate in those with benign tumors. Radical neck dissection was performed in conjunction with submaxillary resection in most patients with malignant lesions, but radical en bloc resection was reserved for those few who had extensive or fixed disease. Net determinate "cure" rates at five and ten years (30 and 20 per cent, respectively) are distressingly low and compare unfavorably with those previously reported in patients treated for carcinoma of the parotid. The high local recurrence rate and the greater incidence in the submaxillary gland of more aggressive tumor types which metastasize readily suggest that current treatment should be more radical. It seems reasonable to expect that results might be improved if en bloc resections were more often performed in patients with less advanced disease, possibly in conjuction with intensive postoperative irradiation in selected cases.     

Anatomic location and variety of nonmalignant neck masses seen in surgical practice.

During a 10-year interval, 189 patients, comprised of 121 females and 68 males ranging in age from 1 to 98 years, were surgically treated for nonmalignant neck masses. Nonmalignant neck masses were located in the thyroid or submaxillary gland in 60 per cent of these patients. Thyroid adenoma, reactive cervical nodes, and mixed tumor of the submaxillary salivary glands represented the three most commonly occurring nonmalignant pathologic conditions in this series. When stratified by age and sex, thyroid abnormalities, specifically thyroid adenoma, occurred most often in females of all ages. In males, reactive nodes were usually seen before 40 years of age; thereafter, tumors of the submaxillary salivary gland predominated. Most studies of nonmalignant neck masses indicate that reactive nodes are the most common condition in patients of all ages. Thyroid conditions were seen most frequently in this group of patients. The probable explanation is a tertiary referral pattern to surgeons. Patients with nonsurgical conditions were, presumably, identified and managed earlier and not referred further, and therefore did not appear in this group of patients.     

Salivary gland tumors and previous radiotherapy to the head or neck: Report of a clinical series

To estimate what proportion of patients with newly diagnosed salivary gland tumors may have radiation-related disease, we interviewed all 275 patients in a surgical practice who had salivary gland resections during an 8 year period. Patients were asked about previous radiation treatment to the head and neck. Thirty-one patients (11 percent) had both ah incident salivary gland tumor and a history of significant exposure. Four of these patients (13 percent) had multiple primary tumors of the salivary glands. The implications and generalizability of these findings have been discussed herein.     

Total thyroidectomy. The indications and results of 630 cases

Over the past twenty years, 630 total thyroidectomies have been performed: 121 (101 females, 20 males) for Grave's disease; 113 (81 females, 32 males) for cold thyroid nodules and head, neck, and thorax irradiation during childhood; and 396 (317 females, 70 males) for a cold dominant nodule of the thyroid. One hundred eighty-three patients had papillary follicular carcinoma, four had medullary carcinoma, five had anaplastic or small cell carcinoma, and one had reticulum cell sarcoma. In this series, patients with Grave's disease had a 5 per cent malignancy rate. Those who had had radiation to the head and neck and thorax during childhood had a 42.5 per cent malignancy rate, and those with a cold dominant thyroid nodule had a 35 per cent malignancy rate. A comparison of the complications and sequelae of total thyroidectomy to those of subtotal thyroidectomy revealed that they were essentially the same. However, the multifold risk of complications in a second neck exploration, plus the anesthetic risk and the time delay when further surgery was then needed after a subtotal procedure, are completely avoided by performing total thyroidectomy primarily. Thus, when surgery is indicated for the management of Grave's disease, thyroid nodules and childhood irradiation, and cold dominant nodules of the thyroid suspected of carcinoma, it is our contention and recommendation that total thyroidectomy be performed.     

Irradiation as an etiologic factor in tumours of the thyroid, parathyroid and salivary glands

Irradiation to the head and neck region, usually of low dosage, results in an increased frequency of thyroid, parathyroid and salivary gland tumours. The authors have reviewed their experience with these tumours. Fifty of 475 patients with carcinoma of the thyroid had received previous irradiation. Papillary or mixed papillar-follicular carcinoma occurred most commonly. Eleven of 100 patients with primary hyperparathyroidism had been irradiated and had a parathyroid adenoma. Twenty of 662 patients with salivary gland tumours had previously been irradiated. Mucoepidermoid carcinoma was the most common tumour. Patients who have been irradiated and have a palpable abnormality of the thyroid or the salivary glands should be treated surgically. The various noninvasive tests are of little value in distinguishing between a benign and a malignant tumour. Those with hypercalcemia, considered to be due to primary hyperparathyroidism, should be treated by exploration of the neck, identification of the four parathyroid glands and excision of an adenoma with biopsy of the three remaining glands. If more than one gland is abnormal, a subtotal parathyroidectomy is recommended.     

Tumors of the salivary glands

In a series of 65 salivary gland tumors seen in patients over eight years, 86 per cent were seen in the parotid gland, fewer than 10 per cent were in the submandibular gland, and none were in the sublingual gland. The remaining tumors were in minor salivary glands. About one half of the patients were in the sixth decade of life. Over 80 per cent of the lesions were benign; 50 per cent were from 1.5 to 2.5 cm in diameter, and the average delay between discovery and removal was over two years. In only one patient was there facial nerve involvement.     

Parathyroid localization. Sonographic-surgical correlation

Sonographic localization of enlarged parathyroid gland was performed in 37 patients suspected of hyperparathyroidism who underwent surgical exploration of the neck. Nine of those patients were clinically asymptomatic. Most of the others presented with urolithiasis. The sonograms were obtained by conventional and high resolution realtime (10 mHz). Of the 37 patients, 31 patients had a single adenoma, three patients had two adenomas, and two patients had hyperplasia. Analysis of the results has shown accuracy of 84 per cent. The sensitivity of the procedure was 79.5 per cent and the specificity was 98 per cent. The exact side and location of the enlarged parathyroid in relation to the thyroid gland was predicted in 91 per cent. The false-negative cases were due to abnormal location (gland in mediastinum or incorporated within the thyroid). The false-positive findings were all colloid cysts located at the periphery of the thyroid parenchyma. Preoperative confirmation and localization of enlarged parathyroid glands facilitated the decision for surgical intervention, especially in hypercalcemic asymptomatic patients and in high operative risk patients. The duration of operation and postoperative complications were significantly reduced.     

Malignant salivary gland neoplasms of the lip.

The charts of fourteen patients with malignant salivary gland tumors of the lip were reviewed. These patients represented 1 per cent of all patients seen during this same period of time with malignant salivary gland tumors. No specific etiologic factors were implicated except that the tumors occurred predominantly in white males. The overall results of treatment were poor, perhaps secondary to delay in diagnosis, very biologically aggressive tumors, or inadequate or improper treatment. Hopefully, the 20 per cent survival can be improved with planned combined sequential surgery and radiation in those selected high risk patients.     

Adenoid cystic carcinoma of the salivary glands. A study of ninety-three cases.

The present study reviews ninety-three cases of adenoid cystic carcinoma of the major (80 cases) and minor (13 cases) salivary glands occuring in ninety-one patients. This tumor is insidious in its presentation and subsequent clinical course with early perineural lymphatic invasion and late metastases. Many patients remain alive but with recurrent disease. The high incidence of recurrent disease (parotid gland 20 of 47, submaxillary gland 20 of 33, and minor salivary glands 7 of 11) suggests inadequate initial surgery at all anatomic sites. Misdiagnosis (16 cases) on frozen or permanent section has led to less than optimum primary treatment. The frequency of perineural lymphatic involvement with recurrence (11 of 19 cases) suggests that the tumor may be extending along the nerve roots in an anatomic area with extensive nerve distribution (the head and neck). Radical neck dissection, in our studies, has contributed to improved survival rates when the primary site has been the submaxillary gland. The treatment of recurrent disease has been primarily surgical (3 operations per patient), and palliation with prolonged survival has been achieved with radical excision of recurrence. The fifteen year determinate cure rate of 19 per cent in comparable to that reported in the world literature. Radiation therapy has been helpful in palliation but has not been curative. Radiation treatment was used for recurrence in twenty-seven patients, and the average time from radiation treatment to death was 3.8 years.     

Nodular thyroid disease in children and adolescents: a high incidence of carcinoma

Over a period of 32 years from 1954 to 1986, 65 patients under the age of 21 years, 52 girls and 13 boys, were operated for nodular thyroids: the overall incidence of carcinoma was 37 per cent. It was 46 per cent in those patients presenting with a solitary nodule. Among the 24 patients with a malignancy, the carcinoma was of the papillary variety in 63 per cent, follicular in 25 per cent and medullary in 12 per cent. Two thirds of the patients had metastatic disease at the time of presentation. All patients with thyroid carcinoma were treated with total thyroidectomy. Other measures included neck dissection and radioactive iodine. When the eight patients with a history of head and neck irradiation and the three patients with medullary carcinoma were excluded, the incidence of carcinoma was 28 per cent. In summary, in spite of the decline in radiation associated cases, the incidence of carcinoma in nodular thyroid disease in the population under 21 years, remains at the relatively high figure of 28 per cent.     

Prognosis of undifferentiated carcinoma and lymphoma of the thyroid

The experience with 126 patients with poorly differentiated thyroid carcinoma or lymphoma treated at the Lahey Clinic between 1931 and 1970 was reviewed. Undifferentiated thyroid tumors predominate in women and present late in life. While no giant cell tumors were found in patients less than forty years of age, small cell carcinoma and especially lymphoma can be seen earlier in life. Giant cell tumors were the most frequently found undifferentiated tumors in men while small cell types were commonest in women. These tumors involve extraglandular structures early; complete surgical removal is possible in only one third of the patients. Clinical course, survival, and biological behavior are closely related to the histologic type of the tumor. While patients who died of giant cell carcinoma had a median survival of three months and a five year survival of 8 per cent, patients with small cell carcinoma and lymphoma have a far better prognosis with a five year survival of 33 and 29 per cent, respectively. Differentiation of small cell carcinoma from lymphoma is often difficult but may be of no clinical significance at present.In view of our results we recommend: (1) total excision of tumor whenever possible, including limited neck dissection when this is required; (2) “debulking” procedures when feasible to aid in tracheostomy placement and use of radiotherapy and chemotherapy; (3) tracheostomy placement in the presence of any airway obstruction; (4) high dose external radiotherapy after operation or used as palliation in patients with nonresectable disease; (5) aggressive combination chemotherapy utilizing either adriamycin or actinomycin when palliation cannot be achieved by surgery and radiotherapy; and (6) thyroid hormone to avoid hypothyroidism, as the thyroid gland is usually functionally destroyed by the effects of invasive tumor and radiotherapy.     

Thyroglossal Duct Cyst Associated with Xanthogranulomatous Inflammation

Xanthogranulomatous inflammation (XGI) is an uncommon destructive chronic inflammatory process mainly occurring in the kidney and gallbladder, characterized by the accumulation of foamy histiocytes, multinucleated giant cells (Touton type), cholesterol clefts and chronic inflammatory cells. The head and neck region is an uncommon site for XGI. This type of inflammatory reaction has been defined in branchial cleft cyst, salivary gland tumors following fine-needle aspiration biopsies, Rathke’s cleft cyst in the pituitary gland, and colloid cyst in the 3rd ventricle. We present herein a unique case of ruptured thyroglossal duct cyst leading to XGI, characterized by an infiltrative subcutaneous central neck lesion, clinically mimicking a thyroid carcinoma. In addition, we also summarize current insights into the pathogenesis of XGI in the head and neck region.     

Impact of esophageal screening in patients with head and neck cancer

We have reviewed the records of 1,982 patients who were treated for head and neck cancer or esophageal cancer from 1962 to 1986. Forty-one patients had primary cancer at both sites. Twenty-one cases of these multiple primaries occurred synchronously and twenty were metachronous. The overall incidence of esophageal cancer in our head- and neck-cancer patients was 2.5 per cent and the incidence of head and neck cancer in our esophageal cancer patients was 7.1 per cent. From 1980 to 1986, 574 cases with a diagnosis of head and neck or esophageal cancer were routinely screened for other aerodigestive malignancies at the time of initial diagnosis. From this group, only six patients had simultaneous lesions of the head and neck and esophagus with only one asymptomatic esophageal carcinoma. Median survival of all 41 multiple primary patients after diagnosis of esophageal cancer was 5.3 months. Two- and three-year survivals were 6.7 per cent and 0 per cent, respectively. There was no significant survival difference for lesions diagnosed simultaneously, synchronously, and metachronously before 1980 or after 1980. All patients died with uncontrolled esophageal cancer except for one patient who died of head- and neck-cancer recurrence. Our experience indicates that active screening of head- and neck-cancer patients for simultaneous esophageal cancer has a low yield and there appears to be no survival advantage for these patients compared with those with subsequently diagnosed esophageal tumors.     

Thyroid and associated polyglandular neoplasms in patients who received head and neck irradiation during childhood

One hundred fifty-one patients with a history of childhood irradiation to the head, neck, and thorax had neck explorations (142 for “cold” thyroid nodules and 9 for hypercalcemia). Fifty-nine of the patients had thyroid carcinoma, and associated glandular tumors were found in 20 others. In addition, 6 female patients developed breast carcinoma; 4 of these women also had thyroid carcinoma. In this series, 48.6% of the patients irradiated for acne and 36.4% with tonsil and adenoid irradiation developed thyroid carcinoma, but only 10.5% with thymic irradiation did so. It is suggested that the workup on these patients include not only complete thyroid and parathyroid testing, but also a careful examination of all salivary glands, both major and minor. Women should have thorough breast examinations and should perhaps be followed as if they were in the potentially high-risk breast group. When thyroid surgery is performed, a total thyroidectomy is recommended.     

Hypothyroidism following radiotherapy for head and neck cancer

Hypothyroidism is not commonly considered a complication of radiotherapy for head and neck cancer. A series of 96 patients treated with radiotherapy alone or combined with surgery for head and neck cancer was retrospectively studied. All patients had radiation ports that included the thyroid gland. Hypothyroidism after radiotherapy was documented in 26% of all patients. The majority of patients had subclinical hypothyroidism manifested by elevated thyroid-stimulating hormone (TSH) levels. The incidence of hypothyroidism dramatically increased to 65% when radiotherapy was combined with surgery that included a partial thyroidectomy. In addition, we report the unusual occurrence of massive head, neck, and hypopharyngeal edema caused by severe hypothyroidism in two patients. We advocate routine monitoring of head and neck cancer patients for hypothyroidism after radiotherapy involving the thyroid gland and recommend levothyroxine replacement therapy for subclinical hypothyroidism.     

Sequelae of radiation facial epilation (North American Hiroshima maiden syndrome)

Radiation for benign problems of the head and neck area has been uniformly recognized as unacceptable practice. This includes epilation for facial hirsutism. Twelve such patients, recently encountered, have characteristic radiodermatitis facies and have demonstrated multisite neoplastic involvement--including skin, thyroid, parathyroid, salivary gland, oral cavity, facial skeleton, and breast--and have also undergone extensive dermatologic treatment of complications of radiodermatitis. There was one cancer death, and three patients are alive with cancer. Such patients have a superficial resemblance to the Hiroshima maiden group of young women who survived atomic bombing and experienced severe facial burns, necessitating extensive plastic surgery. As atomic survivors they are at increased risk for cancer of thyroid, salivary gland, lung, breast, bone marrow, and gastrointestinal tract. The North American Hiroshima maiden should warrant easy clinical recognition and require lifetime scrutiny for multisite neoplastic disease.     

Schwannoma of the submandibular gland

Neurilemmomas (schwannomas) are solitary neurogenic tumors that arise from cells of the neural sheath. They are slow growing and represent a proliferation of Schwann cells. Extracranial neurogenic tumors of the head and neck are uncommon, with benign tumors occurring with greater frequency than malignant tumors. These tumors often mimic primary or metastatic disease in the head and neck. Schwannoma of the salivary gland is a particularly rare form of an extracranial neurogenic tumor, with most presenting in the parotid gland originating from a peripheral branch of the facial nerve. An unusual case of neurilemmoma of the submandibular gland is presented, and the literature concerning this subject is reviewed. We believe this tumor originated in an autonomic nerve of the submandibular gland. The mass was discrete and well demonstrated on CT scan. Total excision of the gland resulted in complete resolution of symptoms with no cranial nerve deficits.