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NECK MASSES                                      243

but a chondrosarcoma requires a total laryngectomy because it is radio-

The question of branchogenic carcinoma is one which has caused consider-
able confusion and discussion over the years. The basic question is whether
carcinoma can arise in a branchial cyst or remnant, or whether the swelling is a
metastatic gland from a silent primary site such as the nasopharynx. The
author has removed a simple branchial cyst in which there was a small area of
squamous carcinoma; this recurred in the tract remnant and required a
radical neck dissection. A five-year follow-up failed to reveal any primary
carcinoma elsewhere in the head and neck. There seems little doubt that such a
branchogenic carcinoma is possibleóbut it is very rare,
9. Metastatic Glands. Primary tumours in the head and neck regions v*\\\
metastasize to neck glands long before they get out of control and spread
distantly. In most instances the primary tumour gives rise to symptoms and
thus it may be easy to diagnose the site of the primary lesion which has
caused the glandular enlargement. Some sites are notoriously silent, however,
and the patient may present with enlarged neck glands long before local
symptoms are complained of. The classic *silent^ sites are the nasopharynx, the
posterior surface of the epiglottis and the pyriform fossae. Most often the
glands in the deep jugular chain are affected but help cannot invariably be
obtained from the situation of the glands in the search for the primary lesion.
The only exception to this is with enlarged glands in the supraclavicular areas.
These on the left side generally arise from carcinoma of the oesophagus, the
stomach or below, and those on the right from lung and bronchial carcinoma.

Primaries from anywhere in the body can present as neck glands, but in
85 per cent of cases the primary tumour will be found above the clavicles and
not uncommonly in the nasopharynx. On rare occasions no primary lesion
ever comes to light.


HISTORY. The patient's age will give some guide as to the cause. Below the age
of 20 the cause is likely to be inflammatory or congenital; between 20 and 40
it may be reticulotic, salivary or inflammatory; and above the age of 40 it is
metastatic cancer until proved otherwise. If the cause is inflammatory the
patient will usually have a pyrexia but if it is due to infectious mononucleosis,
toxoplasmosis, etc. there may only be a complaint of a vague ill-health.
Tuberculosis will be associated with night sweats, and Hodgkin's disease gives
the irregular Pel-Ebstein fever pattern.

Abscesses and salivary gland enlargements are painful, but most of the other
conditions are painless. A history should be sought of any precipitating
factors such as eating (salivary gland disease) or blowing (laryngocele). It is of
importance to ascertain the length of the history of neck masses.

CLINICAL FEATURES. It is important to have a system of examination of the
neck so that no areas are missed. The cursory running of fingers over the neck,
which is commonplace, will only palpate large masses. The examiner should
stand behind the patient and observe the whole neck uncovered from the
hairline to the clavicles. Palpation starts at the mastoid bone and follows the
line of the trapezius muscle downwards to its junction with the clavicle. It is
important to palpate beneath the trapezius muscle as this is where glands may