A 62-year-old man comes to the office for evaluation of a lump in his neck. The patient first noticed the lump under the right side of his jaw about 4 months ago when he cut himself while shaving. The lump is slowly getting larger. He has also had occasional deep-seated right ear pain. The patient has had no fevers, chills, cough, or shortness of breath. He has had no change in his diet and no weight loss. Medical history is significant for hypertension and type 2 diabetes mellitus. The patient smokes 2 packs of cigarettes daily and uses alcohol occasionally. Physical examination shows a firm, nontender, right-sided submandibular mass that is 3 cm in diameter. Ear examination is normal. There are no abnormal skin lesions. Oral cavity examination shows poor dentition and no mucosal lesions. The tonsils are small and soft with no lesions. Chest examination is unremarkable. The abdomen is soft and nontender with no hepatosplenomegaly. There is no other lymphadenopathy. Complete blood count is within normal limits. Which of the following is the most likely cause of this patient's condition?
Malignancy is extremely likely in a patient with a persistent (>2 weeks), palpable (>1.5 cm), firm neck mass; a smoking history; and no preceding infection. By far the most common malignancy in an upper cervical node is mucosal head and neck squamous cell carcinoma (SCC). Indeed, the first (and only) apparent manifestation may be a palpable cervical lymph node, representing regional nodal metastasis. Referred otalgia is another common presenting symptom, facilitated by either the glossopharyngeal nerve (CN IX) (innervates both the base of tongue and the external auditory canal [EAC]) or the vagus nerve (CN X; innervates parts of the larynx/hypopharynx and the EAC).
Identification of the primary source of head and neck SCC is essential to direct treatment. Thorough examination includes endoscopic visualization using laryngopharyngoscopy as well as neck imaging (CT with contrast) to evaluate the primary site and characterize the cervical nodal disease. Fine-needle aspiration of the lymph node is advised over open biopsy to avoid tumor seeding.
(Choice A) Chronic lymphocytic leukemia (CLL) may present in older patients with painless cervical lymphadenopathy. However, it typically causes waxing and waning lymphadenopathy. It would not cause ear pain, and leukocytosis would also be expected.
(Choice B) Granulomatous polyangiitis can present with head and neck symptoms, including ear pain and subcutaneous nodules. However, it is a systemic disease, often with life-threatening renal (eg, glomerulonephritis) and pulmonary (eg, nodules, hemorrhage) manifestations. A solitary lymph node in the neck with no constitutional symptoms would be unlikely.
(Choice C) Hodgkin lymphoma can also cause painless, cervical lymphadenopathy. However, many patients have constitutional "B symptoms" (eg, fever, night sweats, weight loss). Hodgkin lymphoma would not explain the ear pain in this patient, and head and neck SCC is much more common in adult smokers.
(Choice D) Infectious mononucleosis can cause adenopathy, but it is typically bilateral with multiple lymph nodes involved. Additionally, it is typically seen in adolescents or young adults and presents with fever, pharyngitis, and fatigue.
(Choice E) Medullary thyroid carcinoma (MTC) is a rare neuroendocrine carcinoma of the thyroid parafollicular C cells that can be sporadic or associated with a germline RET mutation (multiple endocrine neoplasia type 2). Although MTC can metastasize to lateral neck nodes, a thyroid nodule would also be expected.
(Choice F) Mycobacterial lymphadenitis, often caused by Mycobacterium avium complex, presents as a solitary, enlarging cervical lymph node. However, it typically presents in children age 1-5 years, and the lymph node becomes fluctuant with an overlying violaceous skin discoloration. Tuberculous lymphadenitis is unlikely in a patient with no risk factors. Cervical lymphadenitis is unlikely to cause ear pain.
Educational objective:
Nontender, solitary cervical lymph nodes are concerning for mucosal head and neck squamous cell carcinoma, especially in an adult patient with a smoking history.