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Tubular Neck Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 60s presented to a tertiary care center after several months of having right-sided lateral neck pain. He described the pain as “electric” and “stabbing.” He reported no numbness of the region and had not experienced any other symptoms, including new neck masses. His medical history was significant for obstructive sleep apnea, gastroesophageal reflux disease, a right ear skin cancer excised by a dermatologist, and coronary artery disease with angina on stress test. His physical examination revealed a well-healed excision site of the right ear without new skin lesions. His facial nerve was fully intact. He had full strength of the shoulder and no numbness of the right ear or cheek. Palpation of the lateral neck demonstrated a mass running along the lateral border of the sternocleidomastoid (SCM) muscle. Magnetic resonance imaging (MRI) showed an elongated enhancing tubular structure along the lateral surface of the right SCM muscle (Figure 1).

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D. Perineural spread of cutaneous squamous cell carcinoma

Perineural spread (PNS) is a metastatic process in which cancer invades nearby nerve tissue and spreads along the nerve within the perineurium and endoneurium away from the primary tumor. This results in radiographic changes of the nerve as well as clinical signs and symptoms, including nerve dysfunction, pain, or mass. Spread of disease within nerves is usually quickly progressive owing to a relatively unimpeded path of invasion. PNS is distinct from incidental perineural invasion (PNI), which is the discovery of tumor invasion into nearby nerves during pathologic review.15 PNS has been linked to a worse overall prognosis and thus higher staging of tumors, with a 5-year overall survival rate ranging from 50% to 64%.5,6 Within the head and neck, PNS is commonly seen within the trigeminal nerve causing hypoesthesia, anesthesia, or pain and the facial nerve causing paresis or paralysis, hyperacusis, or taste dysfunction.1,5,7 It is associated with adenoid cystic carcinoma, basal cell carcinoma, squamous cell carcinoma (SCC), and melanoma.1,6

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Article Information

Corresponding Author: Kevin Higgins, MD, MSc, FRCSC, Department of Otolaryngology–Head and Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada (kevin.higgins@sunnybrook.ca).

Published Online: March 29, 2018. doi:10.1001/jamaoto.2018.0019

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

References
1.
Panizza  BJ.  An overview of head and neck malignancy with perineural spread.  J Neurol Surg B Skull Base. 2016;77(2):81-85. doi:10.1055/s-0036-1579778PubMedGoogle ScholarCrossref
2.
Warren  TA, Whiteman  DC, Porceddu  SV, Panizza  BJ.  Insight into the epidemiology of cutaneous squamous cell carcinoma with perineural spread.  Head Neck. 2016;38(9):1416-1420. doi:10.1002/hed.24453PubMedGoogle ScholarCrossref
3.
Warren  TA, Panizza  B, Porceddu  SV,  et al.  Outcomes after surgery and postoperative radiotherapy for perineural spread of head and neck cutaneous squamous cell carcinoma.  Head Neck. 2016;38(6):824-831. doi:10.1002/hed.23982PubMedGoogle ScholarCrossref
4.
Repanos  C, Mitchell  D, Gandhi  M, Wood  M, Panizza  B.  Great auricular nerve perineural spread of squamous cell carcinoma.  ANZ J Surg. 2012;82(3):179-180. doi:10.1111/j.1445-2197.2011.05988.xPubMedGoogle ScholarCrossref
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Mendenhall  WM, Amdur  RJ, Williams  LS, Mancuso  AA, Stringer  SP, Price Mendenhall  N.  Carcinoma of the skin of the head and neck with perineural invasion.  Head Neck. 2002;24(1):78-83. doi:10.1002/hed.10025PubMedGoogle ScholarCrossref
6.
Warren  TA, Nagle  CM, Bowman  J, Panizza  BJ.  The natural history and treatment outcomes of perineural spread of malignancy within the head and neck.  J Neurol Surg B Skull Base. 2016;77(2):107-112. doi:10.1055/s-0036-1579777PubMedGoogle ScholarCrossref
7.
Galloway  TJ, Morris  CG, Mancuso  AA, Amdur  RJ, Mendenhall  WM.  Impact of radiographic findings on prognosis for skin carcinoma with clinical perineural invasion.  Cancer. 2005;103(6):1254-1257. doi:10.1002/cncr.20913PubMedGoogle ScholarCrossref
8.
Ginsberg  LE, Eicher  SA.  Great auricular nerve.  AJNR Am J Neuroradiol. 2000;21(3):568-571.PubMedGoogle Scholar
9.
Stoll  G, Bendszus  M, Perez  J, Pham  M.  Magnetic resonance imaging of the peripheral nervous system.  J Neurol. 2009;256(7):1043-1051. doi:10.1007/s00415-009-5064-zPubMedGoogle ScholarCrossref
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