AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 15

on swallowing ( odynophagia ), or a persistent oral ulcer may be due to cancer. Patients with these symptoms should see an otolaryngologist. In some instances, a cancer in the nasopharynx can obstruct one of the Eustachian tubes, causing unilateral serous otitis media (fluid in the middle ear) and conductive hearing loss in an adult . The most common cause of this condition is a URI, but a unilateral serous otitis without a clear history of a recent “cold” must be referred for nasopharyngoscopy to rule out nasopharyngeal cancer. Occasionally, patients will present with a superficial lymph node located in the posterior triangle of the neck (behind the sternocleidomastoid muscle ). Most commonly, this is a swollen lymph node secondary to some type of skin infection or inflammation on the scalp, so you should check the scalp carefully in such a case. Sometimes, however, this can be a more serious process, such as lymphoma. Usually, upper aerodigestive tract squamous cell carcinoma does not initially spread to the posterior triangle nodes, but in rare cases, this can occur—especially with nasopha- ryngeal cancer. Physicians can be tempted to remove this superficial node of the neck in the office. However, these superficial posterior neck nodes should not be surgically addressed, except by someone very familiar with head and neck surgery. The spinal accessory nerve runs over the top of these nodes and can very easily be damaged if the physician is not expe- rienced with this type of surgery. Parotid Mass A patient may present with a lump in front of or below the ear. This most often represents a parotid neoplasm, of which the most common (70 percent) are the benign mixed-tumor pleomorphic adenoma. A mass in this area, however, can range from a superficial epidermal inclusion cyst or a more serious process, such as lymphoma. Also, it is important to consider a metastasis from skin cancer to a parotid lymph node, which may present as a mass in this area. In this region, it can be challenging to distinguish between a mass that is subcutaneous and one that is deeper in the parotid gland. The ascending ramus of the mandible is deep to the parotid gland; thus, a mass may be well within the substance of the gland and still feel very superficial, because there is a solid background immedi- ately deep to it. Well-intentioned surgeons, thinking this is a sebaceous cyst, may endeavor to remove a mass in this region, and find their dissec- tion extends deep to the parotid fascia. Branches of the facial nerve will pierce through the substance of the parotid gland and inadver- tent injury to one or more of the facial nerve branches may occur. For pathology in this region, it is better to refer the patient to an

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Primary Care Otolaryngology