![]() ![]() The differential diagnosis for lymphadenopathy is extensive. It generally categorizes as neoplastic, infectious, inflammatory, reactive, and nondiagnostic. Because of this, young adults presenting with an asymptomatic neck mass and an insignificant history may have their diagnosis for underlying malignancies such as mucosal HPV-positive HNSCC delayed. ![]() It is crucial to keep in mind that cancers of the head and neck, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland, can present initially as asymptomatic masses. Thus, the clinical approach to neck masses for adults vs. In adults, however, neck masses in patients who are greater than or equal to 18 years old should always be considered to be malignant until proven otherwise. Generally speaking, most neck masses in children are of infectious etiology. Complications that could arise from procedures such as supraclavicular lymph node harvest or biopsies include but are not limited to : ![]() Īs with any surgical procedure, procedures involving the supraclavicular lymph node require a firm grasp of the critical structures and anatomy that surround it. According to the latest guidelines set by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), an open biopsy is only necessary if FNAC, core needle biopsy, physical examinations, and other ancillary test prove to be undiagnostic. Thus, invasive procedures that provide a greater volume of tissue such as an open biopsy of the supraclavicular lymph nodes are an option when the FNAC is nondiagnostic. Despite excisional biopsy being the gold standard in lymphoma cases, a core needle biopsy should be performed alternatively, as it provides adequate results and is less invasive. Although rapid, painless, inexpensive, safe and does not require anesthetic or hospital admission, FNAC comes with its disadvantages, which include the inability to provide the cellular architecture required for accurate subtyping of lymphomas. Investigations of supraclavicular lymph nodes masses include imaging techniques such as computed tomography (CT) or positron emission tomography (PET) followed by ultrasound-guided fine needle aspiration cytology (FNAC). It is also noteworthy that the Virchow node is not always present at the terminal of the thoracic duct (only present in 27% of Japanese subjects). The study noted different numbers of collaterals coming from the thoracic duct and their communication pattern with the Virchow node. A study done on five cadavers found that the Virchow node was attached to the dorsal aspect of the carotid sheath (two out of five cadavers) or on the scalenus anterior muscle (three out of five). Studies have also noted variations in the location of the Virchow node and its histological anatomy relative to the thoracic duct. Researchers also noted a variation in their mean distance from the jugular notch in the right (8.29 +/- 2.15) and left sides (6.10 +/- 1.21). In four out of nine cases, no right supraclavicular lymph nodes were present on the right side while in one out of nine cases, no left supraclavicular lymph nodes were present. In a study done to provide a detailed description of the surgical anatomy of the supraclavicular lymph node flap for free vascularized lymph node transfer, a surgical method to treat lymphedema, dissections on fresh cadavers showed variation in the number of lymph nodes between the right (average of 1.5 +/- 1.85) and left supraclavicular lymph nodes (average of 3 +/- 2.26). The exact number of the supraclavicular lymph nodes, including the Virchow node, and their distance from anatomical boundaries surrounding it can vary to an extent. The right and left vagal nerves then descend anterior to the subclavian arteries to the thorax and the abdomen. The vagus nerve then exits the skull via the jugular foramen and descends inside the carotid sheath posterior and lateral to the common and internal carotid arteries and medial to the internal jugular vein. The vagus nerve takes its origin in the medulla oblongata from various nuclei which are out of the scope of the text. As the nerve approaches the root of the neck, it usually traverses between the subclavian artery and vein and descends to the mediastinum to supply the diaphragm muscle. The nerve forms at the superior lateral border of the anterior scalene muscle and then descends obliquely towards the medial side of the anterior scalene muscle (staying deep to the prevertebral fascia, the supraclavicular lymph nodes and the transverse cervical vessels). The phrenic nerve arises from the ventral rami of roots (C3-C4-C5) and receives a contribution from the cervical sympathetic ganglia. The significant nerves which are related to the supraclavicular lymph nodes are the phrenic and the vagus nerves which lie lateral and medial to the internal jugular vein, respectively. ![]()
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