We present a series of three case reports of patients over the age of 40 with cystic swellings in the lateral neck. Clinically they masqueraded as branchial cysts, but subsequently were diagnosed as being squamous cell carcinoma cystic lymph node metastasis arising from an occult tonsillar primary.

Currently there is an absence of national guidelines for the treatment of lateral neck cysts in the over 40s’ age group that subsequently prove to be cystic metastases from occult tonsillar primaries. This disease process is more common than thought, with up to 80 per cent of so-called branchial cysts in the over 40s’ age group being malignant.

We recommend that patients over the age of 40 presenting with lateral cystic swellings in the neck should have a high suspicion of malignancy and require a panendoscopy, ipsilateral tonsillectomy and blind biopsies of Waldeyer’s ring. This avoids inadvertent excision of a possible cystic lymph node metastasis. If the panendoscopy histology proves to be benign, then proceed to excision of the cyst with frozen section analysis of it. If this confirms it to be benign then that is all that is necessary; if the frozen section is however positive for carcinoma then the surgeon can proceed at that time to a formal neck dissection and therefore avoid a further procedure. In the event of an occult tonsillar malignancy, excision of the cyst as part of a neck dissection with post-operative radiotherapy is recommended.

It is our aim to treat a cystic lymph node metastasis as you would a solid lymph node metastasis.

A 53-year-old man was referred to the ENT department with a large mass in the left supraclavicular fossa. The histological diagnosis showed the mass to have arisen due to a granulomatous vasculitis consistent with Churg-Strauss syndrome (CSS). CSS usually comprises asthma, eosinophilia and systemic vasculitis although limited forms of the disease exist where one of these diagnostic criteria is missing. This is one such case as the patient was non-asthmatic.

The term comorbidity stands for disease processes that co-exist and are not related to the index disease being studied. Comorbidity in cancer has been shown to be a major determinant in treatment selection and survival. Patients with head and neck cancer can have significant comorbidity owing to the high incidence of tobacco and alcohol abuse. No studies to date have addressed this problem in head and neck cancer patients in the United Kingdom. The applicability of the adult comorbidity evaluation – 27 index (ACE-27) and the Charlson index (CI) to assess the comorbidity burden by retrospective notes review is studied here. Retrospective data collection and completion of a comorbidity index in a United Kingdom setting is feasible. We conclude that the pre-assessment visit is a useful time to record comorbidity and as a significant amount of information required for grading relates to historical items, this is best done using a self-administered patient questionnaire.

We present a rare case of unilateral phlebectasia of the anterior jugular vein in a 56-year-old male patient whose complaint is a neck swelling that appears during talking. Although in this age group the most common cause of such a mass in the anterior aspect of the neck increasing in size during any type of straining or Valsalva manoeuvre is a laryngocele, phlebectasia of the anterior jugular vein should be considered in the differential diagnosis. Doppler ultrasound and computed tomography are the most useful and non-invasive methods to use for the investigation. Treatment should be conservative.