Management of unknown primary tumor.

A 37-year-old man is initially seen with a 4-month history of a gradually enlarging, painless rightsided neck mass. He denies any otalgia, dysphagia, odynophagia, hoarseness, fever, night sweats, or weight loss. His medical history is significant only for mild COPD, and he has smoked two packs per day for 20 years. He is married and is a right-handed police officer. Examination of the head and neck reveals the absence of any mucosal lesions in the upper aerodigestive tract by visual inspection, bimanual palpation, and fiberoptic examination of the nasal cavity, nasopharynx, hypopharynx, and larynx. There is no serous otitis media, trismus, parapharyngeal space fullness, or cranial nerve abnormalities. Palpation of the neck shows normal parotid, submandibular, and thyroid glands. There is a 4.0 × 3.5-cm firm, nonpulsatile right level II mass that is freely mobile from the sternocleidomastoid muscle (SCM) and the carotid sheath structures. Fine-needle aspiration biopsy is performed and reveals metastatic poorly differentiated squamous cell carcinoma.