An important prognostic factor for cancers of the head and neck is the presence or absence, level and size of metastatic neck disease .
Both tumor and patient factors affect the pattern of spread of malignant disease to the neck . The primary site of a tumor is important, with some sites having a high incidence of metastases than others at presentation.
Lindberg in 1972 was able to establish the possibility of predicting the site of a primary tumor in the head and neck based on the distribution of cervical metastasis . Following this, the Memorial Sloan-Kettering Hospital in 1981 published 7 levels or regions in the neck which contain groups of lymph nodes that represent the first echelon sites for metastasis from head and neck primary tumors . For example, the nasopharynx, nasal cavities and paranasal sinuses drain via the junctional nodes into the upper deep cervical lymph nodes in levels II-III... e.t.c.
The management of a patient with cervical lymph node enlargement starts with a history of the disease, full clinical examination, and radiological investigations such as CT scan, MRI, ultrasound and radionuclide scanning [3, 4]. These are supplemented by an examination under anesthesia and panendoscopy to look for the primary site of tumor with biopsies of suspicious tumor sites .
Fine needle aspiration biopsy is preferable to open biopsy of a cervical lymph node for the reasons that there is no tumor spread, no inconvenient scar to distort future surgical intervention, no delay between diagnosis and treatment and its simplicity. When a diagnosis of malignancy cannot be made by needle biopsy, then an open biopsy can be done provided it can be followed by a frozen section and a concomitant definitive neck dissection if peroperative positive histological diagnosis is obtained . Open cervical lymph node biopsy can alter patterns of lymphatic drainage for up to 1 year following surgery  and creates a scar which distorts future surgical intervention therefore altering the outcome of treatment .
In our environment, the interplay of several factors contributes to the poor outcome in the management of head and neck cancer patients. These factors include late patient presentation, inaccessible health facilities and delay in the availability of histopathology results following biopsies.
Our study shows that our head and neck cancer patients presented late to the hospital which is a common feature here attributed to poverty and ignorance .
All the patients in our study were referred to the general surgeons by health workers from neighboring primary health centers which explains why they were the first contact health personnel in our tertiary health center.
Facilities for frozen section are not available in our center and delay in getting histopathology results from the open cervical biopsies further compounds our patients' problems as their tumors and disease process progresses further with advanced nodal diseases on presentation to the otorhinolaryngologist who is left with little or no help to offer these patients at the time they present.
Even though FNAB done for 12 of our patients was able to detect malignancy in 9 patients, all had examination under anesthesia to detect the site of primary tumor and to be able to get biopsy material for histological diagnosis. Knowing the site of primary tumor is essential in planning treatment. However, in this study it is not clearly stated by the general surgeons the criteria used for subjecting some patients to open biopsy and others to FNAB.
Majority of our people cannot afford the cost of diagnostic facilities like CT scan. This is further buttressed by the fact that only four patients in our series could afford it- patients number 24, 25, 31 and 38 as seen on Table 3 below. These patients benefitted from this radiological diagnosis and are still alive following treatment.
Nine deaths were recorded in our series. These are shown on Table 3 to be patients' number 5, 6, 10, 11, 26, 32, 35, 36 and 37 who had advanced disease. Three of these also had co-morbid medical conditions (hypertension and diabetes mellitus) and 1 (patient number 35) died before he could have endoscopic biopsy.
The mortalities recorded in our series were all as a result of interplay of the above mentioned factors. To overcome these, we recommend that all head and neck cancer patients especially those with cervical lymph node enlargement on presentation should have an examination under anesthesia and endoscopic biopsies taken from all suspicious primary tumor sites to obtain histological diagnosis rather than be subjected to open cervical lymph node biopsy. This enables planning for early and proper treatment. This can be done by the first contact health personnel or a referral to the otorhinolaryngologist or head and neck oncologist to avoid delay in patient management and to institute early treatment.