19: Head and Neck Flashcards
What are the boundaries of the anterior neck triangle?
- Sternocleidomastoid muscle
- Sternal notch
- Inferior border of the digastric muscle
[Contains the carotid sheath.]
[UpToDate: The anterior triangle is bordered anteriorly by the midline, posteriorly by the sternocleidomastoid muscle, and superiorly by the lower edge of the mandible. Most vital structures are located in the anterior triangle. Trauma to the posterior triangle, excluding the spine, carries a much lower likelihood of significant injury.]
What diagnosis is suggested by the following symptoms and what is the treatment?
- Stridor
- Drooling
- Leaning forward
- High fever
- Throat pain
- Epiglottitis
- Treatment: early control of the airway and antibiotics
[Often will present with thumbprint sign on lateral neck film. Rare since immunization against H. influenzae type B. Mainly occurs in children age 3-5 years.]
What is the treatment for laryngeal cancer?
- XRT if only vocal cord
- Chemo-XRT if beyond vocal cord
- Modified radical neck dissection (MRND) is needed if nodes are clinically positive
[Surgery is not the primary treatment because the goal is to preserve the larynx. Take ipsilateral thyroid lobe with a modified radical neck dissection.]
Where do the following nerves lie in the neck?
- Vagus nerve
- Phrenic nerve
- Long thoracic nerve
- Vagus nerve: Runs between the internal jugular vein and the carotid artery
- Phrenic nerve: Runs on top of the anterior scalene muscle
- Long thoracic nerve: Runs posterior to the middle scalene muscle
What is the treatment for squamous cell carcinoma of the ear?
- Resection and parotidectomy
- Modified radical neck dissection for positive nodes or large tumors
[20% metastasize to the parotid gland.]
What is the treatment for the following infections?
- Peritonsillar abscess
- Retropharyngeal abscess
- Pharyngeal abscess
- Peritonsillar abscess: Needle aspiration 1st, then drainage through tonsillar bed if no relief in 24 hours, may need to intubate to drain (will self-drain with swallowing once opened)
- Retropharyngeal abscess: Intubate the patient in a calm setting, drainage through posterior pharyngeal wall (will self-drain with swallowing once opened)
- Pharyngeal abscess: Drain through lateral neck to avoid damaging internal carotid and internal jugular veins (need to leave a drain in place)
What are the 3 branches of the trigeminal nerve (CN V) and what is its function?
- Ophthalmic, maxillary, and mandibular branches
- Gives sensation to most of the face
- Mandibular branch provides taste to the anterior 2/3 of the tongue, floor of the mouth, and gingiva
- What percent of salivary tumors are in the parotid?
- What percent of parotid tumors are benign?
- What percent of benign parotid tumors are pleomorphic adnomas?
- What percent of salivary tumors are in the parotid? 80%
- What percent of parotid tumors are benign? 80%
- What percent of benign parotid tumors are pleomorphic adnomas? 80%
What are the following characteristics of the nasopharynx?
- Most common tumor of nasopharynx in children
- Most common benign neoplasm of nose/paranasal sinuses
- Most common tumor of nasopharynx in children: Lymphoma (Tx: chemotherapy)
- Most common benign neoplasm of nose/paranasal sinuses: Papilloma
What are the 4 branches of the thyrocervical trunk?
- Suprascapular artery
- Transverse cervical artery
- Ascending cervical artery
- Inferior thyroid artery
[Image-Guided Interventions, Second Edition: The thyrocervical trunk is the second branch of the subclavian artery, and it arises just distal to the vertebral artery from the superior surface of the first segment of the subclavian artery. Near the medial border of the anterior scalene muscle, the thyrocervical trunk classically divides into the inferior thyroid, transverse cervical, and suprascapular arteries. Only slightly more than 50% of individuals have this classic anatomy. Independent origins of one or more of these vessels from the subclavian artery are common.
The inferior thyroid artery is the superior continuation of the thyrocervical trunk. It ascends anterior to the anterior scalene muscle and turns medially just below the sixth cervical transverse process. Here it passes anterior to the vertebral vessels and posterior to the carotid sheath and its contents. It finally descends on the longus colli muscle to the inferior pole of the lateral lobe of the thyroid gland.
Branches of the inferior thyroid artery include muscular branches supplying the infrahyoid muscles, longus colli muscle, anterior scalene muscle, and the inferior pharyngeal constrictor, as well as pharyngeal branches supplying the lower pharynx, thyroid, and parathyroid glands. An important muscular branch is the ascending cervical artery, which arises as the inferior thyroid artery turns medially behind the carotid sheath; it ascends on the anterior surface of the prevertebral muscles, which it supplies, and sends branches to the spinal cord.
The middle branch of the thyrocervical trunk is the transverse cervical artery. This branch passes laterally and slightly posteriorly, anterior to the brachial plexus and the anterior scalene muscle, and enters and crosses the base of the posterior triangle. As it reaches the deep surface of the trapezius muscle, it divides into superficial and deep branches. The superficial branch continues on the deep surface of the trapezius muscle, and the deep branch continues on the deep surface of the rhomboid muscles near the medial border of the scapula. Alternatively, these branches may not arise in common as a transverse cervical artery. The superficial branch frequently arises directly from the thyrocervical trunk as a superficial cervical artery, and the deep branch may arise from the third or, less commonly, from the second part of the subclavian artery as the dorsal scapular artery.
The most inferior branch of the thyrocervical trunk is the suprascapular artery. It descends laterally and crosses anterior to the anterior scalene muscle, phrenic nerve, third part of the subclavian artery, and trunks of the brachial plexus. It reaches the superior scapular border, passes above the superior transverse scapular ligament, which separates it from the suprascapular nerve, and enters the supraspinatus fossa. In addition to supplying the supraspinatus and infraspinatus muscles, the suprascapular artery contributes branches to numerous structures along its course. Other alternative origins of the suprascapular artery include a direct origin from the third part of the subclavian artery or as a branch of the internal thoracic artery.]
What is the treatment for persistent posterior nose bleeding despite packing/balloon tamponade?
Consider internal maxillary artery or ethmoid artery embolization
[90% of nose bleeds are anterior and can be controlled with packing.]
- What is Ludwig’s angina?
- What is the most common cause of Ludwig’s angina?
- What is the treatment for Ludwig’s angina?
- What is Ludwig’s angina? Acute infection of the floor of the mouth, involving the mylohyoid muscle
- What is the most common cause of Ludwig’s angina? Dental infection of the mandibular teeth
- What is the treatment for Ludwig’s angina? Airway control, surgical drainage, and antibiotics
[Ludwig’s angina may rapidly spread to deeper structures and cause airway obstruction.]
What does a modified radical neck dissection (MRND) include and how does it differ from a radical neck dissection (RND)?
- MRND: Takes omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, and ipsilateral thyroid
- RND: Same as MRND pluss accessory nerve (CN XI), sternocleidomastoid, and internal jugular resection
[Most morbidity occurs from the accessory nerve resection in an RND. RND is rarely ever performed any more.]
What is the treatment for the following neck and jaw injuries?
- Maxillary jaw fracture
- TMJ dislocation
- Stensen’s duct laceration
- Maxillary jaw fracture: Most treated with wire fixation
- TMJ dislocation: Treated with closed reduction
- Stensen’s duct laceration: Repair over a catheter stent (Ligation can cause painful parotid atrophy and facial asymmetry)
[UpToDate: Stensen’s duct arises from the anterior border of the parotid gland and is 4 to 7 cm long, narrows to 1.2 mm at an isthmus, and the os is 0.5 mm and is opposite the upper second molar.]
Patients anticipated to require intubation for what period of time should be considered for tracheostomy?
7-14 days
[Tracheostomy decreases secretions, provides easier ventilation, and decreases pneumonia risk.]
What presents in older kids (>10 years old) with trismus (lock jaw) and odynophagia (pain when swallowing) but does not typically cause airway obstruction?
Peritonsillary abscess
[Not to be confused with a retropharyngeal abscess which typically presents in younger kids (<10 years old) and is an airway emergency.]
What presents in younger kids (<10 years old) with fever, drool, and odynophagia (pain when swallowing), is an airway emergency?
Retropharyngeal abscess
[Not to be confused with a peritonsillar abscess which is seen in older kids (>10 years old) and does not obstruct the airway.]
To which lymph nodes does squamous cell carcinoma in the following locations spread?
- Nasopharynx
- Oropharynx
- Hypopharynx
- Nasopharynx: Posterior cervical neck nodes
- Oropharynx: Posterior cervical neck nodes
- Hypopharynx: Anterior cervical nodes
What is the most common cancer of the oral cavity, pharynx, and larynx and what are the 2 biggest risk factors?
- Most common cancer: Squamous cell cancer
- Biggest risk factors: Tobacco and alcohol
[Most common site for oral cavity cancer is the lower lip (due to sun exposure). Cancers of the hard palate have the lowest survival rate because they are harder to resect]
What is the function of the Hypoglossal nerve (CN XII)
Motor to all of the tongue except the palatoglossus
[Tongue deviates to the same side of a hypoglossal nerve injury.]
What is the function of the Glossopharyngeal nerve (CN IX)?
- Taste to the posterior 1/3 of the tongue
- Motor to the stylopharyngeus
[Injury affects swallowing.]
In the larynx, where are the false vocal cords located in relation to the true vocal cords?
The false vocal cords are superior to the true vocal cords
[UpToDate: The false (or “ventricular”) vocal folds are situated superior to the true vocal folds and are separated from them by a lateral recess termed the laryngeal ventricle. The ventricle contains mucus-producing glands that provide lubrication for the true vocal folds, which are themselves devoid of glandular elements. The false vocal folds are adducted only during effortful closure, as with Valsalva and reflex laryngeal closure due to noxious stimuli. They do not normally approximate during phonation; however, this may be observed in pathologic conditions, such as in patients with incompetent true vocal fold closure due to vocal fold paralysis, mass lesion, or presbyphonia (vocal fold changes due to aging of the larynx).
The larynx is subdivided into three regions: the supraglottis, glottis, and subglottis. The supraglottis encompasses the area above the true vocal folds and includes the epiglottis, false vocal folds, aryepiglottic folds, and arytenoids. The glottis consists of the true vocal folds and the immediate subjacent area extending 1 cm inferiorly. The subglottis refers to the region beginning at the inferior edge of the glottis and extending down to the inferior border of the cricoid cartilage.]
What are the 5 branches of the facial nerve (CN VII) and what is its function?
- Temporal, sygomatic, buccal, marginal mandibular, and cervical branches
- Motor function to the face
Which extremely vascular, benign, pharyngeal tumor presents with obstruction or epistaxis in males before the age of 20 years, and is treated with angiography, embolization (internal maxillary artery), followed by resection?
Nasopharyngeal angiofibroma
[UpToDate: Juvenile nasopharyngeal angiofibromas (JNA) are rare tumors exclusively seen in adolescent males, presenting with epistaxis. The lesion is locally invasive but morphologically deceptively bland, showing thin-walled vessels, devoid of smooth muscle, often exhibiting staghorn shapes, and set in a fibrous to myxoid stroma. Local involvement of the nasal cavity and paranasal sinuses may be extensive, with occasional invasion of the skull base. Intraoperative bleeding may be marked and potentially life threatening. Preoperative measures to diminish blood loss, eg, tumor embolization, may be clinically useful.]
What are the boundaries of the posterior neck triangle?
- Posterior border of the sternocleidomastoid
- Trapezius muscle
- Clavicle
[Contains the brachial plexus and the accessory nerve (innervates the SCM, trapezius, and platysma).]
[UpToDate: The posterior triangle is located within the boundaries of the sternocleidomastoid muscle anteriorly, the clavicle inferiorly, and the anterior border of the trapezius muscle posteriorly. Most vital structures are located in the anterior triangle. Trauma to the posterior triangle, excluding the spine, carries a much lower likelihood of significant injury.]
