19 Head and Neck Flashcards
Anterior neck triangle
Sternocleidomastoid muscle
Sternal notch
Inferior border of the diagstric muscle
Contains carotid sheath
Posterior neck triangle
Posterior border of the SCM
Trapezius muscle
Clavical
Contains:
- Accessory nerve (innervates SCM, trapezius, platysma)
- Brachial plexus
Parotid gland secretes:
Serous fluid
Sublingual gland secretes:
Mucin
Submandibular gland secretes:
50/50 serous and mucin
Course of the vagus nerve in neck?
Runs between IJV and carotid artery
Course of the phrenic nerve in neck?
On top of the anterior scalene muscle
Course of the long thoracic nerve in neck?
Posterior to the middle scalene muscle
Trigeminal nerve
Ophthalmic, maxillary, mandibular branches
Sensation to face
Exception: mandibular branch gives taste to anterior 2/3 tongue, floor of mouth and gingiva
Facial nerve
Temporal, zygomatic, buccal, marginal mandibular, cervical branches
Motor to face
Glossopharyngeal nerve
Taste to posterior 1/3 tongue
Motor to stylopharyngeus
Injury effects swallowing
Hypoglossal nerve
Motor to all of tongue except palatoglossus
Tongue deviates to same side of injury
Recurrent laryngeal nerve
Innervates all of larynx except cricothyroid muscle
Superior larygneal nerve
Innervates cricothyroid mucles
Gustatory sweating
Frey’s syndrome
Occurs after parotidectomy
Injury of auriculotemporal nerve that then cross-innervates sympathetic fibers to sweat glands
Thyrocervical trunk
STAT Suprascapular artery Transverse cervical artery Ascending cervical artery Inferior Thyroid artery
First branch of external carotid artery
Superior thyroid artery
Blood supply to trapezius flap
Transverse cervical arteryu
Blood supply to pectoralis major flap
Thoracoacrominal artery
Internal mammary artery
Torus palatini
Congenital bony mass on upper palate of mouth
No need for treatment
Torus mandibular
Congenital bony mass on lingual surface of mandible
No need for treatment
Modified radical neck dissection
Takes omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve and ipsilateral thryoid
Radical neck dissection
MRND + accessory nerve (CN XII), SCM, internal jugular resection
Most common cancer of the oral cavity, pharynx and larynx? Risk factors?
Squamous cell CA
Tobacco and ETOH
Erythroplakia
Premalignant mouth lesion
Vs leukoplakia - non-malignant
Boundaries of the oral cavity
Mouth floor Anterior 1/3 toung GIngiva Har palate Anterior tonisllar pillars Lips
Most common site for oral cavity CA
Lower lip (sun exposure)
Plummer-vinson syndrome
GLossitis
Cervical dysphagia from esophageal web
Spoon fingers
Iron-deficiency anemia
Oral cavity CA - treatment
Wide resection (1cm margin)
MRND
Post op XRT
Indication for MRND for oral cavity CA?
> 4cm
Clinical positive nodes
Bone invasion
Indications for Post-op XRT for oral cavity CA?
<4cm
Positive margins
Nodal/bone involvement
Verrucous ulcer
Well-differentiated SCCA
Cheek
Oral tobacco
Tx: Full check resection +/- flap, NO MRND
Tonsilar cancer
Risk: ETOH, tobacco, male
Tx: Tonsillectomy for biopsy; wide resection with margins
Nasopharyngeal SCCA
Risks: EBV, Chinese
Goes to posterior cervical neck nodes
Tx: XRT, add chemo for advanced, NO surgery
Number one tumor of nasopharynx in children? Treatment?
Lymphoma
Chemotherapy
Most common benign neoplasm of nose/paranasal sinuses?
Papilloma
Oropharyngeal SCCA
Neck mass, sore throa Goes to posterior cervical neck nodes Tx: - <4cm: XRT - >4cm, bone/nodal invasion: surgery, MRND, XRT
Hypopharyngeal SCCA
Hoarseness, early metastasis Goes to ANTERIOR cervical neck nodes Tx: - <4cm: XRT - >4cm, bone/nodal invasion: Surgery, MRND, XRT
Nasopharyngeal angiofibroma
Benign tumor
Obstruction, epistaxis in <20yo males
Extremely vascular
Tx: Angiography and embolization (internal maxillary artery) followed by resection
Larygenal cancer
Hoarseness, aspiration, dypsnea, dysphagia Goal - preserve larynx Tx: - Vocal cords only - XRT - Beyond vocal cords - Chemo-XRT - MRND if nodes are clinically psoitive
Most common benign lesion of larynx?
Papilloma
Benign or malignant?
- Mass in large salivary gland
- Mass in small salivary gland
Most frequent site for malignant tumor?
Large - benign
Small - benign
Parotid most frequent malignant site
Lymphatic drainage of salivary glands?
Intra-parotid and anterior cervical chain nodes
Most common malignant tumor of the salivary glands? Second?
Mucoepidermoid CA
Adenoid cystic CA (sensitive to XRT)
Tx: Resection of salivary gland, prophylactic MRND, postop XRT
Most common benign tumor of the salivary glands? Second?
Pleomorphic adenoma (mixed tumor)
Warthin’s tumor
Tx: superficial parotidectomy
Most commonly injured nerve for parotid surgery?
Greater auricular nerve (numbness over lower portion of ear)
Nerves you need to identify in a submandibular gland resection?
Mandibular branch of facial nerve
Lingual nerve
Hypoglossal nerve
Most common salivary gland tumor in children?
Hemangiomas
Cauliflower ear
Due to undrained hematomas that organize and calcify
Cholesteatoma
Epidermal inclusion cyst of ear
Slow growing - erode as they grow
Presents with conductive hearing loss and clear drainage from ear
Tx: surgical excision
Chemodectomas
Vascular tumor of middle ear (paraganglionoma)
Tx: Surgery and XRT
Acoustic neruoma
CN VIII
Tinnitus, hearing loss, unsteadiness
Can grow into cerebellar/pontine angle
Tx: Craniotomy and resection; XRT
Ear SCCA
20% metastasize to parotid gland
Tx: resection and parotidectomy, MRND (positive nodes and large tumors)
Most common childhood aural malignancy of the middle/external ear?
Rhabdomyosarcoma (rare)
When do you set a nasal fracture?
After swelling decreases
Septal hematoma - treatment?
Drain to avoid infection and necrosis of the septum
CSF rhinorrhea
Cribriform plate fracture
Contrast study to find leak
Tx: Conservative 2-3 weeks - epidural catheter drainage; if needed, transethmoidal repair
Treatment of epistaxis
Anterior - packing
Posterior - internal maxillary artery or ethmoid artery embolization
Radicular cyst
Inflammatory cyst at root of teeth
Can cause bony erosion
Lucent on XRAY
Tx: Local excision or curettage
Ameloblastoma
Slow-growing malignancy of odontogenic epithelium (outside portion of teeth)
Soap bubble appearance on XRAY
Tx: wide local excision
Osteogenic sarcoma
Poor prognosis
Tx: surgery, plus.
Maxillary jaw fractures
Wire fixation
TMJ dislocation
Closed reduction
Symptoms of inferior alveolar nerve damage
Lower lip numbness
Stensen’s duct laceration
Repair over catheter stent
Ligation - painful parotid atrophy and facial asymmetry
Suppurative parotitis
Elderly patient - dehydration
Staph infection
Tx: FLuids, salivation, Abx; drainage if abscess
Sialoadenitis
Acute inflammation of salivary gland related to stone in duct
Tx: incise duct and remove stone
Peritonsillar abscess
Older kids (>10yo) Sx: trismus, odynophagia, NO airway obstruction Tx: Needle aspiration, then drainage through tonsillar bed if no relief in 24hrs
Retropharyngeal abscess
Younger kids (<10yo)
Sx: fever, odynophagia, drool, airway emergency
Tx: Intubate, drain through posterior pharyngeal wall
Parapharyngeal abscess
All age groups - dental infections, tonsillitis, pharyngitis
Vascular invasion and mediastinal spread (prevertebral and retropharyngeal spaces)
Tx: Drain through lateral neck (avoid internal carotid and internal jugular vein) - leave a drain
Ludwig’s angina
Acute infection of floor of mouth - involves mylohyoid muscle
Can spread rapidly - causes airway obstruction
Tx: airway control, surgical drainage, Abx
Preauricular tumors
Parotid until proven otherwise - superficial lobectomy
80% salivary tumors are parotid
80% of parotid tumors are benign
80% of those, are pleomorphic adenomas
Most common distant met for head and neck tumors?
Lung
Posterior neck mass
If not obvious malignant epithelial tumor, consider Hodgkin’s lymphoma until proven otherwise
Dx: FNA or open biopsy
Neck mass workup
- H&P, laryngoscopy, FNA (abx for 2 weeks - re-assess)
If non-diagnostic: - Panednoscopy with biopsy, neck/chest CT
Still non-diagnostic: - Excisional biopsy, prep for MRND
Source of adenocarcinoma found in a neck mass?
Breast, GI or lung primary
Epidermoid carcinoma (SCCA variant) found in cervical node without known primary?
1st - pandendoscopy with biopsies
2nd - CT scan
3rd - Ipsilateral MRND, ipsilateral tonsillectomy, bilateral XRT
Esophageal foreign body
Dysphagia
Dx/Tx: Rigid EGD under anesthesia
Most common place for a swallowed foreign body to rest?
Cricopharyngeus (95%)
Fever and pain after EGD for foreign body - next step?
Gastrografin followed by barium swallow to rule out perforation
Laryngeal foreign body
Coughing
Laryngescopy
Emergent cricothyroidectomy as last resort
Sleep apnea
Associated with MI, arrhythmias, death
Tx: CPAP, uvulopalatopharyngoplasty or permenant trach
Subglottic stenosis
Associated with prolonged intubation
Tx: tracheal resection and reconstruction
Trachesotomy
Consider in patients who will be intubated for >7-14 days
Benefits: decreases secretions, provides easier ventilation, decreases pneumonia risk, more comfortable for patient
Median rhomboid glossitis
Failure of tongue fusion
No treatment needed
Cleft lip
Failure of primary palate fusion - lips, alveolus or both
Repair at 10weeks, 10lbs and hbg 10
Cleft palate
Failure of secondary palate fusion - hard and soft palate
Repair at 12 months
- Earlier - affects maxillofacial growth
- Later - effects speech and swallowing
Most common benign head and neck tumor in adults?
Hemangioma
Mastoiditis
Infection of mastoid cells - destroys bone
Complication of untreated acute suppuritive otitis media
Ear is pushed forward
Tx: Abx, emergent mastoidectomy
Epiglottis
Ages 3-5
Sx: stridor, drooling, tripod position, high fever, throat pain, thumbprint sign on lateral neck film
Tx: Control airway, ABx
