CHAPTER 08: HEAD AND NECK Flashcards

Question

Academy's Classification

Answer 1

1) Radical neck dissection (RND) 2) Modified radical neck dissection (MRND) • MRND1 - keep XI (Accessory n.) • MRND2 - keep XI + either SCM or IJV • MRND3 - keep XI + both SCM and IJV ``` 3) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type ``` 4) Extended radical neck dissection

Answer 2

Medina, Spiro

Answer 3

RND - Extensive cervical involvement or - matted lymph nodes with gross extracapsular spread and invasion into SAN, IJV, or SCM MRND – Clinically obvious lymph node metastases – SAN / SCM / IJV not involved by tumor – Intraoperative decision RND vs MRND Type I (Andersen) - 5-year survival and neck failure rates for RND (63% and 12%) not statistically different compared to MRND I (71% and 12%) END - carotid artery invasion - hypoglossal or digastric muscle resection

Answer 4

Selective neck dissection - Indicated for N0 if primary lesion >20% risk of occult metastasis - Oral T1 N1 – Reduce postsurgical shoulder pain and shoulder dysfunction – Improve cosmetic outcome – Reduce likelihood of bilateral IJV resection if contralateral neck involvement 1. Supra-omohyoid type (oral ca) 2. Lateral type (oropharynx, hypopharynx, supraglottis, and larynx) 3. Posterolateral type (cutaneous & sarcomas) 4. Anterior compartment type (Selected thyroid, parathyroid,subglottic, laryngeal with subglottic extension & cervical oesophagus)

Answer 5

``` Apron (Breach) Half-apron / Hockey stick Conley Y Double Y H MacFee (1 parallel & under mandible, 1 above clavicle) Y incision (inf limb = over SCM) Schobinger, Modified Schobinger (inf limb = over posterior triangle) ``` ``` Learn Jatin Shah's incisions A. Transverse high - supraomohyoid middle - jugular - larynx low - comprehensive - thyroid B. Modified - parotid (Blair + lazy S curving lower into neck to do supraomohyoid dissection) C. Posterolateral (S) D. Comprehensive - RND (Y) ```

Answer 6

1. positive histology in neck dissection 2. N2 disease 3. Extracapsular spread 4. Oral T3 and T4

Answer 7

Specific Early intra-op - Bleeding - Air Embolus: vein (immediate ligation, pack, head down, turn head to left side) - Pneumothorax - Carotid artery injury - Nerve injury (phrenic, vagus, brachial plexus, lingual, hypoglossal, glossopharyngeal) Specific Intermediate - Skin-flap necrosis - Carotid blow out: often fatal, inc risk pts with salivary fistulas, radiotherapy - Chyle leak = damage to thoracic duct. Rx Fat free diet or TPN - Salivary fistula Specific Late - Scar contracture - Neuroma (cervical plexus) - Shoulder pain syndrome (reduced incidence if CN XI preserved) - Cellulitis and facial oedema (IJV excised)

Answer 8

Skin incision 1. Mastoid Process to opposite SCM keeping 2 fingerbreadths below angle of mandible. 2. Trifurcation point is kept posterior to carotid where possible.

Answer 9

Comprehensive - remove contents of all 5 levels 1. Classic Radical 2. Extended Radical 3. Modified Radical 1,2,3 Selective 1. Supraomohyoid - Levels 1-3 + submandibular gland - oral cavity tumours - avoids risk to thoracic duct (level 4 on left) 2. Jugular = Anterolateral Levels 2,3,4 - laryngeal, hypopharyngeal tumours 3. Anterolateral - Levels 1-4 common for T1/2 N0 oral tumours as don’t go to 5 4. Anterior - Levels 2, 3, 4 + tracheo-oesphageal - thyroid tumours 5. Posterior = Posterolateral - Levels 2,3,4,5 - posterior scalp tumours 6. Central - Level 6

Answer 10

- Tell anesthetist: bleeding problem. - Prevent air embolus by pressure on vein distally. - Isolate bleeding point with suction and local dissection. - If possible, repair or oversew IJV defect. - If not possible, plug with finger or gauze - Apply pressure while finishing dissection - If still bleeding plug area with segment of SCM. - May require thoracic surgeon to enter superior mediastinum. - IJV may retract into temporal bone (pack with Surgicel, locate posterior belly of digastric over hole).

Answer 11

Skin incision 1. Vertical limb is curvilinear and ends at midclavicular point. 2. Posterior flap is elevated subplatysmal until anterior border of trapezius. 3. Spinal accessory nerve is preserved at this point in MRND – seen coming into anterior edge of post. triangle 4. Dissection of soft tissue from floor of post. triangle exposing splenius capitus and levator scapulae. 5. Superior edge of SCM is detached from mastoid process. 6. At the lower end, transverse cervical artery and vein are tied off. Inferior belly of omohyoid is divided allowing posterior scalene muscle to be exposed. 7. Lower end of external jugular ligated 8. Roots of cervical plexus come into view – these are preserved until phrenic nerve and motor branches of the cervical plexus are identified. Cutaneous branches of cervical plexus then ligated (to catch accompanying vessels) 9. Brachial plexus comes into view – dissection here is easy because of loose areolar tissue 10. Post triangle dissection now complete.

Answer 12

1. Anterior part of transverse incision now made. 2. Sternal head of SCM exposed using large loop retractor – this, along with manubrial and clavicular attachments is then divided with diathermy – loose areolar tissue between muscle and carotid aids protection of the vessel. 3. Vessels entering the anterior skin flap near the clavicle are preserved (branches of int. mammary which supply skin flap) 4. SCM pulled upwards to reveal carotid sheath. IJV blunt and sharp dissected out 5. Prox. end of transverse cervical artery and vein ligated 6. Thoracic duct dissected out and ligated 7. Tissue pulled out from behind IJV to keep it in continuity with specimen 8. Common carotid and vagus identified and kept out of the way medially whilst bottom end of IJV is double-ligated. 9. Middle thyroid vein enters medial IJV - ligated 10. Dissection continues upwards along carotid sheath until skull base 11. This reveals the hypoglossal nerve, superior belly of omohyoid leading to hyoid – omohyoid detached from here 12. Superior thyroid artery preserved, but vein is ligated. 13. Anterior dissection now complete

Answer 13

1. Superior flap elevated 2. Marginal mandibular nerve is identified over the submandibular gland (2 fingerbreadths below and 2 fingerbreadths anterior to angle of mandible) – preserved by retracting it upwards with skin flap. 3. Facial artery and vein ligated along with branches of occipital artery that enter specimen. 4. Contents of submandibular triangle (level 1 nodes, submandibular gland, its nerve supply and Wharton’s duct) are dissected, preserving lingual and hypoglossal nerves 5. Tail of parotid is separated or transected along posterior belly of digastric which can then be retracted upwards 6. Occipital artery may need to be divided if it is very low. 7. Accessory nerve divided and ligated (vasa nervorum) near jugular foramen 8. Upper end of IJV double ligated. 9. Irrigation, drains x2 (one over trapezius, other over strap muscles), haemostasis 10. Closure and airtight dressing 11. Specimen pinned out on to board, labeled, marked etc.

Answer 14

```  Fistulae  Wound breakdown  XI nerve palsy  XII nerve palsy  Carotid blow-out & if survive like to have CVA  Airway obstruction ```

Answer 15

Parotid - Deep, superficial lobes & tail - Separated by facial nerve - surrounded by continuation of deep cervical fascia - Serous acini mainly - Stensen's duct - opens at 2nd maxillary molar Submandibular - In submandibular triangle - Mucous & Serous Acini - Wharton’s Duct - into anterior floor of mouth Sublingual - In anterior floor of mouth - Multiple ducts of Rivinus → Bartholin's duct → Wharton Minor glands - 600 - 1000 of them - Mainly mucous secreting - Mucous Acini

Answer 16

- 3% of all head and neck malignancy Factors suggestive of malignancy - Pain, Obstruction, infection, Nerve involvement (but pleomorphic (benign) can rarely cause palsy too), Invasion of other structures, Bleeding from the duct, Rapid progression. Bimanual palpation

Answer 17

1. Pleomorphic Adenoma (benign mixed) - Most common - 65% of all salivary lesions, 80% of benign - Slow growing, painless - 30-50yr olds - Rarely - Invasion of nerve → palsy - Superficial parotidectomy better – Simple enucleation → high recurrence (tumour is not encapsulated) - EXCISE - risk of enlargement and CNVII 2. Adenoma - Cannalicular Adenoma (75% in upper lip) - Basal Cell Adenoma (75% in parotid) - Females 2:1 - May look like a mucocoele - Surgical excision usually curative ``` 3. Warthins – Adenolymphoma (papillary cystadenoma lymphomatosum) - 10%of all parotid neoplasms - 10% bilateral - 10 x risk in smokers - 10:1 M:F - 10% malignant - Minimal margin excision or superficial parotidectomy (elderly - observe) ``` 4. Oncocytoma - rare - <1% 5. Monomorphic adenoma - similar presentation to pleomorphic - various cell types - almost exclusive to men 50-70 years

Answer 18

1. Mucoepidermoid - 30% of all malignant parotid tumours - Well differentiated → limited invasiveness rarely mets - Intermediate grade → similar to well diff SCC - Poorly differentiated high grade malignancy, local invasion and regional spread. 2. Adenoid Cystic Carcinoma - 20% - Cribriform = best prognosis - Tubular = intermediate - Solid form = worst prognosis - Skip lesions along facial nerve common, prone to perineural invasion - V high recurrence rate +/- lung mets 3. Malignant Mixed Cell (Carcinoma ex pleomorphic adenoma) - Usually after a benign lesion present for over 10yrs 4. Polymorphous Low-grade adenocarcinoma 5. Acinic Cell Carcinoma 6. Lymphoma - Asociated with Sjogren’s

Answer 19

Blair incision - upper anterior border of ear → preauricular crease → mastoid → hyoid (2cm below mandible) Elevation of skin flap (raise SMAS, down to parotid fascia). Separation of parotid tail (from SCM & digastric). Preserve post. facial vein Isolate and preserve facial nerve (tragal pointer, 1cm anterior and inferior to tragal pointer, note that it's quite deep). Antegrade approach - trace forward from 1cm deep to tragal pointer Retrograde approach - trace back from cervical br (retromandibular vein), marginal br (lower mandible, over facial artery), buccal br (Stensen's duct) - if lesion if very large in retromandibular area Buccal branch - in line tragus and corner of mouth, identify Stensen's duct

Answer 20

3% of head and neck malignancy More common in Far East Affect : nasal cavity, maxillary sinus, ethmoid, sphenoid, frontal sinuses Benign: Osteoma. Fibroma, Fibrous Dysplasia Osseous malignancy: Osteogenic Sarcoma, Ewing’s sarcoma. Connective tissue (malignant): Chondrosarcoma, Fibrosarcoma, Malignant fibrous histiocytoma (MFH), Rhabdomyosarcoma Epithelial Tumours: SCC, Adenocarcinoma, Mucoepidermoid carcinoma, MM

Answer 21

Stage (MRI, CT) Biopsy Ohngren's line - plane b/t medial canthus & angle of mandible. Above line = poorer prognosis (more vital structures invaded) Weber - Fergusson incision for maxillary sinus

Answer 22

History → loose teeth, numb lip, pain, (inf alveolar nerve invasion) Exam → Big tumour, path # X-ray → OPG, PA mandible → specific not sensitive, false -ve CT → specific more sensitive MRI Operative assessment → - If periosteum peels away easily = no invasion (Rim excision) - If periosteum adherent = suspicious (Segmental excision) If periosteum invaded consider rim resection (marginal mandibulectomy) or segmental resection.

Answer 23

Bone invasion occurs 1. soft tissues = infiltrative spread 2. lymphatic channels = embolic spread 3. nerves = permeative spread 4. occlusal surface after tooth extraction DXT may disrupt periosteal integrity → tumour spread

Answer 24

Defects - Segmental - Rim - Atrophic - Pathological Fracture

Answer 25

Rim resection - resect alveolus with preservation of body of mandible. Only if tumour is abutting bone. NOT after radiation as this alters the pattern of tumour spread. - not for edentulous patients Segmental resection - for significant bone invasion or after radiation. Needs reconstruction. - Classify defects: o C = central segment between the canine teeth o L = lateral segment not including condyles o H = lateral and Horizontal segment including the condyle o Many are combination (LC - central and lat but not condyle, LCL = large central but no condyles, HC – central & lateral including condyles) o Central segment most important to reconstruct → if not get Andy Gump deformity o Least important → condyles

Answer 26

* 1597 – Tagliacozzi – distal pedicle from arm to lip * 1768 – Louis – wedge excision & direct closure * Late 1700s – Chopart – local advancement – failed * 1838 – Sabattini – lip switch from lower to upper lip * 1898 – Abbe * 1857 – von Bruns – curvilinear nasolabial flaps * 1853 – Bernard cheek advancement, von-Burrow modification * 1872 – Estlander – for lower lateral / commissure * 1957 – Gillies – fan flap * Karapandzic - myoneurovascular pedicled advancement flap * 1974 - Harii and Ohmori- microvascular free tissue transfer for lip reconstruction

Answer 27

1. No bone recon - span w contoured recon plate, pec major wrap - eventually extrudes, not suitable w DXT 2. Non-vascularised - bone graft max 5cm - autograft, allograft, alloplast - titanium tube filled with cancellous bone 3. Vascularised - pedicled / free 4. Vascularised bone - Free fibula - DCIA - RF - Scapular 5. Osseointegrated implants

Answer 28

NL fold, philtral columns and groove, tubercle, cupid's bow, white roll, commissure, vermilion, labiomental fold

Answer 29

Orbicularis Oris • 2nd branchial arch. • forms sphincter encircling oral aperture • fibres decussate in midline at modiolus • Extrinsic fibres intermingle with buccinator • Intrinsic fibres → incisive and mental slips • Acts to form a whistling expression ``` Elevators • Levator labii superioris alaeque nasi • Levator labii superioris • Levator anguli oris • Zygomaticus major • Zygomaticus minor ``` Depressors • Depressor anguli oris • Depressor labii inferioris • Mentalis

Answer 30

``` Motor • Upper Lip - levators – buccal VII • Lower Lip - depressors – marginal mandibular VII • Orbicularis supplied by both • Platysma - cervical br of VII ``` Sensory • upper – infra-orbital (maxillary V) • lower – mental (inf. alveolar – mandibular V)

Answer 31

* Superior & inferior labial arteries from facial artery * 1 mm posterior to the white roll and 1 mm deep to the mucosa of the lip. * deep to the orbicularis oris muscle

Answer 32

* Upper lymphatics are unilateral, lower is bilateral * Both lips drain into submandibular and submental nodes * Upper lip also drains into peri-parotid and preauricular nodes

Answer 33

Lip has 4 1. Lateral wings  between philtral columns and nasolabial folds 2. Philtrum  between philtral columns 3. Lower lip  between vermillion and labiomental fold 4. Vermillion  between vermillion border and the dry-wet line

Answer 34

1. Oral competence → drooling (loss of sensation innervation and depth of lower sulcus) 2. Adequate access to oral cavity Microstomia → difficult eating, dentures, teeth cleaning and repairs. Stretching devices can be used esp. if < 50% 3. Communication 4. Cosmesis

Answer 35

* Upper lip lesions tend to be BCCs * Lower lip lesions tend to be SCCs * More metastasis with commissural or mucosal

Answer 36

Restoration is designed from within outwards. The lining membrane must be considered first, then the supporting structures and finally the covering. ``` Classification depth size location subunits ``` ``` Anatomic considerations blood supply sensation muscular function motor innervation topographic subunits ```

Answer 37

``` Over 50% full thickness • Webster’s modification of Bernard lip reconstruction = Bernard-Burows / Webster-Bernard (PRS 1960) • Gilles’ fan flap • Karapandzic (1974 BJPS) • McGregor • Nakajima • Abbe (1898 Med Rec) • Estlander (Arch Klin Chir, 1872) • Perialar flaps ``` * Free transfer - radial forearm & PL sling * Replantation

Answer 38

Mucosa only • excised vermillion and mucosal advancement Less than 30% width • wedge / pentagon excision, direct closure ``` Between 30 and 50% • Johansson’s step technique • Karapandzic flap • Abbé flap • Estlander flap ```

Answer 39

* Commonest H&N Ca * 2-5% of overall Ca (10th in UK) * Late presentation > 50% stage III/IV * M>F * Reduced age of onset * Stage I 90% 5yr survival * Stave IV <40% 5yr survival * 2-5% per annum metachronous H&N Ca * Lung tumour – 10% * 20% new Ca @ 5yrs * 50% patients die * Speech/Cosmesis/Swallow

Answer 40

Larynx Function: • Phonation • Breathing • Protection against aspiration ``` Symptoms & Signs: • Dysphagia • Hoarseness (≥4/52) • Neck swelling • Persistent sore or painful throat • Stridor • Unilateral pain assoc with otalgia ```

Answer 41

``` Staging - Cross-sectional imaging, PET-CT Airway ? Tracheostomy Surgery Resection +/- Recon Medical evaluation Dental assessment Speech Rx Dietician assessment: BMI/Feeding regime Cancer Nurse specialist MDT ```

Answer 42

Early Ca o DXT or Laser Rx Advanced Ca - Surgery + post op RT - Chemoradiation ``` Recurrent disease - surgery + free flap Surgical Options Total laryngectomy Partial laryngectomy Partial pharyngectomy Total laryngo-pharyngectomy ``` Reconstruction - ALT, RFF if large build patient

Answer 43

Larynx Function: • Phonation • Breathing • Protection against aspiration ``` Symptoms & Signs: • Dysphagia • Hoarseness (≥4/52) • Neck swelling • Persistent sore or painful throat • Stridor • Unilateral pain assoc with otalgia ```

Answer 44

- Fistulae - Wound breakdown - XI nerve palsy - XII nerve palsy - Carotid blow-out & if survive likely to have CVA - Airway obstruction

Answer 45

``` Staging - Cross-sectional imaging, PET-CT Airway ? Tracheostomy Surgery Resection +/- Recon Medical evaluation Dental assessment Speech Rx Dietician assessment: BMI/Feeding regime Cancer Nurse specialist ```

Answer 46

Early Ca o DXT or Laser Rx Advanced Ca - Surgery + post op RT - Chemoradiation Recurrent disease - surgery + free flap ``` Surgical Options Total laryngectomy Partial laryngectomy Partial pharyngectomy Total laryngo-pharyngectomy ```

Answer 47

No, because scar will contract and cause trismus

Answer 48

- skin flap over DCIA not reliable - they c/o trousers slip down because loss of iliac crest - for curved piece of bone - harvest laterally - for straighter piece - harvest more posteriorly - scapular flap with bone - poor quality bone

Answer 49

- Plan skin cover first – use regional flaps rather than further frees - Harvest the jejunum 40cm from Ligament of Treitz - Ischaemic time for jejunum is 2hrs, so don’t waste time - General surgeon to do laparotomy, but harvest your own jejunum - Top anastomosis, micro, then bottom anastomosis - Soutar says make it short and tight – the neck is extended anyway, so unlikely to end up too tight

Answer 50

- Simple skin tubes – local - Free radial forearm - ALT - VRAM?

Answer 51

``` 7% of all cancers 30% die 20% have synchronous tumour M>F smoking and alcohol increase risk 15x ```

Answer 52

``` lip and oral cavity pharynx larynx paranasal sinus salivary gland thyroid oesophagus ```

Answer 53

``` Age Occupation General health smoking spirits spices sharp teeth syphilis sunlight HPV weight loss, systemic symptoms lumps elsewhere ```

Answer 54

``` Complete HN examination, 20% have synchronous tumours Biopsy of lesion Panendoscopy MRI, CT for neck staging and planning blood tests FBC, U&E, LFTs, Ca etc US neck, FNA of any neck masses PET CT ```

Answer 55

leukoplakia - uniform / verrucous, 15-20% malignant change | erythroplakia - 50% malignant change

Answer 56

Arteries - facial - superior thyroid Vein - IJV - end to side or end to end to a branch - EJV - formed by posterior auricular vein joined by posterior retromandibular vein, crosses SCM facial vein ``` Vessel depleted neck Aeteries - transverse cervical (bottom lateral corner of posterior triangle) - thoracoacromial (pectoral branch) - external carotid ``` Veins - cephalic turn over Vein grafts - in radiotherapised necks

Answer 57

Oral cavity - vermillion border to circumvallate papillae, and junction of soft and hard palate superiorly Oropharynx - circumvallate papillae to tip of epiglottis (hyoid level). Includes soft palate, tonsils, aryepiglottic folds and valleculae Nasopharynx - above oropharynx Hypopharynx - aryepiglottic folds down to origin of oesophagus (cricoid cartilage level). Includes postcricoid region, piriform fossa and posterior pharyngeal wall

Answer 58

T1N0M0 surgery alone - 99%+ debulked, free tissue transfer aids postop DXT DXT alone - 25% debulked, not recommended, as DXT may be needed postop if narrow margins chemotherapy - adjuvant, neoadjuvant, palliation T2 N0 Excision +/- ND (usually yes, for higher risk tongue/ FOM cancers, and for access) +/- DXT T3 N0 Excision and MRND DXT - incomplete or narrow (0.5mm) excision margins, extra capsular spread. perineural invasion, N2/N3 disease ``` T4 Excision and reconstruction Mandible - rim resection if tumour abuts bone, segmental resection if invading or edentulous or previous DXT MRND DXT ```

Answer 59

Well defined tumours: 1cm Ill-defined, recurrent tumours or previously irradiated tissues: 2cm+ Frozen section guided Consider perineural spread along lingual or inf alveolar nerves, divide nerves as close to skull base as possible

Answer 60

Direct closure SSG Local flaps - mucosal - tongue - NL fold (6x3cm) - submental Pedicled flaps - pec major - LD Free flaps - ALT - RFFF

Answer 61

- tend to invade bone early | - 25% nodal mets in T1 tumours

Answer 62

- At presentation, 15% will have mandibular invasion, 30% nodal mets - 10% have occult nodal disease T1 - DXT / surgery T4 - surgery Reconstruction small - buccal mucosal / NL flaps large - PM / free flap

Answer 63

RMT - b/t upper and lower 1/3 molar teeth, medial to ascending mandibular ramus and medial pterygoid muscle (trismus) Lymphatics drain to jugulodigastric and submandibular nodes Reconstruction RFFF +/- bone Pec major

Answer 64

Tumour size Does it cross midline? Is tongue fixed to FOM? Hypoglossal nerve palsy? Investigations EUA MRI

Answer 65

Submandibular 'visor' incision & pull through technique (spares mandible) Lip split and Y incision, paramedian mandible osteotomy Synchronous neck dissection (increased rate of fistula formation) TisN0 - CO2 laser T1 - 1cm excision margins, d/c / SSG T2 - surgery, RFFF Neck dissection DXT T3 - surgery, ALT/LD MRND DXT

Answer 66

less than 5mm - 6% ND | greater than 5mm - 60% ND

Answer 67

T3/T4 tumours post DXT recurrence > 50% tongue involvement Reconstruction - PM myocutaneous - free myocutaneous rectus, ALT - laryngeal suspension, hyoid to mandible

Answer 68

Access - perioral - Slaughter's pull-through - midline / paramedian mandibulotomy +/- midline glossotomy Laryngectomy (if significant tongue base involvement) Neck dissection (50% have nodal disease at presentation) Tracheostomy Reconstruction - RFFF / ALT - PM myocutaneous - Temporalis muscle or TPP fascial flap

Answer 69

buccal and submandibular periosteal branches of facial arteries inferior alveolar artery - supplies teeth and alveolar part of mandible only

Answer 70

Symphyseal Paramedian Lateral Vertical (b/t 2nd incisor and canine) or step or sagittal split (exposes dental roots)

Answer 71

Dentate mandible - via periodontal membrane at occlusal surface Edentulous mandible - via alveolar surface at tooth gaps - where cancellous bone is in contact with overlying mucosa Post-DXT - spread through multiple sites as periosteum no longer resistant to tumour invasion Within mandible - medullary spread - permeative spread along mandibular canal

Answer 72

OPG CT MRI

Answer 73

Rim resection T1-2 non-DXT good vertical height (not edentulous) Segmental resection T3-4 irradiated short vertical height

Answer 74

normal chewing, swallowing and oral competence denture rehab and aesthetics non-vascularised bone graft - iliac crest / rib vacularised bone graft if 5cm+ 1 Fibula - 25cm bone - 10% cannot rely on overlying skin paddle - short pedicle - angiography: peronea magna 2 RFF - 12cm, reliable skin paddle - b/t PT and BR - leave 1/3 of cross-sectional area to avoid fracture 3 DCIA - 15x6cm bone, can also harvest int oblique muscle (ascending br of DCIA) for intraoral lining - 10% cannot rely on skin paddle 4. Scapula - 12x3cm bone with skin paddle - subscapular artery Others - lateral trapezius and spine of scapula - PM with 5th rib / edge of sternum - SCM with medial clavicle

Answer 75

metal plates allogenic bone bone substitutes - hydroxyapetite recon plates - for poor prognosis. Most fail within 1yr after DXT

Answer 76

piriform fossa (70%) post pharyngeal wall (20%) post-cricoid region (10%)

Answer 77

direct closure tubed FC flap free jejunum - take 2nd / 3rd jejunal loop beyond ligament of Treitz

Answer 78

HLA type (ethnicity) EBV dietary nitrosamines (smoking, alcohol less impt)

Answer 79

SCC - keratinising - non-keratinising - undifferentiated

Answer 80

neck nodes (70%), otitis media, obstruction, epistaxis endoscopy biopsy heck node FNA CT / MRI with contrast

Answer 81

- very radiosensitive Stage 1 - DXT to primary and neck Stage 2-4 - DXT +/- chemo Recurrence - salvage surgery

Answer 82

Parotid (serous) Submandibular (S&M) Sublingual (mucous) Minor salivary glands (mucous)

Answer 83

``` 3% of H&N tumours 80% are parotid, 80% are benign Pleomorphic adenoma (75%) Adenolymphoma (Warthin's) (10%) Mucoepidermoid carcinoma (3%) Adenoid cystic (3%) Others: carcinoma ex-PA ``` Submandibular (10-15%) Sublingual and minor salivary glands (10%) The smaller the gland, the more likely the tumour is malignant MRI diagnosis: 93% sensitivity

Answer 84

Haemangiomas

Answer 85

Ectodermal origin Deep and superficial (75%) lobes Enveloped by parotid fascia (continuation of SMAS and investing fascia of neck) Contains - facial nerve - retromandibular vein (posterior branch drains into EJV / post-auricular vein, anterior branch drains into anterior/common facial veins) - ECA - preauricular LNs - auriculotemporal nerve Stensen's duct turns around ant border of masseter to pierce buccinator and travels obliquely into oral cavity opp upper 2rnd molar

Answer 86

Sensation - auriculotemporal nerve (V3) - great auricular nerve (C2,3) - to fascia Secretomotor - preganglionic fibres from inferior salivary nucleus (glossopharyngeal IX) Posterior belly of digastric is at deep inferior surface of gland and where facial nerve emerges from stylomastoid foramen

Answer 87

Deep and superficial parts - separated by free border of mylohyoid Superficial part - grooved by facial artery posteriorly Deep part - lies b/t lingual nerve above and hypoglossal nerve below Wharton's duct - passes deep to mylo and geniohyoid and opens next to frenulum

Answer 88

sebaceous cyst sialolithiasis autoimmune conditions e.g. Sjogren's lymphoma

Answer 89

sebaceous cyst sialolithiasis autoimmune conditions e.g. Sjogren's lymphoma

Answer 90

when features do not suggest pleomorphic adenomas or minor salivary gland tumours

Answer 91

``` pain short history facial nerve involvement bleeding from duct lymphadenopathy skin changes children and elderly ```

Answer 92

Pleomorphic Adenoma - different types of epithelial tissue + different types of stroma (chondroid, myxoid, mucoid) - F:M 2:1, 30's-60's, slow growth - 70% of parotid tumours (tail usually) - invasion of facial nerve rare - 2-10% malignant change - well encapsulated, but simple enucleation has high recurrence rate. Monomorphic (Adenolymphoma, Warthins) Adenoma - uniform epithelial tissue with lymphoid stroma - benign, usu elderly, male 5:1, smokers - 10% of parotid tumours - 10% bilateral - 10% recur after surgery Myoepithelioma - tumour of minor salivary glands, like PA large intramural swelling, slow growth, avoid biopsy - MRI: for excision planning Mucoepidermoid - squamous and mucous metaplasia within ductal epithelium - no discrete capsule - can be well or poorly differentiated

Answer 93

Blair incision • Commonly used, this incision starts at the upper anterior border of the ear, extends downwards along the preauricular crease and continues backwards over the mastoid process. • From here it passes anteriorly in a cervical crease towards the hyoid bone. • The neck incision lies approximately two finger breadths below the mandible. Elevation of the skin flap • The skin flap is elevated from the parotid gland. • Care should be taken to preserve the greater auricular nerve as it may subsequently be required as a nerve graft. Separation of the tail of the parotid gland • The tail of the parotid gland is separated from the sternocleidomastoid and digastric muscles. • Care must be taken not to damage the posterior facial vein as ligation causes venous congestion of the gland. Approach to the facial nerve • The facial nerve can be approached proximally as it enters the gland (antegrade approach) or distally as it exits the gland (retrograde approach). • If the tumour is large, it may prove difficult to retract the parotid and a retrograde approach may be preferred. The antegrade approach • The cartilaginous tragal pointer should be visualized. • The facial nerve can be found 1 cm deep to this point. • A nerve stimulator can be used to confirm identification of the facial nerve. • The superficial lobe of the parotid gland is then separated from the facial nerve by careful dissection along the perineural space. The retrograde approach The distal branches of the facial nerve can be identified at the following sites: • The cervical branch as it runs alongside the retromandibular vein. • The marginal branch below the lower border of the mandible as it runs superficially over the facial artery. • The buccal branches as they run alongside the parotid duct (Stensen’s duct). Identification of Stensen’s duct may be aided by cannulation from inside the mouth.

Answer 94

Mucoepidermoid carcinoma (30%) - M=F, 30-50's - low grade - 86% 5 yr survival - high grade - 22% - intermediate/ high grade: 40% LN +ve (adjuvant DXT). Acidic cell ca (3% of parotid tumours) - 50's - Can be multifocal, occasionally bilateral. - Usually low grade (90% 5-year survival). - Lymph node metastases - 10%. - Total parotidectomy, preservation of uninvolved nerves. - ELND not indicated. - Not usu radiosensitive. Carcinoma ex pleomorphic adenoma (malignant mixed tumour) - sudden onset rapid enlargement of longstanding parotid mass. If very large - requires retrograde gland dissection

Answer 95

Parotid Benign / low-grade (preserve facial nerve) - superficial parotidectomy e.g. mucoepidermoid - deep lobe = total parotidectomy High grade - radical parotidectomy +/- facial nerve +/- surrounding involved structures; masseter, medial pterygoid, styloid process, post belly of digastric, skin Submandibular Low grade - gland excision High grade - gland + surrounding platysma, mylohyoid, hyoglossus, hypoglossal & lingual nerves

Answer 96

Intraop - facial nerve damage, retromandibular vein damage Early - skin flap necrosis, infection, haematoma sialocele, salivary fistula Late - Frey's syndrome = gustatory sweating. Post-ganglionic parasympathetic secrotomotor fibres reinnervate auriculotemporal nerve. Rx: antiperspirants, Botox, tympanic neurectomy, dermofat graft, Strattice interposition

Answer 97

A. Blair incision • upper anterior border of ear, down along pre auricular crease, backwards over mastoid process and anteriorly in a cervical crease towards hyoid bone (2 finger breadths below mandible). B. Elevation of skin flap • The skin flap is elevated from superficial parotid fascia. • Take care to preserve greater auricular nerve (may be required as nerve graft) and EJV. C. Separation of tail of parotid gland • Tail is separated from SCM and post digastric muscles. • Preserve posterior facial vein as ligation causes venous congestion of gland. D. Approach to the facial nerve Antegrade approach • Visualise cartilaginous tragal pointer. Facial nerve is 1 cm deep to this. Confirm with nerve stimulator. • Superficial lobe is separated from facial nerve by careful dissection along perineural space. Retrograde approach (large tumours) • Distal branches of facial nerve can be identified: - Cervical branch alongside retromandibular vein. - Marginal branch below lower border of mandible as it runs superficially over facial artery. - Buccal branches as they run alongside parotid duct (can cannulate Stensen’s).

Answer 98

N0 - no ELND Positive neck / extensive deep lobe involvement, aggressive tumour - MRND Face / scalp primary, parotid secondary - ND Radiotherapy - not very sensitive, only for residual/ recurrent/ high grade T3-4

Answer 99

Blair incision, preserve great auricular nerve (Erb's pt 6cm below tragus on SCM) - identify and mobilise tail of parotid - identify facial nerve (find post belly of digastric, stylomastoid foramen, tragal pointer) - preserve facial nerve if indicated (marginal mandibular runs with retromandibular vein, inf border of mandible and over facial artery) - anterograde dissection - retrograde dissection (find buccal branch) if large tumour

Answer 100

Frey's syndrome is gustatory sweating following parotidectomy, when transected postganglionic parasympathetic secrotomotor nerve fibres reinnervate the auriculotemporal nerve. When the patient is eating, the sweat glands on the temporal and ear skin supplied by auriculotemporal nerve are stimulated. Treatment includes Antiperspirants, dermal fat grafts, Strattice interposition, tympanic neurectomy, Botox

Answer 101

Secondaries (89%) - local invasion (paranasal), breast, lung, melanoma Primary malignant orbital tumours - lymphosarcoma, rhabdomyosarcoma - meingioma, glioma - orbital MM Inflammatory disease - thyroid, automimmune (Behcets), mucoceles Vascular - haemangioma Childhood conditions affecting the orbit - dermoid cyst - rhabdomyosarcoma - haemangioma - optic nerve glioma - teratoma

Answer 102

N0 - no ELND Node +ve neck / extensive deep lobe involvement, aggressive tumour - MRND Face / scalp primary, parotid secondary - ND Radiotherapy - not very sensitive, only for residual/ recurrent/ high grade T3-4

Answer 103

Xray, CT, MRI | Biopsy

Answer 104

Medial wall - Lynch, transcaruncular, endoscopic endonasal Lateral wall - upper eyelid crease, lat canthal, lat orbital rim, coronal Orbital floor - conjunctival, transantral (buccal gingival sulcus), subciliary may cause ectropion

Answer 105

Evisceration - excise within scleral shell Enucleation - excise globe, keep eyelid and muscles Total exenteration - globe, muscles, eyelids, orbital walls

Answer 106

GA, theatre, supine, neck extended, shoulders on a small roll. Check trache size with anaethetist, test balloon, and ensure 1 size bigger and smaller is available. Palpate landmarks (thyroid notch, sternal notch, cricoid cartilage), mark horizontal skin incision midway b/t cricoid cartilage and suprasternal notch Inject LA with adr Dissect through platysma until midline raphe between strap muscles is identified. Palpate inferior limit of field to assess proximity of innominate artery. Cauterize/ ligate aberrant anterior jugular veins and smaller vessels. Midline dissection is essential for hemostasis and avoidance of paratracheal structures. Strap muscles are separated and retracted laterally with West self retainer, exposing pretracheal fascia and thyroid isthmus. Divide isthmus with electrocautery and suture ligature. Check trache tube again, and warn anesthesiologist of impending airway entry. When preparations for transfer of circuitry tubes are complete, deflate endotracheal tube balloon and enter trachea. For an inferior Bjork flap, reflect tracheal flap and tack to skin edges with 3/0 prolene sutures left long and secured to chest and neck skin, facilitating replacement of a displaced tube. After trachea is entered, suction secretions and blood out of lumen and slowly withdraw ETT to a point just proximal to opening. Replace lateral retractors into trachea and insert tracheostomy tube. After airway is confirmed intact based on carbon dioxide return and bilateral breath sounds, secure tracheostomy tube to skin with 4-0 permanent sutures. Attach tracheostomy collar Mepilex Ag dressing to stoma site is changed daily

Answer 107

I would perform the neck dissection with great care as the skin flaps will be less pliable, less vascularised and dissection will be more challenging. After the ND, I would import well-vascularised tissue such as a pectoralis major flap to reduce risk of exposure of vital structures e.g. Carotid

Answer 108

- Surface markings of thoracoacromial vascular pedicle: draw a line from shoulder acromion to xiphisternum + another line vertically from midpoint of clavicle to intersect 1st line - Skin paddle is located inferomedially on pec major - Flap is then raised off the chest wall - To increase reach superiorly, flap can be carefully dissected off inferior aspect of clavicle, and passed under clavicle

Answer 109

Absolute indications for lateral canthotomy include - retrobulbar hemorrhage resulting in acute loss of visual acuity, - increased IOP, - proptosis. - unconscious patient, an IOP greater than 40 mm Hg (normal IOP is 10-21 mm Hg). Lateral canthotomy may also be considered in patients with retrobulbar hemorrhage along with any of the following: afferent pupillary defect, ophthalmoplegia, cherry-red macula, optic nerve head pallor, and severe eye pain. However, these findings are subjective, less reliable, and nonspecific. Contraindication - globe rupture

Answer 110

Trauma Post eyelid surgery Recent retrobulbar anesthesia Spontaneous retrobulbar hemorrhage due to venous anomalies, atherosclerosis, intraorbital aneurysm of ophthalmic artery, hemophilia, leukemia, von Willebrand disease, and hypertension has also been described. Other less common causes of orbital compartment syndrome include orbital cellulitis, orbital abscess, tumors, orbital emphysema, and inflammation.

Answer 111

- pain, - decreased vision, - diplopia, - limited extraocular movements, - proptosis, - ecchymosis around eye, - bloody chemosis, - increased intraocular pressure (IOP), - resistance to retropulsion, - afferent pupillary defect.

Answer 112

``` Instruments required Lidocaine 1-2% with epinephrine Syringe with 25-gauge needle Sterile drapes Normal saline for irrigation Straight hemostat Sterile iris or suture scissors Forceps ``` Lateral canthotomy - LA 1-2ml - Use straight hemostat to crimp skin at lateral corner of eye, all the way down to orbital rim for 1-2 minutes. This crimp functions to achieve hemostasis and to mark location where incision is to be made. Cantholysis - Retract inferior lid downward to visualize lateral canthal tendon. - With scissors directed along lateral orbital rim (pointing away from globe), dissect the inferior crux of lateral canthus tendon and cut it. - If procedure is insufficient (ie, IOP remains >40 mm Hg), cut superior portion of lateral tendon by dissecting superiorly before cutting it.

Answer 113

Pearls - When cutting canthal ligament, aim inferoposteriorly toward lateral rim. This helps to avoid injury to levator muscle, lacrimal gland, and lacrimal artery, which are located in the upper lid. - A successful procedure is marked by improved visual acuity, resolution of a previously detected afferent pupillary defect, and decrease in IOP to below 40 mm Hg. - Always seek emergent consultation with an ophthalmologist when this procedure is performed. - Treatment should not be delayed to obtain imaging. Marcus Gunn pupil (afferent pupillary defect), is tested using the swinging flashlight test. Test is positive when the affected pupil dilates in response to light (the other normal pupil also dilates when light is shone in affected eye). Both pupils constrict when light is shone in normal eye. This results from injury to afferent fibers of cranial nerve II of defective eye, while efferent signals from cranial nerve III of normal eye are uninjured.

Answer 114

Complications - iatrogenic globe injury by forceps or scissor tips - ptosis due to damage to levator aponeurosis, lacrimal gland and lacrimal artery, which lie superiorly. - Ectropion (excessive cantholysis) Less common complications include bleeding and infection. Irreversible vision loss can occur if retina ischemia time is greater than 90-120 minutes.

Answer 115

Incision • T-shaped incision: ∘ Transverse limb from mastoid to contralateral SCM (2 fingerbreadths below mandible in a skin crease) ∘ Vertical limb just posterior to carotid, to midclavicular point.

Answer 116

* Subplatysmal as far as anterior border of trapezius (Avoid EJV). * SAN is seen at posterior border of SCM in posterior triangle.

Answer 117

* Peel soft tissues medially, exposing floor of posterior triangle. * SCM is detached from mastoid. * Transverse cervical vessels ligated. * Inferior belly of omohyoid is divided. * Inferior EJV is ligated. * Motor branches of cervical plexus and phrenic nerve are preserved. * The brachial plexus comes into view as dissection is completed.

Answer 118

* Subplatysmal. * Sternal and clavicular attachments of SCM are divided. * Preserve branches of IMA entering the skin flap near clavicle.

Answer 119

• SCM reflected superiorly. • IJV dissected using sharp and blunt dissection. • Proximal end of transverse cervical vessels ligated. • Thoracic duct ligated. • Fascia between carotid sheath and strap muscles is incised. - Strap muscles retracted medially. - Common carotid artery and vagus nerve retracted medially. • Inferior end of IJV doubly ligated. (Middle thyroid vein may enter IJV medially and is ligated). • Dissection continues superiorly along carotid sheath to skull base. ∘ Lymph nodes posterior to IJV are pulled out to remain in continuity with specimen. • Hypoglossal nerve is preserved. • Superior belly of omohyoid is detached from hyoid. • Superior thyroid artery is preserved, but vein ligated.

Answer 120

• Marginal mandibular nerve preserved by retracting it upwards with skin flap (overlies submandibular gland, 2 fingerbreadths below and anterior to mandibular angle). • Facial vessels and branches of occipital artery ligated. • Contents of submandibular triangle (level I nodes, submandibular gland, its nerve supply and Wharton’s duct) are dissected. • Lingual and hypoglossal nerves preserved. • Tail of parotid separated or transected along posterior belly of digastric and retracted upwards. • SAN ligated and divided near jugular foramen. • Upper end of IJV doubly ligated, and the specimen is delivered. • Haemostasis, skin closure over 2 suction drains.

Answer 121

∘ External beam | ∘ Brachytherapy – implanting radioactive devices into the tumour.

Answer 122

∘ Cure: radical radiotherapy. ∘ Improving post-operative local control: adjuvant radiotherapy. ∘ Symptomatic relief: palliative radiotherapy.

Answer 123

* In N0 neck, there is no difference between control rates at 5 years with elective neck dissection or prophylactic radiotherapy. * Radical radiotherapy alone works best for N1 necks. * > 30% of N2 or N3 necks have microscopic residual disease post radiotherapy. * Very difficult to deal with neck recurrence following DXT.

Answer 124

• Adjuvant treatment for N2 or N3 necks can be given before or after neck dissection. ``` Indications for adjuvant DXT: ∘ Oral cavity primary tumours ∘ T3 or T4 lesions ∘ Close or positive surgical margins ∘ Perineural or lymphovascular invasion ∘ Extracapsular lymph node spread. ```

Answer 125

∘ Mucositis ∘ Xerostomia (often permanent). • Modern 3D CT planning delivers intensity-modulated radiotherapy (minimises collateral radiation damage to adjacent normal tissues, but is very hard to do in oral cancers due to mandible). • Osteoradionecrosis is not commonly seen nowadays. - Mainstay of treatment = resection with vascularised reconstruction.

Answer 126

* Indications are not well established. * Most often used for tumours at high risk of recurrence. * Platinum-containing agents e.g. cisplatin are most effective. * Cetuximab = monoclonal antibody targeted at epidermal growth factor receptor. Confers 9% survival advantage over radiotherapy alone in T3 and T4 lesions.

Answer 127

``` rapid growth pain skin involvement facial nerve palsy deep fixation hard consistency palpable nodes ```

Answer 128

Infections - bacterial parotitis: e.g. S aureus - viral parotitis: mumps Autoimmune - Sjogren's, Mikulicz disease (antiquated name for any parotid gland enlargement not TB, leukaemia or identifiable disease). Blockage - sialolithiasis (calculus)

Answer 129

History Examination - USS (assess tumour and LN, guides FNAC) - FNAC (90% accuracy for benign vs malignant) (Not open biopsy due to seeding) - MRI - Staging CT - PET CT? Discuss at MDT

Answer 130

Controversial / dependent on unit 1. USS + core biopsy 2. Cross-sectional imaging - PET CT (identifies 30% of primaries, but significant false +ves) - CT skull base to diaphragm (primary & synchronous tumours, lymphadenopathy, lung mets) 3. Panendoscopy Visualise ∘ Nose, paranasal sinuses and nasopharynx ∘ Oral cavity, hard and soft palate ∘ Tongue base, tonsil and posterior pharyngeal wall ∘ Vallecula, supraglottis, glottis and subglottis ∘ Pyriform fossa, postcricoid region and proximal oesophagus. ``` 4. Biopsy suspicious areas + ∘ Pyriform fossa ∘ Nasopharynx ∘ Tonsillar fossa ∘ Base of the tongue. ```

Answer 131

Tonsillectomy (ipsi / bilateral) MRND / SND (ipsi / bilateral) Radiotherapy if N2/N3 or extra capsular spread - total mucosal irradiation - neck

Answer 132

``` MRI • Demonstrates abnormalities of soft tissue well. • T1-weighted images: "anatomy" fat = white and water = black. • T2-weighted images: "pathology" water = white and fat = black. ``` CT • Demonstrates bony detail well. • Density measured in Hounsfield units (HU). • Contrast agents usually iodinated compounds. Positron emission tomography (PET) • Useful for locating occult primary tumours and assessing recurrence. • Map shows levels of glucose metabolism within tissues. • Radiolabelled 16 fluorodeoxyglucose (FDG) is preferentially taken up by cancer than normal cells (detectable by gamma camera). • Can incorporate CT or MRI to localise uptake to its precise anatomical site. US • Useful for occult cervical lymphadenopathy and salivary gland tumours. • Soundwaves are partially reflected when tissue density changes.