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ABSITE 2022 > Chapter 19 - Head and Neck++ > Flashcards

Chapter 19 - Head and Neck++ Flashcards

1
Q

Anterior neck triangle:

A

sternocleidomastoid muscle, sternal notch, inferior border of the digastric. Contains carotid sheath

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2
Q

Posterior triangle of neck:

A

posterior border of the sternocleidomastoid muscle, trapezius muscle, clavicle. Contains spinal accessory nerve.

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3
Q

Where is the phrenic nerve located in the neck?

A

on the anterior scalene muscle

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4
Q

What do the parotid glands secrete?

A

mostly serous fluid

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5
Q

What do the sublingual glands secrete?

A

mostly mucin

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6
Q

What do the submandibular glands secrete?

A

50/50 serous/mucin

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7
Q

In the larynx, what are superior, true or false vocal cords?

A

false

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8
Q

Where does the vagus nerve run in the neck?

A

between the IJ and Carotid

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9
Q

What are the branches of the trigeminal nerve?

A

ophthalmic, maxillary, mandibular

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10
Q

What are the branches of the facial nerve?
Commonly damaged during parotid surgery. Most resolve over a period of time.

A
  • temporal
  • zygomatic
  • buccal
  • marginal mandibular (corner of mouth)
  • cervical
    Prevention of injury here is w/ meticulous dissection when dissecting branches off the parotid.
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11
Q

What does the glossopharyngeal nerve do?

A

sensory to posterior tongue
motor to stylopharyngeus
injury affects swallowing

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12
Q

What does the hypoglossal nerve do?

A

motor to all of tongue except palatoglossus
tongue deviates to the side of the injury

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13
Q

What does the recurrent laryngeal nerve do?

A

innervates all of the larynx except cricothyroid muscle

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14
Q

What does the superior laryngeal nerve do?

A

innervates cricothyroid muscle

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15
Q

What is Frey’s syndrome?

A

Occurs after parotidectomy.
Injury of auriculotemporal nerve that then cross innervates with sympathetic fibers to sweat glands of skin.
Gustatory sweating dx by Minor starch/iodine test.
Tx: application of antiperspirant to the involved skin; if fails, surgical interruption of the secretory fibers by tympanic neurectomy; botulinum injection also an option.

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16
Q

Thyrocervical trunk?

A

STAT:
suprascapular artery
transverse cervical artery (trapezius flap)
ascending cervical artery
inferior thyroid artery

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17
Q

What is the first branch of the external carotid artery?

A

superior thyroid

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18
Q

What artery is the trapezius flap based on?

A

transverse cervical artery

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19
Q

what is the pectoralis major flap based on?

A

thoracoacromial artery

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20
Q

What is torus palatini?

A

Congenital bony mass on upper palate of mouth.
Do nothing - can resect if sx or need dentures/prosthetics.

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21
Q

What is torus mandibular?

A

congenital bony mass on anterior lingual surface of mandible

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22
Q

What is a radical neck dissection?

A

Takes accessory nerve (XII), sternocleidomastoid, internal jugular, omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, ipsilateral thyroid.
Most morbidity from accessory nerve resection

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23
Q

What is a modified radical neck dissection?

A

Takes omohyoid, submandibular, sensory c2-c5, cervical branch of facial nerve, ipsilateral thyroid.
No mortality difference b/w radical and modified.

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24
Q

What is the most common canceer of the oral cavity, pharynx, larynx?

A

squamous cell carcinoma

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25
Q

What is the biggest risk for oral cancer?

A

tobacco and etoh

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26
Q

what is more premalignant, erythroplakia or leukoplakia?

A

erythroplakia

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27
Q

What does the oral cavity include?

A

mouth floor
anterior 1/3 of tongue
gingiva
hard palate
anterior tonsillar pillars
lips

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28
Q

what is the most common site for oral cavity ca?

A

lips

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29
Q

what oral cavity site has the lowest survival rate?

A

hard palate - hard to resect

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30
Q

What is plummer-vinson syndrome?

A

glossitis, angular chelitis
koilonychia
cervical dysphagia from esophageal web
iron deficiency anemia
increased oral CA risk

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31
Q

Treatment for oral CA?

A

4cm, nodes, bone - wide resection of 2cm, MRND, adj XRT
re-resect for close/positive margins
+/- chemo

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32
Q

Why are lower lip lesions more common?

A

Sun exposure. May need flaps if more than 1/2 lip removed. Commissure lesions most aggressive.
SCC is the most common skin cancer of lower lip.

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33
Q

Tongue Ca - can you still operate with jaw invasion?

A

Yes

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34
Q

What is a verrucous ulcer?

A

well differentiated tumor of the cheek
not aggressive
tx: full cheek resection, +/- flap, no MRND

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35
Q

What do you do with cancer of maxillary sinus?

A

maxillectomy

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36
Q

Nasopharyngeal Ca: cause, psx, dx, tx

A

psx: EBV assn; nosebleeds or obstruction; often painless neck mass at posterior/deep cervical nodes
dx: endoscopic biopsy, MRI nasopharynx/skull base/neck; stage w/ bone scan and CT chest/abdomen; EBV DNA lvls (prognostic)
- stage I: XRT
- stage II or more: chemoradiation
- kids - lymphoma, chemo
- papilloma - most common benign neoplasm

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37
Q

Oropharyngeal SCC

A
  • neck mass, sore throat
  • goes to deep nodes
  • tx: XRT vs transoral laser microsurgery/robot surgery
  • favor RT alone if old or poor fct status
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38
Q

Tonsillar CA

A

ETOH, tobacco
- asymptomatic until large
- tonsillectomy for biopsy, XRT

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39
Q

Hypopharyngeal SCC

A

hoarseness, early mets
- goes to anterior cervical nodes
- tx: XRT vs transoral laser microsurgery/robot surgery
- favor RT alone if old or poor fct status

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40
Q

Nasopharyngeal angiofibroma

A

benign tumor
- presents in males <20 years old
- vascular
- angio and embo (usually internal maxillary a)

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41
Q

Laryngeal cancer

A

Hoarseness, aspiration, dyspnea, dysphagia
- XRT vs transoral laser microsurgery/robot surgery
- favor RT alone if old or poor fct status
- papilloma most benign lesion

42
Q

Subglottic scca

A

early nodal spread to submental/submandibular
small: xrt/conservative surgery
large: laryngectomy, mrnd, xrt

43
Q

Glottic scca

A

nodal spread to Anterior cervical chain
small: xrt or laser
large: laryngectomy, mrnd, xrt
fixed cords: laryngectomy

44
Q

what can submandibular or sublingual tumors present as?

A

neck mass or swelling in floor of the mouth

45
Q

mass in large salivary gland likely what?

A

benign

46
Q

mass in small salivary gland likely what?

A

malignant

47
Q

where is the most common site of a malignant salivary tumor?

A

parotid

48
Q

1 malignant tumor of salivary gland; wide range of aggressiveness

A

mucoepidermoid CA
- surgical resection (enucleation not adequate)
- adj XRT for high-risk features
- nodes require MRND (nodes I-V) w/ adj XRT

49
Q

2 malignant tumor of salivary gland; long, indolent course, propensity to invade along nerves

A

adenoid cystic CA
- lung most common distant site
- surgical resection (enucleation not adequate)
- adj XRT for high-risk features
- nodes require MRND (nodes I-V) w/ adj XRT
- if unresectable, do XRT

50
Q

What is the nodal drainage of salivary glands?

A

intraparotid nodes and anterior cervical chain

51
Q

General principles of salivary gland tumor sx?

A

malignant of the parotid = parotidectomy
- facial nerve only sacrificed w/ direct invasion
- high-grade tumors should undergo MRND
- post op xrt

52
Q

most common benign tumor of salivary glands?

A

pleomorphic adenoma
- more common in women in their fifth decade of life
- T2 “bright” on MRI
- low malignant potential but are very aggressive
- superficial parotidectomy (do not enucleate)

53
Q

what is the second most common benign tumor of salivary glands?

A

Warthin’s tumor (papillary cystadenoma lymphomatosum)
- rarely seen outside of the parotid gland
- 10% are bilateral
- strong association: middle-aged men who smoke
- painless, mobile mass
- FNA reveals thick turbid fluid - nondiagnostic
- do a conservative parotidectomy

54
Q

What is the most common nerve injury in parotid surgery?

A

greater auricular nerve (numbness over lower portion of auricle); often transected to allow mobilization of the parotid tail from the SCM

55
Q

For a submandibular gland resection, what nerves do you need to identify?

A
  • mandibular branch of facial nerve
  • lingual nerve
  • hypoglossal nerve
56
Q

What is the most common salivary gland tumor in children?

A

hemangiomas

57
Q

What causes cauliflower ear?

A

undrained hematomas that organize and calcify - drain to avoid this

58
Q

what is a chemodectoma?

A

vascular tumor of middle ear
surgery, +/- xrt

59
Q

CN VIII
tinnitus, hearing loss, unsteadiness

A

acoustic neuroma
- craniotomy, resection
- xrt

60
Q

cholesteatoma?

A

epidermal inclusion cyst of ear
conductive hearing loss and clear drainage from ear
if found with mastoiditis, do tympanomastoidectomy

61
Q

Ear CCA

A

20% metastasize to parotid

62
Q

most common childhood aural malignancy?

A

rhabdomyosarcoma

63
Q

When do you set nose fx?

A

after swelling goes down

64
Q

what do you do with a septal hematoma?

A

drain to avoid infection and necrosis

65
Q

CSF rhinorrhea caused by what?

A

cribriform plate fx
CSF has TAU protein

66
Q

epistaxis - what is most common site?

A

anterior= 90%
internal maxillary artery or ethmoid a ligation for posterior

67
Q

What do you do with a radicular cyst?

A

local excision or currettage
- these are lucent on xray

68
Q

slow growing malignancy
soap bubble on x-ray

A

ameloblastoma
can have mets
wide local excision

69
Q

What nerve damage causes lip numbness?

A

inferior alveolar nerve

70
Q

What is suppurative parotitis?

A

usually in elderly, dehydration
staph most common organism
fluids, abx, salivation, drainage

71
Q

acute inflammation of salivary gland in the duct

A

sialoadenitis
- most likely calculi near orifice
- gland excision may eventually be necessary
- incise duct and remove stone

72
Q

What is Stensen’s duct, and what do you do with a laceration?

A

duct of parotid
repair over catheter stent
ligation can cause painful parotid atrophy and facial asymmetry

73
Q

older kids >10:
trismus, odynophagia, severe sore throat, fever, a “hot potato” or muffled voice, drooling; unlikely to have airway obstruction

A

Exam: enlarged/fluctuant tonsil w/ deviation of uvula to opposite side; fullness or bulging of the posterior soft palate near the tonsil with fluctuance.
Dx: US shows peritonsilar abscess (no CT)
Tx: if airway compromise - prompt surgery
- unasyn or clindamycin for 14 days (cover GAS, S aureus, anaerobes); abx can be used alone w/ observation if indeterminate findings on US
- tonsillectomy vs I&D vs needle aspiration

74
Q

younger kids <10, but can be elderly with potts disease:
fever, odynophagia, drool, stiff neck that hurts w/ extension, toxic appearing; impending airway seen in pts with suprasternal retractions and in “sniffing” position

A

Exam: bulging pharyngeal wall; can extend into mediastinum
Dx: if stable, CT shows retropharyngeal abscess
AIRWAY emergency
Tx: intubate, US drain through posterior pharyngeal wall, will drain with swallowing; abx to cover strep, H flu, anaerobes, GNB (vanc/zosyn)

75
Q

all age groups
hx of dental infections, tonsillitis, pharyngitis
morbitiy from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spaces

A

Parapharyngeal abscess
Tx: drainage through lateral neck, leave drain

76
Q

acute infection of floor of the mouth
involves mylohyoid muscle
assn w/ dental infection

A

Ludwig’s angina
- can rapidly spread and cause airway obstruction

77
Q

Periauricular tumors

A

all are parotid tumors until proven otherwise
- dx after superficial lobectomy
- 80% salivary are parotid
- 80% parotid benign
- 80% benign are pleomorphic adenoma

78
Q

What is the most common distant metastases for head and neck tumors?

A

lung

79
Q

Posterior neck masses are what until proven otherwise?

A

hodgkin’s lymphoma

80
Q

3 stages of neck mass workup?

A

1 laryngoscopy, abx if inflammatory, FNA if hard
2 panendoscopy w/ multiple bx, CT of neck/chest
3 excisional bx, prepare for MRND
- adenoma suggest breast, GI, lung

81
Q

Epidermoid found in cervical node without known primary, what do you do?

A

1 panendoscopy
2 CT
3 ipsilateral MRND, ipsilateral tonsillectomy, bilateral XRT

82
Q

Esophageal foreign body?

A

dysphagia, likely just below cricopharyngeus
- dx with rigid EGD under anasthesia
- perforation increases with length of time in esophagus

83
Q

What do you do with fever and pain after EGD for foreign body?

A

CXR and gastrografin followed by barium swallow

84
Q

What do you do with laryngeal foreign body?

A

If dying, secure airway, emergent laryngoscopy, may need bronchoscopy if below cords.
If stable, do flexible bronchoscopy. Rigid bronch for large proximal obstructions.

85
Q

What is sleep apnea associated with?

A

MI, arrhythmmias, death
- more common in obese and those with micrognathia, retrognathia

86
Q

What can be caused by prolonged intubation? What do you do about it?

A

subglotic steniosis. laser, dilation, possible excision

87
Q

when do you do a tracheostomy?

A

when intubation will be greater than 7-14 days. Decreases secretions, provides easier ventilation, decreases pneumonia risk

88
Q

What causes tracheoinominate fistula? what do you do?

A

can happen after tracheostomy.
Place finger in trach hole with pressure, median sternotomy.
Close the trachea, cover with tissue.
avoid by placing trach above the 3rd trach ring

89
Q

Cleft palate - when do you fix?

A

12 months

90
Q

What is the most common benign head and neck tumor in adults?

A

hemangioma

91
Q

CT shows mastoid effusion. Pt has mastoiditis. What do you do?

A

Abx to cover Staph, Strep, Pseudomonas, and H flu.
Necrotic bone or failure of abx - mastoidectomy.
- ear is pushed forward, can be complication of untreated acute suppurtive otitis media

92
Q

epiglottitis occurs when?

A

3-5 years, now rare because of HIB vaccine
early control of airway, abx

93
Q

Kaposi’s sarcoma

A

oral and pharyngeal mucosa most common
can get odynophagia and dysphagia
palliation
XRT, intratumor vinblastine
- most common neoplasm in AIDS

94
Q

What is the role for radiation in malignant parotid masses?

A

unclear surgical margins, high-grade malignancies, invasion of surrounding structures, neural invasion, or metastatic disease

95
Q

How do you manage SCC mets to the neck without known primary?

A

Head/neck exam w/ fiberoptic exam of pharynx/larynx.
Biopsy nodes.
CT head, neck, chest. +/- PET
OR: direct laryngoscopy, esophagoscopy, ipsilateral tonsillectomy, biopsies.
Treated based on the N stage.
Approximately 80% of these will be from the oropharynx, with the ipsilateral tonsil being the most common site followed by the base of the tongue.
For tumors N <2, straight to surgery is preferred, but for tumors with N >2, chemo or radiation is the first step.

96
Q

How do you manage a low-grade parotid carcinoma (eg acinic cell) adjacent to the facial nerve without invasion? The mass is in the superficial lobe.

A

Requires en-bloc resection. A superficial parotidectomy can be performed, and adjuvant radiation therapy is added for treating any residual micrometastases.

97
Q

When is total parotidectomy performed for a low-grade tumor?

A

When it is in the deep lobe.

98
Q

Where does the spinal accessory nerve (XI) exit the skull?

A

Jugular foramen, through posterior triangle of neck.
Innervates the SCM and trapezius

99
Q

Most common site for minor salivary gland malignancies?

A

Palate (adenoid cystic carcinoma most common type).
Lip and tongue are less likely.

100
Q

Adolescent patient presents with anterior midline neck mass that moves up with swallowing. It has not progressed in size. What is the likely dx?

A

Thyroglossal duct cyst - remnants of the tract along which the thyroid gland descended from the foramen cecum. Often have ectopic thyroid glands - low functionality. Must find before surgery.
Tx: resection of the cyst and the midportion of the hyoid bone in continuity and resection of a core of tissue from the hyoid upwards toward the foramen cecum

101
Q

Melanoma of head and neck management.

A

Less than 1 mm - 1 cm margin WLE.
>1 mm depth - 2 cm margin
Mohs surgery helpful.
Lymphoscintigraphy helps ID SLNBx (if >1 mm depth)

102
Q

Suppurative parotiditis psx and tx.

A

Fevers, swelling under jaw.
Abx for S aureus. May need I&D.

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