Chapter 19 - Head and Neck++ Flashcards
Anterior neck triangle:
sternocleidomastoid muscle, sternal notch, inferior border of the digastric. Contains carotid sheath
Posterior triangle of neck:
posterior border of the sternocleidomastoid muscle, trapezius muscle, clavicle. Contains spinal accessory nerve.
Where is the phrenic nerve located in the neck?
on the anterior scalene muscle
What do the parotid glands secrete?
mostly serous fluid
What do the sublingual glands secrete?
mostly mucin
What do the submandibular glands secrete?
50/50 serous/mucin
In the larynx, what are superior, true or false vocal cords?
false
Where does the vagus nerve run in the neck?
between the IJ and Carotid
What are the branches of the trigeminal nerve?
ophthalmic, maxillary, mandibular
What are the branches of the facial nerve?
Commonly damaged during parotid surgery. Most resolve over a period of time.
- temporal
- zygomatic
- buccal
- marginal mandibular (corner of mouth)
- cervical
Prevention of injury here is w/ meticulous dissection when dissecting branches off the parotid.
What does the glossopharyngeal nerve do?
sensory to posterior tongue
motor to stylopharyngeus
injury affects swallowing
What does the hypoglossal nerve do?
motor to all of tongue except palatoglossus
tongue deviates to the side of the injury
What does the recurrent laryngeal nerve do?
innervates all of the larynx except cricothyroid muscle
What does the superior laryngeal nerve do?
innervates cricothyroid muscle
What is Frey’s syndrome?
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.
Thyrocervical trunk?
STAT: suprascapular artery transverse cervical artery (trapezius flap) ascending cervical artery inferior thyroid artery
What is the first branch of the external carotid artery?
superior thyroid
What artery is the trapezius flap based on?
transverse cervical artery
what is the pectoralis major flap based on?
thoracoacromial artery
What is torus palatini?
Congenital bony mass on upper palate of mouth.
Do nothing - can resect if sx or need dentures/prosthetics.
What is torus mandibular?
congenital bony mass on anterior lingual surface of mandible
What is a radical neck dissection?
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
What is a modified radical neck dissection?
Takes omohyoid, submandibular, sensory c2-c5, cervical branch of facial nerve, ipsilateral thyroid.
No mortality difference b/w radical and modified.
What is the most common canceer of the oral cavity, pharynx, larynx?
squamous cell carcinoma
What is the biggest risk for oral cancer?
tobacco and etoh
what is more premalignant, erythroplakia or leukoplakia?
erythroplakia
What does the oral cavity include?
mouth floor anterior 1/3 of tongue gingiva hard palate anterior tonsillar pillars lips
what is the most common site for oral cavity ca?
lips
what oral cavity site has the lowest survival rate?
hard palate - hard to resect
What is plummer-vinson syndrome?
glossitis, angular chelitis koilonychia cervical dysphagia from esophageal web iron deficiency anemia increased oral CA risk
Treatment for oral CA?
4cm, nodes, bone - wide resection of 2cm, MRND, adj XRT
re-resect for close/positive margins
+/- chemo
Why are lower lip lesions more common?
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.
Tongue Ca - can you still operate with jaw invasion?
Yes
What is a verrucous ulcer?
well differentiated tumor of the cheek
not aggressive
tx: full cheek resection, +/- flap, no MRND
What do you do with cancer of maxillary sinus?
maxillectomy
Nasopharyngeal Ca: cause, psx, dx, tx
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
Oropharyngeal SCC
- 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
Tonsillar CA
ETOH, tobacco
- asymptomatic until large
- tonsillectomy for biopsy, XRT
Hypopharyngeal SCC
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
Nasopharyngeal angiofibroma
benign tumor
- presents in males <20 years old
- vascular
- angio and embo (usually internal maxillary a)
Laryngeal cancer
Hoarseness, aspiration, dyspnea, dysphagia
- XRT vs transoral laser microsurgery/robot surgery
- favor RT alone if old or poor fct status
- papilloma most benign lesion
Subglottic scca
early nodal spread to submental/submandibular
small: xrt/conservative surgery
large: laryngectomy, mrnd, xrt
Glottic scca
nodal spread to Anterior cervical chain
small: xrt or laser
large: laryngectomy, mrnd, xrt
fixed cords: laryngectomy
what can submandibular or sublingual tumors present as?
neck mass or swelling in floor of the mouth
mass in large salivary gland likely what?
benign
mass in small salivary gland likely what?
malignant
where is the most common site of a malignant salivary tumor?
parotid
1 malignant tumor of salivary gland; wide range of aggressiveness
mucoepidermoid CA
- surgical resection (enucleation not adequate)
- adj XRT for high-risk features
- nodes require MRND (nodes I-V) w/ adj XRT
2 malignant tumor of salivary gland; long, indolent course, propensity to invade along nerves
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
What is the nodal drainage of salivary glands?
intraparotid nodes and anterior cervical chain
General principles of salivary gland tumor sx?
malignant of the parotid = parotidectomy
- facial nerve only sacrificed w/ direct invasion
- high-grade tumors should undergo MRND
- post op xrt
most common benign tumor of salivary glands?
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)
what is the second most common benign tumor of salivary glands?
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
What is the most common nerve injury in parotid surgery?
greater auricular nerve (numbness over lower portion of auricle); often transected to allow mobilization of the parotid tail from the SCM
For a submandibular gland resection, what nerves do you need to identify?
- mandibular branch of facial nerve
- lingual nerve
- hypoglossal nerve
What is the most common salivary gland tumor in children?
hemangiomas
What causes cauliflower ear?
undrained hematomas that organize and calcify - drain to avoid this
what is a chemodectoma?
vascular tumor of middle ear
surgery, +/- xrt
CN VIII
tinnitus, hearing loss, unsteadiness
acoustic neuroma
- craniotomy, resection
- xrt
cholesteatoma?
epidermal inclusion cyst of ear
conductive hearing loss and clear drainage from ear
if found with mastoiditis, do tympanomastoidectomy
Ear CCA
20% metastasize to parotid
most common childhood aural malignancy?
rhabdomyosarcoma
When do you set nose fx?
after swelling goes down
what do you do with a septal hematoma?
drain to avoid infection and necrosis
CSF rhinorrhea caused by what?
cribriform plate fx
CSF has TAU protein
epistaxis - what is most common site?
anterior= 90%
internal maxillary artery or ethmoid a ligation for posterior
What do you do with a radicular cyst?
local excision or currettage
- these are lucent on xray
slow growing malignancy
soap bubble on x-ray
ameloblastoma
can have mets
wide local excision
What nerve damage causes lip numbness?
inferior alveolar nerve
What is suppurative parotitis?
usually in elderly, dehydration
staph most common organism
fluids, abx, salivation, drainage
acute inflammation of salivary gland in the duct
sialoadenitis
- most likely calculi near orifice
- gland excision may eventually be necessary
- incise duct and remove stone
What is Stensen’s duct, and what do you do with a laceration?
duct of parotid
repair over catheter stent
ligation can cause painful parotid atrophy and facial asymmetry
older kids >10:
trismus, odynophagia, severe sore throat, fever, a “hot potato” or muffled voice, drooling; unlikely to have airway obstruction
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
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
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)
all age groups
hx of dental infections, tonsillitis, pharyngitis
morbitiy from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spaces
Parapharyngeal abscess
Tx: drainage through lateral neck, leave drain
acute infection of floor of the mouth
involves mylohyoid muscle
assn w/ dental infection
Ludwig’s angina
- can rapidly spread and cause airway obstruction
Periauricular tumors
all are parotid tumors until proven otherwise
- dx after superficial lobectomy
- 80% salivary are parotid
- 80% parotid benign
- 80% benign are pleomorphic adenoma
What is the most common distant metastases for head and neck tumors?
lung
Posterior neck masses are what until proven otherwise?
hodgkin’s lymphoma
3 stages of neck mass workup?
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
Epidermoid found in cervical node without known primary, what do you do?
1 panendoscopy
2 CT
3 ipsilateral MRND, ipsilateral tonsillectomy, bilateral XRT
Esophageal foreign body?
dysphagia, likely just below cricopharyngeus
- dx with rigid EGD under anasthesia
- perforation increases with length of time in esophagus
What do you do with fever and pain after EGD for foreign body?
CXR and gastrografin followed by barium swallow
What do you do with laryngeal foreign body?
If dying, secure airway, emergent laryngoscopy, may need bronchoscopy if below cords.
If stable, do flexible bronchoscopy. Rigid bronch for large proximal obstructions.
What is sleep apnea associated with?
MI, arrhythmmias, death
- more common in obese and those with micrognathia, retrognathia
What can be caused by prolonged intubation? What do you do about it?
subglotic steniosis. laser, dilation, possible excision
when do you do a tracheostomy?
when intubation will be greater than 7-14 days. Decreases secretions, provides easier ventilation, decreases pneumonia risk
What causes tracheoinominate fistula? what do you do?
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
Cleft palate - when do you fix?
12 months
What is the most common benign head and neck tumor in adults?
hemangioma
CT shows mastoid effusion. Pt has mastoiditis. What do you do?
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
epiglottitis occurs when?
3-5 years, now rare because of HIB vaccine
early control of airway, abx
Kaposi’s sarcoma
oral and pharyngeal mucosa most common can get odynophagia and dysphagia palliation XRT, intratumor vinblastine - most common neoplasm in AIDS
What is the role for radiation in malignant parotid masses?
unclear surgical margins, high-grade malignancies, invasion of surrounding structures, neural invasion, or metastatic disease
How do you manage SCC mets to the neck without known primary?
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.
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.
Requires en-bloc resection. A superficial parotidectomy can be performed, and adjuvant radiation therapy is added for treating any residual micrometastases.
When is total parotidectomy performed for a low-grade tumor?
When it is in the deep lobe.
Where does the spinal accessory nerve (XI) exit the skull?
Jugular foramen, through posterior triangle of neck.
Innervates the SCM and trapezius
Most common site for minor salivary gland malignancies?
Palate (adenoid cystic carcinoma most common type).
Lip and tongue are less likely.
Adolescent patient presents with anterior midline neck mass that moves up with swallowing. It has not progressed in size. What is the likely dx?
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
Melanoma of head and neck management.
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)
Suppurative parotiditis psx and tx.
Fevers, swelling under jaw.
Abx for S aureus. May need I&D.
