Chapter 19: Head and Neck Flashcards
1
Q
Anterior neck triangle
A
Sternocleidomastoid, sternol notch, inferior border of the digastric muscle; contains the carotid sheath
2
Q
What does the anterior triangle contain?
A
Carotid sheath
3
Q
Posterior neck triangle
A
Posterior border of the SCM, trapezius muscle, and the clavicle; contains the accessory nerve (innervates SCM, trapezius, and platysma) and the brachial plexus
4
Q
What does the posterior neck triangle contain?
A
Accessory nerve (innervates SCM, trapezius, and platysma) and the brachial plexus
5
Q
Secrete mostly serous fluid
A
Parotid glands
6
Q
Secrete mostly mucin
A
Sublingual glands
7
Q
50/50 serous / mucin
A
Submandibular glands
8
Q
Where are the false vocal cords?
A
In the larynx, the false vocal cords are superior to the true vocal cords
9
Q
Has U-shaped cartilage and a posterior portion that is membranous
A
Trachea
10
Q
Where does the vagus nerve run?
A
Between internal jugular vein and carotid artery
11
Q
Runs on top of the anterior scalene muscle
A
Phrenic nerve
12
Q
Runs posterior to the middle scalene muscle
A
Long thoracic nerve
13
Q
Branches of the trigeminal nerve
A
Ophthalmic, maxillary, and mandibular branches
14
Q
Gives sensation to most of the face
A
Trigeminal nerve
15
Q
Taste to anterior 2/3 of tongue, floor of mouth, and gingiva
A
Mandibular branch of trigeminal nerve
16
Q
Branches of facial nerve
A
Temporal, zygomatic, buccal, marginal mandibular, and cervical branches
17
Q
Motor function to face
A
Facial nerve
18
Q
Taste to posterior 1/3 tongue
A
Glossopharyngeal nerve
19
Q
- Motor to stylopharyngeus
- Injury affects swallowing
A
Glossopharyngeal nerve
20
Q
Motor to all of tongue except palatoglossus
A
Hypoglossal nerve
21
Q
Where does tongue go in hypoglossal nerve injury?
A
Same side
22
Q
Innervates all of larynx except cricothyroid muscle
A
Recurrent laryngeal nerve
23
Q
Innervates the cricothyroid muscle
A
Superior laryngeal nerve
24
Q
Occurs after parotidectomy; injury of auriculotemporal nerve that then cross-innervates with sympathetic fibers to sweat glands of skin
- Symptom: gustatory sweating
A
Frey’s syndrome
25
What composes the thyrocervical trunk?
STAT
- Suprascapular artery
- Transverse cervical artery
- Ascending cervical artery
- Inferior thyroid artery
26
What bases the trapezius flap?
Transverse cervical artery
27
1st branch of external carotid artery?
Superior thyroid artery
28
What bases the pectoralis major flap?
Based on either thoracoacromial artery or the internal mammary artery
29
Congenital bony mass on upper palate of mouth
| - Tx: nothing
Torus palatini
30
Congenital bony mass on lingual surface of mandible
| - Tx: nothing
Torus mandibular
31
What does modified radical neck dissection (MRND) involve?
- Omohyoid
- Submandibular gland
- Sensory nerves C2-C5
- Cervical branch of facial nerve
- Ipsilateral thyroid
32
Mortality: modified radical neck dissection (vs) radical neck dissection
No mortality difference compared with RND
33
What does radical neck dissection (RND) involve?
- Omohyoid
- Submandibular gland
- Sensory nerves C2-C5
- Cervical branch of facial nerve
- Ipsilateral thyroid
- Accessory nerve
- SCM
- Internal jugular resection (rarely done anymore)
34
Morbidity: radical neck dissection
Most morbidity occurs from accessory nerve resection
35
MC cancer of oral cavity, pharynx, and larynx
Squamous cell cancer
36
Biggest risk factors: squamous cell CA of oral cavity
Tobacco and alcohol
37
Considered more premalignant than leukoplakia
Erythroplakia
38
What does the oral cavity include?
```
Mouth floor.
Anterior 1/3 tongue.
Gingiva.
Hard palate.
Anterior tonsillar pillars.
Lips.
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39
MC site for oral cavity CA
Lower lip (more common than upper lip due to sun exposure
40
Why is survival rate lowest for hard palate tumors?
Hard to resect
41
Glossitis.
Cervical dysphagia from esophageal web.
Spoon fingers.
Iron-deficiency anemia.
Plummer-Vinson syndrome (oral cavity cancer increased in patients)
42
Tx: oral cavity cancer
- Wide resection (1 cm margins)
- MRND for tumors > 4cm, clinically positive nodes, or bone invasion)
- Postop XRT for advanced ( > 4cm, positive margins, or nodal/bone involvement)
43
When MRND in oral cavity cancer?
Tumors > 4cm, clinically positive nodes, or bone invasion
44
When Post op XRT for oral cavity XRT?
Advanced lesions
- >4 cm
- Positive margins
- Nodal / bone involvement
45
When do you need flaps in lip cancer?
May need flaps if more than 1/2 of the lip is removed
46
Most aggressive lesions: lip CA
Lesions along the commissure are the most aggressive
47
Oral cavity cancer: commando procedure
Tongue CA - can still operate with jaw invasion
48
Well-differentiated SCCA; often found on the cheek; oral tobacco
- Not aggressive, rare metastasis
Treatment?
Verrucous ulcer
| - Tx: full cheek resection +/ flap; no MRND
49
Tx: cancer of maxillary sinus
Tx: maxillectomy
50
- ETOH, tobacco, males
- SCCA most common
- Asymptomatic until large
- 80% have lymph node metastases at time of diagnosis
Tonsillar cancer
51
Treatment: tonsillar cancer
Tonsillectomy best way to biopsy; wide resection with margins after that
52
- EBV
- Chinese
- Presents with nose bleeding or obstruction.
Where does it go?
Nasopharyngeal SCCA
Goes to posterior cervical neck nodes
53
Tx: nasopharyngeal cancer
XRT primary therapy (very sensitive; give chemo XRT for advanced disease- no surgery)
54
Do you do surgery in nasopharyngeal carcinoma?
NO.
| Super sensitive to XRT.
55
```
#1 cause tumor of nasopharynx in children
- Treatment?
```
Lymphoma.
Tx: chemotherapy
56
MC benign neoplasm of nose / paranasal sinuses
Papilloma
57
- Neck mass, sore throat
| - Goes to posterior cervical neck nodes
Oropharyngeal SCCA
58
Tx: oropharyngeal SCCA
XRT for tumors 4 cm, bone invasion, or nodal invasion)
59
- Hoarseness, early metastases
| - Goes to anterior cervical nodes
Hypopharyngeal SCCA
60
Tx: hypopharyngeal SCCA
- XRT for tumors 4 cm, bone invasion or nodal invasion)
61
- Benign tumor
| - Presents in males
Nasopharyngeal angiofibroma
62
Hoarseness, aspiration, dyspnea, dysphagia
| - Try to preserve larynx
Laryngeal cancer
63
Tx: laryngeal cancer
XRT (if vocal cord only) or chemo-XRT (if beyond vocal cord)
- Surgery is not the primary treatment, try to preserve larynx
- MRND needed if nodes clinically positive
- Take ipsilateral thyroid lobe with MRND
64
Most common benign lesion of larynx
Papilloma
65
Where can salivary gland cancers occur?
Parotid, submandibular, sublingual and minor salivary glands
66
Can present as a neck mass or swelling in the floor of the mouth
Submandibular or sublingual tumors
67
Mass in large salivary gland
More likely mass is benign
68
Mass in small salivary gland
More likely mass is malignant, although th operated gland is the most frequent site from malignant tumor
69
Most frequent site for malignant tumor of salivary glands
Parotid gland
70
Often present as a painful mass but can also present with facial nerve paralysis or lymphadenopathy
Salivary gland malignant tumors
71
Lymphatic drainage of salivary gland malignant tumors
Intra-parotid and anterior cervical chain nodes
72
#1 malignant tumor of the salivary glands
Mucoepidermoid CA
| - Wide range of aggressiveness
73
#2 malignant tumor of salivary glands
Adenoid cystic CA
- Long, indolent course; propensity to invade nerve roots
- Very sensitive to XRT
74
Tx: mucoepidoermoid CA, adenoid cystic CA
Resection of salivary gland (e.g., total parotidectomy), prophylactic MRND, and post XRT if high grade or advanced disease
- If in parotid, need to take whole lobe; try to preserve facial nerve
75
Often present as painless mass
Benign tumors of salivary glands
76
```
#1 benign tumor of the salivary glands
- Malignant degneration in 5%
```
Pleomorphic adenoma
77
Tx: pleomorphic adneoma
Superficial parotidectomy
78
Tx: malignant degeneration pleomorphic adenoma
Total parotidectomy
79
```
#2 benign tumor of the salivary glands
- Males, bilateral in 10%
```
Warthin's tumor
80
Tx: Warthin's tumor
Superficial parotidectomy
81
MC injured nerve with parotid surgery
Greater auricular nerve (numbness over lower portion of the ear)
82
What do you need to find in submandibular gland resection?
Need to find mandibular branch of facial nerve, lingual nerve, and hypoglossal nerve
83
MC salivary gland tumor in children
Hemangiomas
84
Ear: need suture through involved cartilage in laceration
Pinna laceration
85
Undrained hematoma that organize and calcify, need to be drained to avoid this
Cauliflower ear
86
Epidermal inclusion cyst of ear; slow growing but erode as they grow; present with conductive hearing loss and clear drainage form ear
Cholesteatoma
87
Tx: cholesteatoma
Surgical excision
88
Vascular tumor of middle ear (paraganglionoma)
Chemodectomas
| - Tx: surgery +/ XRT
89
CNVIII, tinnitus, hearing loss, unsteadiness; can grow into cerebellar / pontine angle
Acoustic neuroma
Tx: craniotomy and resection; XRT is alternative to surgery
90
Tx: acoustic neuroma
Craniotomy and resection
| - XRT is alternative to surgery
91
20% metastasize to parotid gland
Ear SCCA
92
Tx: Ear SCCA
Resection and parotidectomy
| - MRND for positive nodes or large tumors
93
MC childhood aural malignancy (although rare) of the middle or external ear
Rhabdomyosarcoma
94
When do you set nasal fractures?
Set after swelling decreases
95
Management septal hematoma?
Need to drain to avoid infection and necrosis of septum
96
What is CSF rhinorrhea usually secondary to?
Cribiform plate fracture (CSF has tau protein)
97
Tx: CXF rhinorrhea
Repair of facial fractures may help leak; may need contrast study to help find leak.
- Tx: conservative 2-3 weeks; try epidural catheter drainage of CSF; may need transethmoidal repair
98
Treatment: anterior epistaxis
90% are anterior. Can be controlled with packing.
99
Treatment: posterior epistaxis
Consider internal maxillary artery or ethmoid artery embolization for persistent posterior bleeding despite packing / balloon
100
Inflammatory cyst at the root of the teeth; can cause bone erosion; lucent on XR
Radicular cyst
- Tx: local excision or curettage
101
Slow-growing malignancy of odontogenic epithelium (outside portion of teeth); soap bubble appearance on XR
Ameloblastoma
Tx: wide local excision
102
Poor prognosis
| - Tx: multimodality approach that includes surgery
Osteogenic sarcoma
103
Tx: maxillary jaw fractures
Most treated with wire fixation
104
Tx: TMJ dislocations
Treated with closed reduction
105
Cause lower lip numbness
Inferior alveolar nerve damage (branch of mandibular nerve)
106
Management: Stensen's duct laceration
Repair over catheter stent
| - Ligation can cause painful parotid atrophy and facial asymmetry
107
Duct from which saliva gets to mouth from parotid gland
Stensen's duct
108
Usually in elderly patients; occurs with dehydration; staph most common organism
Suppurative parotitis
109
Tx: suppurative parotitis
Fluids, salivation, antibiotics; drainage if abscess develops or patient not improving
- Can be life threatening
110
Acute inflammation of a salivary gland related to a stone in the duct; most calculi near orifice
Sialoadenitis
111
Where does sialoadenitis most frequently occur?
80% of the time affects the submandibular or sublingual glands
112
Cause of recurrent sialoadenitis
Due to ascending infection from the oral cavity
113
Tx: sialoadenitis
Incise duct and remove stone
| - Gland excision may eventually be necessary for recurrent disease
114
- Older kids (> 10 years)
| - Symptoms: trismus, odynophagia; usually does not obstruct airway
Peritonsillar abscess
115
Tx: peritonsillar abscess
Needle aspiration 1st, then drainage thru tonsillar bed if no relief in 24 hours (may need to intubate to drain; will self-drain with swallowing once opened)
116
Younger kids (
Retropharyngeal abscess
117
Tx: retropharyngeal abscess
Tx: intubate the patient in a calm setting; drainage thru posterior pharyngeal wall; will self-drain with swallowing once opened
118
All age groups; occurs with dental infections, tonsillitis, pharyngitis
Parapharyngeal abscess
119
What causes morbidity in parapharyngeal abscess?
Morbidity comes from vascular invasion and mediastinal spread with prevertebral and retropharyngeal spaces
120
Tx: parapharyngeal abscess
Drain through lateral neck to avoid damaging internal carotid and internal jugular veins; need to leave drain in
121
Acute infection of the floor of the mouth, involves mylohyoid muscle
- May rapidly spread to deeper structures and cause airway obstruction
Ludwig's angina
122
MCC dental infection of the mandibular teeth
Ludwig's angina
123
Tx: ludwig's angina
Airway control, surgical drainage, antibiotics
124
All lumps near ear
Parotid tumors until proven otherwise
125
Diagnosis preauricular tumors
Diagnosis is usually made after superficial lobectomy
126
80s of parotid tumors
80% salivary gland tumors are in parotid.
80% of parotid tumors are benign.
80% of benign parotid tumors are pleomorphic adenomas.
127
MC distant metastases for head and neck tumors
Lung
128
If no obvious malignant epithelial tumor, considered to have Hodgkin's lymphoma until proven otherwise.
Need FNA or open biopsy.
Posterior neck masses
129
Neck mass workup
1. H&P, laryngoscopy, FNA (best test for dx); can consider antibiotics for 2 wks with re-eval if though to be inflammatory.
2. Nondx? panendoscopy with multiple random biopsies, neck and chest CT
3. Still no? Excisional biopsy (prepare for MRND)
130
What does adenocarcinoma neck mass suggest?
Breast, GI, or lung primary
131
Work up: epidermoid CA (SCCA variant) found in cervical node without known primary
1. panendoscopy to look for primary; get random biopsies
2. CT scan
3. Still cannot find primary -> ipsilateral MRND, ipsilateral tonsillectomy (MC location for occult head / neck tumor), bilateral XRT
132
MC location for occult head / neck tumor
Tonsils
133
Dysphagia; most just below the cricopharynxgeus (95%)
| - Dx and Tx: rigid EGD under anesthesia
Esophageal foreign body
134
What dictates risk of perforation in esophageal foreign body?
Length of time in the esophagus
135
Fever and pain after EGD for foreign body?
Gastrografin followed by barium swallow to rule out perforation
136
Laryngeal foreign body - coughing
| - Treatment?
Emergent cricothyroidotomy as a last resort may be need to secure airway
137
Associated with MIs, arrhythmias and death
Sleep apnea
138
More common in obese and those with micrognathia / retrognathia -> have snoring and excessive daytime somnolence
Sleep apnea
139
Tx: sleep apnea
CPAP, uvulopalatopharyngoplasty (best surgical solution) or permanent trach
140
Can lead to subglottic stenosis.
Prolonged intubation
141
Treatment: subglottic stenosis after prolonged intubation
Tracheal resection and reconstruction
142
Consider in patients who will require intubation for > 7-14 days
Tracheostomy
143
Why tracheostomy for patients with prolonged intubation?
Decreases secretions, provides easier ventilation, decreased pneumonia risk
144
Failure of tongue fusion.
| - Tx: none necessary
Median rhomboid glossitis
145
When can cleft lip (primary palate involve)?
Involves lip, alveolus or both
146
- Repair at 10 weeks, 10 lb, 10 Hgb.
- Repair nasal deformities at same time
- May be associated with poor feeding
Cleft lip (primary palate)
147
Involves hard and soft palate; may affect speech and swallowing if not closed soon enough; may affect maxillofacial growth if closed too early -> repair at 12 months
Cleft palate (secondary palate)
148
MC benign head and neck tumor in adults
Hemangioma
149
Infection of the mastoid cells; can destroy bone
- Rare; results as a complication of untreated acute supportive otitis media
- Ear is pushed forward
Mastoiditis
150
Tx: mastoiditis
Antibiotics, may need emergency mastoidectomy
151
- Rare since immunization against H. influenza type B
- Mainly in children aged 3-5
- Symptoms: stridor, drooling, leaning forward position, high fever, throat pain, thumbprint sign on lateral neck film
- Can cause airway obstruction
Epiglottitis
152
Tx: epiglottitis
Early control of the airway, antibiotics
