Fiser Chapter 19 HEAD AND NECK Flashcards
Anterior neck triangle
SCM, sternal notch, inferior border of digastric muscle
Contains carotid sheath
Posterior neck triangle
SCM posterior border, trapezium, clavicle
Contains accessory nerve (to SCM, trap, platysma) and brachial plexus
Parotid vs sublingual vs. submandibular gland secretions
Parotid -> serous
Sublingual -> mucin
Submandibular -> 50/50
False versus true vocal cords
False are superior to true in larynx
Location of vagus nerve in neck
Between carotid and IJ
Location of phrenic nerve in neck
On top of anterior scalene muscle
Location of long thoracic nerve in neck
Posterior to middle scalene muscle
Sensory nerve to face
Trigeminal with ophthalmic, maxillary, mandibular branches
Mandibular branch also gives taste to anterior 2/3 of tongue, floor of mouth, gingiva
Motor nerve to face
Facial nerve with temporal, zygomatic, buccal, marginal mandibular, cervical branches
Taste nerves
Trigeminal anterior 2/3 of tongue
Glossopharyngeal posterior 1/3 of tongue
Swallowing nerve
Glossopharyngeal (motor to stylopharyngeus, also taste posterior 1/3 tongue)
Motor nerve to tongue
Hypoglossal (motor to all of tongue except palatoglossus): tongue deviates toward same side of injury
Laryngeal muscle innervation
Superior laryngeal nerve innervates cricothyroid muscle
Recurrent laryngeal nerve innervates all the rest
Gustatory sweating after parotidectomy
Frey’s syndrome: injury to auriculotemporal nerve, that then cross-innervates with sympathetic fibers to sweat glands of skin
Thyrocervical trunk branches
STAT:
Suprascapular artery
Transverse cervical artery
Ascending cervical artery
inferior Thyroid artery
External carotid artery branches
STAPLF (like staple) OPAMST
- Superior thyroid artery
- Ascending pharyngeal
- Lingual
- Facial
- Occipital
- Posterior auricular
- Maxillary
- Superficial temporal
Trapezius flap blood supply
transverse cervical artery
Pectoralis major flap blood supply
Either thoracoacromial artery or internal mammary artery
Torus palatine and Toru mandibular
Congenital bony mass on upper palate of mouth, or on lingual surgace of mandible
Tx: Nothing
Radical versus modified radical neck dissection
Radical: takes accessory nerve, SCM, IJ, omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, ipsilateral thyroid
Modified: leaves accessory nerve, SCM, IJ
No mortality difference between them. Most morbidity occurs from accessory nerve resection
Most common cancer of oral cavity, pharynx, and larynx; risk factors
Squamous cell carcinoma
Risk factors tobacco and EtOH
Erythroplakia versus leukoplakia
Erythroplakia more premalignant
Oral cavity borders
Mouth floor, anterior 1/3 of tongue, gingiva, hard palate, anterior tonsillar pillars, lips
Most common site for oral cavity CA
Lower lip (more common than upper lip d/t sun exposure)
Oral cancer location with lowest survival rate
Hard palate (hard to resect)
Risk factor for oral cavity cancer
-Plummer-Vinson synrome (glossitis, cervical dysphagia from esophageal web, spoon fingers, iron-deficiency anemia)
Oral cavity cancer treatment
- Wide resection (1 cm margins)
- MRND: tumors >4 cm, clinically positive nodes, or bone invasion
- Postop XRT: advanced lesions (>4 cm, positive margins, or nodal/bone involvement)
Lip cancer, most common site, site where most aggressive, and when flaps needed
Lower lip
Along commissure
Flaps if > 1/2 lip removed
Tongue cancer with jaw invasion, can you still operate?
Yes (commando procedure)
Verrucous ulcer
Well-differentiated SCCA often found on the check, associated with oral tobacco; not aggressive, rare metastasis
Tx: full cheek resection +/- flap; NO MRND
MRND indications
Oral cancer > 4 cm, or if node/bone invasion
Maxillary sinus cancer tx
Maxillectomy
Tonsillar CA risk factors, type, tx
EtOH, tobacco, males
SCCA most common
Asymptomatic until large, 80% have node mets at dx
Tx: Tonsillectomy to bx, wide resection with margins afterward
Nasopharyngeal SCCA risk factors, presentation, metastasis, tx, types
- EBV
- Chinese
Presents: nose bleeding or obstruction
Goes to: posterior cervical neck nodes
Tx: XRT primary therapy (very sensitive; give chemo-XRT for advanced disease; NO SURGERY)
Types: is lymphoma in children, give chemotherapy
Papilloma is most common benign neoplasm of nose/paranasal sinuses
Treatment of nasopharyngeal cancer
XRT
Chemo for advanced disease
No surgery!
Oropharyngeal cancer presentation, mets, tx
Presents: neck mass and sore throat
Goes to: posterior cervical neck nodes
Tx: XRT for tumors < 4 cm and no node/bone invasion
Otherwise surgery, MRND, XRT
Hypopharyngeal SCCA presentation, mets, tx
Presents: hoarseness, early mets!
Goes to: anterior cervical nodes
Tx: XRT for tumors < 4 cm, no node/bone invasion
Otherwise surgery, MRND, XRT
15yo male with epistaxis and nasal obstruction
Nasopharyngeal angiofibroma - benign tumor
Extremely vascular
Tx: Angiography and embolization (usually internal maxillary artery), followed by resection
Where do the different types of pharyngeal cancer metastasize to, and what is tx for each?
Nasopharyngeal SCCA: posterior cervical neck nodes
Tx: XRT, chemo-XRT for advanced, NO surgery
Oropharyngeal SCCA: posterior cervical neck nodes
Tx: XRT as long as < 4cm and no node/bone invasion
otherwise surgery, MRND, XRT
Hypopharyngeal SCCA: anterior cervical neck nodes
Tx: XRT as long as < 4 cm and no node/bone invasion
otherwise surgery, MRND, XRT
Hoarseness, aspiration, dyspnea, dysphagia
Laryngeal cancer, if benign then papilloma
Tx: XRT if vocal cord only, otherwise chemo-XRT
Try to preserve larynx, surgery is not primary tx
MRND (with ipsilateral thyroid) if nodes clinically positive
Neck mass and swelling in the floor of the mouth
Salivary gland cancer
Painless mass, benign
Pain and facial nerve paralysis or LAD: malignant
80% of salivary tumors are in parotid
80% of parotid tumors are benign
80% of benign parotid tumors are pleomorphic adenomas
Most frequent SITE for malignant salivary tumor
Parotid
Mass in large salivary gland more likely benign
Mass in small salivary gland more likely malignant
Most frequent malignant salivary tumor
- Mucoepidermoid cancer, wide range of aggressiveness
2. Adenoid cystic cancer: long, indolent course, propensity to invade nerve roots, very sensitive to XRT
Salivary gland cancer lymphatic drainage
Intra-parotid and anterior cervical chain nodes
Tx of salivary gland cancer
Resection of salivary gland (total parotidectomy), prophylactic MRND, postop XRT if high grade or advanced
If in parotid, need to take whole loe, try to preserve facial nerve
Benign salivary gland tumors
- Pleomorphic adenoma: Tx superficial parotidectomy; if malignant degeneration (occurs in 5%), need total parotidectomy
- Warthin’s tumor: males, bilateral in 10%, tx superficial parotidectomy
Most common injured nerve with parotid surgery
Greater auricular nerve (numbness over lower portion of ear)
Facial nerve branches course between superficial and deep lobes
Submandibular gland resection, which nerves must be identified?
Facial nerve mandibular branch, lingual nerve, hypoglossal nerve
Most common salivary gland tumor in children
Hemangiomas
Most common nasopharyngeal tumor in children
Lymphoma, tx chemo
Ear pinna lacerations, how to suture
through involved cartilage
Cauliflower ear
Undrained hematomas that organize and calcify, need to be drained to avoid this
Epidermal inclusion cyst of ear; slow growing but erode as grow; present with conductive hearing loss and clear drainage from ear (dx and tx)
Cholesteatoma
Tx: Surgical excision
Paraganglionoma (vascular tumor of middle ear, dx and tx)
Chemodectoma
Tx: Surgery and XRT
Tinnitus, hearing loss, unsteadiness, tumor in cerebellar/pontine angle
Acoustic neuroma (CN VIII)
Tx: craniotomy and resection, XRT is alrternative
Ear SCCA metastasis and tx
Goes to: parotid gland
Resection and parotidectomy, MRND for positive nodes or large tumor
Most common childhood aural malignancy of middle or external ear
Rhabdomyosarcoma (though rare)
Nasal fracture tx
Set after swelling decreases
Septal hematoma tx
Drain to avoid infection and septum necrosis
CSF rhinorrhea tx
Usually due to cribriform plate fracture
Dx: CSF has tau protein, may need contrast study to help find leak and any facial fractures
-Conservative 2-3 weeks; try epidural catheter drainage of CSF; may need transethmoidal repair
Epistaxis tx
90% are anterior and can be controlled with packing
Consider internal maxillary artery or ethmoid artery embolization for persistent posterior bleeding
Radicular cyst of tooth
Inflammatory cyst at root of teeth, can cause bone erosion, lucent on X ray, tx local excision or curettage
Ameloblastoma of tooth
Slow-growing malignancy of odontogenic epithelium (outside portion of teeth); soap bubble appearance on X ray, tx wide local excision
Osteogenic sarcoma of jaw
Poor prognosis
Tx: multimodality approach including surgery
Maxillary jaw fracture tx
Wire fixation
TMJ dislocation tx
Closed reduction
Lower lip numbness, underlying nerve
Inferior alveolar nerve damage (branch of mandibular nerve)
Stensen’s duct laceration (parotid duct) tx
Repair over catheter stent
Ligation can cause painful parotid atrophy and facial asymmetry
Suppurative parotitis tx
- Occurs in eldery patients with dehydration, staph most common organism, can be life-threatening
- Tx: fluids, salivation, antibiotics, drainage if abscess develops or not improving
Sialoadenitis
Acute inflammation of a salivary gland related to stone in duct; most calculi near orifice; 80% submandibular or sublingual glands
Recurrent d/t ascending infection from oral cavity
Tx: Incise duct and remove stone; gland excision may eventually be necessary for recurrent disease
15yo kid with trismus, odynophagia, airway fine
Peritonsillar abscess
Tx: Needle aspiration first, then drainage through tonsillar bed if no relief in 24hrs (may need to intubate to drain, will self-drain with swallowing once opened)
5yo kid with fever, odynophagia, drooling
Retropharyngeal abscess, AIRWAY EMERGENCY
Can also occur in elderly with Pott’s disease
Tx: Intubate patient in calm setting, drainage through posterior pharyngeal wall, will self-drain with swallowing once opened
Parapharyngeal abscess, morbidity is from what; tx
Occurs with dental infections, tonsillitis, pharyngitis
Morbidity from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spaces
Tx: Drain through lateral neck to avoid damaging internal carotid and IJ; leave drain in
Acute infection of floor of mouth involving mylohyoid muscle
Ludwig’s angina
MCC dental infection of mandibular teeth
May rapidly spread to deeper structures and cause airway obstruction
Tx: airway control, surgical drainage, abx
Preauricular tumor
Parotid tumor until proved otherwise
Most common distant mets for head and neck tumors
Lung
Posterior neck mass
If no obvious malignant epithelial tumor, considered to have Hodgkin’s lymphoma until proved otherwise. Need FNA or open biopsy
Neck mass workup
- H&P, laryngoscopy, FNA (best test for dx); can consider abx for 2 week with re-eval if seems inflammatory
- Panendoscopy with multiple random biopsies, neck and chest CT
- Perform excisional biopsy; need to be prepared for MRND
Adenocarcinoma on bx of head and neck cancer
Suggests breast, GI, or lung primary
Epidermoid CA (SCCA variant) found in cervical node without known primary -> what do you do?
- Panendoscopy with random biopsies
- CT scan
- If still cannot find primary, ipsilateral MRND, ipsilateral tonsillectomy (most common location for occult head/neck tumor), bilateral XRT
Dysphagia, found to have esophageal foreign body (most just below cricopharyngeus) -> dx and tx?
Rigid EGD under anesthesia
Perforation risk increases with length of time in esophagus
Fever and pain after EGD for foreign body -> next step
Gastrografin followed by barium swallow to rule out perforation
Coughing, found to have laryngeal foreign body
May need emergent cricothyroidotomy as last resort to secure airway
Sleep apnea associated with what
MIs, arrhythmias, death
Most common in obese and those with micrognathia/retrognathia
Sleep apnea tx
CPAP
Uvulopalatopharyngoplasty (best surgical solution)
Or permanent trach
Prolonged intubation complication and tx
Subglottic stenosis
Tx: Tracheal resection and reconstruction
Indication for tracheostomy
Patients who will require intubation for > 7-14 days
Decreases secretions, provides easier ventilation, decreases PNA risk (???)
Median rhomboid glossitis
Failure of tongue fusion
Tx: none necessary
Cleft lip (primary palate) tx
Involves lip, alveolus, or both
May be associated with poor feeding
Tx: Repair at 10 weeks, 10 lb, Hgb 10
- Repair nasal deformities at same time
Most common benign head and neck tumor in adults
Hemangioma
Mastoiditis
Infection of mastoid cells, can destroy bone, rare
Results as complication of untreated ACUTE SUPPURATIVE OTITIS MEDIA
Ear is pushed forward
Tx: Abx, may need emergency mastoidectomy
4yo with stridor, drooling, leaning forward, high fever, throat pain, thumbprint sign on lateral neck film
Epiglottitis
Rare since HiB vaccine
Tx: early control of airway, abx
