General Flashcards
Following a cervical tracheal resection, there is difficulty in obtaining a tension free anastomosis, despite full neck flexion.
What maneuvers should be performed:
- Blunt dissection along the anterior tracheal wall to the carina
- Hilar release
- Laryngeal release
Neck muscles that aid in forceful inhalation of air include:
Scalene muscles and SCM
The ____ is active in quiet respiration.
Diaphragm
Gustatory sweating or Fred’s syndrome is related to injury to the _____ n. in surgeries involving the parotid gland.
Auriculotemporal n.
The auriculotemporal n is a branch of CN __, and it carries parasympathetic fibers from CN __ that go to the parotid gland, and sympathetic fibers that go to the sweat glands of facial skin.
1) CN V3
2) CN IX
What causes Gustatory Sweating or Frey’s Syndrome?
Aberrant regeneration of the parasympathetic n. fibers to the sweat glands.
What are treatment options for Gustatory sweating or Frey’s syndrome?
Topical anticholinergic (scopolamine), antiperspirant application, Botox injection, revision surgery to place tissue or alloderm in the wound bed, and radiation
Sialolithiasis is most commonly due to a stone arising from the ___ gland.
Wharton’s duct (Submandibular Gland)
Parotid stones generally are not approachable via direct sialolithotomy unless they are ____.
Near the orifice of Stenson’s duct
The peritonsillar space is bounded by which structures?
Palatoglossus (anterior pillar)
Palatophayrngeus (posterior pillar)
Superior pharyngeal constrictor (superior border)
Capsule of the palatine tonsil (lateral border)
Which muscle functions to support the weight of the arm, retract the scapula, and medially rotate/depress the scapula?
Trapezius
What membrane does the internal branch of the superior laryngeal n. Pass through, and which artery accompanies the nerve?
Thyrohyoid membrane, superior laryngeal artery
Frey syndrome is secondary to injury of which of ___ fibers?
Post-ganglionic parasympathetic fibers from CN IX via the auriculotemporal n of CN V
A 45yo F presents w/ 6mo h/o recurrent parotid swelling and pain that has been treated w/multiple rounds of Abx. She reports improvement on Abx but return of sx after completion of the Abx course. Which organism is the most likely cause of her problem?
MRSA (Staph aureus - the most common causative org in adults)
The diagnosis would be chronic sialadenitis
A 47yo F presents w/asymptomatic L parotid mass. CT imaging shows no evidence of neck disease. She is taken to the OR for parotidectomy w/preservation of the FN. Final path reveals a T1 intermediate grade Adenoid cystic carcinoma w/clear margins. What is the next step?
Adjunctive radiation to the parotid is recommended.
(Adjuvant rads therapy is indicated for T3/T4 intermediate and high grade adenoid cystic carcinoma due to high incidence of PERINEURAL involvement. Rads can also be considered for T1/T2 low-grade adenoid cystic carcinoma w/perineural involvement or tumor spillage)
The infrahyoid muscles lie directly over the trachea. They are responsible for which neck motion?
Depress the hyoid bone and larynx, during speech and swallowing.
During parotidectomy, the facial n. trunk is 1cm ___ and 1cm ___ to the tragal pointer
1cm inferior and 1cm deep to the tragal pointer (a triangle-shaped inferior extension of the cartilage that points in the direction of the facial n.)
A 74yo w/a h/o L-parotid swelling. FNA reveals carcinoma w/squamous features. The pathologist insists that it is not a SCC. What is the likely dx?
High grade mucoepidermoid ca.
MEC is most common malignant tumor of parotid gland. Histology shows mucous and epidermoid squamous cells (most common in high-grade), and mucous cells, cystic areas and mild atypia (in low-grade).
What is the correct sequence of the parasympathetic innervation to the parotid gland?
Inferior salivatory nucleus (in medulla) -> glossopharyngeal n. (CN IX) -> Jacobson’s n. (traverses middle ear and joins tympanic plexus) -> lesser petrosal n. (arises from tympanic plexus) -> otic ganglion -> auriculotemporal n. V3 (post-ganglionic fibers -> parotid gland
Slow growing mass in tail of parotid of 45yo M. No evidence of metastatic lymphadenopathy on PE or imaging. What is the most probable 5yr survival rate of this lesion after adequate therapy?
70% (w/gland excision and ND for positive LNs).
This is a well-differentiated (low-grade) mucoepidermoid carcinoma.
You perform a superficial parotidectomy for a patient w/a solitary cystic mass in the lateral lobe of her parotid. You elect to review specimen w/your pathologist, who identifies dark, “motor-oil” fluid. A H&E stain of the mass is shown. What is the dx?
Papillary cystadenoma lymphomatosum (Warthin) tumor.
Which structures pass between the superior and middle pharyngeal constrictors?
Stylopharyngeus muscle and CN IX
A branch of CN IX sometimes has a close relationship with the ___ pole of the tonsil, and can be damaged during tonsillectomy.
Inferior pole
Prior to performing a parotidectomy for a suspected pleomorphic adenomatous you review the patient’s preoperative CT. You discussed that this was most likely a superficial (lateral) lobe mass with the patient b/c the mass was lateral to which landmark visible on CT?
Retromandibular vein
Infection in the space identified by the arrow in the CT image below may spread directly to all of the following deep neck spaces EXCEPT:
A. Submandibular space
B. Mastication space
C. Parotid space
D. Prevertebral space
E. Visceral space
E. Prevertebral Space
The area above is the parapharyngeal space (inverted pyramid with base at the base of skull and apex at the hyoid).
The parapharyngeal space can spread via direct extension to the parotid, submandibular, retropharyngeal, mastication, visceral (pre-tracheal), and carotid sheath spaces.
Atypia of undetermined significance and follicular lesions of undetermined significance in the thyroid, have an ___% risk of malignancy under the 2017 guidelines.
6-18%
42F w/thyroid nodule. U/S reveals a 1.5cm nodule within the R thyroid lobe. FNA and cytology demonstrate a follicular lesion of undetermined significance. Her TSH is normal. What is the next best step in mgmt for this patient?
A repeat FNA and genetic testing, to r/o cancer in patients whose thyroid nodules are classified “indeterminate” by cytopathology.
(An FNA showing FLUS/AUS carries 6-18% or 10-30% risk of malignancy- risk not high enough to warrant surgery, yet not low enough to be safe for obs alone)
Pyriform sinus tumors involving the ____ and ____ are not candidates for laryngeal preservation and should undergo a total laryngectomy w/partial or total pharyngectomy, depending on the extent of the primary tumor.
APEX and LARYNX
What is the most common arterial supply to the upper, middle, and lower SCM?
In most cases, the upper 1/3rd of the SCM receives its blood supply by branches of the Occipital a.
The middle 1/3rd is supplied by a branch of the Superior thyroid a.
The lower 1/3rd is supplied by a branch of the Suprascapular a.
57M is referred for bx of a tongue lesion. The pathologist notes it is stained with apple green birefringence using Congo red. Patient reveals he has a very labile bp. He also notes frequent kidney stones. Physical exam is concerning for a central neck mass. Based on presentation and path, what is the likely dx of the neck mass?
Medullary thyroid carcinoma.
(calcitonin produced by parafollicular cells can deposit in the tissue, as amyloid; the labile bp is caused by pheochromocytoma and recurrent kidney stones by elevated Ca2+ caused by hyperparathyroidism)
What is the Thyroid Imaging, Reporting, and Data System (TI-RADS) for thyroid nodules?
Composition: cystic (0), spongiform (0), mixed (1), solid (2)
Echogenicity: anechoic (0), isoechoic or hyperechoic (1), hypoechoic (2), very hypoechoic (3)
Shape: wider than tall (0), taller than wide (3)
Margin: smooth or ill defined (0), lobulated/irregular (2), extrathyroidal extension (3)
Echogenic foci
The scores are added up and classified into the “TR” categories
During a total laryngectomy, a surgeon grasps the hyoid and skeletonizes the greater Cornu from its attachments w/a scissor. While dissecting, she is careful to hug the posterior surface of the hyoid bone to avoid injury to what clinically relevant structure?
Hypoglossal nerve.
(loops anteriorly around the occipital artery and crosses the ICA, ECA, and lingual arteries, and courses lateral to the hyoglossus m. and deep to the digastric m. and mylohyoid m.)
FNA is indicated for thyroid nodules greater than __cm, with __features, because there is a risk of thyroid carcinoma even in the setting of multiple nodules.
> /= 1cm.
suspicious sonographic features.
55F presents with hypercalcemia and hyperparathyroidism. U/S of the neck reveals enlarged L inferior parathyroid gland. Sestamibi scan confirms. Which branchial pouch gives rise to this gland?
3rd branchial pouch
What are the boundaries of the paraglottic space?
Mid-medial: ventricle
Supero-medial: quadrangular membrane
Infero-medial: conus elasticus
Posterior: piriform sinus
Lateral: thyroid cartilage
What are the boarders of the parapharyngeal space?
Inferior - greater Cornu of hyoid
Superior - skull base
Anterior - pterygomandibular raphe + medial pterygoid
Posterior - cervical vcertibrae + paravertebral muscles
Medial - fascia overlying lateral pharyngeal wall
If radioiodine (RAI) is indicated following thyroidectomy, TSH should rise to > ___ mU/L to optimize treatment.
> 30 mU/L.
(After surgery/cessation of T4, patient’s serum T4 will decline sufficiently to allow serum TSH to rise >30)
This tumor is most often found in which patient population?
Smokers.
(image shows a Warthin tumor)
High output chyle leaks are best managed ___ with ___ of the lymphatic or thoracic duct.
High output chyle leaks are best managed surgically with ligation of the lymphatic or thoracic duct.
Malignant thyroid nodules are ___echogenic
Malignant thyroid nodules are hypoechogenic
Malignant thyroid nodules have a ___ halo sign.
Absent halo sign
Malignant thyroid nodules have ___calcifications.
Malignant thyroid nodules have microcalcifications
Benign thyroid nodules have ___ calcifications and ___ foci.
Benign thyroid nodules have egg-shell calcifications and punctate echogenic foci**.
The splenius capitis m. acts to _____.
The splenius capitis m. acts to extend the head into an upright position.
The __ are the primary site of exophthalmos in Grave’s disease.
Extraocular muscles (proliferation of fibroblasts + lymphocytic infiltration)
Ohngren’s line runs from the ___ to the ___.
Angle of the mandible to Medial canthus.
The ___ vein forms where the retromandibular vein and posterior auricular vein converge w/in the parotid gland, at the angle of the mandible.
External jugular vein
Blood supply to the upper 1/3d SCM?
Upper: occipital artery
Blood supply to the middle 1/3rd of SCM?
Middle: Superior Thyroid artery
Blood supply to the Lower 1/3rd of SCM?
Lower: suprascapular artery (branch of Thyrocervical trunk)
Medium chain triglycerides (as dietary regimen for treatment of chyle leak) aid in resolution of the chyle leak?
MCTs bypass the lymphatic system/chylomicron absorption and are absorbed directly into the portal circulation (thereby reducing chylous output).
What nerve runs with the Hypoglossal n.?
C1 cervical rootlet (give it branches to the Geniohyoid and Thyrohyoid muscles, and contributing to the ansa cervicalis.
The ___ nerve loops anterior around the occipital a and crosses over the ICA, ECA, and lingual a.
Hypoglossal n.
The ___ nerve is at risk of injury when the hyoid bone is skeletonized, during total laryngectomy.
Hypoglossal n.
The brachiocephalic veins (aka innominate veins) are formed by the union of the ___ + ___ veins.
IJV + corresponding subclavian vein.
The paraglottic space is bounded mid-medially by the ___, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the ___, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the ___, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the _____, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the ____.
The paraglottic space is bounded mid-medially by the ventricle, superomdedial by the quadrangular membrane, inferomedially by the conus elasticus, posteriorly by the pyriform sinus, and laterally by the thyroid cartilage.
