green scantron book-neck Flashcards
MC organisms causing nonsuppurative cervical lymphadentis in kids? Suppurative?
viral adenitis (adeno, rhio, entero) staph/strep
MC source of deep neck infx in kids? Adults?
bacterial lymphadenitis vs odontogenic in adults
what is the organism causing cat scratch disease?
Bartonella henselae
what is the causative animal host in bartonella henselae infx?
cat (kitten); 4% dog, 1% unknown
what are the typical lab findings in pt with cat scratch?
mild eosinophilia, elevated ESR
Is catscratch nec to treat? what about in im co pts? with what?
self limited without issue in 2-3 weeks; in imcp can spread (liver/spleen) so more aggressive tx; azithro/clarithro/bactrim OR cipro in adults
should I&D be completed in cat scratch dz?
can form sinus tract so formal node excision preferable; can aspirate it to decrease suppuration issues
what pathogen causes tularemia and what use to treat? when would you need to do a procedure to treat?
francisella tularensis (aerobic gram negative pleomorphic coccobacillus), IM streptomycin or levofloxacin in adults; I&D if suppurative
villaret vs vernet syndrome
IX/X/XI/XII/sympathetic chain vs IX/X/XI (jugular foramen syndrome)
what organis classically cause jugular vein thrombophlebitis
fusobacterium necrophorum
how does grisel’s sd present
severe neck pain, torticolis, odynophagia
treatment of nontraumatic alantoaxial rotary subluxation
Incision and drainage of any associated abscess with
appropriate antibiotic therapy.
Halo placement with complete spine immobilization
for 3 months, followed by a Philadelphia collar for
2 weeks, with active restriction of neck movement for
9 months thereafter.
How is nontraumatic atlantoaxial rotary subluxation
classified?
n Type 1 rotation with minimal
parapharyngeal space is perforated at its apex by what? what is the clinical signifcance?
carotid sheath; can spread infx to superior mediastinum
What is the key rule of thumb when evaluating the
retropharyngeal space relative to a vertebral body
on lateral neck plain film?
> 1/2 vertebral body width is concerning
retropharyngeal space abscess and spine erosion suggests what?
pott’s dz (TB)
what’s the typical age group of retropharyngeal abscess?
50% 6-12 months or 96% <6 yo
LN’s are found at what level of the retropharyngeal space?
above the hyoid (below is just fat)
what’s the significance of the node of rouviere?
In children, a retropharyngeal abscess results from
a suppurative lymphadenitis of one or more of the
nodes of Rouviere (Immediately medial to the internal carotid artery, Adjacent to the longus capitis, Usually most prominent at C-1/C-2 level)
carotid space infection presents with patient turning their head in what direction?
toward uninvolved side
what’s the name of the carotid sheath? bc it leads from parapharyngeal space to mediastinum?
Lincoln’s highway
When imaging the floor of mouth and sublingual space,
how is dental artifact minimized? Is dental artifact present
on MRI?
CT scan plane parallel to fillings of lower teeth
will allow for the least amount of artifact.
MRI can be distorted by dental amalgam with
high ferrous content.
The submaxillary space refers to what two spaces?
What are the most common sources of infection in
this area?
The submaxillary space includes both the sublingual
and submandibular spaces. Common sources of
submaxillary space infections are Ludwig’s angina
of odontogenic origin from the sublingual space and
submandibular sialadenitis from the submaxillary
space.
What are the boundaries of the masticator space? what does it contain?
Inferior: inferior border of mandible
Superior: temporalis fossa (where the temporalis
inserts on the calvarium)
Lateral: fascia over masseter
Medial: fascia over medial pterygoid muscle
Masseter, medial and lateral pterygoids, and
temporalis muscles; Third branch of the trigeminal
nerve (V3) (from foramen ovale — connects to
cavernous sinus); alveolar artery and vein; enveloped
by the superficial layer of deep cervical fascia.
What is the treatment of cervical necrotizing fasciitis
treatment?
IV antibiotics with gram-positive coverage,
supplement clindamycin to block toxin production
Radical surgical debridement with excision to
healthy bleeding tissue, leave neck open
Treat hypocalcemia (secondary to fat
saponification — the fat necrosis consumes calcium)
Manage any underlying immunocompromise
(diabetes, HIV, etc.)
Consider hyperbaric oxygen
What usually causes lymphadenopathy in HIV
patients?
Benign follicular hyperplasia
What is the most common malignancy in HIV
patients?
Kaposi’s
What is the classic presentation of tuberculous
cervical lymphadenopathy compared to atypical
mycobacterial lymphadenopathy?
Tuberculous: bilateral
Atypical: unilateral
Where is the most common location for atypical
mycobacterial cervical adenitis?
Submandibular and mandibulofacial lymph nodes
What is the most common age group to be affected
by atypical mycobacterial infection? What exposure has been linked to atypical
mycobacterial infections?
1–4 years old; eating dirt
Should atypical mycobacterial infections be treated
with incision and drainage? What is the appropriate
surgical therapy? When is surgical debridement of atypical
mycobacterial infection indicated?
No, because there is risk of a subsequent draining
sinus tract.
Excision of the involved node and tract to the skin (if
present) is preferred.
When skin breakdown results in a draining sinus
tract that doesn’t resolve with medical therapy
Is surgery ever indicated in fungal adenitis? MCC of fungal LAD?
In patients where there is a subtotal response,
removal of residual disease may be indicated. histo/aspergillus/candida
What defines a malignant paraganglioma?
Metastases, as the histologic appearance of benign
and malignant paragangliomas are similar.
What is the inheritance pattern for familial
paragangliomas?
AD
What consults should be obtained preoperatively
before carotid body tumor excision?
Vascular surgery
Interventional neuroradiology
What are the first objectives of surgery for carotid
body tumor?
Proximal and distal control with vessel loops
Identification and preservation of neural structures
if possible
Preparation for vascular reconstruction if necessary
What nerves are at risk for injury during surgical
resection of a carotid body tumors?
Vagus nerve, particularly the superior laryngeal
nerve branch
Hypoglossal nerve
Glossopharyngeal nerve (for tumors extending
superiorly)
Carotid body tumor is less mobile in what
direction?
Craniocaudal
Vagal paragangliomas most commonly arise from
what structure?
nodose gangloin (The inferior ganglion of the vagus nerve, is a sensory ganglion of the peripheral nervous system. It is located within the jugular foramen where the vagus nerve exits the skull. It is larger than and below the superior ganglion of the vagus nerve.)
Vagal paraganglioma displaces the ICA where?
Displace ICA anteriorly and medially
It does not widen the bifurcation.
What are potential long-term complications of
radiation therapy for carotid body tumor?
Microvascular disease, carotid artery disease,
temporal bone osteoradionecrosis, radiation-induced
malignancy
What is the Glasscock-Jackson classification system for a
glomus tympanicum paraganglioma? glomus jugulare ?
Type I — Small mass on the promontory
Type II — Tumor fills the middle ear space
Type III — Tumor fills middle ear and mastoid
Type IV — Tumor extends medial to carotid artery
or through tympanic membrane and into external
auditory canal
Type I — Small mass involving the jugular bulb,
middle ear or mastoid
Type II — Tumor extends under the internal auditory
canal
Type III — Tumor extends to the petrous apex
Type IV — Tumor extends to the clivus or
infratemporal fossa
How does a lipoma appear on MRI?
Bright on T1, dark on T2
How do cervical teratomas present?
Cervical teratomas generally are diagnosed in the
fetal or neonatal period, presenting as a paramedian
neck mass, often with secondary aerodigestive tract
compromise due to mass compression. and so can cause Maternal polyhydramnios due to obstruction of the
fetal aerodigestive tract.
How do teratomas differ from teratoid cysts?
Both teratomas and teratoid cysts are composed
of all 3 germ layers. In teratomas there is cellular
differentiation such that recognizable organ
structures may be found within the masses. vs teratoid cyst is very undifferentiated and lined by squamous epithelium or respiratory epithelium
borders of paraphyarngeal space?
pyramid: base skull base, apex greater cornu of hyoid (junction of the posterior belly of the digastric muscleand the hyoid bone)
anterior: Pterygomandibular raphe — ligamentous band of
buccopharyngeal fascia and the medial pterygoid
muscle fascia
posterior: carotid sheath
medial: Buccopharyngeal fascia over the superior constrictor
muscle
lateral: Medial pterygoid muscle fascia, Mandibular ramus, Retromandibular portion of the deep lobe of the parotid gland, Posterior belly of digastric muscle
What fascia separates the prestyloid and poststyloid
compartments?
Tensor-vascular-styloid fascia separates the
parapharyngeal spaces into two compartments.
What is the most reliable way on MRI to determine
if a mass is in the prestyloid or poststyloid PPS?
Prestyloid:
- Extraparotid mass: Fat plane between tumor and medial
parotid, Parapharyngeal fat displaced anteriorly
and laterally, ICA displaced POSTERIORLY
- Intraparotid mass: No fat plane between mass and medial
parotid, Parapharyngeal fat displaced anteriorly or
medially, ICA displaced POSTERIORLY
Poststyloid:
- Fat displaced anteriorly and laterally
- Carotid artery displaced ANTERIORLY and/or
medially
Within the prestyloid space, what 2 landmarks can be used
to approximate the line of the facial nerve?
A line from the stylomastoid foramen to the
retromandibular vein defines the approximate
location of the facial nerve.
What is the diagnostic accuracy of FNA in neck
masses?
95% overall accuracy (95% for benign and 87% for
malignant)
What should be avoided in adult neck masses? why? when is it acceptable to do it?
Incisional or excisional biopsies are generally contraindicated in order to avoid tumor seeding in
the setting of head and neck cancer. When other methods have been nondiagnostic
and lymphoma or a benign lesion are high on the
differential diagnosis.
What is a modified radical neck dissection? What are the types of modified radical neck
dissection? which one is a “functional” ND
Excision of all lymph node in levels I–V as with RND
but with preservation of one or more nonlymphatic
structures (SAN, SCM, and/or IJV)
Type I (SAN preserved)
Type II (SAN, IJV preserved)
Type III (SAN, IJV, and SCM preserved)
type III
What is the indication for a selective neck dissection?
N0 neck stage and a primary lesion with a 20% or
greater risk of occult metastasis.
When to do unilateral versus bilateral selective
supraomohyoid neck dissection?
Bilateral if the primary tumor is located in:
- Anterior tongue
- Oral tongue or floor of mouth that approach the midline
What pathology from a supraomohyoid neck
dissection would prompt adjuvant radiation therapy?
Certainly for extracapsular spread it is recommended; most agree that if two or more
lymph nodes are positive, postoperative adjuvant
therapy should be used. Certain negative prognostic indicators at the primary site may also necessitate adjuvant radiation (such as perineural or
lymphovascular invasion or advanced T stage).
Should a unilateral or bilateral selective neck
dissection be performed for hypopharyngeal
squamous cell carcinoma?
Bilateral selective neck dissection for the majority
of hypopharyngeal tumors because of extensive
submucosal spread and involvement of multiple
subsites.
What are the indications for a selective anterior
compartment neck dissection?
Selected cases of thyroid carcinoma Parathyroid carcinoma Subglottic carcinoma Laryngeal carcinoma with subglottic extension Cancer of the cervical esophagus
What is the indication for a selective posterolateral
neck dissection?
Cutaneous malignancies on scalp posterior to a
coronal line connecting the external auditory canals.
n Melanoma
n Squamous cell carcinoma
n Merkel cell carcinoma
Soft tissue sarcomas of the scalp and neck
What should be done in the management of a
suspected air embolism?
What anesthetic should be discontinued if air
embolus occurs?
Left lateral decubitus and Tredelenberg positioning
Cover wound with wet gauze
Consider central catheter line removal of air bubble
Systemic support
Nitrous oxide
What is the classical physical examination finding
of an air embolus?
A “mill wheel murmur”
At what volume of drainage per day is conservative
management often successful?
<1200 cc/day
How does one repair a chylous fistula?
The duct has only single layer of epithelium — very
thin and likely to tear — so just oversew it
Consider fibrin glue or sclerosing agent such as
doxycycline or tetracycline.
Best to identify at initial surgery
Placement of healthy muscle flap over area can be
considered (sternocleidomastoid or pectoralis major
flap)
What other treatment option exists?
Tetracycline sclerosis administered through an
indwelling drain or catheter
Talc pleurodesis
