green scantron book-neck Flashcards
1
Q
MC organisms causing nonsuppurative cervical lymphadentis in kids? Suppurative?
A
viral adenitis (adeno, rhio, entero) staph/strep
2
Q
MC source of deep neck infx in kids? Adults?
A
bacterial lymphadenitis vs odontogenic in adults
3
Q
what is the organism causing cat scratch disease?
A
Bartonella henselae
4
Q
what is the causative animal host in bartonella henselae infx?
A
cat (kitten); 4% dog, 1% unknown
5
Q
what are the typical lab findings in pt with cat scratch?
A
mild eosinophilia, elevated ESR
6
Q
Is catscratch nec to treat? what about in im co pts? with what?
A
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
7
Q
should I&D be completed in cat scratch dz?
A
can form sinus tract so formal node excision preferable; can aspirate it to decrease suppuration issues
8
Q
what pathogen causes tularemia and what use to treat? when would you need to do a procedure to treat?
A
francisella tularensis (aerobic gram negative pleomorphic coccobacillus), IM streptomycin or levofloxacin in adults; I&D if suppurative
9
Q
villaret vs vernet syndrome
A
IX/X/XI/XII/sympathetic chain vs IX/X/XI (jugular foramen syndrome)
10
Q
what organis classically cause jugular vein thrombophlebitis
A
fusobacterium necrophorum
11
Q
how does grisel’s sd present
A
severe neck pain, torticolis, odynophagia
12
Q
treatment of nontraumatic alantoaxial rotary subluxation
A
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
13
Q
parapharyngeal space is perforated at its apex by what? what is the clinical signifcance?
A
carotid sheath; can spread infx to superior mediastinum
14
Q
What is the key rule of thumb when evaluating the
retropharyngeal space relative to a vertebral body
on lateral neck plain film?
A
> 1/2 vertebral body width is concerning
15
Q
retropharyngeal space abscess and spine erosion suggests what?
A
pott’s dz (TB)
16
Q
what’s the typical age group of retropharyngeal abscess?
A
50% 6-12 months or 96% <6 yo
17
Q
LN’s are found at what level of the retropharyngeal space?
A
above the hyoid (below is just fat)
18
Q
what’s the significance of the node of rouviere?
A
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)
19
Q
carotid space infection presents with patient turning their head in what direction?
A
toward uninvolved side
20
Q
what’s the name of the carotid sheath? bc it leads from parapharyngeal space to mediastinum?
A
Lincoln’s highway
21
Q
When imaging the floor of mouth and sublingual space,
how is dental artifact minimized? Is dental artifact present
on MRI?
A
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.
22
Q
The submaxillary space refers to what two spaces?
What are the most common sources of infection in
this area?
A
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.
23
Q
What are the boundaries of the masticator space? what does it contain?
A
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.
24
Q
What is the treatment of cervical necrotizing fasciitis
treatment?
A
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
25
What usually causes lymphadenopathy in HIV
| patients?
Benign follicular hyperplasia
26
What is the most common malignancy in HIV
| patients?
Kaposi's
27
What is the classic presentation of tuberculous
cervical lymphadenopathy compared to atypical
mycobacterial lymphadenopathy?
Tuberculous: bilateral
Atypical: unilateral
28
Where is the most common location for atypical
| mycobacterial cervical adenitis?
Submandibular and mandibulofacial lymph nodes
29
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
30
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
31
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
32
What defines a malignant paraganglioma?
Metastases, as the histologic appearance of benign
| and malignant paragangliomas are similar.
33
What is the inheritance pattern for familial
| paragangliomas?
AD
34
What consults should be obtained preoperatively
| before carotid body tumor excision?
Vascular surgery
| Interventional neuroradiology
35
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
36
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)
37
Carotid body tumor is less mobile in what
| direction?
Craniocaudal
38
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.)
39
Vagal paraganglioma displaces the ICA where?
Displace ICA anteriorly and medially
| It does not widen the bifurcation.
40
What are potential long-term complications of
| radiation therapy for carotid body tumor?
Microvascular disease, carotid artery disease,
temporal bone osteoradionecrosis, radiation-induced
malignancy
41
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
42
How does a lipoma appear on MRI?
Bright on T1, dark on T2
43
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.
44
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
45
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
46
What fascia separates the prestyloid and poststyloid
| compartments?
Tensor-vascular-styloid fascia separates the
| parapharyngeal spaces into two compartments.
47
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
48
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.
49
What is the diagnostic accuracy of FNA in neck
| masses?
95% overall accuracy (95% for benign and 87% for
| malignant)
50
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.
51
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
52
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.
53
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
54
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).
55
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.
56
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
```
57
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
58
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
59
What is the classical physical examination finding
| of an air embolus?
A “mill wheel murmur”
60
At what volume of drainage per day is conservative
| management often successful?
<1200 cc/day
61
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)
62
What other treatment option exists?
Tetracycline sclerosis administered through an
indwelling drain or catheter
Talc pleurodesis
63
What should be monitored in a chyle leak?
Monitor fluids, electrolytes, lymphocytes, proteins
64
Where is the duct located relative to the thyrocervical
| trunk and transverse cervical artery?
Duct is anterior (superficial).
65
What are the ways to avoid postoperative cerebral
edema in patients requiring bilateral neck
dissections with internal jugular vein sacrifice?
```
Staged neck dissection (6 wks apart)
Saphenous vein graft (40–60% clot)
Perioperative steroids
Reverse Trendelenberg
Minimize fluids
Early mobilization
```
66
What is mortality rate with carotid blowout?
50%
67
What is the only nerve to run lateral to medial in the
| neck?
Phrenic
68
What is the differential diagnosis of postoperative
| shortness of breath after head and neck surgery?
```
Obstruction
Atelectasis
Pneumothorax
Pulmonary embolus
Phrenic nerve injury
```
69
What are the 2 most common midline neck masses
| in a child? how differentiate bt two?
TGDC, dermoid; TGDC deep to strap vs superficial to strap
70
Define the cleft, arch, and pouch of the branchial
| system.
There are four predominant branchial arches. Each
arch, which is composed of mesoderm, is divided
by an external cleft composed of ectoderm, and an
internal pouch composed of endoderm.
71
What are the 2 types of first branchial cleft
| anomalies?
Works type 1: duplication anomalies of the
membranous ear canal; origin is ectodermal; they do
not contain cartilage.
Works type 2: duplication anomalies of the
membranous and cartilaginous ear canal; origin is
ectodermal and mesodermal; they contain cartilage.
72
Which type of first branchial cleft anomaly has a
sinus tract opening located at or below the angle of
mandible? which requires a superficial parotid?
Type 2
The tract typically opens just inferior or posterior to
the angle, always superior to the level of the hyoid
bone.
Type 2
73
What type of imaging may be useful if you suspect a
| patient has a first branchial cleft anomaly?
MRI with gadolinium to evaluate the lesion’s
relationship to the parotid gland and hence facial
nerve.
If a sinus opening is present, a contrast fistulogram to
outline the tract may also be useful.
74
What clinical presentations may be associated with a
| first branchial cleft anomaly?
Parotid region mass
Otorrhea
Draining cervicofacial sinus tract
75
What percent of branchial anomalies are first
| branchial anomalies?
About 8%
76
First branchial cleft anomalies are associated with
| what craniofacial syndromes?
Treacher Collins
Goldenhar
Branchiootorenal syndrome
77
The first branchial cleft gives rise to what structure?
External auditory canal
78
The first branchial arch gives rise to what nerve and
| muscles? bones? vessel?
Trigeminal nerve (CN V)
Muscles of mastication, anterior belly of digastric,
mylohyoid, tensor veli palatini, tensor tympani
Mandible
Malleus head and neck
Incus body and short process
None. The embryonic vessels of first branchial arch
origin usually spontaneously degenerate.
79
The first branchial pouch gives rise to what
| structures?
Eustachian tube
Tympanic cavity
Mastoid antrum and cells
Inner layer of the tympanic membrane
80
How does the external opening of a first branchial cleft anomaly differ from that of a preauricular sinus tract?
The external opening of a first branchial cleft
anomaly is typically inferior to the tragus, whereas a preauricular sinus tract opening is characteristically superior to the tragus.
81
The tympanic membrane has what embryologic origin?
The tympanic membrane forms from the apposition of the first branchial pouch and cleft.
82
What is the medial limit of dissection for definitivelyexcising a preauricular sinus tract?
The temporalis fascia (most easily identified by extending the preauricular incision to the supraauricular crease)
83
What needs to be done to definitively excise a preauricular pit?
The pit needs to be excised with a surrounding ellipse of skin in continuity with its associated tract (dermal sac); such may penetrate the auricular cartilage.
84
What are the hillocks of His? what are preauricular pits? What arches form them?
- hillocks of His are 6 embryologic buds that give rise to the external ear.
- incomplete fusion of Hillocks of His.
- From the first branchial arch: hillock 1 becomes tragus, 2 helical crus, 3 helix.
- From the second branchial arch: hillock 4 becomes antihelix, 5 antitragus/scapha, 6 lobule.
85
A sinus/fistula tract opening of second branchial cleft origin would be in what location? What is the potential course of a second branchial sinus/fistula tract relative to the carotid vessels? stylohyoid ligament? what is the overall course?
In the middle third of the anterolateral neck (below the level of the hyoid bone) just anterior to the border of sternocleidomastoid muscle.
Deep to the external carotid and superficial to the internal carotid.
deep to stylohyoid ligament
Tract passes lateral to CN IX, and CN XII.
It courses superior and lateral to CN XII to turn medially to pass between internal and external carotid. The tract usually terminates close to middle constrictor muscle or may have an internal opening into tonsillar fossa.
86
What is the CT appearance of a second branchial cleft cyst?
What is the MRI appearance of a second branchial cleft cyst?
Well-defined, nonenhancing mass of fluid
attenuation
T1–usually hypointense, but can vary according to protein content
T2–hyperintense
Gad–no enhancement
87
What is the histopathologic appearance of a second branchial cleft cyst?
It can be epidermal-lined (cleft) or respiratory-lined (pouch) or both if a true fistula. There may also be lymphoid elements, granular and keratinaceous cellular debris.
Hair, sweat, sebaceous glands
88
The second branchial pouch gives rise to what structures?
Palatine tonsils
| Supratonsillar fossa
89
The second branchial arch gives rise to what bones? muscles? nerve? vasculature?
```
Hyoid lesser horn
Malleus manubrium
Incus long process, lenticular process
Stapes capitulum and crura
-
Facial nerve
Muscles of facial expression, platysma, stapedius, and posterior belly of the digastric
-
The second arch arteries usually degenerate. A persistent stapedial artery results from failure of that degeneration.
```
90
On what side of the neck do 3rd branchial cleft anamolies typically present?
left
91
What is the potential course of a third branchial
anomaly relative to the hypoglossal nerve?
What is the potential complete course of a fistula
tract of third branchial origin
superficial to XII
It ascends lateral to common carotid, passes posterior
to internal carotid, superficial to CN XII and inferior
or deep to CN IX; it then courses medially through
the lateral aspect of thyrohyoid membrane to
open into the piriform sinus; it usually pierces the
thyrohyoid membrane superior to internal branch of
the superior laryngeal nerve.
92
The third branchial arch gives rise to what nerve/
| muscles? bone? artery?
Glossopharyngeal nerve
Stylopharyngeus muscle and superior constrictor
The greater horn and body of the hyoid bone
proximal internal, external, common carotid
93
third branchial pouch gives rise to what structures?
Inferior parathyroids
Thymus
Piriform fossa
94
What is the potential course of a left fourth branchial
| anomaly relative to common carotid artery? to the aortic arch?
Posterior, descends in sheath to enter chest
| loops around it in the chest
95
What is the potential course of a left fourth branchial
anomaly relative to the hypoglossal nerve?
What is the potential course of a left fourth branchial
anomaly relative to the superior laryngeal nerve?
What is the potential course of a left fourth branchial
anomaly relative to the recurrent laryngeal nerve?
Lateral to CN XII
Inferior to SLN
Lateral to RLN
96
```
fourth branchial arch gives rise to what
cartilaginous structures?
artery?
nerves?
pouch?
```
Thyroid cartilage
Part of the epiglottis
Cuneiform cartilages
Aortic arch
Proximal right subclavian artery
vagus
superior parathyroids, cervical esophagus
97
You suspect a thymic cyst in a child. Would you
| consider any laboratory tests?
Calcium
Thymic cysts are associated with parathyroid
disorders (they are both derived from the third and
fourth branchial pouches).
98
What is the expected potential location of a thymic
| cyst?
Anywhere along the course of thymic descent from
the angle of the mandible to the midline of the neck
and superior mediastinum.
99
Thymic cyst typically occurs on what side?
How do you make the diagnosis of a thymic cyst?
left
Histopathology shows thymic remnants and
Hassall’s corpuscles (multiple layers of epithelioid
cells).
100
When is thymic tissue the largest in a relative sense?
| In an absolute sense?
It is largest relative to the other tissues at birth.
| It is largest on an absolute scale in puberty.
101
Both thymic cysts and third/fourth branchial
anomalies may have tracts that lead to the
hypopharynx and the lower neck. How can they be
distinguished on pathology?
There is thymic tissue in the cyst wall of the thymic
cyst. The thymic cyst also differs in that it is lined by
cuboidal, columnar, or squamous epithelium.
102
When you are putting toys near an infant with
fibromatosis colli, which side will help them stretch
in the desired direction?
Put the toys on the affected side, so the infant
| stretches the affected side as they turn toward the toy.
103
When does fibromatosis colli first present?
Does fibromatosis colli enlarge over time?
When does the fibromatosis colli mass involute?
Usually within the first two weeks of life,
infrequently as late as 6–8 weeks
It can increase in size over the first 1–3 months of life.
Often at 2–3 months, but can persist as long as 6–8 months
104
What is the imaging study of choice for fibromatosis
| colli?
Ultrasound — it should demonstrate that the lesion
is confined to the muscle with no abnormality in the
adjacent tissue. If this is the case, then the diagnosis
is confirmed. Ultrasound typically also shows the
mass moving with the muscle, with an isoechoic or
hyperechoic appearance.
105
What will be the favored head position for an infant
with fibromatosis colli?
x
What will be the favored head position for an infant
with fibromatosis colli?
Tilts head ipsilateral with chin pointing contralateral
106
What is the differential diagnosis for a firm neck
mass at the level of the inferior sternocleidomastoid
in a neonate?
ectopic thymus,
rhabdomyosarcoma, or alternative soft tissue
sarcoma, neuroblastoma, lymphoma, and neurogenic
neoplasms
107
What are the nonmuscular causes of infant torticollis?
What percent of infant torticollis has a non-muscular
cause?
Cervical spine problems such as Klippel Feil
syndrome
Ocular disease, such as superior oblique palsy.
Neurologic disease such as brachial plexus or central
nervous system problems.
20%
108
What is the recurrence rate of thyroglossal duct cyst
| after a Sistrunk? simple excision?
3–6%
35-50%
109
You are performing Sistrunk and inadvertently
rupture the cyst. Does this result in an increased
recurrence rate?
What factors are associated with a higher rate of
intraoperative rupture?
Yes
Prior infection
Prior drainage procedure
Close proximity to skin
110
You are performing a revision for a recurrent
thyroglossal duct cyst. What approach should you
take?
An en bloc anterior dissection: Resect an ellipse of
skin around the prior incision. Excise 3–4 cm of strap
muscles down to the level of the pretracheal fascia.
Remove a wider portion of the central hyoid bone.
Excise the central 1-cm core of tongue tissue.
111
A 4-year-old boy presents with a midline neck mass.
It elevates with tongue protrusion. What imaging
would you consider?
This exam description is consistent with a
thyroglossal duct cyst. An ultrasound confirms
that the mass is cystic and confirms the presence of
normal thyroid tissue.
112
Can a thyroglossal duct cyst undergo malignant
| transformation?
Carcinoma is present in <2% of thyroglossal duct
cysts. Carcinoma is more frequent in females than
males, generally in the third to sixth decade of life. (PTC)
113
What is the relationship of the thyroglossal duct cyst
tract to the hyoid bone?
The tract can be anterior, posterior, or through the
hyoid bone.
65% of lesions are infrahyoid, 15% at the hyoid, 20%
| suprahyoid
114
What is the classic relationship of a subcutaneous
dermoid to the overlying skin?
What is a dermoid?
What is the difference between an epidermal
inclusion cyst versus a dermoid cyst?
It can be attached to the skin but is typically mobile
without skin fixation.
It is a congenital cyst which contains epidermis and
appendages (ie, sebaceous glands, hair follicles). The
contents are typically “cheesy” in consistency.
An epidermal inclusion cyst has no appendages,
whereas a dermoid has appendages.
115
What percent of children with Down syndrome have
atlantoaxial instability?
What is a reasonable screening protocol for a child
with Down syndrome who is preoperative for a
procedure which requires neck extension?
9–22%
Clinical neurologic assessment
Cervical lateral plain films in neutral, flexion, and
extension positions
116
What is atlantoaxial instability?
What is the radiographic finding for children with
atlantoaxial instability?
ligamentous laxity. It is defined by too much mobility between the anterior surface of the odontoid and the posterior
edge of the anterior arch of the atlas.
The atlantodens interval is measured in lateral
flexion and extension. If the interval is more than
4–4.5-mm, then there is instability, likely due to
failure of the transverse ligament.
117
What spinal anomalies are associated with
| Goldenhar syndrome?
Butterfly vertebrae, hemivertebrae, supplemental
| vertebrae
118
What must be breached in order to qualify an injury
| as penetrating neck trauma?
The platysma muscle
119
Neck penetrating trauma zone 1 is:
Sternal notch to cricoid
120
When should a rigid esophagoscopy be done in
zone 1 injuries?
What other evaluation procedures should be
considered in patients with zone 1 injuries?
If swallow study results are equivocal or if the
patient’s status prevents such a swallow study
evaluation from being performed (ie, intubated).
Direct laryngoscopy, bronchoscopy
121
What imaging should be obtained in stable patients
with zone 1 injuries?
Do zone 1 penetrating neck injuries warrant
angiography even if the patient is asymptomatic?
- Arteriography of aortic arch, carotid, and vertebral
vasculature; balloon occlusion control or testing if
injury is suspected.
- In some institutions, CT angiography is done.
The disadvantage to this would be the inability
to intervene if an injury is seen. Also, the contrast
load may prohibit formal angiography in the acute
setting.
- Gastrografin followed by a barium
pharyngoesophagram.
yes
122
What type of swallow study is recommended in a
| zone 1 injury?
Gastrografin swallow followed by barium swallow if
equivocal (barium is less viscous but more irritating
to soft tissue if it leaks out)
123
Zone 1 neck penetrating trauma has high risk of
| injury to what?
Great vessels
Trachea
Lungs
Esophagus
124
What is the appropriate treatment of
pharyngoesophageal injury in penetrating neck
trauma if <24 hours since injury?
What is the appropriate treatment of
pharyngoesophageal injury in penetrating neck
trauma if >24 hours since injury?
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Primary closure (often do a layered closure
and rotate in some healthy muscle such as a
sternocleidomastoid flap)
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Consider diversion/drainage procedure, leaving
large passive drains
Reconstruction with a regional flap, muscle
transposition or esophagectomy, depending on the
extent and timing of injury
125
What is the treatment of choice for common carotid
injury from penetrating neck trauma?
What is the mortality rate from carotid injury from
penetrating neck trauma?
Primary repair if possible; if not enough vessel is left,
consider a synthetic patch or saphenous vein graft.
Vascular surgery consultation
Ligation is a last resort
10-20%
126
What is the appropriate management of zone 2 neck
| trauma in a stable patient?
Traditionally, immediate exploration in the OR
was recommended. Now, if patient is stable,
can consider a CT angiogram of the neck and a
panendoscopy or gastrograffin swallow followed by
barium swallow.
127
In patients with zone 2 neck penetration trauma,
what clinical scenarios dictate mandatory surgical
exploration?
Airway distress/stridor
Gunshot wound that crosses the midline
Active hemorrhage or expanding hematoma/bruit
Active air egress through wound
Arteriography not available
Obvious serious injury/hemodynamic instability that
is deemed to be due to the neck wound
128
In zone 2 neck penetrating trauma, what does
selective management include?
n Angiogram. Although the historical approach
was to perform a formal angiogram via femoral
catheterization, there is a trend toward obtaining
a CT angiogram in order to avoid the potential
morbidity of standard angiography.
- If vascular injury is observed, then the patient
should be taken for neck exploration.
- Swallow study
- Panendoscopy
129
For zone 3 neck penetrating trauma, what imaging
| should be obtained?
Arteriography (balloon occlusion, if necessary)
| Gastrografin swallow followed by barium swallow
130
Following a patient admitted after zone 3 neck
penetrating trauma, what are the key aspects of the
physical examination?
Sequential neurological examinations
Frequent intraoral examinations to detect an
expanding retropharyngeal or parapharyngeal
hematoma.
131
Zone 3 neck penetrating trauma has high risk of
| injury to what structures?
Distal carotid artery
Parotid/facial nerve
Pharynx
132
Neck penetrating trauma zone 3 is:
Angle of mandible to base of skull
133
Do injuries to nasoparhynx or oropharynx generally
| require closure?
If small enough, and in general, no because such injuries
| are not subjected to dependent drainage of saliva.
134
What percent of aerodigestive injuries are
| asymptomatic?
10–15%
135
What is the mortality rate from carotid injury from
| penetrating neck trauma?
10–20%
136
In zone 2 neck penetrating trauma, what percentage
| of elective neck explorations are negative?
50–70%
137
What percent of zone 3 penetrating neck trauma with
| arterial injury are asymptomatic?
25%
138
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What is the characteristic presentation of Rosai-
Dorfman disease (sinus histiocytosis)?
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Typically presents in childhood with massive, nontender,
| often bilateral lymphadenopathy
139
How do you diagnose Kawasaki disease? how old are pts?
85% of patients are less than 5 years of age.
Criteria are:
- Fever of 5 days duration or longer
- Presence of 4 of the following:
- Extremity erythema/swelling/desquamation
- Nonexudative conjunctivitis
- Groin and lower extremity polymorphous
rash
- Cervical lymphadenopathy (in 40%)
- Changes in lips or tongue (such as fissured
lips or a strawberry tongue)
140
what is castleman's dz? what are the variants? what can develop in these patients?
rare benign lymphprolifertive dz
Hyaline-vascular (90% of cases)
Plasma cell (more likely to be multifocal and is often associated with constitutional symptoms—10% of cases)
kaposi's, lymphoma
141
what is kikuchi dz? treatment?
Subacute necrotizing lymphadenopathy
etiology unknown, but might be viral
usually self resolve <6 months, steroids might speed recovery
142
What does each layer of cervical fascia encompass?
Superficial cervical fascia: platysma
Deep cervical fascia:
- Superficial layer: sternocleidomastoid, strap
muscles, trapezius
- Middle or visceral layer: thyroid, trachea,
esophagus
- Deep layer (also prevertebral
fascia): vertebral muscles, spine, phrenic
nerve, brachial plexus
143
As the SMAS continues above the zygoma, what is it continuous with? and what superior to this?
Temporoparietal fascia (which is continuous with the galea superiorly)
144
What is the blood supply to the sternocleidomastoid muscle?
1. Occipital artery or direct from external carotid artery
2. Superior thyroid artery
3. Transverse cervical artery or branch directly from the thyrocervical trunk
4. Occasionally there is also contribution from the posterior auricular artery
145
What are the lymph node level subzones?
Level Lymph Node Group
Ia Submental nodes
Ib Submandibular nodes
IIa Upper jugular, anterior to IX
IIb Upper jugular, posterior to IX (submuscular
recess)
III Middle jugular nodes
IVa Lower jugular nodes (behind clavicular head of sternocleidomastoid muscle)
IVb Lower jugular nodes (behind sterna head of sternocleidomastoid muscles)
Va Posterior triangle nodes (spinal accessory group)
Vb Posterior triangle nodes (transverse cervical artery group, supraclavicular group)
VI Anterior (central) compartment lymph nodes
(paratracheal, perithyroidal, Delphian
146
What defines a jugulodigastric lymph node? What is its normal size?
Level II nodes located where the IJV is crossed by the posterior belly of the digastric
Normal size is ≤1.5 cm (other neck nodes should be <1 cm)
147
What are the anatomic limits of Level II?
Superior — skull base
Posterior — posterior limit of sternocleidomastoid
Inferior — carotid bifurcation (surgical landmark), hyoid bone (radiographic landmark)
Medial — lateral border of the sternohyoid muscle
148
What are the anatomic limits of Level IV?
Superior — omohyoid (surgical landmark), inferior border of the cricoid cartilage (radiographic
landmark)
Posterior — posterior limit of SCM
Inferior — clavicle
Medial — lateral border of sternohyoid muscle
149
What is the clinical significance of the difference between lymph node levels IIa and IIb?
Drainage patterns:
- Oropharynx and nasopharynx can go directly to IIb — XI should be mobilized
- Oral cavity, larynx and hypopharynx usually
will first drain to level IIa prior to involving
level IIb. In these patients, it may not be necessary to dissect IIb if level IIa is not involved.
150
What is the functional difference between levels Ia and Ib?
Drainage patterns:
- Lower lip, floor of mouth, ventral tongue —Ia
- Other oral cavity subsites — Ib as well as II
and III
151
What is the clinical significance of the difference between levels IVa and IVb?
Level IVa nodes — increased risk if Level VI is
involved
Level IVb nodes — increased risk if Level V is
involved
152
What is the clinical significance of the difference between levels Va and Vb?
Nasopharyngeal and cutaneous tumors more
| commonly affect Va, whereas
153
The superior laryngeal nerve (SLN) divides at what level?
Divides into internal and external branch just
| posterior and inferior to the tip of hyoid
154
What is the course of the external branch of the superior laryngeal nerve?
What is the course of the internal branch of the superior laryngeal nerve?
Where does the superior laryngeal nerve run relative to the carotid artery?
The external branch of the SLN follows the superior thyroid artery on the inferior constrictor muscle until it enters the cricothyroid muscle.
The internal branch of the SLN follows the superior laryngeal branch of the superior thyroid artery until it pierces the lateral thyrohyoid membrane.
The superior laryngeal nerve passes posterior to the carotid artery at the same level as the hypoglossal nerve.
155
What transverse process does the spinal accessory cross?
Crosses lateral to transverse process of the atlas (C1)
156
Which artery crosses the spinal accessory nerve?
Occipital artery
157
Where are potential places to find the spinal
| accessory nerve?
By retracting the posterior belly of the digastric
muscle superiorly, look for it crossing superficial to the internal jugular vein around the lateral process of C1.
Penetrates the deep surface of the sternocleidomastoid muscle.
Exits posterior surface of sternocleidomastoid muscle approximately 1 cm above Erb’s point.
Traverses the posterior triangle ensheathed by the superficial cervical fascia and lies on the levator scapulae.
Enters the trapezius muscle approximately 5cm above the clavicle.
