H&N Flashcards
boundaries of anterior triangle and posterior triangle
ant: bounded by the lower border of the mandible superiorly, the midline
anteriorly, and the anterior border of the sternocleidomastoid posteriorly
pos: posterior border of the sternocleidomastoid
anteriorly, the anterior border of the trapezius posteriorly, and the clavicle inferiorly
ddx midline lump
- Submental lymph node
- Thyroglossal cyst
- Thyroid nodule in the isthmus
- Sublingual dermoid cyst
- Plunging ranula (retention cyst of the sublingual)
ddx anterior triangle lump
- Lymph node – along anterior border of sternocleidomastoid (levels II, III, IV)
- Thyroid nodule
- Submandibular gland mass (see later section on Salivary gland swellings)
- Branchial cyst + fistula
- Chemodectoma (carotid body tumour)
- Carotid aneurysm
- Pharyngeal pouch
ddx posterior triangle lump
- Lymph node – level V and supraclavicular lymph node groups
- Cystic hygroma
- Cervical rib
- Brachial plexus neuroma/schwannoma
thyroglossal cyst
- what is it
- embryology of thyroid
- tx
A cystic expansion of the remnant thyroglossal tract
embryologic descent of the thyroid from the foramen cecum at the base of the tongue to low anterior neck
Sistrunk procedure – resection of the cyst, its tract and central portion of the hyoid bone
Dermoid cyst
- features/ what is it
- causes
- tx
Cyst lined by epidermis, with evidence of adnexal structures such as hair follicles, sebaceous glands and sweat glands – cystic teratoma
Causes:
- congenital: devt inclusion of epidermis along line of fusion of skin dermatomes (eyebrow, nose, neck)
- acquired: forced inclusion of skin into subcutaneous tissue following injury (fingers)
Mgx: surgical excision
Rannula
- what is it
- types
- causes
- tx
mucous extravasation cyst involving a sublingual gland and is a type of mucocele
simple: confined to floor of mouth
plunging: extend through mylohoid musculature
causes: congenital (imperforate salivary duct), acquired (trauma to sublingual gland)
tx:
- complete resection with Assoc sublingual gland
- else marsupialisation and suture of pseudocyst wall to oral mucosal
branchial cyst
- what is it
- features
- FNA findings
- cx
- mgx
What: congenital epithelial cysts, which arise on the lateral part of the neck from a failure of obliteration of the second branchial cleft in embryonic development.
Features: smooth, firm, ovoid, fluctuant but not transilluminable, a.w branchial fistula
FNA: opalescent fluid with cholesterol crystals under microscopy
cx: recurrent infections – purulent discharge, fixation to surrounding
structures
mgx:
surgical excision of cyst
fistula: perform fistulogram, inject Bonney’s blue dye to delineate tract. tx with abx if infected
location of bifurcation of common carotid artery
- significance?
upper border of thyroid cartilage
- location of carotid body and sinus
- what are paraganglion cells
- types of paraganglionomas
group of non-neuronal cells derived of the neural crest. They are named for being generally in close proximity to sympathetic ganglia.
2 types: - neuroendocrine cells - chromaffin (chromaffin cells) > phaeochromocytomas (adrenals non malignant, extra adrenal - malignant, secrete hormones) - non chromaffin (glomus cells) > carotid body tumours (do not secrete hormones)
Chemodectoma
- location
- risk of malignancy
- features
- ddx
- diagnosis
- tx
carotid body tumour
- @ bifurcation of C carotid art
- usually benign but locally invasive. malignant risk 10% but no histo features, only diagnosed through mets to LN
- solid, firm @ hyoid bone (lvl2 of neck). pulsatile but NOT expansile. move side to side but not up and down.
- carotid artery aneurysm (expansile, bruit, Horner syndrome)
- NO FNAC. use CT/MRI.
CT: homogenous mass with intense enhancement with IV contrast
angiography: gold standard - tx: R/o phaeo.
sx excision with pre-op embolisation. remove enlarged I/L LN.
alt: RT
pharyngeal pouch
- what is it
- features
- cx
- diagnosis
- tx
aka Zenker diverticulum
- A herniation of the pharyngeal mucosa between 2 parts of the inferior
pharyngeal constrictor – thyropharyngeus & cricopharyngeus – weak area situated posteriorly
(Killian‟s Dehiscence)
- c/o cystic swelling in neck, squelching, halitosis, regurgitate, dysphagia, hoarseness, weight loss
- cx: aspiration, diverticular neoplasm
- diagnosis: barium swallow
tx:
- small: leave
- endo: cricothyroid myotomy
- sx: diverticulotomy + cricothyroidotomy or diverticulopexy
cystic hygroma
- what is it
- features
- cx
- mgx
congenital cystic lymphatic malformation. It consists of thin- walled, single or multiple interconnecting or separate cysts which insinuate themselves widely into the tissues at the root of the neck.
- Lobulated cystic swelling that is soft, fluctuant, and compressible. brilliantly transilluminable.
- a.w trisomy 21. may obstruct delivery. compressive problems - SOB, dysphagia
- aspiration/ sclérosant or sx excision
Cervical rib
- features
- diagnosis
- tx
Thoracic outlet syndrome
- Arterial: pallor, gangrene or necrosis of the tips of the fingers
- Venous: oedema, cyanosis
- Neurological: complaints of radicular symptoms (pain, paraesthesia), wasting of the small muscles of the hand
diagnosis: cxr, nerve conduction study, Adson test
tx: PT exercises, analgesia, blood thinners, surgery
Levels of LN in the neck
IA: submental IB: submandibular II: upper jugular III: mid jugular IV: lower jugular Va: posterior triangle Vb: supraclavicular VI: ant compartment
pathophysiology behind Virchow’s node
thoracic duct commences at cisterns chyli > aortic opening > ascend behind oesophagus > at root of neck, enter junction between L IJV and L subclavian veins
virchow node lies between 2 heads of SCM
approach to LN enlargement
1. Infection > bac: TB, strep/staph/klebsiella > viral: EBV, CMV, HIV > fungal/ parasites 2. Neoplastic - lymphoma - mets > H&N Pri: NPC, oral cavity, larynx, thyroid, skin > other Pri: lung, GIT, breast, renal 3. Inflammatory: Kikuchi (female, painful, self-limiting/ acute). Kimura (chronic inflammatory, males, pruritic leisions), SLE, sarcoidosis
B symptoms of lymphoma
fever, night sweats, LOW
Submandibular gland
- significant anatomical relations
- nerve supply
- name of duct
- histology
large superficial part and a small deep part that are continuous with one another around the free posterior border of the mylohyoid
closely related to lingual nerve, submandibular ganglion, hypoglossal nerve.
Nerve: parasympathetic supply. preganglionic from superior salivary nucleus > submandibular ganglion > lingual n (facial n/ chorda tympani)
Wharton (drain into sublingual papilla adjacent to frenulum)
mixed serous and mucinous
Impt structures passing through parotid gland?
- Facial n and branches: temporal, zygomatic, buccal, marginal mandibular, cervical
- retromandibular vein
- external carotid artery > superficial temporal and maxillary artery
Parotid duct
- nerve supply
- duct name, surface marking
- histology
parasympathetic.
pre gang: inferior salivary nucleus > otic ganglion > auriculotemporal n (glossopharyngeal n)
stensen (inter tragic notch to midpoint of philtrum. drain into mouth, opp second molar tooth)
histo: serous
Sublingual
- nerve supply
- histo
superior salivary nucleus > submandibular ganglion > lingual n (facial n/ chorda tympani)
histo: mucous
3 organ sites involved in mumps
parotiditis, orchitis, pancreatitis
Causes of parotid swelling
PARENCHYMAL - neoplasia: benign, malignant, lymphoma/ leukemia - stones: sialolithiasis - infection/ inflammation: mumps, acute sialolithiasis, HIV - autoimmune: Sjögren - infiltration: sarcoidosis - systemic dz: alcoholic liver dz, DM, pancreatitis, acromegaly, malnutrition NON PARENCHYMAL - nodes: mets - blood vessels: AVM, haemangioma - lymphangioma - schwannoma - lipoma
causes of bilateral parotid swelling
mumps, HIV, sarcoidosis, Sjögren syndrome, lymphoma/leukaemia
systemic dz: alc liver dz, DM, pancreatitis, acromegaly, malnutrition
Types of parotid neoplasia
benign: pleomorphic adenoma, warthin, monomorphic adenoma, oncocytoma
malignant: mucoepidermoid, Adenoid cystic carcinoma, carcinoma ex-pleomorphic, acinic cell adenocarcinoma
SCC
lymphoma/ leukaemia
Types of salivary gland tumours
EPITHELIAL Adenomas: 4 Carcinomas: 4 + squamous cell carcinoma, undifferentiated NON EPITHELIAL - haemiangioma - lymphangiomas - neurofibroma - schwannoma - lipoma - sarcoma - malignant lymphoma
Pleomorphic adenoma
- features
- malignant risk
Slow-growing, painless swelling occurring in the lower pole of the parotid
Irregular and lobulated surface, texture of cartilage
Chance of malignant transformation if left for 10-15 years
Warthin tumour
- RF
- other names
- features
- malignant risk
- males, older age, smoking
- papillary cystadenoma lymphomatosum/ adenolymphoma
- bilateral (10%), multifocal (10%), contain mucin (milky), slowlynenlarging, cystic/ fluctuant
- BENIGN
most common malignant tumour in parotid
mucoepidermoid
most common malignant tumour in other salivary glands (other than parotid)
adenoid cystic CA
Cx of parotidectomy
IMMED
- damage to facial n
- rupture of parotid tumour capsule
- incomplete resection of tumour
EARLY (<30d)
- facial n palsy
- great auricular n injury (loss of sensation of pinna)
- parotid fistula
- trismus (inflammation of masseter muscle)
- wound infection/ seroma
- hemorrhage/ hematoma
- skin flap necrosis
LATE (>30d)
- facial synkinesis
- hypoesthesia of great auricular n
- recurrent tumour
- cosmesis
- frey syndrome - gustatory sweating
gland with highest risk of sialolithiasis and why
submandibular - higher mucus and calcium content - long duct - slow flow of saliva against gravity (usually in duct > gland)
what % of sialolithiasis can be seen on x ray
80-95% of submandibular stones are radio-opaque and can be seen on an X-ray of the floor of the mouth
60% of parotid stones are radio-opaque.
mgx of sialolithiasis
CONSERVATIVE
- hydration, soft diet, good oral hygiene
- massage gland, milk duct, apply moist hot towel
- analgesia - NSAID
- antibiotics if needed (augmentin)
SURGICAL
- trans oral removal of stones
- partial gland resection
others: lithotripsy, wire basket removal, sialoendoscopy
Hypercalcemia symptoms
Bones - painful (osteitis fibrosa cystica)
Stones - kidney stones
Abdo groans - N&V, constipation, indigestion
Psychic moans - lethargy, fatigue, memory loss, psychosis, depression
tx of hypercalcemia
asymptomatic: avoid thiazide, lithium carbonate, dehydration, vitD, high Ca diet
saline hydration calcitonin IV bisphosphonate (zoledronic acid) glucocorticoid (if due to lymphoma, sarcoid, granulomatous dz) urgent dialysis if severe
