H&N Evaluation and management of the neck Flashcards
Malignancies involving the neck primarily arise as
metastatic lesions (most commonly from the
upper aerodigestive tract). What percentage of
neck malignancies will arise primarily in the neck,
and what are the most common sites of origin?
15%. Thyroid, salivary gland, and lymphoma
What percentage of neck masses in pediatric
patients are benign?
> 90%, most commonly inflammatory
Approximately what percentage of neck masses in
adult patients are neoplastic?
~ 80%
What is the most common head and neck malignancy in the pediatric population and the second most common head and neck malignancy in the adult population after squamous cell carcinoma?
Lymphoma
What are common sites of origin for locoregional
metastatic disease to cervical lymph nodes?
● Upper aerodigestive tract
● Head and neck skin
● Major and minor salivary glands
● Thyroid gland
What are the most common sites of origin for
distant metastatic disease to cervical lymph
nodes?
● Lung ● Thoracic esophagus ● Ovary ● Prostate ● Kidney
What is the most likely site of origin for squamous
cell carcinoma metastatic to cervical lymph nodes
with an unknown primary?
Oropharynx (tonsil and tongue base)
What are the most common symptoms associated
with nodal metastases to the neck?
● Palpable neck mass
● Symptoms resulting from compression (e.g., dysphagia,
dysphonia)
● Symptoms resulting from invasion (e.g., recurrent laryngeal nerve paralysis, accessory neuropathy, pain)
What is the most common anterior neck mass
diagnosed on physical examination?
Thyroid nodule
What are important features of lymphadenopathy
that can be detected on a careful physical
examination?
● Location ● Mobility on palpation and with swallowing ● Potential deep involved structures ● Firm (i.e., not rubbery) ● Involvement of the skin
True or False. Nodal cervical metastases from locoregional tumors are generally extremely painful.
False
When malignant lymphadenopathy is immobile
and invasion or adherence of the nodal disease to
underlying structures is suspected, what is the
neck referred to as, and what implications does
this have on management?
Fixed. It may be unresectable.
What is the best diagnostic test for determining
the cause of a neck mass without a known primary
tumor?
FNA biopsy
What diagnostic test is indicated if an FNA biopsy
is performed on a suspicious cervical lymph node
with an unknown primary and the pathology
demonstrates lymphoid cells?
Excisional lymph node biopsy, most commonly in the
operating room
Although there has been a significant amount of
research into the application of sentinel lymph
node biopsy for head and neck cancer, currently
the literature supports its routine use for what
types of cancer?
Cutaneous malignancies (especially melanoma). May also
be used for known oral cavity cancer in patients with cN0
neck disease.
What are the general steps involved with per-
forming a sentinel lymph node biopsy?
● Primary tumor is injected with technetium-99 sulfur
colloid in the radiology suite.
● Lymphoscintigraphy is performed, and the sentinel node
is identified.
● Patient is brought to the operating room (generally
within 4 hours).
● Use the gamma probe to confirm the location of the
sentinel node and design surgical incision.
● Slowly inject ~ 0.3 mL of isosulfan blue intradermally (not
subcutaneously). This should result in a lacelike pattern
under the skin. This should be done at least 10 minutes
before any local anesthetic is injected if any is injected at all.
● Expose the tissue suspected of harboring the sentinel
lymph node.
● Using the gamma probe (pointing away from the primary
site if possible to avoid shine-through), identify the area
containing the node. Visual confirmation of a blue node is
supportive but not required if the gamma probe is
suggestive.
● Excise the node and perform a 10-second gamma count
in the dissection field to confirm that the sentinel node(s)
was (were) removed.
● With the node placed away from the primary site and
sentinel biopsy site, perform a confirmatory gamma
count for 10 seconds to ensure you have removed the
correct node.
● Excise the primary with appropriate margins. This may be
done first if the primary is in close proximity to the
sentinel lymph nodes.
● Depending on the pathology report results, the wound
can be closed or a formal neck dissection is performed.
Note: It is not unusual for multiple lymph nodes to be
identified. If the dissection bed after sentinel node excision
contains > 10% of the gamma count detected before the
node was removed, further exploration for remaining nodes
is warranted.
In patients with common carotid artery or internal
carotid artery invasion with tumor, which test
should be employed before surgical resection of the involved carotid artery?
Carotid artery balloon occlusion test
What imaging modality is most commonly used
for the initial workup of an adult neck masses?
CT with contrast
What imaging modality is best for evaluation of
perineural spread associated with neck masses?
MRI
What imaging modality is best used to determine
distant metastatic spread of disease and as an
adjunct in patients with an unknown primary
tumor?
PET/CT
What is the AJCC node (N) staging system for head and neck cancer (including salivary gland; exclud-
ing nasopharynx and thyroid)?
● Nx: Regional lymph nodes cannot be assessed
● N0: No regional lymph node metastases
● N1: One lymph node involved ≤ 3 cm
● N2a: One ipsilateral lymph node involved > 3 cm and ≤ 6
cm in size
● N2b: More than one ipsilateral involved lymph node,
none > 6 cm
● N2c: Contralateral or bilateral lymph node involve-
ment ≤ 6 cm
● N3: Lymph node > 6 cm
What is the AJCC lymph node (N) staging system
for nasopharyngeal cancer?
● Nx: Regional lymph nodes cannot be assessed.
● N0: No regional lymph node metastases
● N1: Unilateral metastases in one of more lymph node ≤
6 cm, above the supraclavicular fossa
● N2: Bilateral metastases in lymph nodes ≤ 6 cm, above the
supraclavicular fossa
● N3a: Tumor > 6 cm
● N3b: Tumor extends to the supraclavicular fossa.
What is the AJCC lymph node (N) staging system
for soft tissue sarcomas?
● Nx: Regional lymph nodes cannot be assessed.
● N0: No regional lymph node metastases.
● N1: Regional lymph node metastases
What is the AJCC lymph node (N) staging system
for thyroid cancer?
● Nx: Regional lymph nodes cannot be assessed.
● N0: No regional lymph node metastases
● N1a: Metastases to level VI (pretracheal, paratracheal,
and prelaryngeal/Delphian node(s))
● N1b: Metastases to unilateral, bilateral, or contralateral
cervical or superior mediastinal lymph nodes
For a patient with squamous cell carcinoma of the
head and neck, the presence of nodal disease
traditionally results what 5-year overall survival?
50%
In well-differentiated thyroid cancer, for what patient population does the presence of nodal
metastases not influence their overall stage or
prognosis?
Patients younger than 45 years
What pathologic nodal features have been associated with poor prognosis in head and neck cancer?
● Extracapsular spread (may not be true for HPV positive tumors) ● Skipped nodal levels ● Involvement of levels IV and V ● Number of involved nodes ● Size of involved nodes ● Bilateral nodal disease ● Matted lymph nodes
What is the difference between a therapeutic and
an elective neck dissection?
● Elective: Performed in a clinically N0 neck owing to high
risk (> 20%) for occult metastases
● Therapeutic: Performed in a clinically N(+) neck
What type of neck dissection is delayed after primary chemoradiation therapy?
Staged neck dissection
What type of neck dissection is performed for recurrent disease after primary therapeutic intervention?
Salvage neck dissection
What is removed in a radical neck dissection?
● Lymph node levels I–V
● SCM muscle
● Spinal accessory nerve
● Internal jugular vein
What are the three types of a modified radical
neck dissection?
All three include dissection of levels I–V. Each type varies from a radical neck dissection by preserving the sternocleidomastoid (SCM), internal jugular vein (IJV) and/or spinal accessory nerve (SAN):
● Type I: Preserves SAN
● Type II: Preserves SAN + IJV
● Type III (complete): Preserves SAN + IJV + SCM
The NCCN (2011) recommends using the term
comprehensive neck dissection instead of radical
or modified radical. How does the NCCN define a
comprehensive neck dissection?
Resection of nodal levels I–V, regardless of preservation of
SCM muscle, spinal accessory nerve, or IJV
In a select neck dissection, the surgeon will
remove the lymphatic basins at highest risk for
disease, which may vary according to the tumor,
subsite, and individual patient. What is the most
accurate way to refer to a select neck dissection?
Select neck dissection, levels X–X (detailing which levels
were removed). However, the most common select neck
dissections have associated terminology with which it is
important to be familiar
In what type of neck dissection are levels I–III
dissected, preserving the nonlymphatic structures
of the neck?
Supraomohyoid neck dissection. Select neck dissection
levels I–III
In what type of neck dissection are levels I–IV
dissected, preserving the non-ymphatic structures
of the neck?
Lateral neck dissection. Select neck dissection (levels I–IV)
In what type of neck dissection are levels III–V
dissected, preserving the nonlymphatic structures
of the neck?
Posterolateral neck dissection. Select neck dissection (levels
II–IV)
In what type of neck dissection is level VI
dissected, preserving the nonlymphatic structures
of the neck?
Anterior/central neck dissection. Select neck dissection
level VI
In what type of neck dissection are lymph node
basins in addition to the more common I–V
dissected?
● Extended neck dissection. This can include a radical neck
dissection, modified neck dissection, or select neck
dissection.
● May designate using the type of dissection followed by
the levels and additional lymph nodes dissected in
parenthesis.
What type of neck dissection is generally recom-
mended for oral cavity cancer?
Select neck dissection (level I-III) at minimum, with level IV
for oral tongue cancers. Bilateral dissection should be
considered for those with floor of mouth, ventral tongue, or
midline tongue involvement in those undergoing elective
ipsilateral neck dissection with no plans for postoperative
radiation therapy.
What type of neck dissection is generally recom-
mended for oropharyngeal cancer?
Select neck dissection (level II-IV). Bilateral dissection
should be considered for base of tongue tumors, posterior
oropharyngeal tumors, and those that cross midline.
Dissection of retropharyngeal nodes should be considered.
Routinely dissecting level IIB in cN0 necks is controversial.
What type of neck dissection is generally recommended for hypopharyngeal and laryngeal cancer?
Select neck dissection (level II–IV) and occasionally VI
In what type of neck dissection does the surgeon
attempt to identify the first-echelon lymph node
or nodes draining a particular subsite in an effort
to determine whether the cancer has metastasized
locally?
Sentinel lymph node biopsy
A meta-analysis of the EORTC (no. 22931) and RTOG (no. 9501) showed a benefit to postoperative concurrent chemoradiation in patients with locally advanced oral cavity, oropharynx, larynx,
and hypopharynx squamous cell carcinoma when
what risk factors were present?
Positive surgical margins and/or extracapsular spread
What branches of the vagus nerve are at highest
risk for injury during neck dissection for head and
neck cancer?
Recurrent laryngeal nerve and superior laryngeal nerve and
its branches
After a select neck dissection (levels IA, IB, IIA, IIB,
III), you note weakness in your patient’s ipsilateral
depressor anguli oris and depressor labii inferioris
and resultant asymmetry during smiling. What
structure was likely injured?
Marginal mandibular branch of CN VII
Describe the surgical techniques that can be used
to decrease the risk of injury to the marginal
mandibular nerve during neck dissection.
● Place incisions 3 to 4 cm (or two fingerbreadths) below
the mandible.
● Ligate the common facial vein under the superficial layer
of the deep cervical fascia with a long tie. Lift this with
the skin flap (this may limit oncologic dissection).
● Elevate plane between the submandibular gland and
superficial layer of the deep cervical fascia (this may limit
oncologic dissection).
● Identify marginal mandibular nerve as it branches from
the cervical branch of the facial nerve.
What is the reported rate of marginal mandibular
nerve injury after neck dissection (particularly level
IB and occasionally level IIA), and what is the most
common postoperative House-Brackmann score
associated with neural injury?
Immediate: ~ 20%. Permanent: < 5%
House-Brackmann grade II–III/VI
What sequelae results from resection of the spinal
accessary nerve?
Shoulder syndrome: Denervation of the trapezius muscle
resulting in destabilization of the scapula and inability to
abduct the shoulder > 30 degrees, pain and shoulder girdle
deformity. Injury from dissection around spinal accessory
nerve in levels IIB and VA may also result in shoulder
syndrome.
What nerve can be injured during dissection in
level IV, which can result in paralysis of the ipsilateral hemidiaphragm?
Phrenic nerve
What factors increase the risk of postoperative wound infection or breakdown after neck dissec-
tion?
● Previous radiation therapy
● Pharyngocutaneous or pharyngocervical fistula with
salivary contamination
● Chylous fistula
● Hematoma
● “Tight” wound closure with compromised vascular
function
● Comorbidities: Immunocompromised, malnourished,
peripheral vascular disease, poorly controlled diabetes,
and so forth
When planning a neck incision, why should you
place any “T-limb” at 90 degrees to the main
incision?
To maximize vascular supply and minimize skin flap necrosis
How should carotid artery exposure after neck
dissection be dealt handled?
Coverage with vascularized tissue, preferably a myocutaneous flap (e.g., pectoralis major flap)
What are the risk factors for carotid blowout,
which include rupture of any component of the
carotid system, after management of head and
neck cancer?
● Radiation therapy (≥ 70 Gray to the neck; accelerated
fractionation schedule)
● Neck dissection (radical = 8x increased risk)
● Wound infection, breakdown, pharyngocutaneous fistula
with salivary contamination
● Mobile foreign material (wet to dry dressing)
● Tumor involvement of the vessel
● Malnutrition
What are the incidence and mortality rates associated with carotid blowout after management of the neck?
● Incidence: < 4% (occurs months to years after intervention/diagnosis)
● Mortality: 3 to 50%
Why might patients receiving endovascular management for an acute carotid blowout fare better (less neurologic sequelae) than those undergoing
emergent surgical intervention?
Patients going to surgery are more likely to have acute
hemorrhage, common carotid rupture, and hemodynamic
instability.
What sequelae can result from sacrifice of both
internal jugular veins?
Facial and cerebral edema, increased intracranial pressure, altered mental status, syndrome of inappropriate antidiuretic hormone secretion, abducens palsy, and blindness
have all been associated.
What is the prevalence of a persistent chylous
fistula after neck dissection in area IV?
1 to 3%. Most are in the left neck, but 25% have been reported in the right neck.
What is the normal volume of chyle that passes
through the lymphatic duct per day, and what
does it contain?
2–4 L/day. Fat (chylomicrons, long-chain fats), protein,
electrolytes, and lymphocytes
What are the possible sequelae of a persistent
chyle leak?
Hypovolemia, electrolyte disturbances, hypoalbuminemia,
coagulopathy, immunosuppression, infection (sepsis,
wound infection), peripheral edema, possible chylothorax
(50% mortality if left untreated), mortality (now 0.25% with
treatment)
Suspected chylous fluid can be tested for what
components to confirm that it is in fact chyle?
● Chylomicrons
● Triglycerides (> 5 g/L)
● Sudan III stain positive
What steps can initially be used to treat persistent
chyle leaks less than 500 mL per day (low-output)
after neck dissection?
● Low-fat, medium-chain fatty acid–only diet
● Suction wound drainage
● Pressure dressing
● Consult dietician or nutritionist and follow laboratory
results closely.
If not successful, consider total parenteral nutrition (TPN).
Some recommend for output < 500 mL/day x 5 days or longer.
In a patient with a high-output chyle leak after neck dissection, despite maximal medical therapy or in the presence of complications, what treatment is recommended?
Neck exploration and ligation of the thoracic duct. Other surgical options should also be considered (thoracoscopic
or laparoscopic approach).
What laboratory test should be checked yearly in
patients treated with neck radiation therapy?
Thyroid function tests (TSH)
What is the difference in impact on quality of life
between a radical neck dissection and a modified
radical neck dissection?
Radical neck dissection results in significantly worse
shoulder function and a trend toward increased pain. No
difference in subjective appearance, activity, recreation,
chewing, swallowing, or speech occurs.
