Head and Neck Flashcards
Contraindications for partial laryngopharyngectomy
- Involvement of piriform sinus apex or post cricoid region
- Ipsilateral vocal cord paralysis
- Cricopharyngeus involvement
- Poor pulmonary reserve
Parapharyngeal space boundaries
Inverted pyramid with base at the skull base, apex at the greater cornu of hyoid bone.
Medial - lateral pharyngeal wall
Lateral - parotid gland
Anterior - medial pterygoids
Posterior - pre vertebral fascia
Infections here can spread everywhere except prevertebral space
Retropharyngeal space boundaries
Anterior - buccopharyngeal fascia
Posterior - alar fascia (prevertebral)
Lateral - paraphryngeal spaces (+ carotid sheath)
The danger space is behind it and can allow for communication into prevertebral space and mediastinum!
What is BRAF mutation specific for in thyroid cancer?
Papillary thyroid carcinoma, predicts more aggressive course (likely to have a higher TNM stage)
Indications for neck dissection for parotid tumor
- Cervical lymphadenopathy
- Tumor > 4 cm
- High grade histology
- ACC of minor salivary glands (higher cervical met rate)
Features of mucoepidermoid carcinoma of parotid that decrease survival rates?
Greater squamous components and atypia = more aggressive behavior, poorer survival
Most common MALIGNANT salivary gland tumor in kids?
Most common BENIGN salivary gland tumor in kids?
Malignant - Mucoepidermoid (same in adults)
Benign - Pleomorphic adenoma (just like in adults, also more common in parotid just like adults). Second most - Hemangioma
High risk features for thyroid cancer
Microcalcifications, taller than wide, irregular margins, extrathyroid extensions, PET positive, personal history of radiation, presence of Hurthle cells
Mechanism of PPIs
Act on parietal cells (which secrete gastric acid and IF)
Action of the lateral cricoarytenoid muscle
Medial rotation of the arytenoids, ADDuction of VC
Water clear cell hyperplasia features
Only parathyroid disorder where superior parathyroids are larger than inferior. Histopath resembles renal cell carcinoma. Patient should undergo 4 gland exploration (at risk for bilateral disease).
Features: Severe hypercalcemia
What can you use to avoid taking patient of thyroid hormone during RAI?
Give thyrogen (human recombinant thyroid hormone)
Most common type of spread of mucoepidermoid carcinomas of the salivary gland?
30-40% preponderance toward lymphatic spread upon diagnosis.
Most common benign tumor of the lacrimal gland
Pleomorphic adenoma, progressive proptosis
What automatic stage does anaplastic thyroid get?
Automatically a stage IVa due to the aggressive nature (intrathyroid only)
IVb - extrathyroid spread or regional mets
IVc- distant mets
Risk of malignant transformation for severe dysplasia in head and neck?
~30%
Course of the parotid duct?
Passes OVER the masseter muscle and then pierces buccinator then enters oral cavity.
What is the gonion?
Most posterior aspect of angle of mandible (only one of the “ions” that is NOT midline)
TNM breakdown for MUCOSAL melanoma
Starts at T3!
T3 - mucosal disease but no evidence of cartilage erosion.
T4a - includes deep soft tissue, cartilage, bone, overlying skin.
T4b - includes dura, brain, skull base, CN, masticator space, carotid, prevertebral space, mediastinal
N0 - No regional LN mets
N1 - Yes regional LN mets
M0 - No distant mets
M1 - Distant mets
What are Killian’s triangle borders?
Located between cricopharyngeus and thyropharyngeus muscles (inferior constrictor muscle, where a ZENKER’s is located)
What is the Reflux Symptom Index, how is it scored
9 Qs about reflux, score greater than 13 suggests laryngopharyngeal reflux (LPR).
Methods of laryngeal carcinoma pathway to spread?
Broyle’s tendon (vocalis tendon insertion thyroid cartilage), pre epiglottic space, paraglottic space
When do you add adjuvant chemotherapy to radiation therapy?
Extracapsular extension and/or positive margins
Where is Killian Jameson triangle located?
Between oblique and transverse fibers of cricopharyngeus muscles (lateral diverticulum)
General effect of PTH (ca2+ and phos)
PTH increases tubular reabsorption of Ca2+ (increases serum calcium) and decreases tubular reabsorption of phos.
What are the chances of a hypofunctioning thyroid nodule in a patient with Graves being malignant?
45%. These tumors are usually more aggressive (more local and distant mets) as compared to someone without Graves.
What percentage decrease of baseline PTH at 10 min post op confirms succesful removal of a hyperfunctioning parathyroid adenoma?
50%
What is the role of HPV oncoprotein E6 and E7 in tumorgenesis?
E6 - Bind and degrades p53 (tumor suppressor gene)
E7 - Binds and inhibits RB tumor suppressor gene
Three types of adenoid cystic carcinoma?
Treatment for adenoid cystic carcinoma?
- Tubular
- Cribiform with less than 30% solid
- Cribiform with greater than 30% solid (WORST prognosis)
TX: Parotidectomy + ND + adjuvant RT should be offered to patients with risk factors for recurrence such as intermediate or high-grade tumors, close or positive margins, perineural invasion, lymph node metastases, lymphovascular invasion, and T3-4 tumors.
T staging for piriform sinus
T1 - One subsite and/or < 2 cm
T2- More than one subsite OR 2-4 cm
T3 - Primary tumor > 4 cm OR vocal cord fixation or extension into esophagus
T4 - Invades adjacent structures.
T3 Tumour more than 4 cm in greatest dimension, or with fixation of hemilarynx or extension to oesophageal mucosa
T4a Tumour invades any of the following: thyroid/ cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissue.
T4b invades prevertebral fascia, encases carotid artery, or invades mediastinum
Boundaries of the paraglottic space?
Superior: Quadrangular membrane
Inferior: Conus elasticus
Posterior: Pyriform sinus
Lateral: Thyroid cartilage
Medial: Ventricle
Malignant associations for Sjogrens? Pleomorphic Adenoma?
Sjogrens - MALT (non hodgkins) lymphoma
Pleomorphic adenoma - 2-3% risk of carcinoma ex-pleomorphic adenoma.
Features of tongue base cancer cervical mets?
- 20% bilateral cervical mets
- Often levels II-IV
- 60% have detectable cervical mets at time of presentation
- SCC accounts for 90% of all tongue base cancers.
Narrowest part of airway in peds vs adults?
Pediatrics: Cricothyroid
Adults: glottic inlet
Features of granular cell tumor?
- Sessile grey mass on posterior true vocal cord.
- Histopath: pseudoepitheliomatous hyperplasia
- Stains positive for PAS and S-100 (arise from schwann cells.
Grades of laryngeal trauma (5)
1 - Minor hematoma, no fracture
2 - Edema, hematoma, minor mucosal disruption, non displaced fracture
3 - Massive edema, large displaced fracture, exposed cartilage (need trach, surgical repair)
4 - Same as above but two or more fractures
5 - Complete seperation. Needs fiberoptic intubation then repair…
SAW mnemonic for laryngeal subsites for sarcoid, amyloid and Wegeners
Sarcoidosis - supraglottis
Amyloidosis - glottis
Wegeners - subglottis (get ANCA)!
Role of the suprahyoid muscles?
Aid in elevating hyoid and widening esophagus during swallowing.
How does adenoid cystic carcinoma spread and what is most common site of distant metastasis?
Peirneural spread, most common distant site is the lungs (often shows up later). Rarely metastasizes to the lymph nodes.
What is Lemierre Syndrome?
Fusobacterium infection in oropharynx –> jugular vein suppurative thrombophlebitis.
Risk for septic pulmonary emboli.
TX - IV abx (pip-tazo)
Borders of the pre-epiglottic space?
Thyroid cartilage + thyrohyoid membrane: Anterior
Hyoepiglottic ligament + hyoid: Superior
Thyroepiglottic ligament + epiglottis: Inferior/posterior
What CN pass through/along the cavernous sinus?
III, IV, V1, V2 and VI.
Arterial supply to the SCM?
Occipital, Superior thyroid, Suprascapular (from thyrocervical trunk)
Two most common jugular foramen schwanommas and SX?
1: Vagal
2: Glossopharyngeal, mid frequency SNHL
What nerve branch innervates the carotid body (aka is responsible for changes in vitals during CB tumor resection?
Carotid sinus nerve - a branch of the glossopharyngeal CN IX
ALT free flap blood supply?
Descending branch of lateral circumflex femoral artery (off of profundus femoris system).
Gottfredson’s Syndrome
CN VI and XII palsy - usually due to metastatic tumor to clivus
Vernet’s Syndrome
Jugular foramen syndrome - Involves IX, X XI.
Pectoralis Flap Blood Supply
Thoracoacromial artery
Trapezius Flap Blood Supply
Descending branch of occipital, transverse cervical, dorsal scapular artery
Latismus Dorsi Flap Blood Supply
Thoracodorsal artery + vein and nerves
Temperopariatel Fascia Blood Supply
Superficial temporal artery
Deltopectoral Blood Supply
Internal Mammary artery
Submental flap blood supply
Facial nerve
Supraclavicular blood supply
Transverse cervical
Scapula Free Flap Supply
Circumflex scapular artery + vein
Fibula Free Flap Supply + nerve
Fibular artery (peroneal artery), lateral cutaneous branch of peroneal nerve
Iliac Crest Supply
Deep circumflex artery + vein
Rectus Abdominas Flap Supply
Inferior + super epigastric arteries
Gracillus Flap Supply
Adductor artery from profunda femoris, anterior br of obturator nerve
Three types of cartilage
Hyaline (most common, thyroid cartilage), elastic (in ear, epiglottis), Fibrocartilage
What is graves opthalmopathy caused by?
Proliferation of fibroblasts in EXTRAOCULAR MUSCLES
Method of spread of adenoid cystic carcinoma?
Perineural spread, frequently presents years after TX with pulmonary mets.
SX and TX for adductor spasmodic dysphonia?
Tight, strained voice, difficulty counting 80-89, difficulty with VOWELS (we eat eggs every easter).
Gold standard TX = botox into thyroarytenoid
What type of epithelium lines the supraglottis? glottis?
Supraglottis - psuedostratified columnar
Glottis (including true vocal cord) - Stratified sqamous
Mnemonic for the carotid segments?
C’mon Please Learn Carotid Clinical Organizing Classification
C: Cervical
P: Petrous
L: Lacerum
C: Cavernous (abuts lateral sphenoid)!
C: Clinoid
O: Opthalmic
C: Communicating
Difference between Yag laser and CO2 laser?
Yag: Photomechanical, less damage to adjacent tissues,
CO2: Photothermal, increased depth, increased damage
Course of parasympathetics nerve fibers to parotid?
Preganglionic parasymp fibers originate in inferior salivatory nucleus –> leave brainstem with CN IX (leave with tympanic nerve) –> pass through middle ear, forming the tympanic plexus –> lesser petrosal nerve arrives from this plexus –> exits formane ovale with V3 to reach otic ganglion –> POST ganglionic fibers leave ganlgion through communicating branch to auriculotemporal nerve to reach the parotid.
What cells are associated with hodgkins lymphoma and what is the age distribution for this disease?
Reed Sternberg Cells
Bimodal distribution - First peak at 15-40, second > 50 years.
Which salivary gland cancers are associated with androgen receptor target which may impact adjuvant and palliative treatment options?
Salivary DUCT cancers
Which subtype of papillary thyroid carcinoma has the best prognosis?
Follicular
Horner’s Syndrome Triad?
Miosis (constriction, also anisocoria), anhidrosis, upper eye lid ptosis. Due to sympathetic chain injury.
What is this (salivary gland tumor)?
Adenoid cystic. Remember this doesn’t usually do regional lymph node spread though it can show up later with lung mets. Usually does perineural spread.
Nasopharyngeal TNM staging?
See picture
What passes through pterygopalatine fossa?
Deep petrosal nerve, greater superficial petrosal, maxillary nerve (V2), nerve of pterygoid canal
Mechanism of Frey syndrome?
Result of abberent regrowth of POST ganglionic parasympathetic fibers to sweat glands of the skin. The nerve fibers originate from CN IX but travel with the auriculotemporal nerve (branch of V3)
What is this (salivery gland tumor)?
- Mucoepidermoid
- mixture of cystic, mucin glandular cells, squamous cells WITH keratin pearls
What makes up the tympanic plexus?
Tympanic neve (Jacobson’s, branch of IX) + internal carotid plexus nerves
Where is a:
Zenker Diverticulum
Laimer Diverticulum
Killian Jameson Diverticulum
Lateral Pharyngeal Diverticulum
Killian’s triangle is located between the cricopharyngeus muscle and the inferior constrictor muscle (thyropharyngeus). A diverticulum through this triangle is called a Zenker’s diverticulum.
Laimer’s triangle is located between the cricopharyngeus muscle and the most superior aspect of the esophageal contstrictor.
A Killian-Jamieson diverticulum is located between the oblique and transverse fibers of the cricopharyngeus muscle.
Lateral pharyngoceles are variable in location but are all located superior and lateral to the cricopharyngeus muscle.
Elements of stroboscopy (4)?
Glottic closure, mucosal pliability/stiffness, phase symmetry, regularity
When to do elective neck dissection for oral cavity cancer?
The National Comprehensive Cancer Network (NCCN) recommends elective neck dissection for tumors with DOI > 4mm.
DOI < 2 mm ok for observation.
Features of Warthin’s tumor?
Benign, most common in smokers, usually bilaterally.
Path: Classic dual layer epithelium with nests of lymphocytes
Imaging: High uptake on PET (like maligant tumors)
What laser is used for respiratory papilomatosis and why?
KTP laser - highly absorbed by hemoglobin and poorly absorbed by surrounding tissue (so good for those needing multiple surgery as it minimizes scarring).
Course of internal branch of superior laryngeal nerve?
Pierces thyrohyoid membrane to provide sensory innervation, accompanied by superior LARYNGEAL artery.
Lab features of primary hyperparathyroidism and most common cause?
High serum PTH, calcium, Vit D and LOW serum phosphate -→ HIGH urine phosphate
Caused by adenoma 75% of the time (and diffuse hyperplasia the rest of the time).
What does ultimobranchial body give rise to and what type of cancer is associated with these cells?
Calcitonin producing parafollicular cells (medullary thyroid carcinoma arises from these cells)
Blood supply for carotid body tumor and what is the classic histopath seen?
Ascending pharyngeal artery (ECA), Zellballen pattern seen on histology
Pathologic VS Clinical N staging for P16+ Oropharynx SCC?
pN0 = no regional LN
pN1 = 1-4 LNs
pN2 = 5+ LNs
cN0 = No regional LNs
cN1 = One or more IPSIlateral LN < 6 cm
cN2 = Contralateral or Bilateral LNs < 6 cm
cN3 = LN > 6 cm
What nerve variation is associated with a retroesophageal subclavian artery and what is embryology?
Non recurrent RLN (associated with RIGHT abberent subclavian artery)
Due to failure of 4th pharyngeal arch to develop!
Top 4 salivary MALIGNANT neoplasms (from most common to least)
- Mucoepidermoid (mostly parotid)
- Adenoid Cystic (mostly parotid)
- Adenocarcinoma (mostly MINOR glands)
- Acinic Cell (2nd most common in peds though, mostly parotid)
Top 3 BENIGN salivary neoplasms
- Pleomorphic adenoma (mostly parotid)
- Warthins (Bilateral, smokers, can light up light lymphoma/malignancies on MRI)
- Benign Cyst
MRI pearls to differentiate benign vs malignant salivary neoplasms (think T2)?
- Bilateral HIGH T2 signal, NO enhancement - Warthins (or Lymphoma?)
- Unilateral HIGH T2 signal, NO enhancement - Pleo
- LOW T2 signal that enhances - Malignancy
- Glomus tumor (post styloid space) - salt and pepper flow voids
- Neurogenic tumors (post styloid space) - enhance with gadolinium
Cranial Foramina Contents
- Superior orbital fissure
- Foramen rotundum
- Foramen ovale
- Internal acoustic meatus
- Jugular foramen
- Foramen spinosum
- Vidian Canal
Not shown:
Foramen spinosum: Middle meningeal a. + v.
Vidian canal: Vidian nerve (superficial greater petrosal + lesser petrosal) and vidian artery (from ICA)
For hypopharyngeal tumor, what upgrades N to N3b?
ENE in any lymph node greater than 3 cm or ENE in any node that is part of multiple ipsilateral, contralateral or bilateral = automatically N3b.
Oropharynx HPV POSITIVE N staging
N1: One or more ipislateral LN < 6 cm
N2: Bilateral or contralateral LN < 6 cm
N3: Nodal disease > 6 cm
What mutation is associated with hereditary HN paragangliomas?
Succinate dehydroginase (SDH) gene
What provides sensory innervation to subglottis, glottis and supraglottis?
Subglottis: RLN
Glottis and Supraglottis: Internal branch of SLN
What is the risk of malignant transformation of lichen planus vs verrucous leukoplakia?
Lichen planus: 1-2% (still need to observe/follow)
Verrucous leukoplakia: 50-75%, seen in older women
What branchial arch is the supraglottis derived from? What about glottis and subglottis?
Supraglottis: 3rd and 4th branchial arches
Glottis + Subglottis: 6th branchial arch
Indication for adjuvant RT for adenoid cystic salivary gland carcinoma?
T3/T4, intermediate and high grade, or consider for any of the tumors (low grade too) with extensive perineural invasion (very common for adenoid cystic)!
Shamblin Classification for Carotid body tumors?
1: Small tumor minimal attachements to carotid
2: Large tumor with moderate attachement to carotid
3: Large tumor encasing carotid vessels
Type 1 and 2 considered resectable, type 3 will likely need sacrifice of vessel.
What are the fascial layers that surround the retropharyngeal space and danger space?
Retropharyngeal space: buccopharyngeal fascia (anterior)
alar fascia (posterior)
Danger space: alar fascia (anterior)
prevertebral fascia (posterior)
First Bite Syndrome Mechanism?
-Loss of sympathetic innervation to parotid gland –> unopposed PARAsympathetic innervation
-More common (though still rare) after deep lobe parotidectomy
What follow up labs should be ordered with a neck node diagnosis of adenocarcinoma?
Thyroglobulin, Calcitonin, PAX8, TTF-1 staining
If negative: ND w/wo parotidectomy is indicated
Where do carotid body tumors arise from and what is the Shamblin classification (I-III)?
Arise from adventitia of bifurcation of carotid
I: Small tumor, minimal attachement to carotid
II: Large tumor, moderate attachement to carotid
III: Large tumor encasing carotid
What is this?
Ossifying Fibroma
VS
Fibrous dysplasia tends to be homogeneously radiopaque with a woven pattern of bone tissue on histology.
Gorlin Syndrome - SX, Gene, Alternate name?
SX: Frontal bossing, jaw keratocysts, risk of basal cell carcinomas
Gene: PTCH1
Alternate Name: Nevoid Basal Cell Carcinoma Syndrome
Indications for Adjuvant RT for MERKEL cell caricnoma?
Tumor > 1 cm, positive or limited surgical margins, LVI, immunocompromised state
What does survivorship include and when does it start?
Surveillance, intervention, coordination, prevention: SIC-P you survived!
Starts the DAY someone reaches a cancer diagnosis (through entire life)
