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FRACS 2024 > Head and neck > Flashcards

Head and neck Flashcards

1
Q

What is the most common benign salivary gland tumour?

A

Pleomorphic adenoma

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2
Q

What is the most common malignant salivary gland tumour?

A

Mucoepidermoid

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3
Q

Of the following which is most likely to be malignant;
a tumour in parotid, a tumour in submandibular gland, a tumour in sunlingual gland?

A

Smaller glands higher risk.
Mini malignant
Big benign

Parotid Gland: 75-85% are Benign
Submandibular Gland: 57-63% are Benign
Minor Glands: 85% are Malignant

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4
Q

What is the anterior triangle of the neck? What are the important contents?

A

Borders are:
Anterior: Midline between mentum and sternal notch.
Superior: Mandible
Lateral: SCM Anterior border

Contents:
Muscles
- digastric
- stylohyoid
- mylohyoid
- geniohyoid
- sternohyoid
- omohyoid
- thyrohyoid
- sternothyroid
- plastysma

Arteries
- common, internal and external carotid
- branches from ext carotid = superior thyroid, ascending pharyngeal, lingual, facial, mylohyoid atery (maxillary via inferior alveolar).

Veins
- internal and anterior jugular
- facial

Nerves
- Hypoglossal
- ansa cervicalis
- mylohyoid nerve from the mandibular division of the trigeminal nerve via inferior alveolar nerve
- vagus and its branches internal and external branches of superior laryngeal and recurrent laryngeal.

Glands
- Submandibular
- lymph nodes

Other
Hyoid bone
Thyroid
Parathyroids
Larynx
Trachea
Oesophagus

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5
Q

What is the posterior triangle of the neck? What are the important contents?

A

Borders are:
Posterior: Trapezius
Inferior: Clavicle
Anterior: SCM Posterior border

Contents:
Spinal accessory nerve & brachial plexus

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6
Q

What are the triangles within the anterior triangle?

A

Digastric = Borders; two bellies of diagstric and lower border of mandible. Floor; Mylohyoid and hyoglossus

Carotid triangle = Borders; SCM, posterior belly of digastric and superior body of omohyoid. Floor; middle and inferior constrictors, hyoglossus and thyrohyoid

Submental triangle = Borders; Two anterior bellies of digastric and body of hyoid bone. Floor; Parts of both mylohyoid muscles.

Muscular triangle = Borders; SCM, superior belly omohyoid & midline of neck.

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7
Q

What is the exception to the rule “all intrinsic muscles of the larynx lie inside the larynx”?

A

Except the cricothyroid which lies on the outside of the larynx

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8
Q

What is the exception to the rule “All intrinsic muscles of the larynx either close or loosen the cords”?

A

Except posterior cricoarytenoid which opens them and cricothyroid which tightens them

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9
Q

What is the exception to the rule “All intrinsic muscles of the larynx are innervated by the recurrent laryngeal nerve”?

A

Except the cricothyroid which is supplied by external branch of superior laryngeal nerve.

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10
Q

What is the exception to the rule “The hypoglossal nerve passes lateral to all important structures in the neck”?

A

Except the facial vein which passes lateral (superficial) to the nerve.

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11
Q

What is the exception to the rule “All muscles of the pharynx remain relaxed until a bolus arrives”?

A

Except the cricopharyngeus which remains closed until a bolus approaches.

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12
Q

What is the exception to the rule “All muscles of the pharynx are supplied by the pharyngeal plexus (IX, X & sympathetic)

A

Except stylopharyngeus which is supplied by the glossopharyngeal nerve (IX) & cricopharyngeus which is supplied by the recurrent laryngeal nerve (X).

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13
Q

What are the cervical lymph node levels?

A

I
Ia: Submental
Ib: Submandibular Triangle
Separated by Anterior Digastric

II: Upper Jugular
IIa: Anterior to Accessory Nerve
IIb: Posterior to Accessory Nerve

III: Middle Jugular (Hyoid to Inferior Cricoid)

IV: Lower Jugular

V: Posterior Triangle (Behind SCM)
Va: Superior to Cricoid
Vb: Inferior to Cricoid

VI: Central
Boundaries: Hyoid, Carotid Artery, Sternal Notch

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14
Q

How much saliva and what types are produced by each of the salivary glands?

A

Parotid - 20%, Serous
Submandibular - 65-70%, serous and mucin
Sublingual - ~10%, mucin (to lesser degree serous)

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15
Q

Spot diagnosis

A

Torus palatinus - exotosis of bony palate covered in mucosa. Benign. Only interfere if impairing with mastication or speech.

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16
Q

Tell me about Sialolithiasis and siladenitis. (DIPSCHIT)

A

Sialolithiasis = stone in salivary gland duct.
Siladenitis = inflammation of salivary gland.

Incidence and risk factors (stones):
- stagnant flow of saliva
- inflammation or injury
- males >female
- hypovolaemia or diuretics
- anticholinergic medications
- tobacco

Pathophysiology:
Most commonly in submandibular gland (80-90%) due to its longer duct, slow flow of saliva against gravity and its high mucin and calcium content.

Signs and symptoms:
Pain
Swelling
Stone may be visible

Histo: NA

Investigations:
Diagnosed clinically but imaging used if concern for abscess or differentials.

Treatment:
- conservative, good hydration
- duct massage
- salivation (hard candies, lemon drops)
- NSAIDs
If Fails: Minimally Invasive Intervention
Sialoendoscopy with Stone Removal
Laser Lithotripsy
Extracorporeal Lithotripsy
If Still Fails: Surgical Stone Removal
ABX if Concerned for Secondary Infection (Fever/Purulence)

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17
Q

An elderly man, smoker is post op day 7 and has newly swollen and red area near angle of jaw. What is the diagnosis and the risk factors. How would you treat it?

A

Suppurative parotiditis.

At risk are elderly dehydrated patients around 4-12days post op, smokers and those with sialolithiasis (men >women).

Treatment includes good hydration, salivation and IV antibiotics. Uncommonly would you need to surgically drain unless abscess or abx failure after 48h.

18
Q

What is the most common kind of head and neck cancer and what are the risk factors?

A

SCC.

Risk factors:
- smoking
- chewing betel nut quid
- alcohol
- radiation
- peridontal disease
- immunosuppresion
- HPV

19
Q

Where is the primary most likely from for each of the following mets;
- mets in cervical lymph nodes
- mets in larynx or salivary glands
- mets in mouth or pharynx

A
  • mets in cervical lymph nodes
    = tonsil or base of tounge,
  • mets in larynx or salivary glands
    = lungs
  • mets in mouth or pharynx
    = oesophagus
20
Q

What is the work up for a lump in the neck of unknown origin?

A

History & examination
- any clues as to infectious source?
- is it pulsatile
- ca risk factors
- include oral examination

Triple endoscopy
- laryngoscopy
- bronchoscopy
- OGD

Imaging
CT/MRI/USS

Biopsy
- FNA preferred initially as maintains surgical planes and low risk of spread +/- CNB
(ensure not pulsatile - differential = carotid body tumour)
Excision biopsy if FNA/CNB non-diagnostic

21
Q

What is Lateral abberant thyroid tissue?

A

Ectopic thyroid tissue usually as a result of metastatic spread of papillary thyroid cancer.

22
Q

What cancers are most common on the lips?

A

Squamous Cell Carcinoma (SCC) is Most Common on the Lower Lip

Basal Cell Carcinoma (BCC) is Most Common on the Upper Lip

Lips Cancers Are Most Aggressive if Along the Commissure

23
Q

What is your approach to management of the primary and the lymph nodes in oral or lip SCC?

A

Primary Treatment:
- Early-Stage (Stage I-II): Wide Local Excision (WLE)
Margin: 5-mm (Some Now Advising 1-mm as Sufficient)
Also Include Neck Management: Sentinel Lymph Node Biopsy (SLNB)

  • Advanced-Stage (Stage III-IV): Surgical Resection & Adjuvant Radiation
    Also Consider Adjuvant Chemotherapy
    Basic Indications: > 4 cm, Positive LN or Bony Invasion

Neck Management:
Early-Stage (Stage I-II): Selective Neck Dissection (SND) or Sentinel Lymph Node Biopsy (SLNB)
SND: Levels I-III, Possibly Level IV for Select Cancers
Advanced-Stage (Stage III-IV): Selective Neck Dissection (SND) or Modified Radical Neck Dissection (MRND)
*Neck Management is Evolving with Extent of Dissection Controversial

24
Q

What is the TNM staging for SCC lip/oral?

A

T1 = <2cm
T2 = 2-4cm
T3 = >4cm
T4 = invading other structures e.g. bone

N0 = no nodes
N1 = 1 ipsilateral <3cm
N2 = 1 ipsilateral >3cm or with extranodal extension OR multiple ipsilateral <6cm
OR bilateral/contralateral <6cm
N3 = >6cm

M1 = distant mets

25
Q

List some differentials for a parotid mass/enlargement.

A

Benign (more common than malignant 85% of parotid tumours are benign)
Neoplastic:
- pleomoprhic adenoma (most common benign tumour ~84%)
- warthins tumour
- cystadenoma
- lymphadenoma
- lipoma

Infective/inflammatory:
- siladenitis/silaolithiasis
- supparative parotiditis

Malignant
Primary
- mucoepidermoid
- adenoidcystic
- adenocarcinoma

Mets
- head and neck SCC
- melanoma

26
Q

What is a pleomorphic adenoma?

A

It is the most common tumour of the parotid gland. It is benign proliferation of epithelial and myoepithelial cells with chondromyxoid stroma.

Most originate from the superficial lobe.

They can have pseudopodia or satellite nodules making them high risk for recurrence. They do have a risk of malignant degeneration of 1.5% in 5 years and 10% in 15 years.

27
Q

How are salivary gland cytopathology specimens graded?

A

Using the Milan staging system:

Category: (risk of malignancy)
Category I: Nondiagnostic (25%)
Category II: Non-Neoplastic (10%)
Category III: Atypia of Undetermined Significance (AUS) (10-35%)
Category IV: Neoplasm
4i: Benign (5%)
4ii: Salivary Gland Neoplasm of Uncertain Malignant Potential (SUMP) (35%)
Category V: Suspicious for Malignancy (60%)
Category VI: Malignant (90%)

28
Q

What is the treatment of a pleomorphic adenoma?

A

Surgical excision with superficial parotidectomy (if in superficial lobe - 80-90% are in superficial lobe). Needs cuff of normal tissue due to propensity for local reccurrence due to pseudopodia or satellite lesions.

If it is in submandibular or sublingual this requires gland excision.

29
Q

What is the treatment of mucoepidermoid or other malignant salivary gland tumours?

A

Primary tumour:
- excision and adjuvant rtx
- Superficial/Lateral Parotid Lobe (Low-Grade & Small): > Superficial Parotidectomy
- Larger Tumors > May Require a Partial Deep-Lobe Resection
- If High-Grade or with Lymph Node Metastases: > Total Parotidectomy
- Deep Parotid Lobe: > Total Parotidectomy
- Submandibular Gland: Gland Excision with Level Ib Lymph Node Excision
Sublingual Gland: Wide Local Excision (WLE) with Level I Lymph Node Excision

Lymph nodes:
- Clinically Negative: Selective Neck Dissection (Controversial)
- Parotid Tumor: Levels I-IV
- Submandibular/Sublingual Tumors: Levels I-III
»If LN Positive: Modified Radical Neck Dissection (MRND)

  • Clinically Positive: Ipsilateral MRND
30
Q

What are some complications of parotid surgery specific to the parotid surgery (i.e. don’t list generic surgical complications)

A
  • Facial nerve damage or neuropraxia (often due to retraction and higher risk in deep or total parotid surgery)
  • Freys syndrome (gustatory sweating)
  • Great auricular nerve injury or neuropraxia (numbess of lower ear)
  • salivary fistula (usually self limiting, may require serial aspirations or anticholinergic).
31
Q

How do you preserve the facial nerve?

A

Taking care to meticulously dissect the superficial parotid gland off it and identifying it by retracting the parotid anteriorly, identifying the tragal pointer and locating the facial nerve trunk between the tragal pointer and the posterior belly of digastric.

The facial nerve is usually located 1cm anterior and inferior to the tragal pointer tip (unless pushed up by tumour). The other way to identify and preserve it is to follow the tympanomastoid suture line. This is the most consistent landmark to follow.

I also perform the surgery without the patient paralysed such that facial nerve movements can be monitored for with the addition of NIM stimulator.

32
Q

What are the branches of the facial nerve?

A

Two Zebras Bite My Cake

Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical

33
Q

What options are available during the operation if the facial nerve has been identified as cut.

A

If short segment then neurorraphy

If long segment then cable graft

Postoperatively need open disclosure and eye care to prevent exposure keratitis (eye patch, lubricating eye drops, artificial tears).

34
Q

What is Frey’s syndrome?

A

Ipsilateral gustatory sweating and flushing that occurs post parotid surgery.

This is due to abberant regeneration/reinnervation of the parasympathetic fibres to the parotid gland with the postganglionic sympathetic fibres of the sweat gland

(remember P for para and parotid, S for sympathetic and sweat)

Incidence 35%
Diagnose with iodine starch test
Treat with antiperspirant or neurectomy or botox if refractory or severe.

35
Q

What is meant by each of these terms;
1. selective neck dissection
2. radical neck dissection
3. modified radical neck dissection
4. therapeutic neck dissection
5. elective neck dissection
6. planned neck dissection
7. salvage neck dissection

A
  1. Removes Only the Lymph Node Levels at Highest Risk for Metastases (Levels Removed Depend on the Location of the Primary Tumor)
  2. Removes All Ipsilateral Cervical Lymph Node Levels I-V (Spares Level VI)
  3. Spares At Least One of (Compared to RND):
    Spinal Accessory Nerve (SAN/CN-XI) – Highest Morbidity of the Dissection
    Sternocleidomastoid Muscle (SCM)
    Internal Jugular Vein (IJV)
    Reduces the Morbidity from RND with No Difference in Mortality
  4. For Clinically Positive Metastatic Cervical Lymphadenopathy
  5. For Clinically Negative Metastatic Cervical Lymphadenopathy but Increased Risk of Occult Disease
  6. Done for High-Risk Residual Cancer 6-8 Weeks After Other Neck Treatment (Chemoradiotherapy)
  7. Done for Clinically Evident Metastatic Disease After Previous Treatment
36
Q

What is a central neck dissection?

A

Removes Cervical Lymph Node Level VI
Indications: Midline Cancers of the Anterior Lower Neck
Commonly Used for Thyroid Cancers

Technique

Retract the Strap Muscles Laterally
Skeletonize the Carotid Artery Along the Medial Border
Mobilize the Lateral Thyroid
Protect the Recurrent Laryngeal Nerve
Excise All Loose Areolar Tissue Between the Carotid Artery & Trachea
Superior Extent: Hyoid Bone
Inferior Extent: Suprasternal Notch
May Require Median Sternotomy if Deeper/Lower Disease is Evident
Thyroid/Parathyroid Tissue:
Thyroid Gland is Generally Resected as Part of the en Bloc Resection
Parathyroid Glands are Identified & Reimplanted
Complete on Contralateral Side if Indicated

37
Q

What is a branchial cyst?

A

If the pharyngeal clefts are not obliterated by the 2nd pharyngeal arch, they can persist into adulthood as branchial (pharyngeal) cysts.

They are typically located in the lateral aspect of the neck, arising at any point along the anterior border of the sternocleidomastoid muscle. These cysts may intermittently swell, particularly in association with upper respiratory tract infections.

Definitive treatment is surgical excision, but this is not indicated in all cases.

38
Q

What nerves are at risk during submandibular gland surgery? What do they supply?

A
  • Lingual nerve (runs lateral and then tucks under the submandibular duct to terminate medially to give branches to supply mucus membrane of anterior 2/3rd of tongue.
  • Marginal mandibular branch of facial nerve (Exits the anterior-inferior portion of the parotid gland at the angle of the jaw and traverses the margin of the mandible in the plane between platysma and the investing layer of deep cervical fascia curving down inferior to the submandibular gland where it provides motor innervation to muscles of the lower lip and chin).
  • Hypoglossal nerve (Lies deep to the submandibular gland and enables tongue movement. It controls hyoglossus, intrinsic, genioglossus and styloglossus muscles).
39
Q

What is the blood supply to the submandibular gland?

A

facial and lingual arteries from external carotid.

40
Q

Describe the structure of the submandibular gland.

A

They are paired irregularly shaped glands ~3-4cm in length dived into a larger superficial part and smaller deep part by the mylohyoid muscle. They are situated in submandibular triangle in the submandibular fossa in the medial aspect of the body of the mandible. They give off a single duct (whartons duct) that terminates in lingula frenulum in 1-3 openings.

41
Q

Describe the course of the submandibular duct.

A

The duct starts on the medial surface of the superficial part of the submandibular gland behind the posterior border of the mylohyoid muscle. Initially, the duct continues upward and slightly posteriorly to form the genu of the duct which curves around the free edge of mylohyoid. Subsequently, the duct continues anteriorly to pass between hyoglossus and mylohyoid, then between genioglossus and sublingual gland. It eventually emerges from the sublingual papilla, adjacent to the lingual frenulum on either side of the floor of the mouth.

Another important fact about the submandibular duct is that it is crossed twice by the lingual nerve along its course

FRACS 2024 (18 decks)

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