Head and Neck

Question 1

the ATA defined the boundaries of level VI and VII nodes

Answer 1

superiorly : hyoid bone
laterally : the carotid arteries
anteriorly : superficial layer of the deep cervical fascia
posteriorly : deep layer of the deep cervical fascia

and the innominate artery on the right and its corresponding axial plane on the left inferiorly.

Question 2

the second most common congenital neck mass after thyroglossal duct cyst

Answer 2

Branchial cleft anomalies

Question 3

Branchial cleft anomalies arise from ?

Answer 3

aberrant development or incomplete obliteration of the external clefts and internal pouches that develop from the 6 mesodermal arches

Question 4

Describe each branchial arch with its structures

Answer 4

The first arch : the middle ear, eustachian tube, and external auditory canal

The second arch : lining of the palatine tonsils.

The third arch : inferior parathyroid glands and the thymus.

The fourth arch : superior parathyroid glands and C-cells of the thyroid.

Fifth Arch Nothing

Question 5

What is the MC Branchial cleft anomaly

Answer 5

BCAs arising from the second arch are the most common, accounting for 70 to 90%.

Question 6

describe the course tract of BCA from second arch

Answer 6

anywhere along a tract arising from the tonsillar fossa,

running by the glossopharyngeal and hypoglossal nerves, coursing between the internal and external carotids
and ending at the anterior border of the sternocleidomastoid

Question 7

How do they Present and Diagnosis and TX

Answer 7

manifest in the third to fifth decade as cysts
presenting as a nontender, soft mass lying deep to the sternocleidomastoid

Ultrasound > round mass of uniform low echogenicity
CT and MRI > may be used
FNA > to rule out malignancy

complete surgical excision of the cyst or tract is the therapy of choice

Question 8

Post Sentinel LNB Right Upper Back

Answer 8

Shoulder syndrome secondary to spinal accessory nerve (SAN; 11th cranial nerve) injury

Question 9

SAN injury impairs motor function to the trapezius muscle leading to

Answer 9

weakness of shoulder abduction
drooping of the shoulder

Other symptoms and signs include shoulder pain and stiffness and winging of the scapula.

Question 10

Coarse of SAN

Answer 10

exits the skull through the jugular foramen
pierces the sternocleidomastoid muscle
innervates it
runs lateral to it
is close to the greater auricular nerve
(which is a sensory nerve and can serve as a landmark for surgeons to find the SAN)

Then through the posterior triangle (level V) ends by innervating the trapezius

Question 11

Most Common Parotid Tumor

Answer 11

-Pleomorphic adenomas
usually benign
diagnosed on FNA
low chance (3-10%) of occult malignancy
Malignant transformation more likely if the pleomorphic adenoma recurs

Question 12

What is the Tx

Answer 12

Superficial parotidectomy without node dissection

low risk of facial nerve injury

Question 13

the second most common parotid tumors ?

Answer 13

Warthin tumors (monomorphic adenomas)

often seen in older patients, men, and smokers, and they are often bilateral

Question 14

The most common midline mass in a child ?

Answer 14

Thyroglossal duct cyst
a remnant from the migration of the thyroid.

Question 15

when postintubation tracheal stenosis develops ?

Answer 15

PITS will usually develop within 3 to 6 weeks

Bronchoscopy with dilation is the initial recommended treatment for acute symptoms of PITS
Otherwise if Stable one Stage Resection anastamosis
suprahyoid laryngeal release provide additional 1.0 to 1.5 cm for Repair if needed

Question 16

Level IA nodes

Answer 16

submental region
drain the floor of the mouth, anterior tongue, anterior mandibular alveolar ridge, and lower lip.

Question 17

Level IB nodes

Answer 17

submandibular region
drain the oral cavity, anterior nasal cavity, midface, and submandibular gland.

Question 18

Level II nodes

Answer 18

IIA (anterior to spinal accessory nerve)
IIB (posterior to spinal accessory nerve)

drainage to oral and nasal cavities, nasopharynx, oropharynx, hypopharynx, larynx, and parotid gland.

Question 19

Level III nodes

Answer 19

mid jugular nodes
drain the oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.

Question 20

Level IV nodes

Answer 20

lower jugular nodes
drains the hypopharynx, thyroid, cervical esophagus, and larynx.

Question 21

Level V nodes

Answer 21

in the posterior triangle
VA (superior to level of cricoid)
VB (inferior to level of cricoid)
drains the nasopharynx, oropharynx, and skin and soft tissue of the posterior scalp and neck

Question 22

Level VI

Answer 22

pretracheal and paratracheal nodes
drainage to the thyroid gland, glottis and subglottic larynx, apex of the piriform sinus, and cervical esophagus.

Question 23

For neck Mass, If FNA demonstrates carcinoma but a primary site is not identified on physical exam

Answer 23

-laryngoscopy
-esophagoscopy
-bronchoscopy
-CT scan of the neck with intravenous contrast will identify the primary source of malignancy in a patient with a neck mass believed to be associated with a head and neck malignancy.

Question 24

in Zenker Diverticulum Barium will show

Answer 24

barium-filled diverticulum at the level of the
cricothyroid cartilage

Question 25

Ultrasound of the neck can confuse a diverticulum with a thyroid nodule, What indicates Zenkers ?

Answer 25

If air is seen in the cystic structure, then a diverticulum must be considered instead of a thyroid nodule.

Question 26

Features Support Non Operative Management for Tracheal Injury

Answer 26

-injuries 4 cm or smaller
-involve less than one-third of the circumference
-wound edges that are well opposed
-do not show significant tracheal tissue loss.
-hemodynamically normal
-without an associated esophageal injury
-without signs of sepsis

Question 27

Tracheal Injury and Incision Site

Answer 27

cervical injuries > transverse collar incision 2 cm above the sternal notch +- Sternotomy

injury 2 to 3 cm from the carina > right posterolateral thoracotomy fourth or fifth intercostal space

injury is distal to the carina on the lef > left posterolateral thoracotomy fifth intercostal space