Head and Neck Flashcards
DDx Cervical Lymph Node?
Infection, Lymphoma, Mets
HPI for Cervical Lymph Node?
URI, sore throat, TB exposure
HIV, B symptoms
h/o cancer, XRT, thyroid sx, previous surgeries
Imaging for Cervical Lymph Node?
CXR infectious or malignant if positive get CT neck and chest
US guided FNA
PET if recurrent dz or met activity
What is Tx based on for a Cervical Lymph Node?
Benign (clear h/o sore throat or URI)-
observe for several weeks possible ABX and if persist w/u and remove
Lymphoma (can be dx based on FNA but still needs excision for final path confirmation),
stage it! CT N/C/A/P + BM bx (stage 4)-> CHOP
SCC- (See below for more exhaustive detail)
(2 Tests before any surgery!) CXR and Panendoscopy, CT H&N, if found excise primary site and MRND and 5000 rads
if still negative put patient to sleep -> direct laryngoscope c random bx of suspicious tissue (nasopharynx, base of tongue)
nothing - assume is mets and perform a radical neck dissection and give 5000 rads to entire neck
adenocarcinoma from (Broad-thyroid, lung, breast, salivary glands, prostate, GI) -
EXTENSIVE w/u all and if none is found including ER/PR and Mucin -> MRND, give 5000 rads (entire neck?) XRT and follow
if primary is found = Stage 4 dz and chemo may be offered
Describe a MRND?
create skin subplatsymal skin flaps
locate and protect mandibular (parallel to lower border of mandible) and cervical branches when creating superior flap
commence in posterior triangle anterior to trap removing areolar and lymphatic tissue
divide external jugular vein ) posterorinferior corner of dissection)
attempt to save the spinal accessory nerve unless involved with tumor
continue along anteriorly superiorly to the clavicle
ID phrenic nerve on anterior scalene b/w brachial (laterally) and IJV (medially and inside the carotid sheath ligate close to clavicle and avoid thoracic duct left side) , severing the omohyoid muscle to to provide better exposure and dividing SCM
divide anterior facial vessels as dissection heads superiorly
ID hypoglossal crosses 1 cm above the carotid bifurification
also ID lingual nerve and salivary duct to facillitate removal of submental and submandibular triange
remove contents of sub mental and submandibular triangles
Ligate submax duct
leave drains
Neck Mass DDX?
LN, primary neck tumor, congenital mass, sarcoidosis
Neck Mass HPI?
Hx- Very Important ! age of patient, duration, location, palpation
age
Hx- smoker, previous cancers, surgeries, URI, B symptoms, XRT
Neck mass Significance of age, location and timing
age
young patients- congenital, lymphadenitis, leukemias and lymphoma
middle aged- lymphoma, primary neck tumors
Elderly-Neoplastic
Location
over LN- enlarged LN,
Carotid bifurication- carotid body tumor
over anterior border of SCM- branchial cyst;
midline above thyroid- Thyroglossal cyst
midline, submental and firm- dermoid cyst
Posterior triangle, cystic- cystic hygroma
duration
few weeks- infectious vs few months to years - congenital or neoplastic
Neck mass PE?
PE- complete H&N, ENT, skin lesions, scars, LNs, liver & spleen, B sx,
how it feels, color
Neck mass test? and Labs?
U/S - cystic? solid?
FNA if vascular –> MRI
still no then pan-endoscopy (bronch, upper endoscopy, colonoscopy)
CXR, abdominal CT, PET
labs- CBC, +-TFT, calcitonin, calcium
if lymphoma needs core or excisional biopsy
Older age and + risk factors- CT H&N
Treatment of congenital neck tumors?
Congenital- usually young
Carotid body tumors, ganglionomas, schwanommas, cystic hygroma (posterior triangle, young), teratoma, branchial cyst = Tx local excise
Hemangioma -Observe; capillary or cavernous, AVMs—>embolize then excise
Branchial Cleft Cyst
1st cleft- open at angle of mandible, passes through facial nerve
2nd cleft- open anterior of the SCM passes b/w carotid bifurication
3rd cleft- open at lower border of SCM, passes behind carotid
Thyroglossal cyst (if infected, growing or concerned)—>sistrunk procedure
(transverse incision over mass, dissect off strap muscles, follow sinus tract down to base of tongue, include middle hyoid bone c specimen)
Treatment of cancer and sarcoidosis of the neck?
Cancer (mostly elderly patients)
Adenocarcinoma, SCC, BCC, sarcoma, melanoma (Needs SLNB), Testicular = resection of primary (if known) +- MRND, XRT
Lymphoma = staging CT scan, BM bx= stage I,II ->XRT; stage III,IV —>CHOP
Sarcoidosis
young black female c joint pain, CXR (b/l patchy), path - noncaseating granuloma, Tx- Steroids
RF for SCC of the Oropharynx
RF- ETOH, Smoking, other lesions removed
PE for SCC of the Oropharynx
Bimanual palpation, visual inspect, indirect laryngoscopy, LN
Staging and treatment for those stages of SCC of the Oropharynx
Stage 1 = 5 mm margins
Stage 2 = 2-4cm —>1 cm margins
Stage 3 = >4cm or node positive wide margins >1cm , MRND, 5000 rads
Stage 4 = distant mets- neoadj chemo and radiation
For stage 1 or 2 single modality surgery or radiation depending on how accessible it is (ex vocal cords) anterior vs posterior
If lesion not accessible (oral posterior, tonsils) then 6000 Rads and rebiopsy for residual tumor
Stage 3 or 4 combined modality (if involved LN to neck should get XRT to ENTIRE neck)
Treatment for SCC of the Oropharynx
For stage 1 or 2 single modality surgery or radiation depending on how accessible it is (ex vocal cords) anterior vs posterior
If lesion not accessible (oral posterior, tonsils) then 6000 Rads and rebiopsy for residual tumor
Stage 3 or 4 combined modality (if involved LN to neck should get XRT to ENTIRE neck)
consider doing just agree full thickness skin graft behind ear or base of neck
wedge resection of lip c 0.75 - 1 cm margins if total less 1/3 of length of lip if larger than advancement flap
XRT
medial canthus of eye or nose
5000 rads if close margins
Salivary Gland PE and HX?
mass at angle of mandible in front of ear
not tender or is it painful?, no smoking
PE if roll mass over the mandible if it sinks under likely a LN
assess facial nerve function! (runs right in b/w the parotid)
Salivary Gland testing?
FNA differentiate epithelial vs non epithelial
epithelial (Mixed, Warthin, Adenoma) vs non epithelial (cyst, LN, Hemangioma, Lipoma) —>get a high res US
Salivary gland imaging?
CT scan- det depth, size, invasion, LN enlarged
Salivary gland surgery?
Superficial parotidectomy c FS (low or high grade?)
malignant low grade- total parotid +- post op XRT
malignant high grade- radical parotid +MRND +postop xrt
Salivary gland consent?
Superficial Parotidectomy
preop consent- facial nerve injury, Freys syndrome, salivary fistula
Borders of a parotid gland resection?
Anatomic borders of parotid:
ant- mandibular rami
post- tympanic portion of temporal bone and mastoid process,
sup by external acoustic meatus, zygomatic arch, TMJ.
Describe a parotidectomy for salivary gland tumor?
- Don’t use paralytics, and have nerve stimulator
- Preauricular incision following angle of mandible (Mod Blair)
- Raise subplatysmal flaps
- Identify and save main trunk of greater auricular nerve divide branches that go into parotid
- Divide posterior facial vein but save retromandibular vein (prevents venous engorgement)
- As dissection cont anteriorly peripheral branches of facial nerve appear. Dissect superficial to them and spare them!
- Mobilize anterior border of SCM develop plane b/w muscle and mastoid
divide the temporoparotid fascia - Expose main trunk of facial nerve inferior to membranous portion of external auditory canal. (styloid process is deep and post belly of digastric is superficial)
- Trace trunk of facial nerve into parotid and dissect branches distally.
- Remove superficial lobe of parotid by dissecting in plane of nerve. (Nerve is b/w superficial and deep lobe)
Send frozen and if benign you are done
II. Close over drain.
Malignant Salivary gland parotid treatment?
Tumor adherant to nerve?
Massive tumors involving facial nerve with paralysis pre op?
suspicious nodes or high grade lesion?
Malignant-Complete conservative parotidectomy (spare facial nerve and branches)
-Tumor adherent to nerve- dissect off nerve and radiation 5000-6000 gy
-Low grade tumor involving portion of facial nerve treat with subtotal parotidectomy with preservation of uninvolved branches
-Massive tumors involving facial nerve with paralysis pre op can sacrifice nerve.
If nerve worked preop then attempt nerve graft -
MRND if suspicious nodes or high grade lesion they tends to metastasize.
ID facial nerve in Salivary gland tumor?
ID facial nerve -
ext auditory canal cartilage (Superficial) - nerve is 1 cm deep and inf to the tip
posterior belly of digastrics m (Superficial )- nerve is deep to it
Styloid process (d
eep)- nerve is superficial to it
facial n branches and treatment for severed?
facial n branches- The Zebra Bit My Cat - temporofrontal (eye brow lift procedure), Zygomatic (lateral torsoraphy to close eye), Buccal (nothing, min dysfunction), Mandibular (need to sever contralateral if injured) Cervical (platsyma)
facial injured- c/s PRS immediate repair, microscope, collagen tube c silicone glue 10 prolene
Frey Syndrome?
Freys Sx- rarely needs tx, botox, raise flap of skin and put facia or allured under the flap
Thyroid Nodule (palpable) ddx?
DDx- cyst, adenoma, hyperplastic nodules, thyroiditis, cancer papillary, follicular, medullary, Hurthe, anaplastic
Thyroid Nodule (palpable) PE
PE-Have pt swallow, does it move up and down c thyroid cartilage (thyroglossal duct cyst moves up and down c swallowing as well as tongue protrusion), compressive sx, mobility, size, LNs, hard, fixed, Phebertons sign (facial plethora, neck vein distension, dyspnea thoracic inlet obstruction)
>1 cm nodule is significant
Thyroid Nodule (palpable) HPI?
Hx- h/o XRT, FHx, Thyroid hx, onset of sx, dysphagia, dysphonia, hoarseness, MTC (diarrhea/flushing), hyper/hypothyroid sx, Thyroiditis (Cold, cough,URI)
rapid growth and new onset hoarseness- concerning
