HEAD AND NECK

Question 1

Differential diagnoses for neck mass

Answer 1

Infectious processes
(laryngitis or thrush),

congenital anomalies
(laryngocele),

autoimmune diseases
Wegener’s granulomatosis,
sarcoidosis,
amyloidosis

Question 2

work up for neck mass

Answer 2

operative
direct laryngoscopy,
esophagoscopy
Laryngoscopy

CT scan

+/- PET

with biopsies under general anesthesia for treatment planning

confirm absence of a second primary tumor (up to 10% of patients).

Question 3

patient presents with regional metastasis in the neck without evidence of primary tumor location

Answer 3

thorough head and neck exam, including

fiberoptic nasopharyngoscopy and laryngoscopy,

A fine needle aspiration biopsy of the neck mass should be performed, either directly or with ultrasound guidance,

A contrast-enhanced CT of the neck and chest including the skull base

If no primary tumor is identified with anatomic (CT) imaging, PET scanning may aid in diagnosis.

operating room

direct laryngoscopy,

esophagoscopy,

tonsillectomy (if tonsils are present),

biopsies directed by the previous workup.

Question 4

The most common sites for an unknown primary with neck node

Answer 4

MOST common:
tonsils
tongue base,

followed by:
nasopharynx
hypopharynx.

Question 5

Tx options for early stage (I, II) disease.

Answer 5

Treatment According to the AJCC guidelines,

surgery

OR

RADIATION therapy

tumors are limited in their extent,

no evidence of regional or distant metastasis.

Question 6

Tx options for advanced disease

Answer 6

Multimodality treatment is necessary

stage (III, IV) disease,

locally aggressive
or
have metastasized.

surgery
adjuvant radiation OR chemoradiation.

followed every 1 to 3 months for the first year,

every 2 to 4 months for the second year,

every 4 to 6 months until the fifth year.

At this point, the patient is considered to be cured of disease and can follow up yearly or on an as-needed basis.

A key factor in oncologic surveillance is to encourage patients to be seen early if they develop new pain (or worsening pain) at the primary site, new otalgia, dysphagia, odynophagia, hoarseness, significant weight loss, hemoptysis, or hematemesis.

Case Conclusion The patient was staged as a T3N1M0 (stage 3) squamous cell cancer of the supraglottic larynx.

Options for chemoradiation versus primary surgery with postoperative radiation were discussed.

The patient successfully underwent surgical excision of his tumor with total laryngectomy, bilateral selective neck dissections of levels II to IV, cricopharyngeal myotomy, tracheoesophageal puncture for later speech rehabilitation, and placement of a temporary Dobhoff feeding tube.

Question 7

Branches of the facial nerve

Answer 7

Temporal 
zygomatic 
 buccal 
mandibular 
cervical

Question 8

Potential complications of parotidectomy

Answer 8

Salivary fistula:
Increase amylase and drainage for example 15,000
parotid duct tail prob the source

Manage:
NPO five days
Dobhoff tube

Frey syndrom:
Inappropriate connection of (para?!) sympathetic aprocrine nerves with the facial nerve causes gustatory sweating

Management:
Botox is now standard
used to try interposition

Question 9

Operative location of the facial nerve

Answer 9

One cm anterior and inferior to the tragus point

Crosses the post to your belly of the digastric

Crosses the mastoid process

Exits the styoid mastoid foramena