Head and Neck Flashcards
Neck structures anterior to posterior beneath clavicle
Subclavian Vein Phrenic nerve Anterior Scalene Subclavian Artery Middle Scalene Long Thoracic
Anterior Triangle
Midline of neck
Ant SCM
Apex: Sternal notch
Base: Lower border of body of mandible
Posterior Triangle
Post SCM
Trapezius muscle
Middle third of clavicle
What does anterior triangle contain?
Carotid Sheath - common carotid, internal jugular, vagus nerve
What does posterior triangle contain?
Spinal accessory nerve
Brachial plexus
What is recurrent laryngeal a branch of?
Vagus
R Recurrent laryngeal route
Vagus ant to subclavian artery -> then recurrent laryngeal wraps behind subclavian to tracheoesophageal groove
What innervates the cricothyroid muscle?
Superior laryngeal nerve
L Recurrent laryngeal route
Vagus runs anterior to aortic arch btw cca and subclavian -> then recurrent laryngeal wraps behind around arch and up to tracheoesophageal groove
What happens if you cut the superior laryngeal nerve?
Difficulties with tone, hitting high notes
Squamous cell of neck
5th most common cancer
Men to women 5:1
Alcohol/Tobacco synergistic risk factors
HPV risk factor
Local squamous cell with no + nodes, no distant mets
Stage I and II
Locally agressive III or distant mets squamous IV
Stage III and Stage IV
Stage I and II
Tumor board
Wide local exicision if resectable
Radiation if non resectable
Stage III and IV
Multimodality
Surgery (local excision with modified radical neck dissection) + Radiation and/or Chemo
Oral squamous cell size cut offs?
4 cms or node involvement/bone invasion
Need: Surgery (local excision with modified radical neck dissection) + Radiation
More malignant salivary tumors smaller glands or larger glands?
Smaller more malignant (submandibular)
Larger more benign (Parotid)
MC malignant salivary tumor
Mucoepidermoid cancer
MC benign salivary tumor
Pleomorphic adenoma
Mucoepidermoid cancer treatment
“Resection” + total parotidectomy + facial nerve preservation + “modified radical neck dissection” on that side + “post op radiation”
Adenoid cystic tumor - treatment
Resection + modified radical + post op radiation
Adenoid cystic treatment if invading facial nerve
Just radiation - sensitive to it
Palpable lymph node -> biopsy -> malignant, can’t find primary, what do you do
Head and neck exam Fiberoptic nasopharynx/larynx FNA of any nodes available CTA head neck chest +/- PET OR regardless of finding something: Direct laryngoscopy, esophagoscopy, IPSILATERAL TONSILLECTOMY (MC site) base of tongue is second MC, modified radical; bilateral xrt
How to biopsy melanoma
Punch or exicisional biopsy, not shaved
Margins of melanoma
1 cm margin for lesions < 1 mm in depth
2 cm margin for lesions > 1 mm in depth
Adjust margins if abutting facial nerve
Confirm negative margins prior to reconstruction -> mohs
Lymphadenectomy of melanoma -> how determine where nodes are
Get lymphosyntigraphy -> then do modified radical neck etc
Sentinel nodes for melanoma
If clinically node negative then for > 1 mm in depth
If primary lesion anterior to tragus line
Drains anterior to parotid basin
Do superficial parotidectomy and anterior lymph node basin dissection
If primary lesion posterior to tragus line
Drains posterior to parotid basin
Do superficial parotidectomy and posterior lymph node basin dissection
Melanoma adjuvant therapy
INF-Alpha -> especially if mets
Salvage radiation therapy -> esp if regional positive nodes
Monoclonal antibodies/oncogene inhibitors
Painless mass on roof of mouth
Toris pallatinus - overgrowth of cortical bone
Tx: Nothing, unless interferes with dentures -> resect
Oral cavity cancer MC site
Lower lip
Reconstruction for lower lip if:
> 50% of lip resected need flap reconstruction
EBV
Nasopharyngeal squamous cell
Tx: primary radiation
Tx for pleomorphic adenoma
superficial parotidectomy
Gustatory sweating
Frey’s syndrome
Injury to auriculotemporal nerve -> cross innervates with facial nerve fibers
Post op fever, pain, large swelling at angle of jaw
Suppurative parotiditis
Staph aureus
Antibiotics, possible I and D if abscess
Post op from tracheostomy -> bleeding from site
Tracheoinominate fistula
Tx: Place finger in tracheostomy and hold finger against sternum, take to OR, median sternotomy w/ resection of inominate, close hold in trachea with strap muscle flap (DO NOT place synthetic graft, do not reconstruct)
Parotid gland function
Secretes mostly serous fluid
Sublingual Gland function
Secretes mostly mucin
Submandibular gland function
50/50 serous/mucin
Laryngeal/tracheal anatomy
- Where are false cords related to true cords
- What makes up the trachea
- False cords are superior to true cords
- Trachea has U shaped cartilage anterior, and membranous portion posterior
Relation of nerves to other structures
- Vagus in carotid sheath?
- Phrenic?
- Long thoracic?
- Vagus is btw medial CC and lateral IJ and is more post in sheath
- On top of anterior scalene musc
- Post to middle scalene
CN head/neck functions
- CN V trigeminal
- CN VII Facial
- CN IX glosspharyngeal
- CN XII hypoglossal
- CN V = sensation to face; motor to muscles of mastication, motor corner of mouth (Marg mand nerve); taste ant 2/3 tongue
- CN VII = temporal, zygomatic, buccal, mm, cervical branches motor
- CN IX = taste to post 1/3 tongue, motor stylopharg, involved in swallowing
- CN XII = motor to tongue
Neck nerve functions
- Recurrent laryngeal
- Superior laryngeal
- Recurrent laryngeal - Motor to strap muscles except cricothyroid
- Sup laryngeal - Cricothyroid
Frey’s syndrome
Symptom - gustatory sweating
After parotidectomy -> injured auriculotemporal nerve cross innervates with sympthetic sweat glands of skin
Thyrocervical trunk arteries?
Suprascapular
Transverse cervical
Ascending cervical
inferior Thyroid
External carotid branches?
Some anatomists like freaking out poor medical students
S: superior thyroid artery. A: ascending pharyngeal artery. L: lingual artery. F: facial artery. O: occipital artery. P: posterior auricular artery. M: maxillary artery. S: superficial temporal artery.
Which artery is responsible for blood supply to trapezius flap?
Transverse cervical
Which two areteries are responsible for blood supply to pect major flap?
Internal mammary
Thoracoacromial artery
Torus palatini
Congenital bony mass in upper palate of mouth
Tx: Nothing
Torus mandibular
Congenital bony mass on lingual surface of mandible
Tx: Nothing
What does a modified radical neck dissection involve?
Omohyoid, submandibular gland, C2-C5 sensory nerves, cervical branch of facial, ipsilateral thyroid
No MORTALITY diff when compared with radical dissection
What does a radical neck dissection involve?
MRND + CN XI, SCM, IJ resection
Head and neck chemotherapy?
5FU and cisplatin
MC oral cavity cancer
Squamous cell
- # 1 RF oral cancer
Tobacco, EtOH
(separately there is inc risk in people with Plummer-Vinson Syndrome
MC site for oral cavity cancer
Lower lip
Which tumors have the lowest survival rates
Hard palate tumors -> difficult to resect
Oral cavity cancer treatment
Wide resection (1 cm margin)
MRND for tumors > 4cm, positive nodes, bone invasion
Postop XRT if > 4cm, + nodes, bone invasion
Lip CA
Tongue CA
Maxillary sinus CA
Tonsillar Ca
L - Commissure is more aggressive (flap if >1/3 removed)
T - Commando procedure if jaw invasion
M - Maxillectomy
T - Tonsillectomy (80% have LN mets by diagnosis)
Nasopharyngeal SCCA
- Etiology
- Nodal mets to…
- Tx:
- Misc facts
Eti: EBV; usually Asian; presents with nose bleed/obstruction
Nodal mets to posterior cervical nodes
Tx: XRT primary tx
Misc: Lymphoma is MC NP cancer in kids; Papilloma is MC benign neoplasm of nose/paranasal sinuses
Oropharyngeal SCCA
- Symptoms
- Nodal mets to….
- Tx:
- Misc facts
- Sx: Neck mass, sore throat
- Nodal mets to post cervical nodes
- Tx: XRT for tumors < 4 cm w/o nodes/bone invasion
- Tx: Wide res/MRND/XRT for > 4 cm/nodes/bones
