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ENT > Head and Neck Oncology/Anatomy > Flashcards

Head and Neck Oncology/Anatomy Flashcards

6
Q

Ways to locate the facial nerve are…

A
  1. Tragal pointer: the facial nerve may be located 1 cm medial,inferior, and deep from tragal cartilage
  2. Tympanomastoid Suture Line: the facial nerve is 6–8 mm deep to the inferior end of the tympanomastoid suture line
  3. Digastric Attachment to Digastric Ridge: identifies the plane of the facial nerve
  4. Retrograde Dissection from Distal Branches: may be required in select cases
  5. Styloidmastoid Foramen: may identify the main trunk
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20
Q

What are the layers of the SCALP?

A
  • S - Skin
  • C - Close connective tissue & cutaneous vessels & nerves.
  • A - Aponeurosis (epicranial aponeurosis)
  • L - Loose connective tissue (scalping layer, “Danger Zone”)
  • P - Pericranium (periosteum of skull bones)
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26
Q

Lymph node levels of the neck

A
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27
Q

List the branches of the external carotid artery

A

SALFOPMS

  1. Superior thyroid artery
  2. Ascending pharyngeal artery
  3. Lingual artery
  4. Facial artery
  5. Occipital artery
  6. Posterior auricular artery
  7. Maxillary artery (terminal)
  8. Superficial temporal artery (terminal)
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28
Q

List the segments of the internal carotid artery

A

Please Let Children Consume Our Candy (intracranial branches)

  1. Cervical segment - C1
  2. Petrous segment - C2
  3. Lacerum segment - C3
  4. Cavernous segment - C4
  5. Clinoid segment - C5
  6. Ophthalmic - C6
  7. Communicating - C7
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29
Q

Contents of the superior orbital fissure

A

Live Frankly To See Absolutely No Insult (Lacrimal, Frontal, Trochlear, Sup div oculomotor, Abducens, Nasociliary, Inferior div of oculomotor)

  • oculomotor nerve (III)
  • trochlear nerve (IV)
  • lacrimal, frontal and nasociliary branches of ophthalmic (V1)
  • abducens nerve (VI)
  • superior and inferior divisions of ophthalmic vein
  • sympathetic fibers from cavernous plexus
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30
Q

Where is the foramen rotundum?

A

In the sphenoid bone, connecting middle cranial fossa to pterygopalatine fossa.

Contains the V2 branch of the trigeminal nerve (Standing Room Only)

Best seen on CORONAL CT

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31
Q

Where is the foramen ovale?

A

Located in posterior sphenoid bone, posteriolateral to the foramen rotundum.

Contains the V3 branch of trigeminal nerve (Standing Room Only), accessory meningeal artery, lesser petrosal nerve (to parotid), emissary veins, otic ganglion.

OVALE - Otic ganglion, V3, Accessory meningeal artery, lesser petrosal nerve, emissary veins

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32
Q

What traverses the foramen spinosum?

A

middle meningeal artery (cause of epidural hematoma)

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33
Q

What traverses the foramen lacerum?

A
  • internal carotid artery
  • greater petrosal nerve
  • branch of ascending pharyngeal artery
  • emissary viens from extracranial pyerygoid plexus to inctracranial cavernous sinus

This is a route for nasopharyngeal carcinoma to gain access to the cavernous sinus

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34
Q

Where is the vestibular aqueduct?

A

Contains tubular prolongation of the membranous labyrinth, the ductus endolymphaticus, which ends between the layers of the dura mater

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35
Q

What traversus the jugular foramen?

A

Usually larger on the right*

  • Glossopharyngeal nerve (9)
  • Vagus nerve (10)
  • Spinal Accessory Nerve (11)
  • Sigmoid sinus (becoming IJ)

Anteriorly - pars nervosa - contains Jacobson nerve (9)

Posteriorly - pars vascularis - contains CN10, 11, Arnolds nerve (10), jugular bulb, ascending pharyngeal artery

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36
Q

What is Vernet’s syndrome?

A

Damage to jugular foramen, which can lead to paresis of CN 9/10/11, i.e.

  • Glomus tumors (most frequent)
  • Meningiomas
  • Schwannomas
  • CPA tumors
  • Trauma
  • Infection
  • Cholesteatoma
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37
Q

What is Arnold’s reflex?

A

Stimulation of the Arnolds nerve (auricular branch of CN 10) leading to cough

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38
Q

Where is the vidian canal?

A

AKA Pterygoid canal

  • Just anterior to foramen lacerum in the MCF to the pterygopalatine fossa
  • Contains the nerve of the pterygoid canal, artery of the pterygoid canal, and vein of the pterygoid canal
  • Carries parasympathetics from the FN
  • Carries sympathetics from deep petrosal nerve
  • Innervates the nose, palate, lacrimal gland
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39
Q

Describe Paragangliomas of the head and neck

A

Rare tumors

Can cause Vernet syndrome

  1. Carotid body tumor - located at the carotid body, splaying the bifurcation. Most common paraganglioma of the HN
  2. Glomus tympanicum - confined to middle ear, arise from inferior tympanic branch of CN 9, or Jacobsons nerve. Second most common
  3. Glomus Jugulotympanicum - extends between the cochlear promontory and jugular foramen. Arises from Arnolds nerve (CN 10)
  4. Glomus jugulare - confined to jugular foramen, extends to middle ear
  5. Glomus vagale - arise from CN 10, least common
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40
Q

Describe radiologic features of paragangliomas

A

CT

  • Bony erosion
  • Moth eaten pattern
  • Lyre sign - splaying of ICA and ECA by carotid body tumor

MRI

  • T1 may show “salt and pepper” appearance

Angiography

  • Intense tumor blush, with ascending pharyngeal artery feeding tumor
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41
Q

What is Lyre sign?

A

From Carotid body tumor splaying ICA and ECA

Seen on angiography or CTA

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42
Q

Describe the relationship of the dural venous sinuses

A

This is important because a sigmoid sinus thrombosis, as can be seen in COME, can lead to a cavernous sinus thrombosis via the superior and inferior petrosal sinuses

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43
Q

What are the major subsites of the oral cavity?

A
  1. Lips
  2. Anterior tongue
  3. Floor of mouth
  4. Buccal mucosa
  5. Upper/lower alveolar ridges
  6. Hard palate
  7. Retromolar trigone

Often spread to levels 1/2/3

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44
Q

What are the major subsites of the oropharynx?

A
  1. Tonsil
  2. Base of tongue
  3. Soft palate
  4. Pharyngeal walls

Often spread to levels 2/3, but also can spread to retropharyngeal nodes (differentiates from oral cavity)

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45
Q

What are the indications for post operative chemoradiation in head and neck cancer?

A
  1. positive margins
  2. multiple involved lymph nodes
  3. extracapsular tumor extension
46
Q

What are the major subsites of the hypopharynx?

A
  1. Pyriform sinuses
  2. Post-cricoid region
  3. Pharyngeal walls

Often spreads to levels 2-4 and retropharyngeal nodes

Also can have submucosal spread and skip lesions

47
Q

What are the major subsites of the larynx?

A
  1. Supraglottis (FVF, aryteniods, epiglottis, AE folds)
  2. Glottis (TVF, ant commissure, post commissure)
  3. Subglottis (glottis to 1st tracheal ring)

Between the thyroid cartilage and the vocal cord lies the paraglottic space, which is continous with the pre-epiglottic space. This serves as a pathway for submucosal spread of tumors from glottis to the supraglottis, and vice versa (transglottic)

Subglottic tumors tend to metastasize to paratracheal nodes (level 6)

48
Q

AJCC Staging of Oral Cavity

A

Definition:

The anterior borderisthe junction of the skin and vermilion border of the lip. The posterior border isformed by the junction
of the hard and soft palatessuperiorly, the circumvallate papillae inferiorly, and the anterior tonsillar pillars laterally

TX Primary tumor cannot be assessed.
T0 There is no evidence of primary tumor.
Tis Carcinoma isin situ.
T1 Tumor is 2 cm or lessin greatest dimension.
T2 Tumor is more than 2 cm but not greater than 4 cm in
greatest dimension.
T3 Tumor is more than 4 cm in greatest dimension.
T4 (lip) Tumor invades through cortical bone, inferior alveolar
nerve, floor of mouth, orskin of face—i.e., chin or nose.
T4a (oral cavity) Tumor invades adjacentstructures(e.g., through cortical bone, into deep [extrinsic] muscle of tongue
[genioglossus, hypoglossus, palataglossus, and styloglossus], maxillary sinus,skin of face).
T4b Tumor invades masticator space, pterygoid plates, or skull base and/or encasesthe internal carotid artery.

49
Q

AJCC Staging of Oropharynx

A

Definition:

The oropharynx includesthe base of the tongue, the inferiorsurface of the soft palate and uvula, the anterior and posterior

T1 Tumor is 2 cm or lessin greatest dimension.
T2 Tumor is more than 2 cm but not more than 4 cm in greatest
dimension.
T3 Tumor is more than 4 cm in greatest dimension.
T4a Tumorinvadesthe larynx, deep/extrinsic muscle of the tongue,
medial pterygoid, hard palate, or mandible.
T4b Tumor invades the lateral pterygoid muscle, pterygoid plates,
lateral nasopharynx, orskull base or encasesthe carotid artery

50
Q

AJCC Staging of Larynx - Supraglottic

A
  • T1 Tumor is limited to one subsite of the supraglottis, with normal vocal cord mobility.
  • T2 Tumor invades mucosa of more than one adjacent subsite of the supraglottis or glottis orregion outside the supraglottis(e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus), without fixation of the larynx.
  • T3 Tumor is limited to the larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex).
  • T4a Tumorinvadesthrough the thyroid cartilage and/orinvadestissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
  • T4b Tumorinvades prevertebralspace, encasesthe carotid artery, or invades mediastinalstructures.
51
Q

AJCC Staging of Larynx - Glottis

A
  • T1 Tumor is limited to the vocal cords(s) (may involve anterior or posterior commissure), with normal mobility.
  • T1a Tumor islimited to one vocal cord.
  • T1b Tumor involves both vocal cords.
  • T2 Tumor extendsto the supraglottis and/orsubglottis, and/orwith impaired vocal cord mobility.
  • T3 Tumor is limited to the larynx with vocal cord fixation and/or invades paraglottic space, and or minor thyroid cartilage erosion (e.g., inner cortex).
  • T4a Tumorinvadesthrough the thyroid cartilage and/orinvadestissues beyond the larynx (e.g., trachea, soft tissues of the neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
52
Q

AJCC Staging of Larynx - Subglottis

A
  • T1 Tumor is limited to the subglottis.
  • T2 Tumor extends to the vocal cord(s), with normal or impaired mobility.
  • T3 Tumor islimited to the larynx, with vocal cord fixation.
  • T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).
  • T4b Tumorinvades prevertebralspace, encasesthe carotid artery, or invades mediastinalstructures.
53
Q

AJCC N-staging of lymph nodes

A
  • NX Regional lymph nodes cannot be assessed.
  • N0 There is no regional nodes metastasis.
  • N1 Metastasis is in a single ipsilateral lymph node, 3 cm or less in greatest dimension.
  • N2 Metastasis is in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or metastasis is in multiple ipsilateral lymph nodes, none more that 6 cm in greatest dimension; or metastasis is in bilateral or contralateral lymph nodes, none greater than 6 cm in greatest dimension.
  • N2a Metastasis is in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension.
  • N2b Metastasis is in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.
  • N2c Metastasis is in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
  • N3 Metastasis is in a lymph node more than 6 cm in greatest dimension.
54
Q

AJCC Staging of Hypopharynx

A

Definition:

The hypopharynx includesthe pyriform sinuses, the lateral and posterior hypopharyngealwalls, and the postcricoid region.

  • T1 Tumor is limited to one subsite of the hypopharynx and 2 cm or less in greatest dimension.
  • T2 Tumor invades more than one subsite of the hypopharynx or an adjacent site, or measures more than 2 cm but not more than 4 cm in greatest dimension without fixation of the hemilarynx.
  • T3 Tumor is more than 4 cm in greatest dimension or with fixation of the hemilarynx.
  • T4a Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissue.
  • T4b Tumor invades prevertebral fascia, encases the carotid artery, or involves mediastinal structures.
55
Q

AJCC Staging of the Maxillary Sinus

A
  • T1 Tumor is limited to the maxillary sinus mucosa,with no erosion or destruction of bone.
  • T2 Tumor is causing bone erosion or destruction, including extension into the hard palate and/or middle nasal meatus, except extension to the posterior wall of the maxillary sinus and pterygoid plates.
  • T3 Tumor invades any of the following: bone of the posterior wall of the maxillary sinus, subcutaneous tissues, floor, or medial wall of the orbit, pterygoid fossa, or ethmoid sinuses.
  • T4a Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontalsinuses.
  • T4b Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus.
56
Q

AJCC Staging of the Nasal Cavity and Ethmoid Sinus

A
  • T1 Tumor is confined to the ethmoid sinus with or without bone erosion.
  • T2 Tumor invades two subsites in a single region or extendsto involve an adjacent region within the nasoethmoidal complex, with or without bony invasion.
  • T3 Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate.
  • T4a Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates,sphenoid or frontalsinuses.
  • T4b Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx, or clivus.
57
Q

AJCC Staging of the Salivary Glands

A

Definition:

The salivary glandsinclude the parotid,submandibular,
sublingual, and minorsalivary glands.

  • T1 Tumor is 2 cm or less without extraparenchymal extension.
  • T2 Tumor is greater than 2 cm but not more than 4 cm without extraparenchymal extension.
  • T3 Tumor is more than 4 cm and/or extraparenchymal extension.
  • T4a Tumor invades the skin, mandible, ear canal, and/or facial nerve.
  • T4b Tumor invades the skull base and/or pterygoid plates and/or encases the carotid artery.
58
Q

AJCC Staging of the Thyroid

A

Definition:

The thyroid is composed of a right and left lobe, with an isthmus connecting the two lobes.

  • TX Primary tumor cannot be assessed.
  • T0 There is no evidence of primary tumor.
  • T1 Tumor is 2 cm or less in greatest dimension and is limited to the thyroid.
  • T2 Tumor is more than 2 cm but not more than 4 cm in greatest dimension, and is limited to the thyroid.
  • T3 Tumor is more than 4 cm in greatest dimension, and is limited to the thyroid or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).
  • T4a Tumor of any size extends beyond the thyroid capsule to invade subcutaneoussoft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.
  • T4b Tumor invades prevertebral fascia or encasesthe carotid artery or mediastinal vessels. Anaplastic is always T4
59
Q

AJCC Staging of the Nasopharynx

A

Definition:

The nasopharynx includesthe vault, the lateralwalls, the posterior walls, and the superior surface of the soft palate.

  • T1 Tumor is confined to the nasopharynx.
  • T2 Tumor extends to soft tissues.
  • T2a Tumor extends to the oropharynx and/or nasal cavity, without parapharyngeal extension.
  • T2b Tumor extends into the parapharyngeal space.
  • T3 Tumor involves bony structures and/or paranasal sinuses.
  • T4 Tumor has intracranial extension and/or involves cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space.
60
Q

Where and what is Erb’s point?

A

AKA Punctum Nervosum

Formed by union of C5 and C6 nerve roots

Lateral root of brachial plexus 2-3 cm above clavicle

  1. Lesser occipital nerve
  2. Great auricular nerve
  3. Transverse cervical nerve
  4. Supraclavicular nerve

Injury to Erb’s point is common during birth or fall onto the shoulder.

Leads to Erb’s palsy - or waiter tip position

61
Q

Is the facial nerve (marginal mandibular nerve) deep or superficial to the platysma?

A

Deep

62
Q

Where is the palatovaginal canal?

A
  • canal between the sphenoid bone and the palatine bone that connects the nasopharynx with the pterygopalatine fossa
  • transmits the pharyngeal branch of the third part of the maxillary artery.
63
Q

Show the gross anatomy of the masticator space

A

1 Parapharyngeal space. 2 Masticator space. 2* Masticator space (suprazygomatic portion). 3 Mucosal space. 4 Submandibular space. 5 Medial pterygoid muscle. 5’ Lateral pterygoid muscle. 6 Masseter muscle. 7 Ramus of the mandible. 8 Submandibular gland. 9 Soft palate. 10 Venous plexus of the parapharyngeal space. 11 Levator veli palatini muscle. 12 Tensor veli palatini muscle. 13 Eustsachian tube. 14 Foramen ovale. 15 Cavernous sinus. 16 Sphenoidal sinus. 17 Nasopharynx. 18 Greater wing of the sphenoid bone. 19 Temporal lobe. 20 Root of the zygomatic arch. 21 Temporal muscle

64
Q

Where is the Crista Ethmoidalis?

A

SPA just posterior and lateral to this

65
Q

What is the Holman-miller sign?

A

Seen in juvenile nasopharyngeal angiofibroma

The anterior bowing of the posterior wall of the maxillary antrum which is seen on lateral skull film or cross-sectional imaging.

This is a nonspecific sign that can be produced by any slowly growing mass, whereas erosion of the pterygoid lamina is probably a pathognomonic sign for juvenile nasopharyngeal angiofibroma

66
Q

What is the Pterygoid Hamulus?

A

End of the pterygoid, curved

Tensor veli palatini glides around it

67
Q

What is Dorello’s Canal?

A

Bony enclosure surrounding the abducens nerve and the inferior petrosal sinus as the two structures merge with the cavernous sinus

68
Q

Describe the features of Ameloblastoma

A

Rare, benign tumor of odontogenic epithelium (ameloblasts, or outside portion, of the teeth during development) much more commonly appearing in the lower jaw than the upper jaw

Rarely malignant or metastatic

69
Q

What is Broyles ligament?

A

Fibrous membrane that connects the vocal ligament to the thyroid cartilage

Penetrates the body of the thyroid

Contains lymphatics and blood vessels and can therefore can act as an avenue for extension of laryngeal cancer outside the larynx

70
Q

What is the Zygomaticotemporal nerve?

A
  • It is derived from the maxillary nerve, a branch of the trigeminal nerve. It runs along the lateral wall of the orbit in a groove in the zygomatic bone, receives a branch of communication from the lacrimal nerve, and passes through the zygomaticotemporal foramen in the zygomatic bone to enter the temporal fossa.
71
Q

What is the zygomaticofacial nerve?

A
  • passes along the infero-lateral angle of the orbit, emerges upon the face through the zygomaticofacial foramen in the zygomatic bone, and, perforating the orbicularis oculi to reach the skin of the malar area
72
Q

What is the lesser supraclavicular fossa?

A

triangular space between the two heads of origin of the sternocleidomastoid muscle.

73
Q

What is the Killian’s dehiscence?

A
  • Triangular area in the wall of the pharynx between the thyropharyngeus part of the inferior constrictor of the pharynx and the cricopharyngeus muscle, also of the inferior constrictor muscle of the pharnyx
  • Responsible for Zenkers Diverticulum
74
Q

What are the features of Zenker’s Diverticulum

A

Pharyngoesophageal Diverticulum

Complications

diverticulitis, fistula formation, perforation, bleeding

Pathophysiology

pulsion diverticulum (created from elevated intraluminal pressure) creates a herniation typically at Killian’s triangle

False Diverticulum

diverticulum contains mucosa and submucosa only

Symptoms

insidious dysphagia, spontaneous regurgitation of undigested food, malodorous breath, aspiration, may become obstructive

Diagnosis

esophagram and endoscopy (80–90% located on the left side)

Treatment

may observe or complete a cricopharyngeal myotomy for small defect and minimal symptoms; symptomatic defects and large diverticuli (>1.5 cm) require a transcervical diverticulectomy with cricopharyngeal myotomy (must complete a cricopharyngeal myotomy
to prevent recurrence)

75
Q

What are the branches of the maxillary artery?

A

DAM I AM Piss Drunk But Stupid Drunk I Prefer, Must Phone Alcoholics Anonymous

D - deep auricular artery
A - anterior tympanic artery
M - middle meningeal artery

                         I - inferior alveolar artery

                        A - accessory meningeal artery
                         M - masseteric artery

                        P - pterygoid artery
                         D - deep temporal artery
                         B - buccinator artery
                         S - sphenopalatine artery
                         D - descending palatine artery
                          I - infraorbital artery
                         P - posterior superior alveolar artery
                         M - middle superior alveolar artery
                         P - pharyngeal artery
                         A - anterior superior alveolar artery
                         A - artery of the pterygoid canal
76
Q

What 3 layers compose the carotid sheath?

A

The 3 major facial layers make the sheath

  1. Investing fascia
  2. Pretracheal fascia
  3. Prevertebral fascia

Contains the:

  1. Common carotid and ICA
  2. Internal Jugular Vein
  3. Vagus Nerve
  4. Cervical lymph nodes

ENT (17 decks)

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