Head and Neck, Skin and Soft Tissue Surgery Flashcards
Glands that make up the salivary glands
Major paired glands
- parotid
- submandibular
- sublingual
Minor glands (in mucosal lining of upper digestive tract)
General rule about salivary tumours
The smaller the gland from which it originates, the greater the chance that it will become malignant
Types of salivary tumours
- adenomas
- carcinomas
- non-epithelial
- malignant lymphomas
- secondary mets
- unclassified
- tumour-like lesions
Which nerve is associated with the parotid gland?
Facial nerve
Where in the parotid gland are most tumours found?
In the superficial lobe
Top 3 parotid malignancies in South Africans
- squamous cell carcinoma of the skin
- mucoepidermoid carcinoma
- malignant melanoma of the skin
Clues if a parotid gland tumour is malignant
- previous skin cancer of head and neck
- irradiation of parotid region
- rapid growth
- pain
- local invasion (trismus, skin infiltration, fixity, facial nerve involvement, mets to lymph/lungs)
Potential investigations for parotid tumours
- imaging
- fine needle aspiration cytology
- Trucut and open biopsy
When is FNAC useful for parotid tumour?
- exclude inflammatory disease
- exclude lymphoma
- exclude mets
- patients who dont want surgery
- inoperable tumours
Potential consequences of parotidectomy
- scar
- greater auricular nerve (loss of sensation, neuroma)
- facial nerve (Temp weakness)
- Frey’s syndrome (gustatory sweating)
Why does Frey’s syndrome occur?
- sweating over the area while eating
- short-circuiting of secretomotor nervers that supply the parotid and the nerves that innervate the sweat glands
Presentation of submandibular gland neoplasms
Mass projecting into the neck or the lateral floor of the mouth
Differentials for submandibular neoplasm
- sialolithiasis
- sialadenitis
- enlarged lymph nodes
Nerves that pass close to the submandibular glands
- hypoglossal
- lingual
- marginal mandibular
Diagnosis of submandibular neoplasm
- FNAC
- resection
Management of sublingual gland neoplasm
- biopsy in the oral cavity (significant likelihood of malignancy)
When to suspect HIV parotid lymphoepithelial cysts
- multiple
- bilateral
- associated cervical lymph nodes
- HIV positive
Treatment of HIV lymphoepithelial cysts
- antiretrovirals
- aspirate and inject sclerosant
Regions of the neck
1 = submandib gland, nodes, 2 = upper jug nodes, carotid body 3 = mid-jug nodes 4 = inferior jug nodes, Virchow Trossier node, thyroid 5 = nodes 6 = thyroid, parathyroid
Differentials for central neck masses
- thyroglossal duct remnant
- dermoid cyst
- cervical lymphadenopathy
- lipoma
- haemandioma
- fibroma
- thyroid/-related
Special investigation of neck lumps
- biopsy
- FNAC
- CXR
- barium swallow
Operation to remove thyroglossal duct cyst
Sistrunk operation
Where do inclusion dermoid cysts present?
Between the cricoid bone and suprasternal notch
How can branchial cleft remnants present?
- cyst
- sinus
- fistulae
Where are cystic hygromas found?
- in the anterior and posterior triangles of the neck
- may extend into the mouth
Features of a cystic hygroma
- soft
- irregular
- compressible
- transilluminate
What is a pharyngeal pouch?
- a pulsion diverticulum
- behind the pharynx
between the thyro-pharyngeus and crico-pharyngeaus muscles
Best way to diagnose a pharyngeal pouch
Barium swallow
Where is a carotid body tumour found?
Arising from the sympathetic baroreceptor at the carotid bifurcation
- asymptomatic mass at the angle of the jaw
Features of a carotid body tumour
- moves from side to side
- transmits pulsation
- referral to vascular for doppler and excision
Who gets acute lymphadenitis?
Children - secondary to tonsillar, ear or scalp infections
What is cervical tuberculous lymphadenitis?
Matted glands with overlying oedema
What is scrofula?
Late cervical tuberculous lymphadenitis where the glands caseate and cause sinus formation
Where do melanocytes originate?
The neural crest
Natural history of benign melanocyte lesions
- junctional naevus
- compound naevus
- intradermal naevus
- spindle-cell naevus/ halo naevus
Where are dysplastic naevi typically found?
- on the trunk
- also scalp, buttocks and breast
Clinical diagnosis of malignant melanoma
- change in size
- change in outline
- change in colour
- change in elevation
- change in surface characteristics
- change in surrounding tissues
- intermittent itching/tingling
- recurrent minor bleeding
Clinicopatholofical types of melanoma
- superficial spreading melanoma
- lentigo maligna melanoma
- nodular melanoma
- acral lentiginous melanoma
Classification of melanoma
Clark classification by depth
High risk areas for melanomas with poor prognosis/ high recurrence
BANS region
- upper back
- posterolateral arm
- posterior neck
- posterior scalp
Requirements for a skin biopsy of possible melanoma
- full thickness of skin
- 3mm margin
- some subcutaneous tissue
Management of disseminated melanoma disease
- chemo
- radiation
- immunotherapy
- surgery
Criteria for urgernt referral for a soft tissue lesion
- mass >5cm
- painful lump
- lump that is increasing in size
- lump that is deep to muscle fascia
- recurrence of a lump after previous excision
What are desmoid tumours?
Neoplasms of fibroblastic tissue that lack the ability to metastasize
Who is prone to desmoid tumours?
- sporadic
- pregnant women (abdo wall)
- FAP (mesenteric root): highest mortality
From where do sarcomas arise?
The mesoderm
- muscle
- fat
- fascia
- synovium
Genetic associations with sarcoma
- neurofibromatosis
- Gardners syndrome
- Li-Fraumeni syndrome
- lymphoedema
- irradiation
- Kaposi’s sarcoma
Sarcoma sites of develoment
80% soft tissue
- 20% bone
- usually site of bulk (upper thigh, shoulder, retroperitoneu
Pathological classification of sarcomas
- sarcoma
- lipsarcoma
- leiomyosarcoma
- synovial sarcoma
- malignant nerve sheath tumour
Grades of sarcoma
- low: excision only
- intermediate (atypia): excision and radiotherapy
- high (necrosis): wide excision and radiotherapy and chemotherapy
- disseminated: palliative
Clinical presentation of sarcoma
- painless mass in lumb, trunk or retro-peritoneum
- pain or immobility of joint
- paraneoplastic phenomena
Differentials for sarcoma
- haematoma
- ruptures muscle
- benign soft tissue tumour
- cold abscess
- false aneurysm
- incarcerated hernia
Investigations for sarcoma
- aspiration cytology (Exclude haematoma)
- TruCut core biopsy
- CT for staging
- MRI
Treatment modalities for sarcoma
- surgery (palliative or curative)
- radiotherapy (external beam)
- chemo (Adjuvant
