Head and Neck Surgery Flashcards
Cholesteatoma
- Keratinizing squamous epithelium grows from the tympanic membrane or the auditory canal into the middle ear mucosa or mastoid air cells.
- Presentation: Sometimes asymptomatic. May present as painless foul-smelling otorrhea or conductive hearing loss.
- May be congenital or acquired:
- Primary acquired: Eustacian tube dysfunction -> inward retraction of tympanic membrane
- Secondary acquired: Epithelial metaplasia onto the tympanic membrane in chronic/recurrent otitis media
- Dx: Otoscopy. X-ray of mastoid and CT of temporal bone to rule out bony destruction. Audiometry to assess hearing.
- Tx: Surgery is ALWAYS indicated due to risk of complications.
- Complications: Conductive deafness, perilymph fistula, facial nerve paralysis, erosion of temporal bone and subsequent thrombosis or meingitis
Otosclerosis
- Etiology: Abnormal bone growth of the bony labyrinth, primarily at the oval window.
- Presentation: Progressive conductive hearing loss, often bilateral. Most common in 20-40 year old women. Symptoms often increase during pregnancy or after menopause due to hormonal responsiveness.
- Dx: Pure tone audiometry.Carhat’s notch (trough at 2000 Hz) in bone conduction curve is pathognomonic.
- Tx: Replacement of the upper part of the stapes with a prosthesis (stapedotomy)
Ludwig’s angina
- Rare and often fatal soft-tissue infection (a form of cellulitis) of the neck and floor of the mouth
- Etiology: Often periodontal abscess, diabetes is predisposing factor
- Pres: fever, dysphagia, and swelling of the submandibular and anterior portion of the neck in the setting of apparent tooth infection
- Tx: Surgical drainage, IV meropenem or pip-tazo, airway protection
- Complications: Aggressively progresses and compromises the airway
Meniere disease
- Etiology: Decreased resorption of endolymph resulting in inner ear pressure. Increased concentration of potassium in perilymph.
- Presentation: Episodic, unilateral vertigo, sensorineural hearing loss, nystagmus, tinnitus, and sensation of fullness
- Episodes last from 20 minutes to 12 hours
- Dx: Clinical history and low- to mid-frequency SNHL on audiometry
- Tx: Symptomatic
- Abortive therapy: Vestibular supressants (benzodiazepines, 1st generation antihistamines)
- Maintenance: Diuretics
- Definitive: Surgical or chemical vestibular ablation for those with refractory disease that significantly impairs QOL.
Suppurative sialadenitis
- Infection of salivary gland
- Presentation: Fever, tender swelling in area of salivary gland, intra-oral purulent drainage
- Etiology: Most commonly S. aureus and mixed oral flora
- Dx: Clinical. Gram stain of purulent drainage.
- Tx: Wait for results of gram stain. Then, if positive, inpatient treatment with metronidazole and nafcillin is first-line. Adjunctive therapies include gland massage, sialogogues, oral hygiene, fluids.
Abx coverage for a retropharyngeal abscess
Amp-sulbactam covers all etiologies and is preferred for these infections. Of course, drainage is also necessary if there is an accumulation, and if the patient presents in respiratory distress the first step is intubation.
Abx coverage for acute unilateral pyogenic lymphadenitis
Clindamycin
Almost always caused by a gram positive coccis and mixed anaerobes. This knocks it out.
Panendoscopy
- Allows for comprehensive evaluation of the entire upper airway and digestive tract.
- Most appropriate initial step in evaluating suspected oropharyngeal cancer because it enables assessment of the extent of the known tumor as well as other primary sites of cancer.
Tympanic membrane perforation
- Dry ear precautions
- Abx if infected
- Tympanostomy for those that don’t heal spontaneously
Nasal septum blood supply
Treatment progression of persistent nosebleed
- Packing
- Embolization
- Cautery in the OR
Complications of acute rhinosinusitis
- Pott’s Puffy Tumor (progression of acute sinusitis into the soft tissues of the forehead)
- Acute otitis media
- Orbital cellulitis/orbital subperiosteal abscess
*
Chronic rhinosinusitis
x
How to determine of rinorrhea is CSF?
Beta-2-transferrin
Oropharyngeal tonsilar cancer is most often due to. . .
. . . HPV
Vaccine preventable! Always on the ddx for peritonsilar abscess.
Conclusions of 1990 study on cervical lymph node involvement in primary SCC of the oral cavity
- Zone I, II, and III are at greatest risk in patients with early disease
- Zone IV rarely involved in N0 cases, but positive in ~15% of N+ cases
- Zone V only likely to have involvement in the context of distal neck metastases
- Conclusions:
- N0 patients get supraomohyoid dissections
- N+ patients get anterolateral dissections
- If nodes + in OR, consider extending to Zone IV or Zone V
Singer nodule
- Nodule on the true vocal cord
- Etiology: excessive vocal cord use (singer, teacher, football coach, someone who yells for a living)
- Sx: Hoarseness of voice (dysphonia)
- Pathology: Myxoid degeneration of the vocal cord, typically bilateral
- Treatment: Vocal rest
True vs False vocal cord
False vocal cords are also known as the vestibular folds
Cancer and singer nodules basically only occur on. . .
. . . the true vocal cords. Not the false vocal cords.
Laryngeal papilloma
- Benign tumor
- Caused by HPV 6 and 11 (low risk HPVs)
- Kids have multiple, adults have single (mnemonic: kids play together)
- Sx: Dysphonia
Laryngeal carcinoma
- Carcinoma involving the larynx.
- Risk factors: Smoking, alcohol, squamous papillomas or papillomatosis (HPV 6 and 11)
- Pathology: Squamous cell carcinoma
- Overwhelmingly occurs on true vocal cords
- Sx: Dysphonia in the context of painless cervical lymphadenopathy
Melanoma biopsy
- Initial biopsy should be full thickness to assess Breslow depth
- Excisional for small lesions
- Full-thickness punch biopsy for large or cosmetically sensitive lesions
- Margins are taken from the surgical bed following initial biopsy based on the Breslow depth
Microinvasive melanoma staging
-
Breslow microstaging:
- Measurement taken from granular layer to tumor base
- Or from ulcer base to tumor base, if an ulcerated lesion
- Stages:
- Stage I: < 0.75 mm
- Stage II 0.75-1.5 mm
- Stage III: 1.51-2.25 mm
- Stage IV: 2.25-3.0 mm
- If Breslow depth > 1 mm:
- Lymphoscintigraphy
- Sentinel lymph node biopsy
Therapeutic lymph node dissection
- Complete lymph node clearance of the lymph node basin where melanoma has spread in case of + SNLB or clinically enlarged LN
- This treatment improves susrvival in patients with melanoma metastases isolated to regional LNs
- Can cause significant lymphedema as a side effect, so risk-benefit must be weighed
Subungal melanoma
- Melanoma originating from the nailbed
- Most effective treatment option is excision with wide margins, unlike most melanomas
- Requires amputation of one phalanx proximal to the melanoma
Regional chemotherapy
- Chemotherapy option unique to melanoma treatment
- Deliver of extremely high local doses of chemotherapy to disease isolated to an extremity
- Few to no systemic consequences, but there is high locoregional toxicity, and there are often functional losses of involved extremities
Types of melanoma
- Superficial spreading (70% of cases, favorable prognosis)
- Lentigo maligna (subtype of above, much worse prognosis)
- Nodular sclerosing (15% of cases)
- Acral lentigonous (more common in people of African, Asian, Hispanic descent)
Rule-of-thumb for melanoma margins
Breslow in mm is roughly margin size in cm, with a cap at 2 cm until you are past 4 mm
Most common melanoma metastasis sites
- Lung
- Brain
- Liver
- Bone
-
Gut and Gall bladder
- CBC and LFTs are often monitored annually to screen for metastatic disease
Indications for tonsillectomy
-
Paradise Criteria:
- At least 3 episodes for at least 3 years
- At least 5 episodes for at least 2 years
- At least 7 episodes within a single year
-
Specific indications:
- Peritonsillar abscess (second episode or first with Hx tonsillitis)
- Tonsillar asymmetry with symptoms suspicious for MALT lymphoma
- Refractory OSA
- Halitosis with history of tonsil stones
Procedural complications for tonsillectomy
- Dental injury
- Temporomandibular joint (TMJ) dislocation
- Bleeding
- Glossopharyngeal nerve injury
- Airway obstruction
- Aspiration
Vascular supply to tonsils
Relationship of tonsils to imporant nervous structures
Syndrome of glossopharyngeal nerve injury following tonsillectomy
- Characterized by neuropathic pain in the distribution of the auricular and pharyngeal branches of the glossopharyngeal nerve
- Throat and retroauricular pain
- If vagal nerve is involved, syncope, asystole, seizures, bradycardia, hypotension may occur
- There is not sufficient evidence to support the possibility of posterior tongue hypogeusia following glossopharyngeal nerve injury during tonsillectomy
“Sudden, episodic vertigo reproduced by valsalva menvuer”
- Classic for perilymphatic fistula
- Will be accompanied by a progressive sensorineural hearing loss
- May also be precipitated by loud noises
- Rare complication of head trauma
- Leakage or loss of endolymph from semicircular canals and cochlea into surrounding tissues
Margins for basal cell carcinoma
Most places: 3-5 mm margins (“narrow margin”)
On the face or cosmetically sensitive areas: Moh’s srugery
Referred otalgia may be a presenting symptom of. . .
. . . mucosal head and neck squamous cell carcinoma
Thus, in the absence of a good explanation, it warrants flexible laryngoscopy
Firm, enlarged, ulcerated tonsil
Squamous cell carcinoma of the tonsil
Auricular hematomas
- High risk of infection and abscess formation
- Since there is no other blood supply, hematoma may produce avascular necrosis of the auricular cartilage. Subsequently scarring permanently deforms the ear (cauliflower ear)
Possible complications of a retropharyngeal abscess
- Communication to mediastinum -> superior mediastinitis
- Communication to over the carotid sheath -> Thrombosis of IJV and associated deficits in CN IX, X, XI, XII (9-12)
- Communication to the alar fascia -> spread to the posterior, inferior mediastinum at the level of the diaphragm and inferior mediastinitis
Septal hematoma
- Much like the auricular hematoma
- Following nasal truama
- Presents as inability to breathe through nose and fluctuant septal mass on exam
- Tamponades the supply of nutrients and causes avascular necrosis of the septal cartilage if it is not incised and drained appropriately.
- Tx: Urgent incision and drainage. Then, place packing and give prophylactic antibiotics. Follow-up in a few days.
