Head and Neck Tumors / Parotid Flashcards
A 74-year-old man with type 2 diabetes mellitus develops squamous cell carcinoma (SCC) of the mandible. His history is significant for bilateral distal fibular fractures sustained 10 years ago from a motor vehicle collision, which were repaired with open reduction and internal fixation. He states that the ability to eat and chew will be important to him. Which of the following statements regarding mandibular reconstructive options is correct?
A) The bone quality of the scapular flap is superior to the iliac crest flap
B) Dental rehabilitation with implants is more predictable in osteocutaneous radial forearm flap than the iliac crest flap
C) Free fibular flaps have a higher rate of donor site morbidity than iliac crest flaps
D) A history of distal fibular fractures is not an absolute contraindication to the use of a free fibular flap
E) Iliac crest bone flaps have lower failure rates than osteocutaneous radial forearm flaps
The correct response is Option D.
A history of fibular fracture is not an absolute contraindication to using a free fibular flap. According to a systematic review, iliac crest flaps have the highest rate of failure when compared to all the other methods combined (fibular, radial, scapular). While not contraindicated, dental implants are less frequently placed in patients reconstructed with radial forearm bone flaps. More donor site morbidities have been reported for fibular than iliac crest flaps. Scapular flaps provide inferior bone quality to fibular and iliac crest flaps.
A 57-year-old man undergoes superficial parotidectomy. Facial nerve neuropraxia results in gustatory sweating and which of the following additional symptoms?
A) Anosmia
B) Base of tongue dysgeusia
C) Hyperlacrimation
D) Migraine headache
E) Synkinesis
The correct response is Option C.
Hyperlacrimation, or Bogorad syndrome, is a known complication after Bell palsy or other injury and insults to the facial nerve. Similar to Frey syndrome, the predominant theory for this form of gustatory hyperlacrimation is due to aberrant facial nerve regeneration.
Epiphora in general can also occur due to poor “pumping mechanisms” in the eyelids as well as prolonged ectropion and conjunctival show after facial nerve injury. However, hyperlacrimation during gustatory activity is a specific and definable pathology. Treatment for this syndrome includes subtotal lacrimal gland resection, botulinum toxin type A, and various forms of enlarging the lacrimal tract.
Synkinesis is a common event after facial nerve regeneration, when the nerve improperly fires and there is lack of typical mimetic muscle coordination.
The anterior portion of the tongue taste buds are innervated by facial nerve fibers from the chorda tympani to the lingual nerve, but the base of the tongue is innervated by cranial nerves IX and X.
Anosmia is loss of smell that occurs through cranial nerve I injury or obstruction and can lead to taste disturbances.
Migraine headaches can be associated with a variety of syndromes and need to be differentiated from other forms of headaches. Ramsay Hunt syndrome can lead to facial nerve dysfunction and facial pain, but this pain is not associated with facial nerve regeneration or migraine headaches.
An 18-year-old man comes to the office for evaluation because of swelling of his chin. A panoramic x-ray study (Panorex) is shown. Which of the following types of cyst is the most likely diagnosis?
A) Dentigerous
B) Gingival
C) Periapical
D) Primordial
E) Residual
The correct response is Option A.
This radiograph is most consistent with a dentigerous cyst.
Dentigerous cysts are the second most common and develop in the dental follicle of an unerupted tooth. On radiograph there is usually a lucency attached at an acute angle to the tooth. The mandibular and maxillary third molars are the most commonly affected.
Odontogenic cysts are epithelial lined cysts that are defined by location and histologic characteristics.
Periapical cysts are the most common and usually form from necrotic pulp after a tooth infection. They usually present as a radiologic lucency at the apex of the tooth.
A gingival cyst is a superficial cyst in the gingiva. A primordial cyst develops instead of a tooth. This is a rare cyst.
A residual cyst may result from a retained periapical cyst after teeth have been removed.
An obese 65-year-old man who undergoes resection of an oral tongue nodule has a 5 × 9-cm defect of the hemitongue and floor of the mouth. Which of the following is the most appropriate method of reconstruction?
A) Full-thickness skin grafting
B) Primary closure
C) Radial forearm fasciocutaneous flap
D) Rectus abdominis musculocutaneous flap E) Submental artery island flap
The correct response is Option C.
The radial forearm fasciocutaneous free flap is the most appropriate reconstructive choice among those listed. It is generally a thin, pliable flap with a long pedicle and vessels of adequate caliber for straightforward microvascular anastomosis. The physical characteristics of this flap are well-suited to preserving the mobility of the remaining hemitongue, resulting in reasonable speech and swallowing function following surgery in most cases.
The primary goals of reconstruction following hemiglossectomy include watertight wound closure such that oral secretions do not communicate with the neck contents and result in a fistula, and restoration of speech and swallowing function by preserving the mobility of the remaining native tongue. Primary closure would result in severe tongue tethering and impaired speech and swallowing. Although likely to contract less than a split-thickness skin graft, a full-thickness skin graft may also restrict mobility of the tongue and is unlikely to achieve a watertight wound closure. The submental artery island flap is based on a branch of the facial artery that can be used to close defects up to approximately 7 × 18 cm, depending on neck skin laxity. This flap is generally unreliable following neck dissection in which the facial artery and its branches may be ligated. The rectus abdominis musculocutaneous free flap is a highly reliable free flap but is often too bulky to permit optimal mobility of the remaining tongue, especially in patients with truncal obesity.
A 15-year-old boy is brought to the office by his parents because he has had swelling in the right lateral mandibular region for the past two months. Physical examination shows a firm, nonmobile mass of the body of the mandible. CT scan is shown. Biopsy of the lesion shows ameloblastoma. Which of the following is the most appropriate management?
(A) Cryotherapy
(B) Curettage
(C) Enucleation
(D) Segmental resection
The text of question 104 incorrectly stated “swelling in the right lateral mandibular region.” The text should read “swelling in the left lateral mandibular region.”
The correct response is Option D.
The surgical management of an ameloblastoma is controversial. Treatment modalities include cryotherapy, curettage, enucleation, or segmental resection and reconstruction. There are three main types of ameloblastomas: peripheral, unicystic, and multicystic tumors. Peripheral tumors are odontogenic in origin and have histologic characteristics consistent with intraosseous ameloblastomas. However, they occur in the soft tissues covering the tooth-bearing parts of the jaw. These peripheral tumors can be treated with local excision. Unicystic ameloblastomas can be treated conservatively with enucleation because they appear clinically as a cyst. When the tumor involves the periphery of the connective tissue wall of the cyst, a peripheral ostectomy should be considered. Multicystic ameloblastomas or large ameloblastomas that involve the surrounding of the bone and extend into the soft tissues are locally aggressive and should be treated with segmental resection and reconstruction.
A 72-year-old, immunosuppressed man presents with a 12-mm squamous cell carcinoma of the mucosal lower lip and no palpable or imageable masses of the neck. On pathology, there is perineural and lymphaticovascular invasion, with a depth of invasion of 11 mm. Which of the following patient characteristics establishes his cancer stage as at least Stage III?
a. Depth of invasion
b. Immunosuppressed status
c. Lymphaticovascular involvement
d. Perineural invasion
e. Tumor size greater than 1 cm
The correct response is Option A.
For squamous cell carcinoma of the skin, perineural invasion, lymphaticovascular involvement, and immunosuppression status are associated with worse outcomes but are not part of the staging manual. A tumor less than 2 cm in diameter is a T1, and without nodal involvement, would be a Stage I. Depth of invasion (DOI) greater than 10 mm upstages the patient to Stage III, according to the new 8th edition American Joint Committee on Cancer (AJCC), and would mandate an elective neck dissection and possible radiation (much more likely with his other negative features of the cancer). DOI is defined as the distance deep to the adjacent normal mucosal basement membrane.
Reference(s)
- Dirven R, Ebrahimi A, Moeckelmann N, Palme CE, Gupta R, Clark J. Tumor thickness versus depth of invasion - analysis of the 8th edition American Joint Committee on cancer staging for oral cancer. Oral Oncol. 2017 Nov;74:30-33.
- Elghouche AN, Pflum ZE, Schmalbach CE. Immunosuppression impact on head and neck cutaneous squamous cell carcinoma: a systematic review with meta-analysis. Otolaryngol Head Neck Surg. 2018 Oct 23:194599818808511.
- Subramaniam N, Murthy S, Balasubramanian D, et al. Adverse pathologic features in t1/2 oral squamous cell carcinoma classified by the American Joint Committee on cancer eighth edition and implications for treatment. Head Neck. 2018 Oct;40(10):2123-2128.
Chronic exposure to which of the following substances is associated with the development of squamous cell carcinoma of the nasal sinus cavity?
(A) Alcohol
(B) Asbestos
(C) Benzene
(D) Nickel
(E) Tobacco
The correct response is Option D.
Chronic exposure to nickel has been shown to be associated with the development of squamous cell carcinoma of the nasal sinuses. This is the most common malignancy of the sinonasal tract, affecting the maxillary sinus most frequently, followed by the nasal sinus cavity, ethmoid sinus, and sphenoid sinus. In one study, workers at a nickel refinery in Norway developed squamous cell carcinoma at 250 times the expected rate, with a latent period varying from 18 to 36 years.
Exposure to alcohol and tobacco has been associated with squamous cell carcinoma of the upper aerodigestive tract, not the sinonasal tract. Exposure to asbestos has been shown to increase the risk for development of pleural mesothelioma, and benzene exposure is associated with the development of hemopoietic malignancies.
A 66-year-old man is being evaluated because of a four-month history of a painful sore in his mouth. Physical examination shows a 3-cm ulcerative lesion of the right buccal mucosa, and a 2.5-cm node in Zone II of the right neck. Biopsy of specimens from the lesions shows squamous cell carcinoma. No distant metastases are noted. Which of the following is the most accurate TNM staging of this tumor?
A ) T1 N1 M0
B ) T2 N1 M0
C ) T1 N2a M0
D ) T2 N2a M0
E ) T3 N2a M0
The correct response is Option B.
Tumors of the oral cavity and oropharynx are staged according to the TNM (tumor, node, metastasis) system. A tumor with dimensions greater than 2 cm but less than or equal to 4 cm would be staged as T2. A single, 2.5-cm, mobile node would stage this tumor as N1.
Oral Cavity and Oropharynx:
T1 Tumor ≤ 2 cm T2 Tumor > 2 but < 4 cm T3 Tumor > 4 cm T4 Tumor invades adjacent structures, such as cortical bone, tongue, skin, or soft tissue of
the neck
N1 One ipsilateral node: < 3 cm N2a One ipsilateral node: > 3 but ≤ 6 cm N2b Multiple ipsilateral nodes: ≤ 6 cm N2c Bilateral contralateral nodes: ≤ 6 cm N3 Any nodes > 6 cm
A 58-year-old man is evaluated because of floor-of-mouth cancer that is invading the mandible. A segmental mandibulectomy and reconstruction with an osteocutaneous free flap that includes bone from the lateral border of the scapula are planned. The vascular pedicle supplying this flap is based on which of the following arteries?
A) Circumflex scapular
B) Dorsal scapular
C) Lateral thoracic
D) Thoracoacromial
E) Transverse cervical
The correct response is Option A.
The circumflex scapular artery, which is a branch of the subscapular artery, supplies blood to the lateral and medial borders of the scapular bone. The scapula free flap was first described in 1978 by Saijo. It can be harvested as part of a chimeric flap that includes other tissues supplied by the subscapular arterial system, such as the latissimus dorsi muscle, serratus anterior muscle, and scapular or parascapular skin. The tip of the scapula receives its blood supply from the angular branch of the thoracodorsal artery and has also been utilized as a pedicle for the inferior portion of the scapula. While the scapular bone is not as thick as the fibula bone, it provides adequate stability for mandibular reconstruction. Cutaneous branches of the circumflex scapular artery supply the scapular and parascapular skin and, therefore, a skin flap can be harvested simultaneously to close soft-tissue defects.
The transverse cervical artery and the dorsal scapular artery primarily supply the trapezius muscle and overlying skin. The thoracoacromial artery supplies the pectoralis major muscle and overlying skin. The lateral thoracic artery supplies both the lateral portion of the pectoralis major muscle and the skin in the axillary region.
A 51-year-old male carpenter requires a partial glossectomy for recurrent oral squamous cell carcinoma. He runs for five miles three days a week. He underwent radiation therapy two years previously. Microsurgical transfer of which of the following free flaps is most appropriate for reconstruction?
A) Deltopectoral flap
B) Rectus abdominis flap
C) Sural artery perforator flap
D) Vastus lateralis flap
The correct response is Option C.
Partial glossectomy defects require a small, thin, pliable flap for optimal reconstruction. The workhorse for glossectomy reconstruction has long been the radial forearm flap (RFF), which often requires a skin graft for donor site closure. However, various reports of donor site morbidity related to the RFF, including delayed healing, decreased grip and pinch strength, and radial nerve sensory problems, make this flap less suitable for a patient whose vocation involves manual labor. The sural artery perforator flap has become increasingly popular as an alternative donor site for very thin, pliable tissue. This flap, which usually arises from perforators from the medial sural artery, results in minimal donor morbidity. Muscle flaps are less desirable for intraoral reconstruction due to the need for an epithelialized surface and the difficulty in achieving skin graft adherence. The rectus abdominis flap is too bulky for partial glossectomy reconstruction. The deltopectoral flap, which arises from the 1st intercostal perforator, is rarely transferred as a free flap. Sacrifice of the vastus lateralis muscle in an avid runner is not recommended.
A 45-year-old woman is evaluated because of an enlarging lump below her left ear that she first noticed five months ago. Physical examination shows asymmetrical weakness of the facial nerve. A 2-cm mass is noted just over the mandibular angle. The mass is firm and slightly tender on palpation. Which of the following is the most likely diagnosis?
A ) Adenoid cystic carcinoma
B ) Lymphoma
C ) Metastases to upper jugular lymph node
D ) Pleomorphic adenoma
E ) Warthin tumor
The correct response is Option A.
This malignancy is the second or third (depending on the study) most common in the parotid gland after mucoepidermoid carcinoma. Facial weakness combined with pain to touch of a mass anywhere in the parotid gland, which may extend well below the ear and into the buccal space, is a salivary malignancy until proven otherwise. Adenoid cystic carcinoma is well known for its neurotropism, and concomitant findings of weakness of the facial nerve and pain in the distribution on cranial nerve V are not uncommon. Adenoid cystic carcinoma is one of the most common malignancies of the submandibular and minor salivary glands. Facial nerve involvement is a significant poor prognostic indicator in any location.
Pleomorphic adenoma and Warthin tumor are benign lesions not associated with pain and weakness of the facial nerve. Likewise, lymphoma, a more rare tumor of the parotid gland, is not associated with facial nerve involvement. Lymphoma is usually associated with various collagen connective diseases, such as Sjögren syndrome. Metastatic jugular nodes, which become very large, can be locally destructive. These are usually fast growing and associated with a primary lesion with all of its related morbidity, eg, dysphagia and dysphonia.
Which of the following types of head and neck tumors are most often associated with Epstein-Barr virus infection?
A) Larynx
B) Maxillary sinus
C) Nasopharynx
D) Tongue
E) Tonsil
The correct response is Option C.
Nasopharyngeal cancers are most often associated with Epstein-Barr virus (EBV) infections and arise from the mucous epithelium of the nasopharynx and are relatively rare in the United States. However, these tumors are endemic in Africa and East Asia, accounting for as many as 18% of head and neck cancers in China. Nasopharyngeal tumors are classified as either squamous cell cancers, keratinizing undifferentiated carcinoma, or non-keratinizing undifferentiated carcinoma. EBV infection is most strongly associated with the non-keratinizing undifferentiated subtype and is thought to increase malignant transformation. Nasopharyngeal cancers are most commonly treated with chemotherapy and radiation, with surgery reserved for recurrent or unusual cancers. Reconstruction of skull base defects is most commonly performed using microsurgical transfer of soft-tissue flaps. Alcohol and tobacco are the most common risk factors for head and neck cancers in general, and laryngeal cancers in particular, with cigarette smoking increasing the lifetime risk 5- to 25-fold. Other risk factors for head and neck cancers in general include cigar smoking, environmental exposures, dietary factors (red meat, betel nuts), and human papillomavirus (HPV) infection. HPV infections are most commonly associated with oropharyngeal cancers (tongue, tonsil). Significant risk factors for maxillary sinus cancers include cigarette smoking and environmental factors such as exposure to wood dust.
A 2-year-old boy is brought to the office because of an 18-month history of a subcutaneous mass near his left preauricular region. It has not increased in size. Physical examination shows a 2-cm nontender mass located in the area over the parotid gland. There is no facial nerve deficit. MRI confirms a lesion in the left superficial lobe of the parotid gland. Which of the following is the most likely diagnosis?
A) Adenocystic carcinoma
B) Hemangioma
C) Mucoepidermoid carcinoma
D) Pleomorphic adenoma
E) Warthin tumor
The correct response is Option B.
Salivary gland tumors frequently occur within the parotid gland, and the vast majority (75%) of parotid tumors are benign. In older children, however, parotid tumors are much more likely to be malignant (50%). In young children, the most common diagnosis is hemangioma. As in the scenario described, the lesion appears to be benign, and, in this age group, malignancy is rare. In older children, mucoepidermoid carcinoma is most common, as in adults.
Adenocystic carcinoma, or cylindroma, is infrequent in the parotid gland (7%) but quite common in the minor salivary glands (35%). It is a slow-growing mass, often associated with pain and facial palsy. These tumors are aggressive, with one third to one half of affected patients developing metastatic disease.
Adenocarcinomas comprise 10% of malignant parotid gland tumors. These tumors vary according to grade and histologic appearance. They occur most frequently after the fifth decade of life and commonly involve the minor salivary glands. In the parotid gland, they manifest as fixed masses characterized by occasional pain or facial palsy.
Mucoepidermoid carcinoma is the most common malignancy of the parotid gland. It is rarely bilateral. It may be low-grade or high-grade. Low-grade tumors are slow-growing and indolent; high-grade tumors are much more aggressive. The recurrence rate of high-grade tumors is increased, and the facial nerve is frequently affected.
Pleomorphic adenomas, or benign mixed tumors, are the most common salivary gland neoplasms, comprising about 60% of all salivary gland tumors and 80% of benign tumors.
They occur as painless salivary masses that are firm and well circumscribed. Facial weakness is not found. Bilateral tumors are rare. This tumor is treated by resection, and in rare cases (recurrence), can transform into a malignant mixed tumor.
Warthin tumor is a common neoplasm of the parotid gland, accounting for 10% of all parotid tumors. These tumors are usually painless and tend to grow slowly, oftentimes over a period of several years. They are more common in older men and are frequently bilateral. Warthin tumors are usually treated with superficial parotidectomy with only minimal margins needed. Recurrence is common.
A 62-year-old woman comes to the office because of squamous cell carcinoma of the tongue and floor of the mouth. Examination shows a 3 x 3-cm partial defect of the tongue and the floor of the mouth. The lesion will be resected and the defect reconstructed at the same time using a submental musculocutaneous flap. Exposure of the pedicle of this flap allows which of the following levels of nodes to be exposed and sampled?
A) Level I
B) Levels I and II
C) Levels I, II, and III
D) Levels I, II, III, and IV
E) Levels II and III
The correct response is Option A.
The submental flap is a potentially thin flap. Its pedicle is the submental artery, which arises off the facial artery. The pedicle is described as traveling between the submandibular gland and digastric muscle belly. It also dives deep and lies in between the mylohyoid and geniohyoid. Exposing the pedicle requires incision along the mental region, then in a transverse incision 1 to 2 cm below the mandibular body.
Level I nodes lie within the submental region with the mandibular body being the superior border and the hyoid bone being the inferior margin. They are further divided into 1a-submental, which lies anterior to the anterior belly of the digastric, and the 1b-submandibular, which lies posterior to the anterior belly of the digastric. Thus, exposure to the pedicle alone also exposes all the level I nodes.
Level II nodes are the upper jugular group, which are clustered around the upper third of the internal jugular vein. The superior border is the skull base, the hyoid is the inferior border, the anterior border is the anterior edge of the sternocleidomastoid, and the posterior edge is the posterior edge of the sternocleidomastoid.
Level III nodes are the middle third of the internal jugular, with the hyoid being the superior border, cricoid cartilage the inferior border, and the anterior posterior borders the anterior and posterior edges of the sternocleidomastoid, respectively.
Level IV nodes are the lower third of the internal jugular with the cricoid cartilage as the superior border and the clavicle as the inferior border. Again, the anterior border is the anterior edge of the sternocleidomastoid, and the posterior edge is the posterior edge of the sternocleidomastoid.
A 6-month-old boy undergoes excision of a midline nasal mass. Operative findings include neural tissue without evidence of a dural covering. No underlying defect of the bone is noted. The mass in this patient is most likely which of the following types of lesions?
(A) Dermoid
(B) Encephalocele
(C) Glioma
(D) Neurilemoma
(E) Neurofibroma
The correct response is Option C.
Based on the operative findings, this mass is a glioma. A congenital midline nasal mass is most likely to be a dermoid cyst, an encephalocele, or a glioma. Diagnosis can be facilitated by preoperative imaging studies. A dermoid cyst, which is the most common congenital nasal mass, typically contains sebaceous material and may communicate with the intracranial space. An encephalocele, which is a protrusion of the brain through an embryologic defect in the skull, is always covered by the dura. However, the content of the dural sac may vary. Gliomas consist of glial neural tissue and are not surrounded by dura. However, they may maintain a connection to it. Gliomas require thorough resection because of the risk of recurrence.
A neurilemoma or neurofibroma is not likely to arise as a midline nasal mass in a 6-month-old infant.
A 67-year-old woman comes to the office because of a 2-month history of halitosis and pain and swelling in the jaw. History includes placement of dental implants 20 years ago. The patient is currently undergoing chemotherapy for Stage IV lung cancer with metastases to the spine. Physical examination shows exposure of the mandible and dental implant posts. A photograph is shown. Examination of a specimen obtained on biopsy is consistent with osteonecrosis and is negative for malignancy. Administration of which of the following is the most likely cause of this patient’s condition?
A ) Bevacizumab
B ) Bisphosphonate
C ) Cetuximab
D ) Dexamethasone
E ) Doxorubicin
The correct response is Option B.
The patient described has osteonecrosis of the mandible and an orocutaneous fistula caused by bisphosphonate (Zometa) therapy. Bisphosphonates bind to calcium crystals in the bone and are resistant to degradation by alkaline phosphatase. As such, they inhibit osteoclast-mediated bone resorption. They are used in the treatment of osteoporosis and, in higher doses, for treatment of bone metastases. Although they are an important tool in cancer therapy, bisphosphonates can initiate osteonecrosis of the jaw, particularly in the presence of trauma, infection, foreign body, and radiation injury. Prevention with oral hygiene and avoidance of invasive dental procedures is important. However, once osteonecrosis occurs, it must be treated. Treatment often consists of stopping bisphosphonate therapy and thorough debridement of bone with removal of hardware. More extensive surgical intervention is determined on a case-by-case basis. In the scenario described, the patient was treated with a marginal mandibulectomy, removal of involved dental implant posts, and a submental artery flap to cover the floor-of-mouth defect and seal the orocutaneous fistula.
Although bevacizumab (Avastin) and dexamethasone (Hexadrol) have been associated with poor wound healing, and doxorubicin (Adriamycin) and cetuximab (Erbitux) have been associated with mouth sores, none has been associated with osteonecrosis.
A 47-year-old Caucasian man comes to the office regarding a painful enlarging mass at the base of the tongue. He does not smoke cigarettes. The lesion measures 4.5 cm. A biopsy of the lesion is performed and shows (+) p16 staining, nonkeratinized squamous cell carcinoma. Further imaging and workup demonstrate an ipsilateral solitary lymph node measuring 2.3 cm. No distal metastatic disease is found. Which of the following best describes the stage of his disease?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
The correct response is Option B.
The correct answer is Stage 2. Previously, this patient would have been Stage 3. The American Joint Committee on Cancer (AJCC) revised its staging system for squamous cell cancers that stain p16 positive. These lesions are related to the human papillomavirus (HPV) and have been found to be less virulent tongue base or oropharyngeal cancers. Recent studies have demonstrated that 5 year survival difference for patients with Stage 4 disease as <50% for HPV-negative patients and >70% for HPV-positive patients, thus prompting the AJCC to study and revise the staging system for HPV-positive oropharyngeal cancers. These lesions tend to be more sensitive to radiation therapy and chemoradiation and a better prognosis overall. Patients with HPV-related squamous cell cancers tend to be younger, male, and Caucasian. HPV-related squamous cell cancers now represent the majority of newly diagnosed oropharyngeal carcinomas in the United States. This new staging system for HPV (+) related cancers went into effect 1/1/2017.
A 6-month-old boy undergoes excision of a midline nasal mass. Operative findings include neural tissue without evidence of a dural covering. No underlying defect of the bone is noted. The mass in this patient is most likely which of the following types of lesions?
(A) Dermoid
(B) Encephalocele
(C) Glioma
(D) Neurilemoma
(E) Neurofibroma
The correct response is Option C.
Based on the operative findings, this mass is a glioma. A congenital midline nasal mass is most likely to be a dermoid cyst, an encephalocele, or a glioma. Diagnosis can be facilitated by preoperative imaging studies. A dermoid cyst, which is the most common congenital nasal mass, typically contains sebaceous material and may communicate with the intracranial space. An encephalocele, which is a protrusion of the brain through an embryologic defect in the skull, is always covered by the dura. However, the content of the dural sac may vary. Gliomas consist of glial neural tissue and are not surrounded by dura. However, they may maintain a connection to it. Gliomas require thorough resection because of the risk of recurrence.
A neurilemoma or neurofibroma is not likely to arise as a midline nasal mass in a 6-month-old infant.
A 57-year-old man undergoes resection of a malignant lesion involving the mandible. He does not smoke cigarettes. Which of the following flaps is most appropriate to use for reconstruction of the resulting mandibular defect from ramus to ramus?
A) Cadaveric bone graft with scapular free flap
B) Fibular free flap
C) Lateral thigh flap with rib graft
D) Myocutaneous pectoralis major flap with reconstructive plate
E) Osteocutaneous radial forearm free flap
The correct response is Option B.
The most appropriate flap for a large defect from ramus to ramus is a fibular free flap. It allows a large segment of vascularized bone and a skin paddle to be used for reconstruction.
The osteocutaneous radial forearm free flap is good for limited osteocutaneous defects, and has less bone available for reconstructing the mandibular defect than the fibular flap. It is not the best choice in this instance, because the bone defect is much larger than this flap can reliably provide.
The myocutaneous pectoralis flap has been used historically in mandibular reconstruction; however, it is prone to break down over the reconstruction plate, and is a less ideal choice than a free fibular flap to reconstruct the described defect.
A scapular free flap requires repositioning the patient and would not provide adequate vascularized bone to reconstruct the described mandibular defect. It is not typically used, even with cadaveric bone, to reconstruct large mandibular defects.
The anterolateral thigh flap is also used in soft tissue reconstruction, but does not provide vascularized bone for reconstructing the large bony defect in this particular case, and non-vascularized rib graft would not be a good substitute for a large mandibular defect.
A 30-year-old man is evaluated one week after the sudden onset of inability to move the left side of his face. He has a recent history of a viral upper respiratory illness but is otherwise healthy and takes no medications. Physical examination shows unilateral facial paralysis. Which of the following is the most appropriate next step in management?
A ) Electromyography
B ) MRI
C ) Nerve excitability test
D ) Schirmer test
E ) Observation
The correct response is Option E.
Following viral illness, Bell palsy is by far the most common form of unilateral facial paralysis. A period of three weeks should be allowed for observation before an extensive work up is initiated. Electromyography characterizes muscle activity but requires an interval of 14 to 21 days following paralysis before accurate results are possible. This is most useful in determining late prognosis in complete nerve paralysis. MRI is highly accurate in identifying mass lesions of other defects along neural pathways. In association with recent viral illness, this young, healthy individual is unlikely to demonstrate neoplasia relative to his risk for Bell palsy. Nerve excitability testing measures the membrane polarization, ion channel function, and paranodal/internodal condition of peripheral nerves. This technique is helpful in characterizing a wide variety of neuromuscular disorders, including multifocal motor neuropathy, conduction block in carpal tunnel syndrome, and diabetic neuropathy. Still, an observation period of three weeks is appropriate before testing is requested. Schirmer test uses paper strips inserted into the eye for several minutes to measure the production of tears. More than 10 mm of moisture on the filter paper in five minutes is a normal test result.
A 59-year-old woman who has worked in rubber manufacturing for 35 years is referred by her primary care physician because of a firm, nontender, 1-cm mass with ulceration on the hard palate between the central incisors and the incisive foramen. This suspected minor salivary gland tumor is most likely to drain into which of the following nodal basins?
A) Submandibular nodes
B) Parathyroid nodes
C) Parotid nodes
D) Posterior triangle nodes
E) Occipital nodes
The correct response is Option A.
The area of the lips, gums, teeth, tongue, and anterior hard palate will drain to the submental and submandibular region (Level I).
Levels IA (submental) and IB (submandibular) are separated by the anterior digastric muscle.
Group II drains the naso-/oro-/hypopharynx and parotid and is called the upper jugular group.
Group III ( middle jugular group) drains the naso-/oro-/hypopharynx and larynx.
The lower jugular group (level IV) drains the larynx, cervical esophagus, and hypopharynx.
Group V is the posterior triangle group and drains the naso- and oropharynx.
Group VI is the anterior central group below the hyoid and above the sternal notch. The group drains the thyroid, parathyroid, cervical esophagus, and larynx. More posteriorly the hard palate and soft palate will drain to the retropharyngeal space and deep cervical nodes.
A 54-year-old man has a recurrent multinodular tumor 18 months after undergoing superficial parotidectomy for removal of a pleomorphic adenoma. Physical examination shows normal function of the facial (VII) nerve. In addition to radical resection of the tumor, which of the following is the most appropriate management?
(A) Chemotherapy
(B) Cryotherapy
(C) Hormone therapy
(D) Immunotherapy
(E) Radiation therapy
The correct response is Option E.
Multinodular local tumors are the most common form of recurrence in patients with previously removed pleomorphic adenomas, and the most appropriate management of these tumors is radical resection followed by radiation therapy. The extent of resection depends on the nature of the recurrence and the extent of the previous surgery; however, the facial nerve should be preserved if possible. If the facial nerve cannot be preserved, immediate reconstruction with
a nerve graft is indicated. In addition, radiation therapy has been shown to result in a marked decrease in the risk for multinodular recurrence in patients with parotid gland tumors when compared with surgery alone.
Chemotherapy is not used for treatment of multinodular local recurrent pleomorphic adenomas. Cryotherapy is recommended for control of nonresectable hepatic tumors. Hormone therapy and immunotherapy are not appropriate management options in patients with parotid gland tumors.
Which of the following viruses is implicated in the pathogenesis of nasopharyngeal carcinoma?
A) Epstein-Barr virus
B) Hepatitis C virus
C) Human herpesvirus 8
D) Human immunodeficiency virus
E) Human papillomavirus
The correct response is Option A.
All phases of the Epstein-Barr virus life cycle are associated with human disease. In immunocompromised individuals, infected cells increase in number, and eventually B-cell growth control pathways are activated, inducing transformation and leading to malignancies such as nasopharyngeal carcinoma, Burkitt lymphoma, post-transplant lymphomas, and gastric carcinomas. Human papillomavirus (HPV) is increasingly recognized as a pathogenic risk factor for oropharyngeal cancer development. Accumulating molecular and epidemiological data now show that high-risk types of HPV are responsible for a subset of oropharyngeal cancer. Oral verrucous and squamous cell carcinomas have been reported in patients infected with hepatitis C virus, and the infection has been found to be more prevalent in patients with oral lichen planus. Infection with HIV is not known to be directly pathogenic in malignant transformation, but rather it increases the susceptibility to opportunistic infections and viral-promoted cancers. Human herpesvirus 8, also known as Kaposi sarcoma–associated herpesvirus, has been found in nearly all tumors in patients with Kaposi sarcoma.
A 30-year-old woman with cerebral palsy has excessive salivation at rest (unstimulated) that is not controlled with administration of glycopyrrolate (Robinul). Removal of which of the following salivary glands is most likely to reduce salivary flow in this patient?
A ) Minor
B ) Parotid
C ) Sublingual
D ) Submandibular
The correct response is Option D.
The parotid and submandibular glands are the main contributors to salivary flow. Minor salivary glands are present in the oral cavity and pharynx. They are minor contributors, creating less than 10% of the saliva. The secretory unit of the salivary glands is constructed of acinar cells, myoepithelial cells, intercalated duct, striated duct, and excretory duct. The acini are responsible for secreting serous and mucous constituents of saliva. The parotid gland is purely a serous-secreting gland, whereas the submandibular is predominately serous, with 10% of the acinar cells producing mucous secretions. In the unstimulated state, the submandibular gland produces most of the saliva, whereas the parotid gland is responsible for most of the saliva produced in the stimulated state. Total salivary flow can reach 1.5 L daily in healthy individuals.
Xerostomia is a common complication resulting from radiation therapy for head and neck cancer. Xerostomia is defined as dry mouth (reduced or absent saliva flow) caused by damage to the salivary glands. Xerostomia has late effects on oral health, specifically dry mouth, sore throat, altered taste, dental decay, changes in voice quality, and impaired chewing and swallowing function. Xerostomia may also contribute to the development of mandibular osteoradionecrosis after radiation.
Salivary flow reduces to 50 to 70% of baseline after 10 to 16 Gy radiation and is undetectable after 40 to 42 Gy radiation. Xerostomia has been reported to occur in 60 to 90% of survivors of head and neck cancers treated with radiation therapy.
Management of xerostomia is focused on prevention and treatment. Although there are multiple options and advances that have been made in the management of this condition, there are no specific regimens that will prevent or completely treat xerostomia. Prevention of xerostomia includes cytoprotection using amifostine or pilocarpine. Radiation therapy techniques that spare the salivary gland may be more effective than cytoprotective agents. Such techniques include the use of intensity-modulated radiation therapy to spare the parotid gland and submandibular gland. Surgical submandibular gland transfer has also been described. Treatment of radiation-induced xerostomia includes salivary substitutes, salivary stimulants, acupuncture, and gene therapy.
A 70-year-old man who has smoked cigarettes for the past 37 years has a 2.5-cm indurated mass of the lateral floor of the mouth that is adherent to the body of the mandible. A 2-cm lymph node can be palpated in the ipsilateral submandibular region; there are no distant metastases. Histologic examination of a biopsy specimen of the lesion shows squamous cell carcinoma.
According to TNM classification, which of the following is the correct clinical classification of this tumor?
(A) T2 N1 M0
(B) T3 N1 M0
(C) T3 N2 M0
(D) T4 N1 M0
(E) T4 N2 M0
The correct response is Option D.
In this patient who has a 2.5-cm squamous cell carcinoma of the lateral floor of the mouth that is adherent to the adjacent mandible, as well as a 2-cm palpable lymph node but no evidence of distant metastases, the tumor is correctly classified as T4 N1 M0. The staging of squamous cell carcinomas of the oral cavity involves three descriptors: T, N, and M. The T descriptor is based on the diameter or surface area of the primary tumor. The N descriptor describes nodal status. The M descriptor indicates distance of metastasis beyond the neck. This staging criteria allows physicians to predict patient outcomes and choose appropriate therapy based on comparisons with patients in large studies.
A TNM classification table for squamous cell carcinoma of the oral cavity is shown below.
Status of Tumor (T)
TX - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor 2 cm or less in greatest dimension
T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 - Tumor more than 4 cm in greatest dimension
T4 (lip) - Tumor invades adjacent structures (eg, through cortical bone, inferior alveolar nerve, floor of mouth, skin of face)
T4 - (oral cavity) Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue, maxillary sinus, skin; superficial erosion alone of bone/tooth socket by a gingival primary tumor is not sufficient to classify as T4)
Status of Lymph Nodes (N)
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 - Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a - Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N3 - Metastasis in a single ipsilateral lymph node more than 6 cm in greatest dimension
Status of Metastasis (M)
MX - Distant metastasis cannot be assessed
M0 -No distant metastasis
M1 - Distant metastasis
Which of the following findings is most likely in patients who undergo superficial parotidectomy for treatment of sialadenitis?
A) Frey syndrome at 3 months postoperatively
B) Hematoma after the first 24 hours postoperatively
C) Permanent postoperative facial nerve dysfunction
D) Salivary fistulae
E) Tinnitus
The correct response is Option D.
Frey syndrome occurs with injury and abnormal regeneration of the auriculotemporal nerve, but is a late complication (median time at presentation: 11 months). Postoperative facial nerve dysfunction can occur in up to 60% of patients, but the majority (90%) resolve without need for operative intervention. Tinnitus is not a recognized complication of superficial parotidectomy, and hematoma is an early complication (<24 hours). Patients with sialadenitis alone have increased risk for developing salivary fistulae.
A 17-year-old boy is diagnosed with an infected molar and scheduled for dental extraction. Before the day of surgery, he is brought to the emergency department because of drooling, protruding tongue, bilateral woody edema of the submandibular region, and tenderness of the neck. Which of the following is the most likely diagnosis?
A) Ludwig angina
B) Periapical abscess
C) Peritonsillar abscess
D) Primary mononucleosis
E) Reactive lymphadenopathy
The correct response is Option A.
Drooling, protruding tongue, and woody edema (non-fluctuant) of the submandibular region are classic signs for Ludwig angina, or deep space infection of the floor of the mouth. The source is frequently dental periapical abscess, often molar in origin where the mandible bone is thinner, allowing the infection to spread to the floor of the mouth. Treatment includes ICU monitoring of the airway for possible impending intubation, antibiotics, and surgical drainage (and in this case, extraction of the tooth as well).
Mononucleosis is not characterized by woody edema. Peritonsillar abscess is more frequently unilateral with lateral pharyngeal space symptoms without woody edema. Periapical abscess of the tooth involves localized symptoms without generalized bilateral submandibular symptoms, although this can eventually lead to Ludwig angina.
Reactive lymphadenopathy is the result of head and neck infection and does not result in the symptoms described in this scenario.
A 14-year-old girl is brought to the office because of a 1-month history of a painful, growing lesion in the hard palate with “electric-shock sensations” on palpation. Results of incisional biopsy show adenoid cystic carcinoma of the minor salivary glands. Which of the following is the most appropriate next step in management of this patient?
A) Chemotherapy
B) CT scan and MRI
C) Excision with 1-cm margins
D) Excision with 2-cm margins
E) Radiation therapy
The correct response is Option B.
Although minor salivary gland tumors are much less common than major salivary gland tumors, minor salivary gland tumors are much more likely to be malignant. Additionally, pediatric salivary cancers represent only about 5% of all salivary cancers, but are also more likely to be malignant (almost 50% were malignant in Armed Forces Institute of Pathology series of 168 pediatric salivary gland tumors). Finally, the palate is the most common source of minor salivary gland tumors, which are more likely to be malignant and higher stage when detected.
The clinical presentation of paresthesias of adenoid cystic carcinoma (ACC) suggests perineural invasion. One series (University of Maryland) of 243 minor salivary gland tumors found 78% of them were malignant, and of those malignant tumors, 15% were ACC. Given the perineural invasion symptoms, imaging, in particular MRI, can detect perineural invasion and help plan the degree of surgery.
In this scenario, clinical exam pointed to perineural invasion, which should be imaged to plan for surgery. Chemotherapy is not used in the treatment of this disease. Radiation therapy alone is not usually performed, as this is considered a surgical disease. However, it can be used as adjuvant therapy in addition to surgery. Excisional biopsy usually recommends 1- to 2-cm margins. Patients with high-stage, perineural invasion, lymphadenopathy, or other signs of extensive disease may receive surgery with adjuvant radiation therapy. Regardless, ordering a CT scan and MRI is a reasonable initial approach before surgical treatment.
A 59-year-old man with tongue cancer undergoes a hemiglossectomy, neck dissection, and reconstruction with a radial forearm fasciocutaneous free flap. On postoperative day 10, he fails a swallowing study for all food consistencies. Postoperative radiation therapy is scheduled to begin in 2 weeks. What is the appropriate next step in management?
A) Laryngectomy for aspiration
B) Percutaneous endoscopic gastrostomy tube placement
C) Revision of the free flap
D) Tracheoesophageal puncture
E) Observation with delay of radiation therapy for 10 weeks
The correct response is Option B.
Most patients who undergo hemiglossectomy can expect reasonable speech and swallowing function when reconstructed with a thin, pliable free flap, such as the radial forearm fasciocutaneous free flap, that facilitates unrestricted residual tongue movement. Although his swallowing may likely improve as he recovers from surgery and tissue edema resolves, this patient will need a feeding tube to maintain his nutrition at this time. Additionally, it can be difficult for many patients who have undergone substantial tongue resections to meet their caloric needs even if they pass their initial swallowing study during radiation therapy and short-term feeding tube placement may be indicated.
Tracheoesophageal puncture with placement of a one-way valve speech prosthesis is used to restore speech function in patients who have received a laryngectomy and does not apply to this patient. Revision of the free flap is not indicated in the early postoperative period as it is unlikely to significantly improve swallowing and may delay adjuvant treatment. A laryngectomy for aspiration would only be indicated as a last resort in a patient with chronic, long-term aspiration of oral secretions resulting in recurrent pneumonia, most commonly following more extensive tongue resections, such as a total glossectomy, including removal of the tongue base. Postoperative radiation therapy should be administered within 4 to 6 weeks of surgery for maximal effectiveness and, therefore, delaying for 10 more weeks may adversely affect this patient’s survival.
A 65-year-old man undergoes hemiglossectomy and modified radical neck dissection for tongue cancer. Which of the following flaps is most appropriate for reconstruction?
A ) Jejunum
B ) Latissimus
C ) Radial forearm
D ) Scapula
E ) Vertical rectus abdominus myocutaneous
The correct response is Option C.
The radial forearm flap is based on the radial artery and its vena comitans. In addition, the cephalic vein can usually be harvested together with the flap to provide venous outflow. In the patient described, the radial forearm flap is the best choice because it provides a thin, pliable skin paddle suitable for repair of a hemiglossectomy defect. In addition, the long pedicle vessels enable anastomosis to the contralateral neck. The scapula flap can be used in this defect; however, the flap is more bulky. The latissimus flap and the rectus flap are similarly too bulky for a hemiglossectomy and are better choices for a total glossectomy. Finally, the jejunum flap is not useful for a hemiglossectomy defect and is used most commonly for circumferential pharyngeal defects.
A 50-year-old woman has a Mohs resection defect starting 15 mm below her lower lip vermilion border and extending 3 cm caudally; the width of the defect is 4.5 cm. Exposed bony mandible is noted in the depth of the wound. A photograph is shown. The simplest and most aesthetically pleasing reconstruction is likely to be based on which of the following arterial branches?
A) Facial
B) Radial
C) Superficial temporal
D) Thoracoacromial
E) Transverse cervical
The correct response is Option A.
One of the branches of the facial artery is the submental artery. This vessel provides flow to the so-called submental flap, which can be made myofascial or musculocutaneous as it includes the platysma muscle. The flap is almost adjacent to the defect and provides similar skin in color and texture. The donor site is typically closed primarily after undermining the lower neck.
The thoracoacromial artery provides flow to the pectoralis flap. Although the pectoralis myocutaneous flap could be used here, it would be bulky, would have to exclude breast tissue, would not have a similar color match, and would create a tether from the chest to the chin. The superficial temporal artery can allow for a large laterally based forehead flap; in the era prior to free tissue transfer, this flap was used for even intraoral reconstruction. In theory, such a flap could reach the mental area, but the dissection would be very tedious and the donor site alterations significant. The transverse cervical artery can provide a flap of thin supraclavicular skin that, as a free flap, could be used in this area but certainly would not be the simplest option. Likewise the radial forearm free flap based on the radial vessels would not be a good color match and would be a lengthy, complex surgery.
A 24-year-old woman comes to the office because of a painless swelling of the jaw. The swelling first appeared 3 years ago and has increased in size since then. She has never smoked cigarettes and has no family history of cancer. CT scan of the jaw is shown. Which of the following is the most likely diagnosis?
A) Ameloblastoma
B) Dental abscess
C) Fibrous dysplasia
D) Osteoradionecrosis
E) Squamous cell carcinoma
The correct response is Option A.
Ameloblastomas are benign, locally invasive odontogenic tumors accounting for 1% of tumors of the jaw and 10% of odontogenic tumors. Approximately 80% occur in the mandible and 20% occur in the maxilla. The peak incidence occurs in the third and fourth decades of life but may also arise in children and adolescents. On x-ray study, ameloblastomas may be unilocular or, more commonly, multilocular with a ?soap bubble? or ?honeycomb? appearance. Treatment may include enucleation and curettage or more radical resection. Segmental mandibulectomy with immediate reconstruction is favored currently and is associated with the lowest recurrence rates. In rare cases, metastatic ameloblastoma and ameloblastic carcinomas have been reported.
Dental abscesses are infectious processes and present with pain, acute swelling, and fever. CT scans are usually not necessary, although periapical x-ray studies and pantomography are usually obtained. Fibrous dysplasia is a benign hamartomatous lesion that has a diffuse, ?ground-glass? appearance on x-ray study. It is usually treated conservatively, with shaving and recontouring of the bone. Osteoradionecrosis is a late complication related to radiation therapy for cancer. It is often associated with pain, bone exposure, and, as a late finding, orocutaneous fistula. Findings upon CT scan include cortical erosion and loss of bony trabeculation within the marrow space. Pathologic fractures may also be present. Squamous cell carcinoma is rare in young people who do not smoke cigarettes, but it can occur. It is usually associated with a mucosal lesion. On x-ray study, bony invasion may be noted in locally advanced cases.
Which of the following is the primary treatment for keratocystic odontogenic tumor?
A) Curettage only
B) Enucleation and chemoablation
C) Enucleation only
D) Marginal mandibulectomy
E) Segmental mandibulectomy
The correct response is Option B.
The most common benign tumors of the jaw are ameloblastoma (37%) and keratocystic odontogenic tumor (KCOT) (14%). Ameloblastomas are slow growing, occur in the 4th to 5th decades of life, and arise from odontogenic epithelium. KCOTs are locally aggressive, occur earlier in life, and also arise from odontogenic epithelium.
Curettage or enucleation results in higher recurrence rates. Addition of Carnoy’s solution (absolute alcohol, chloroform, glacial acetic acid, and ferric chloride) to the enucleated site for 3 minutes addresses the most common issue of local recurrence.
Segmental or marginal resection of the mandible is reserved for recurrence after resection locally.
A 68-year-old woman has had a slowly enlarging nodule on the right upper eyelid for the past eight months. Physical examination shows a dark purple 8-mm nodule on the eyelid; ipsilateral parotid and cervical nodes can be palpated. Histologic examination of a biopsy specimen of the lesion shows uniform sheets of small oval cells within the deep epidermis and subcutaneous fat that have indistinct margins.
These findings are most consistent with
(A) basal cell carcinoma
(B) malignant melanoma
(C) Merkel cell carcinoma
(D) microcystic adnexal carcinoma
(E) squamous cell carcinoma
The correct response is Option C.
This patient has findings consistent with Merkel cell carcinoma, an extremely aggressive tumor most commonly encountered in the head and neck region of elderly women. These nodules are pink to deep purple in color and rarely ulcerate. Light microscopy will show dense sheets of oval cells with indistinct borders that invade the deep dermis, subcutaneous fat, and muscle while sparing the papillary dermis and epidermis. Some surgeons advocate the use of electron microscopy and immunohistochemistry because these lesions can be mistaken for metastatic oat cell carcinoma or poorly differentiated lymphoma. A biopsy specimen of the lesion will most likely stain positive for neuron-specific enolase.
Because 33% of affected patients will experience a local recurrence within one year of initial treatment and approximately 50% will ultimately develop nodal metastases, wide local excision with a margin of 2.5 cm to 3 cm is indicated. En bloc resection of involved nodes and postoperative radiation therapy are also recommended; chemotherapy and prophylactic nodal dissection are controversial treatment options. Long-term survival rates are poor; only 55% of patients diagnosed with Merkel cell carcinoma will survive for three years. Factors that are associated with a poor prognosis include male gender, early age at initial onset, and location of the tumor on the head, neck, or trunk.
Basal cell carcinomas are common slow growing tumors of the head and neck that can be pigmented or ulcerated. Because these tumors rarely metastasize, local excision with 5 mm margins is recommended.
Malignant melanoma is a highly aggressive tumor of brown pigmentation that often develops within an existing nevus. Exposure to ultraviolet radiation has been associated. Melanomas of the hands and feet are associated with a significantly worse prognosis than those of the arm and leg. Excision with wide margins is advocated for treatment of malignant melanoma.
Microcystic adnexal carcinomas are rare, flesh colored nodules involving the upper lip, nose, and periorbital regions in middle aged patients. Perineural invasion is almost always seen with this locally aggressive and often recurrent tumor. Ulceration and nodal metastases are rare. Appropriate management of microcystic adnexal carcinoma is Mohs’ micrographic resection, including complete histologic examination of the tumor margins. Radiation therapy is ineffective.
Squamous cell carcinomas arise from the malpighian layer and have a strong association with actinic radiation. Cutaneous squamous cell carcinomas have a rough, ulcerated appearance and most frequently affect the head and neck region. The overall rate of metastasis is extremely low. Direct excision or radiation therapy are equally advocated as initial treatment. Recurrent lesions are treated with Mohs’ micrographic resection.
A 25-year-old woman is evaluated because of facial swelling around the jaw and loosening teeth. The swelling has worsened progressively. Physical examination shows unilateral right facial swelling around the third molar. CT scan of the mandible shows a radiolucent, multicystic, unilocular lesion in the right mandibular angle and confirmed root resorption. Which of the following series of treatments is most appropriate for this patient?
A) Local curettage of the lesion followed by cancellous bone graft reconstruction
B) Neo-adjuvant radiation therapy, segmental mandibulectomy, and reconstruction
C) Segmental mandibulectomy and reconstruction
D) Segmental mandibulectomy, reconstruction, and postoperative chemotherapy after adjuvant therapy
E) Segmental mandibulectomy, reconstruction, dental rehabilitation, and sentinel node biopsy
The correct response is Option C.
The patient described has an ameloblastoma. Ameloblastomas are benign tumors of odontogenic origin. Treatment is surgical. Conservative management, such as local curettage, is associated with high recurrence rate. The most appropriate treatment is segmental mandibulectomy, reconstruction, and dental rehabilitation. Because ameloblastoma is benign, neither adjuvant therapy nor neoadjuvant therapy is indicated.
A 58-year-old man undergoes total laryngopharyngectomy for recurrent squamous cell carcinoma. The pedicle to the most appropriate flap for reconstruction of the resulting total circumferential pharyngectomy defect extending from the base of the tongue to the cervical esophagus is located between which of the following muscles?
A) Flexor carpi radialis and palmaris longus
B) Teres minor, teres major, and long head of the triceps
C) Teres minor, teres major, long head of the triceps, and humerus
D) Vastus lateralis and rectus femoris
E) Vastus medialis and rectus femoris
The correct response is Option D.
The best option for reconstruction in this patient requiring circumferential pharyngeal reconstruction is the anterolateral thigh flap. This fasciocutaneous flap is supplied by perforators from the descending branch of the lateral femoral circumflex vessels, which are a branch of the profunda femoris vessels. The descending branch runs between the vastus lateralis and rectus femoris muscles, not the vastus medialis and rectus femoris.
The radial forearm flap is based on the septum between the flexor carpi radialis and brachioradialis muscles in the arm. Although it can be used to reconstruct partial, noncircumferential pharyngectomy defects, it is not ideal for a long, circumferential defect in a previously radiated neck.
The pedicle runs between the flexor carpi radialis and brachioradialis, not the palmaris longus.
The circumflex scapular artery emerges from the triangular space in the back, which is defined by the teres minor, teres major, and the long head of the triceps. It is the pedicle to the parascapular and scapular flaps.
Option C defines the quadrangular space that transmits the axillary nerve and posterior humeral circumflex artery.
In the panoramic x-ray study (Panorex) shown, which of the following is the most likely diagnosis of the bilateral expansile lesions?
A) Ameloblastoma
B) Central giant cell granulomas (CGCG)
C) Neurofibromas
D) Odontogenic keratocysts
E) Osteosarcoma
The correct response is Option C.
Bilateral expansile lesions of the inferior alveolar nerve canal is pathognomonic of neurofibroma. The lesions on the Panorex are both expansile and not locally destructive of bone, as is common in ameloblastoma and odontogenic keratocysts. Central giant granulomas are most often multilocular, with cortical rupture and root atrophy. Osteosarcoma always has cortical destruction.
A 21-year-old woman is evaluated for a painless enlargement along the left lower jaw. Panoramic x-ray study (Panorex) is shown. Which of the following is the most likely diagnosis?
A) Cherubism
B) Dentigerous cyst
C) Desmoid tumor
D) Giant cell tumor
E) Tuberous sclerosis
The correct response is Option B.
The findings on the panoramic x-ray study (Panorex) are most consistent with a dentigerous cyst, also referred to as a follicular cyst. These lesions are not tumors, but cysts that originate from the separation of the dental follicle from the crown of an unerupted tooth. Thus, dentigerous cysts arise during development and are odontogenic (from the tooth or its precursors) in origin. The cysts are lined by specialized epithelium that is instrumental in the formation of tooth enamel. This tissue usually atrophies and becomes part of the gingiva after the enamel is formed; a cyst forms when fluid accumulates between the atrophied or reduced enamel epithelium and the crown of an unerupted tooth. These cysts are most common around the mandibular third molar (wisdom tooth) and are seen most often in teenagers/young adults. They present as a painless bone expansion and appear on x-ray study as a well-circumscribed, unilocular radiolucency, often with a sclerotic rim. The relationship between the cyst and the tooth varies.
Giant cell tumor, desmoid tumor, and osseous tumors associated with tuberous sclerosis are solid, not cystic lesions. The former two lesions tend to be more erosive on x-ray study and have a largely solid composition. Bony tumors arising in the context of tuberous sclerosis are uncommon, but tend to be solid. Cherubism is a rare autosomal dominant disorder that begins in childhood and in which mandibular and maxillary bone is replaced by fibrous tissue and cysts. It reportedly improves over time but can be disfiguring
A 37-year-old man sustains a deep laceration of the cheek from a broken bottle resulting in injuries to the facial (VII) nerve and the parotid duct. The nerve is repaired, and the parotid duct is repaired just distal to the masseter muscle over a stent. Treatment with ampicillin-sulbactam is started. Two days later, there is marked swelling and fluctuance in the cheek but no erythema or fever. Which of the following is the most appropriate next step in management?
A) Aspiration and application of compression dressings
B) External incision and placement of a passive drain
C) Intraoral incision and placement of a passive drain
D) Reexploration and revision of the parotid duct repair
E) Reoperation for ligation of the parotid duct proximal to the site of injury
The correct response is Option A.
The patient described has a sialocele, either from a leak at the site of the parotid duct repair or from direct injury to the gland. An abscess is less likely, given the prophylactic antibiotic treatment, no erythema, and no fever. Most occurrences of sialocele after parotid duct injury or repair will resolve with compression with or without repeated aspiration. Anticholinergic medications may help by decreasing salivary flow.
External drainage of a sialocele may result in a fistula and should be avoided. Spontaneous external fistulas after parotid duct repair may be treated with intraoral drainage and compression.
If the sialocele persists, excision of the cyst or pseudocyst may be required, with intraoral drainage over a stent, but this would not be appropriate initial management.
Attempts to revise the parotid duct repair would not likely be fruitful because of postoperative inflammation and unnecessary if an adequate stent were in place and compression were applied.
Ligation is indicated for initial management of proximal injuries to the parotid duct. Significant swelling of the parotid gland will generally occur after this procedure but typically resolves rapidly with atrophy of the gland.
A 60-year-old man is evaluated for a 6-cm ameloblastoma of the right maxilla. Reconstruction using an osteocutaneous iliac crest free flap is planned. Which of the following arteries supplies arterial blood to this flap?
A) Deep circumflex iliac
B) Deep inferior epigastric
C) Descending genicular
D) Lateral circumflex femoral
E) Peroneal
The correct response is Option A.
The deep circumflex iliac artery is the major blood supply to the iliac crest free flap. It gives rise to periosteal branches and nutrient endosteal branches that supply the iliac crest bone posterior to the anterior superior iliac spine. It also gives rise to an ascending branch that supplies the internal oblique muscle and several musculocutaneous perforators that supply the overlying skin, allowing a myo-osseous or osteocutaneous free flap to be harvested, respectively. Use of the iliac crest osteocutaneous free flap has been described by several authors for maxillary as well as mandibular reconstruction, and the bone itself provides ample stock for accommodating osseointegrated implants for dental restoration.
The peroneal artery is the blood supply to the fibula free flap. Use of this flap is contraindicated when the peroneal artery contributes markedly to the blood supply of the distal lower extremity. The descending genicular artery is a branch of the superficial femoral artery and is the blood supply to the medial femoral condyle osseous free flap. Alternately, the medial superior genicular artery, another branch of the superficial femoral artery, can be used to supply this flap, but the pedicle is shorter. The descending branch of the lateral circumflex femoral artery is the blood supply to the anterolateral thigh free flap, which is a cutaneous perforator flap. The deep inferior epigastric artery is the blood supply to the rectus abdominis musculocutaneous free flap or the deep inferior epigastric perforator flap.
A 38-year-old woman has onset of gustatory sweating and flushing of the left cheek one year after undergoing superficial parotidectomy on the left for removal of a parotid tumor. The most likely cause of her current symptoms is dysfunction of which of the following nerves?
(A) Auriculotemporal
(B) Chorda tympani
(C) Facial
(D) Infraalveolar
(E) Lingual
The correct response is Option A.
This 38-year-old woman with gustatory sweating has findings consistent with Frey syndrome, a condition that occurs in more than 50% of patients who have undergone parotidectomy. Frey syndrome is thought to be caused by the development of anastomoses between postganglionic parasympathetic fibers from the otic ganglion, which are carried by the auriculotemporal nerve, and postganglionic sympathetic fibers in the sweat glands that lie within the vascular plexus of the skin. The fibers of both systems are cholinergic and mediated by acetylcholine.
The Minor starch-iodine test can be used to establish a diagnosis of Frey syndrome in symptomatic patients. In this test, 10% povidone-iodine is applied to the cheek, allowed to dry, and covered with cornstarch. Following the administration of a lemon drop stimulus, a region of blue discoloration will elicit the location of the gustatory sweating. Intracutaneous botulinum toxin, which relieves the hyperhidrosis and flushing associated with Frey syndrome by blocking neurotransmission of acetylcholine, can be administered to confirm the diagnosis. Although one series of botulinum toxin injections may result in relief of symptoms for as long as one year, repeat injections are frequently required.
Appropriate operative management is direct excision of involved skin and interposition of any one of a number of autologous tissues, including sternocleidomastoid muscle, fascia lata, lyophilized human dura, a SMAS flap, or a dermal graft between the skin and the parotid gland. Human preserved dermal allograft has been used recently with some success for interposition grafting.
The chorda tympani mediates taste sensation to the anterior two-thirds of the tongue via the facial (VII) nerve, which innervates the muscles of facial expression. The infraalveolar nerve provides sensation to the teeth, while the lingual nerve provides sensation to the tongue.
An otherwise healthy 35-year-old woman is evaluated for a 3-cm left parotid mass. Physical examination shows weakness of facial muscles on the side of the tumor. CT scan shows several enlarged cervical lymph nodes. Parotidectomy is performed, and pathologic examination shows a mixed population of poorly differentiated epithelial cells and intermediate cells with occasional secretory cells and neural invasion. Which of the following is the most likely diagnosis?
A) Hemangioma
B) Mucoepidermoid carcinoma
C) Pleomorphic adenoma
D) Squamous cell carcinoma
E) Warthin tumor
The correct response is Option B.
Salivary gland tumors are relatively rare and make up about 3 to 4% of all head and neck neoplasms. Approximately 80% of salivary gland tumors originate in the parotid gland. Approximately 80% of parotid gland tumors are benign. Facial paralysis may be associated with malignant tumors and is a sign of neural invasion. Malignant tumors may also metastasize to the regional lymph nodes and to distant sites.
Mucoepidermoid carcinoma is the most common malignancy of the parotid gland and the second most common malignancy of the submandibular and minor salivary glands. Mucoepidermoid carcinomas contain two major elements: mucus-secreting cells, and epithelial cells of the epidermoid variety. Low-grade tumors are associated with a predominance of mucus-secreting cells lining cysts and intervening nests of well-differentiated epidermoid cells. High-grade tumors show few or no mucus-secreting cells and the epidermoid cells are poorly differentiated. Intermediate-grade tumors are defined by less cyst formation than low-grade tumors with nests of epidermoid and less differentiated intermediate cells. The biologic behavior of mucoepidermoid carcinomas correlates with their histologic grade. On the basis of the nerve invasion, the appropriate treatment for this patient includes radical parotidectomy with facial nerve sacrifice. A neck dissection should also be performed for high-grade lesions or those with suspicious adenopathy. Postoperative radiation therapy is usually recommended for higher-grade mucoepidermoid cancers.
Pleomorphic adenoma, also known as benign mixed tumor, is the most common benign tumor of the parotid gland. This tumor is histologically characterized by epithelial and connective tissue elements, with stellate and spindle cells interspersed with a myxoid background. Warthin tumor (papillary cystadenoma lymphomatosum) is the next most common tumor of the parotid gland and is also benign. Warthin tumors predominantly occur in males and are bilateral in 10% of patients. Histologically, they are characterized by papillary cysts and mucoid fluid as well as nodules of lymphoid tissue. Hemangiomas are the most common salivary gland tumors found in children, and usually involve the parotid gland. Like other hemangiomas, they are benign and characterized by a rapid growth phase around the age of 1 to 6 months, followed by gradual involution over 1 to 12 years. Histologically, the tumors are composed of capillaries lined by proliferative endothelial cells. Squamous cell carcinoma is a malignant tumor that rarely involves the parotid gland, in comparison with the skin and aerodigestive tract. When squamous cell cancers occur in the parotid gland, they are usually of metastatic origin, although primary squamous cancers of the salivary glands do occur. They are histologically identical to squamous cell cancers arising from other sites with epithelial cells that form sheets or compact masses that invade adjacent connective tissue. Round nodules of keratinized squamous cells, known as “keratinous pearls,” are the hallmark of well-differentiated squamous cell carcinoma.
A 45-year-old woman is evaluated for a 2.5-cm, biopsy-proven squamous cell carcinoma of the left floor of the mouth. Imaging studies show cortical mandibular invasion, but no enlarged cervical lymph nodes or distant metastatic disease. A tracheostomy is performed. Immediate reconstruction is planned. Which of the following is the most appropriate surgical treatment for this cancer?
A) Wide local excision alone
B) Wide local excision and marginal mandibulectomy
C) Wide local excision and neck dissection
D) Wide local excision, marginal mandibulectomy, and neck dissection
E) Wide local excision, segmental mandibulectomy, and neck dissection
The correct response is Option E.
Oral cavity cancers are staged based on the following criteria set forth by the American Joint Committee on Cancer:
Primary tumor staging for oral cavity cancers (T)
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ
T1Tumor = 2 cm in greatest dimension
T2Tumor >2 cm but not more than 4 cm in greatest dimension
T3Tumor >4 cm in greatest dimension
T4aModerately advanced, local disease
Lip – Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face
Oral cavity – Tumor invades adjacent structures (e.g., through cortical bone, into deep extrinsic muscle of the tongue, maxillary sinus, or skin of face)
T4bVery advanced, local disease
Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery
The cancer described is a stage T4aN0M0 cancer of the floor of mouth. The T-stage is 4a based on cortical mandibular invasion demonstrated by radiographic imaging. Concern for mandibular invasion should be raised whenever a tumor abuts or is fixed to the mandible.
Mandibulectomy is indicated. Cortical invasion of the mandible is an indication for segmental mandibulectomy, in which the full thickness of the involved mandible and grossly disease-free margin are removed by osteotomies. Marginal mandibulectomy involves removal of the alveolar ridge and varying amounts of the inner or lingual table of the mandible depending on the location of the tumor. Marginal mandibulectomy is performed when cancers abut the mandible or invade the periosteum, but do not grossly invade the cortex of the bone.
Although clinically and radiographically the neck does not have nodal metastases (stage N0), surgical treatment is usually performed due to the risk for occult nodal metastases (20% or more in some studies). Such dissection also facilitates reconstruction by exposing potential recipient blood vessels for microvascular free tissue transfer.
A 64-year old woman comes to the office because of a nonhealing radiated scalp wound. Medical history includes resection of invasive basal cell carcinoma of the scalp, reconstruction with a scalp rotation flap, and high-dose postoperative radiation therapy (60 Gy) 10 years ago. Clinical examination shows a full-thickness wound consisting of erythematous, ulcerated, and necrotic skin, and exposed, foul-smelling skull at the base of the wound. Which of the following is the most appropriate next step in management of this patient?
A) Biopsy of the wound
B) Craniectomy with free flap reconstruction
C) MRI
D) Resection of involved scalp with split-thickness skin grafting
E) Vacuum-assisted closure (VAC)
The correct response is Option A.
The first step in managing this patient is biopsy of the wound to rule out cancer recurrence. Although the diagnosis is most likely osteoradionecrosis of the skull, one would not proceed with the next steps of management until recurrence of cancer is ruled out. In this patient, the management sequence would include a biopsy to rule out cancer recurrence, followed by CT scan to delineate the extent of the skull involvement. MRI would not delineate the extent of the bony involvement.
The rates of osteoradionecrosis occurrence vary in the literature (from 1.8 to 37%). Although the rate and severity of osteoradionecrosis are most consistently associated with doses of radiation exceeding 50 Gy, there are reports of osteoradionecrosis in patients who received doses as low as 30 Gy.
This patient would require extensive craniectomy by a neurosurgeon to debride the wound of necrotic bone and, in most cases, reconstruction with free tissue transfer. Vacuum-assisted closure would not be a viable option for this patient, nor would resection of the scalp with split-thickness skin grafting.
A 35-year-old woman undergoes surgical resection of a left parotid gland malignancy. The facial nerve was resected with the tumor, leaving a 5- to 7-cm gap between the proximal nerve stump and the distal nerve branches. Which of the following is the most appropriate treatment?
A) Cable nerve grafting
B) Cross-facial nerve grafting
C) Hypoglossal nerve to facial nerve transfer
D) Innervated gracilis muscle free flap reconstruction
E) Nerve repair with a conduit
The correct response is Option A.
When a facial nerve has been divided or resected, the best outcomes for regaining function are usually obtained from direct repair, or cable nerve grafting when too great a distance for direct repair separates the nerve ends.
While autologous nerve grafts from “expendable” donor nerves, such as the great auricular nerve or sural nerve, have long been the gold standard, nerve repair using biologic or synthetic nerve conduits has also produced reasonable results, in some series equivalent to cable nerve grafts. Conduit nerve repair has the advantage of having no donor site morbidity. However, the length of the gap between the proximal and distal cut nerve ends is usually limited to less than 3 cm for the best chances of nerve recovery.
When direct repair or cable nerve grafting is not possible—for example, when the nerve has been resected very proximally up to the intracranial portion of the nerve—cross-facial nerve grafting between redundant branches of the normal contralateral nerve and the distal facial nerve stumps of the paralyzed side can produce reasonable results with spontaneous symmetrical facial movement. Performing a nerve transfer from a donor nerve, such as the masseteric (V), spinal accessory (XI), or hypoglossal (XII) nerve can provide facial tone and symmetry at rest, and, in some cases, volitional movement with training. A temporary nerve transfer to these nerves is sometimes performed as a “babysitter” procedure while awaiting axonal growth through cross-facial nerve grafts.
When nerve repair or nerve transfers from the contralateral face or donor nerves are not feasible, such as after motor endplate degeneration has occurred in the facial muscles, innervated free muscle flap transfers can restore facial movement to the lower face. Muscles commonly used for facial reanimation include the gracilis, pectoralis minor, serratus anterior, and latissimus dorsi, because of their thinness, good excursion, and low donor site morbidity. In addition to a microvascular anastomosis, an epineural nerve repair is performed either to a cross-facial nerve graft or to a donor cranial nerve such as the masseteric nerve.
An 80-year-old man presents with floor of mouth cancer on the right side. In addition to the 1-cm area of ulceration, there is a hard, warm, nonmobile, painful mass in the submandibular area. This mass most likely originated from which of the following types of tissue?
A) Bone
B) Fat
C) Muscle
D) Nerve
E) Salivary
The correct response is Option E.
The submandibular gland duct, also known as the Wharton duct, ends in the area of the floor of the mouth and is typically blocked when cancer invades this area. As a result, there is backup of salivary content, the gland enlarges, becomes firm and painful, and can even become infected. This event has no prognostic implications. However, an enlarged node, such as the perifacial nodes, can mimic this finding and can upstage a cancer patient. If a bimanual examination of the gland cannot be performed because of the patient’s pain, a CT scan is easily confirmatory. In general, lymph nodes are mobile, with the rare exception of external bony erosion. Nonetheless, a complete head and neck physical examination can be key to interpreting the findings described.
Bony expansion from a floor-of-mouth cancer is possible, but will not usually present as a painful mass. In general, fat is not involved. Nerve involvement can also occur, and perineural invasion in the lingual nerve can cause its enlargement, but not with this presentation. A sublingual infection or hematoma (e.g., Ludwig angina) can present with what is typically a swollen bilateral submandibular mass, as the infection/abscess extends below the mylohyoid muscle. This process can cause immediate airway compromise and many recommend an emergent tracheostomy. This pathology is almost always related to bacterial infections of the mouth, most commonly related to dental caries.
A 59-year-old man is referred to the office with a diagnosis of esophageal adenocarcinoma. After esophagectomy, the surgeon elects to perform a supercharged pedicled jejunal flap for complete esophageal reconstruction. Which of the following is the most likely recipient site complication?
A) Chylothorax
B) Fistula
C) Flap failure
D) Hematoma
E) Isolated neck cellulitis
The correct response is Option B.
All of the complications listed in the options have been described in relationship to esophageal reconstruction with a jejunal flap. The most common complication involves abdominal wound infection, occurring in 21% of patients. The most common medical complication is pneumonia, occurring in 18% of the patients.
Regarding the recipient site, in multiple reviews of esophageal reconstruction with jejunal flaps, fistulas have the highest complication rate (up to 14%). The rate of complication for neck cellulitis, hematoma, flap failure, and chylothorax are 5%, 4%, 1%, and 1%, respectively.
A 64-year-old post-menopausal woman is referred for evaluation and treatment of mandibular osteonecrosis. Discontinuation of which of the following medications should be considered?
A) Alendronate
B) Calcitonin
C) Estrogen
D) Raloxifene
E) Teriparatide
The correct response is Option A.
Bisphosphonate-related osteonecrosis of the jaw is a condition found in patients who have received intravenous and oral forms of bisphosphonate therapy for various bone-related conditions such as osteoporosis. The patient may develop exposed, nonvital bone involving the maxillofacial structures. Osteonecrosis may occur following minor trauma with decreased capacity for bone healing due to the effects of bisphosphonate therapy. Treatment may involve antimicrobial rinses, systemic antibiotics, systemic or topical antifungals, and discontinuation of bisphosphonate therapy.
Raloxifene is in a class of drugs called estrogen agonists/antagonists that have been developed to provide the beneficial effects of estrogens without their potential disadvantages. It is neither an estrogen nor a hormone. Raloxifene used to be called a selective estrogen receptor modulator (SERM).
Calcitonin is a synthetic hormone for the treatment of osteoporosis. The naturally occurring hormone is involved in calcium regulation and bone metabolism.
Teriparatide, a type of parathyroid hormone, is approved for the treatment of osteoporosis in postmenopausal women and in men who are at high risk for fracture.
Estrogen therapy with or without progesterone is approved for the prevention of osteoporosis in postmenopausal women. Estrogen reduces bone loss, increases bone density in both the spine and hip, and reduces the risk for hip, spine, and other fractures in postmenopausal women.
A 65-year-old man is evaluated because of hypernasal speech and nasal regurgitation 12 months after he underwent resection of a soft palate tumor. Examination shows patent nasal passages and no soft palate. Which of the following is the most appropriate treatment?
A) Injection of corticosteroids to the inferior turbinates
B) Placement of an obturator prosthesis
C) Skin grafting
D) Tracheotomy
E) Observation only
The correct response is Option B.
The patient describes velopharyngeal insufficiency post-soft palate resection.
Prosthetic obturation is the traditional means of reconstructing palatal defects. After 12 months, observation has already been performed without resolution of symptoms. Skin grafting of soft palatal defects is of little use because it does not adequately reestablish the bulk necessary for through-and-through palatal defects, therefore leading to contracture and palatal dysfunction. Tracheotomy would exacerbate speech and swallowing difficulties and therefore is not appropriate. Injecting the inferior turbinates with corticosteroids would not functionally correct the velopharyngeal insufficiency and is therefore not appropriate.
A 46-year-old man undergoes excision of a 1-cm cyst on the right cheek that is thought to be an epidermal inclusion cyst. Histologic examination of a biopsy specimen shows pleomorphic adenoma. Which of the following is the most appropriate management?
(A) Observation
(B) Reexcision of the lesion
(C) Superficial parotidectomy
(D) Superficial parotidectomy and selective lymph node dissection
(E) Total parotidectomy
The correct response is Option C.
Pleomorphic adenoma is most appropriately managed with superficial parotidectomy. A pleomorphic adenoma is an isolated, firm, round tumor surrounded by a delicate capsule. It is the most common benign tumor of the salivary glands and is rarely associated with malignant transformation. Approximately 90% of pleomorphic adenomas affecting the parotid gland lie superficial to the facial nerve.
Because pleomorphic adenomas are characterized by microscopic extension of tumor through the capsule, and thus associated with a multifocal pattern of recurrence, superficial parotidectomy with preservation of the facial nerve is indicated.
Observation and/or simple reexcision are inadequate management and are likely to result in recurrence. Lymph node dissection is an unnecessary, excessive procedure in a patient with a benign tumor. Total parotidectomy is also excessive and can lead to serious morbidity resulting from injury or sacrifice of the facial nerve.
In a 58-year-old man undergoing total parotidectomy, which of the following is the most appropriate technique to safely identify the facial nerve trunk?
(A) Identifying the temporal branches of the nerve and performing a retrograde dissection
(B) Using the midpoint between the fascial covering of the parotid gland and the earlobe as a landmark
(C) Using the plane between the superficial and deep lobes of the parotid gland as a landmark
(D) Using the tympanomastoid suture as a landmark
(E) Using a nerve stimulator
The correct response is Option D.
The safest and most convenient way to identify the facial nerve trunk during a parotidectomy procedure involves the use of the tympanomastoid suture as a landmark. This structure is defined as the suture line located between the posterior bony auditory canal and the mastoid portion of the temporal bone. The facial nerve can be found at a point 6 mm to 8 mm below the inferior end of the tympanomastoid suture line. If the region of the suture line is carefully dissected (ie, with a fine hemostat) in the direction of the facial nerve, the soft tissues can then be separated to reveal the glistening, white facial nerve.
Identification and dissection of the temporal branches of the facial nerve is a difficult, dangerous procedure; tagging of the distal branches is instead more reliable. With this technique, the surgeon identifies the marginal mandibular nerve as it crosses the facial vein and then performs a retrograde dissection to the nerve trunk.
Because the earlobe is not a fixed point, it cannot be used as a landmark. A tragal pointer, which is defined as the cartilaginous portion of the external auditory canal at its bony junction with the skull, is used instead. The facial nerve can be found within 5 mm from this point as it exits the stylomastoid foramen.
The plane between the superficial and deep lobes of the parotid gland is obscure; a proximal approach is safer and more effective.
Nerve stimulators are used as aids and are not the primary means for identifying the nerve trunk.
A 70-year-old man comes to the office because of a 6-month history of a wound in the right supraorbital region that is draining fluid. Photographs are shown. History includes type 1 diabetes mellitus, chronic obstructive pulmonary disease, and basal and squamous cell carcinoma in the supraorbital area, which was treated with Mohs micrographic surgery, cranial burring, split-thickness skin grafting, and radiation. He has smoked one pack of cigarettes daily for 60 years. Physical examination shows a 4 × 2-cm area of exposed bone with no mobility in the immediately adjacent skin. Echocardiography shows an ejection fraction of 25%. Examination of a specimen obtained on biopsy shows recurrence of squamous cell carcinoma. After excising the tumor, a bony deformity of the supraorbital rim and exposed dura are present. Which of the following is most appropriate to correct this patient’s defect?
A ) Alloplastic reconstruction and a local flap
B ) Rib graft with local soft-tissue coverage
C ) Scalp flap
D ) Skin graft
The correct response is Option C.
In the scenario described, bony reconstruction will not impact function, and therefore soft-tissue coverage is adequate. A scalp flap is the most appropriate option because it will bring in blood supply and soft-tissue coverage without the risks associated with extended general anesthesia.
Skin grafting would likely not heal in a radiated bed. The long history of a draining wound is a contraindication to the use of alloplastic material. Although a rib graft would provide bony support, it would also increase risk because of the donor site morbidity in the patient described, who has chronic obstructive pulmonary disease and is at high risk for postoperative pneumonia.
A 62-year-old woman comes to the office because of skin necrosis and scabbing following a minor injury 6 weeks ago. A photograph is shown. History includes glioblastoma that was treated with craniotomy and radiation therapy 20 years ago. Debridement is performed, exposing the calvaria and dura. Which of the following is the most appropriate treatment for this patient?
A) Bone burring with skin grafting
B) Coverage with acellular dermis matrix
C) Coverage with a free flap
D) Coverage with scalp rotation flaps
E) Negative pressure wound therapy
The correct response is Option C.
The patient described has severe radionecrosis of the skin and the underlying bone from the previous radiation therapy. The skin is thinned, and spontaneous necrosis with scabbing can be seen in the photograph and will require extensive debridement including necrotic skin and underlying bone. As a result, closure with scalp rotation flaps will be inadequate because of the extensive skin damage, size of the defect, and exposed underlying dura. Similarly, bone burring will not be possible even if the underlying calvaria was preserved due to the history of radiation. Negative pressure wound therapy is not an option due to exposure of the underlying dura and brain matter. Similarly, acellular dermis will not be effective due to the damaged underlying tissues and chronic contamination. Radical debridement and coverage with a free flap (e.g., latissimus flap) will offer the best option for reconstruction in this patient because this procedure will deliver healthy vascularized tissues to cover the exposed cranial structures.
A 15-year-old boy is brought to the office by his parents because he has had swelling in the right lateral mandibular region for the past two months. Physical examination shows a firm, nonmobile mass of the body of the mandible. CT scan is shown. Biopsy of the lesion shows ameloblastoma. Which of the following is the most appropriate management?
(A) Cryotherapy
(B) Curettage
(C) Enucleation
(D) Segmental resection
The text of question 104 incorrectly stated “swelling in the right lateral mandibular region.” The text should read “swelling in the left lateral mandibular region.”
The correct response is Option D.
The surgical management of an ameloblastoma is controversial. Treatment modalities include cryotherapy, curettage, enucleation, or segmental resection and reconstruction. There are three main types of ameloblastomas: peripheral, unicystic, and multicystic tumors. Peripheral tumors are odontogenic in origin and have histologic characteristics consistent with intraosseous ameloblastomas. However, they occur in the soft tissues covering the tooth-bearing parts of the jaw. These peripheral tumors can be treated with local excision. Unicystic ameloblastomas can be treated conservatively with enucleation because they appear clinically as a cyst. When the tumor involves the periphery of the connective tissue wall of the cyst, a peripheral ostectomy should be considered. Multicystic ameloblastomas or large ameloblastomas that involve the surrounding of the bone and extend into the soft tissues are locally aggressive and should be treated with segmental resection and reconstruction.
A 59-year-old man comes to the emergency department because of erythema of a neck incision and salivary drainage from the wound 10 days after undergoing pharyngolaryngectomy with immediate hypopharyngeal reconstruction with a jejunal free flap to treat recurrent carcinoma of the larynx. He underwent radiation therapy for laryngeal cancer 3 years ago. Endoscopic evaluation shows a viable jejunal free flap. Which of the following is the most appropriate initial management?
A ) Debridement and anterolateral thigh free flap
B ) Debridement and ipsilateral pectoralis major myocutaneous flap
C ) Debridement of the wound edges and local flap advancement closure
D ) Local wound care
E ) T-tube decompression of the jejunal segment
The correct response is Option D.
Complications of free jejunal transfer include thrombosis and flap loss, salivary fistula, and stricture. Thrombosis and flap loss typically occur in the first few days after surgery. Because of the poor ischemic tolerance of the jejunum flap, thrombosed flaps are rarely salvageable. In these instances, early debridement and repeat free flap reconstruction is the best approach. The instance of salivary fistula is approximately 10%, with the majority of patients having received prior radiation therapy. Postoperative salivary fistula after free jejunal transfer can usually be treated conservatively with maintenance of nothing by mouth (NPO) status, dressing changes, and wound care. Larger and more persistent leaks may respond to advancement of wound edges and local flap closure with T-tube decompression of the bowel segments, or pectoralis myocutaneous flap reinforcement of the wound closure. In the setting of a viable free tissue transfer, conservative measures are the most appropriate initial management of this complication.
A 47-year-old man comes to the office for consultation about reconstruction following excision of a squamous cell carcinoma from the right mandibular angle and the body and floor of the mouth. The surgery entailed resection of the right hemimandible and dissection of the right neck. Which of the following is the most appropriate method of reconstruction?
(A) Osteocutaneous fibula flap
(B) Osteocutaneous radial forearm flap
(C) Osteocutaneous scapular flap
(D) Rectus flap with reconstruction plate
The correct response is Option A.
The patient described is set to undergo a right mandibular resection and right neck dissection. The simplest method of reconstruction is a right (ipsilateral to the recipient vessels) osteocutaneous fibula flap. This flap results in optimal placement of the pedicle vessels for microvascular anastomosis.
Unless osseous flaps are unavailable, a rectus flap with reconstruction plate should be avoided because of the high incidence of plate exposure after external beam radiation therapy.
A radial forearm flap would not provide adequate bone length for reconstruction of the defect described. Similarly, an osteocutaneous scapular flap lacks adequate bone stock for repair of such an extensive defect.
A 50-year-old woman with hypertension and diabetes comes to the office because of a large mid-palatal cancer. She undergoes a total palatectomy. A photograph is shown. Which of the following is the most appropriate method of reconstruction?
A) Anterolateral thigh free flap
B) Bilateral temporalis muscle flaps
C) Fibula osteocutaneous free flap
D) Iliac crest bone grafting
E) Rehabilitation with a palatal obturator
The correct response is Option C.
This patient has a bilateral maxillectomy defect following resection via a Le Fort I osteotomy. While small defects can be successfully addressed with prosthetic palatal obturators that fit through the wound margins and clasp to the remaining teeth, larger defects can rarely be obturated because of their weight and instability due to lack of dentition and an alveolar ridge. Bone grafting is also not an option for such a large defect, particularly one resulting from a malignancy where postoperative radiation therapy is likely. In general, bone grafts are only indicated in benign conditions with bone loss less than 5 cm in length. Even when these conditions are met, they require coverage with well-vascularized tissue. Temporalis muscle flaps can be used to reconstruct palatal defects, but in this case, the skeletal elements of the mid face have been removed. Temporalis muscle flaps alone will result in loss of mid face projection. Similarly, the anterolateral thigh free and rectus abdominis myocutaneous free flaps are frequently used to reconstruct posterior maxillary defects but, though bulkier than temporalis muscle flaps, will not maintain midfacial projection in this patient with loss of the entire palate and premaxilla.
The most appropriate reconstruction for this patient is the fibula osteocutaneous free flap. This flap will restore midfacial height, width, and projection. It has adequate bone stock for osseointegrated implant placement dental restoration as well. The skin paddle is used to close the palatal defect, separating the oral cavity from the nasal cavity.
Several other osteocutaneous free flaps, including the iliac crest and scapular osteocutaneous free flaps, have also been used for similar reconstructions.
A tumor that has metastasized to the mandible in a 70-year-old man is most likely to have originated from which of the following anatomic sites?
A) Colon
B) Kidney
C) Lung
D) Testis
The correct response is Option C.
The mandible is an uncommon site for metastatic tumor spread and is usually evidence of more widespread disease. They may arise from numerous sources and usually present with the discovery of a new nodular mass with or without ulceration. Imaging studies demonstrate radiolucent/hypodense lesions. In male patients, the most common age range is the fifth to seventh decades. In men, the most common primary site is the lung; in women, it is the breast. Of note, the posterior mandible appears to be the most common bony site of involvement. The mean survival time is 8 months.
A 79-year-old woman undergoes excision and elective neck dissection of a 2.5-cm invasive squamous cell carcinoma of the right lateral surface tongue. She has no history of head and neck cancer, and there is no radiologic or clinical evidence of nodal or metastatic disease. Wide excision with adequate margins and ipsilateral modified radical neck dissection is performed. Elective neck dissection is most likely to result in which of the following outcomes in this patient?
A) Decreased local recurrence
B) Fewer postoperative complications
C) Increased incidence of distant metastasis
D) Increased nodal relapse
E) Increased overall survival
The correct response is Option E.
This patient will have increased overall survival compared with a patient who does not have elective neck dissection. The patient described has Stage II (T2 N0 M0) oral cancer (larger than 2 cm but not larger than 4 cm, has not spread to lymph nodes with no metastatic disease). There has been much debate regarding management of the neck in patients with early-stage oral cancers. The two primary options include elective neck dissection (ie, at the time of the primary tumor resection) versus therapeutic neck dissection in the case of nodal relapse. In a prospective, randomized, controlled trial study of patients with T1 or T2 node-negative oral squamous cell carcinoma, patients received either elective neck dissection at the time of primary tumor resection or therapeutic neck dissection after nodal relapse. At 3 years, patients who underwent elective neck dissection had a higher rate of survival compared with the therapeutic surgery group (69.5 vs. 45.9%, P<0.001).
Patients who undergo elective neck dissection at the time of primary tumor resection have an increased number of postoperative complications and decreased nodal recurrence. Distant metastasis was the same between the two groups.
A 45-year-old man is scheduled to undergo reconstruction after resection of an adenoid cystic carcinoma. An intraoperative photograph is shown. Closure of the palate, support of the orbit, and contour for the cheek are planned. Which of the following is the most appropriate reconstructive procedure?
A ) Free dorsalis pedis flap coverage with vascularized toe
B ) Free radial forearm flap coverage with vascularized radius
C ) Free rectus abdominis flap coverage and iliac crest bone grafting
D ) Pedicled pectoralis flap coverage with vascularized rib
E ) Pedicled temporalis flap coverage with vascularized split calvarial bone flap
The correct response is Option C.
Reconstruction of mid face defects after oncologic resection is challenging. The defect described involves a large portion of the mid face with resection of the hard palate and orbital floor (Cordeiro type IIIb). Therefore, reconstruction should aim to provide closure of the palate, support for the orbit, and contour for the cheek. Of the choices given, the free rectus abdominis flap with iliac crest bone graft is the most appropriate option because it provides volume for reconstruction of the maxillary defect, closure of the palatal defect, and support of the eye structures with an iliac crest bone graft.
The dorsalis pedis flap is not an appropriate choice because of its low volume and donor site defect.
The free radial forearm flap lacks sufficient volume to reconstruct this extensive defect of the mid face.
The pedicled pectoralis flap does not reach this mid face defect reliably.
The pedicled temporalis flap with vascularized split calvarial bone flap similarly does not reach this defect because of its short arc of rotation.
A 60-year-old woman with a history of squamous cell carcinoma of the scalp treated with resection, skin grafting, and total scalp radiation therapy is evaluated for osteoradionecrosis of the cranial vertex. After full-thickness debridement, which of the following is the most appropriate method for soft-tissue reconstruction?
A) Coverage with a free latissimus dorsi musculocutaneous flap
B) Coverage with a pedicled trapezius musculocutaneous flap
C) Coverage with a scalp rotation flap
D) Negative pressure wound therapy
E) Skin grafting
The correct response is Option A.
In the patient described, with a history of previous radiation therapy and a full-thickness defect, a free latissimus dorsi musculocutaneous flap would be the best choice for soft-tissue reconstruction.
Skin grafting over an implant cranioplasty would not be a suitable option in this setting. Skin grafts could be considered in nonradiated, partial-thickness defects of the scalp or for coverage of scalp rotation flap donor sites.
A pedicled trapezius musculocutaneous flap would not reach the cranial vertex without undue tension and is better suited for full-thickness occipital defects.
Scalp rotation flaps are ideal for defects up to 8 cm in diameter in a nonradiated scalp. The patient’s history of previous radiation therapy would likely compromise the viability of a large rotation flap in this setting.
Negative pressure wound therapy over an implant cranioplasty in a radiated field would not allow for soft-tissue healing and coverage.
A 66-year-old man comes for a follow-up examination 7 months after resection of a T4 N1 M0 squamous cell carcinoma in the region of the retromolar trigone, including alveolectomy, followed by soft-tissue reconstruction with a platysma flap. Postoperatively, he received radiation therapy to the primary tumor site (6 Gy) and to the neck bilaterally (64 Gy). He completed radiation therapy 5 months ago. Examination today shows a malodorous, tender area of exposed, soft bone at the operative site. A panoramic x-ray study (Panorex) is shown. Multiple biopsies are negative for recurrent carcinoma. Which of the following is the most appropriate management?
A ) Long-term intravenous antibiotic therapy
B ) Open reduction and internal fixation
C ) Segmental resection and vascularized tissue transfer
D ) Sequestrectomy
The correct response is Option C.
The patient described has osteoradionecrosis of the mandible, a complication that occurs in up to 40% of patients receiving adjuvant radiation therapy for head and neck malignancies caused by hypoxia, hypovascularity, hypocellularity, and impaired collagen synthesis. The traditional definition is an area of exposed, irradiated bone that is nonhealing over 3 months. Treatment depends on the severity of the disease. Debridement and antibiotic therapy, plus or minus
hyperbaric oxygen therapy, with soft-tissue reconstruction as needed, may be curative in up to 90% of cases of osteoradionecrosis limited to the alveolar ridge or mandible superior to the alveolar canal. When more extensive destruction of the mandible is present, or when there is a pathologic fracture, as seen in the scenario described, resection of all the necrotic bone and soft tissue is indicated, followed by reconstruction with vascularized bone and soft tissue. Successful healing occurs in up to 80 to 90% of patients with more extensive disease when treated in this way. Local flaps are of limited use for soft-tissue coverage because of the radiation.
A 54-year-old woman comes to the office for consultation regarding a mass in the mouth that was diagnosed as squamous cell carcinoma. Physical examination shows one ipsilateral 1-cm lymph node. A photograph and CT scan are shown. Which of the following is the most appropriate TNM staging of this patient’s tumor?
(A) I
(B) II
(C) III
(D) IV
The correct response is Option D.
According to the American Joint Committee on Cancer (AJCC) TNM staging, if a tumor invades the mandible through the cortical bone, it is, by definition, a stage IV tumor regardless of size. In this case, considering that there is one node less than 3 cm on the ipsilateral side, the appropriate staging of this tumor is IVA.
Stage II and III tumors do not involve invasion of the mandible or adjacent structures. Stage IVB involves metastasis to a lymph node more than 6 cm in greatest dimension. Stage IVC involves distant metastasis.
Oral Cavity:
T1 Tumor <2 cm
T2 Tumor >2 but <4 cm
T3 Tumor >4 cm
T4 Tumor invades adjacent structures such as cortical bone, tongue, skin, or soft tissues of the neck
N1 One ipsilateral node <3 cm
N2a One ipsilateral node >3 and <6 cm
N2b Multiple ipsilateral nodes <6 cm
N2c Bilateral contralateral nodes <6 cm
N3 Any nodes >6 cm
M0 No distal metastasis
M1 Distal metastasis
A 9-month-old boy has had the midline nasal mass shown since birth. On the basis of the photographic and CT findings, which of the following is the most likely diagnosis?
(A) Dermoid
(B) Encephalocele
(C) Glioma
(D) Rhabdomyosarcoma of the orbit
(E) Untreated obstructive hydrocephalus
The correct response is Option B.
Nasal dermoids, gliomas, and encephaloceles are congenital midline nasal lesions that share a similar embryopathogenesis. Early in development, a small fontanelle, the fonticulus frontalis, is briefly present between the frontal and nasal bones. A second prenasal space is seen at the same time between the nasal bones and the nasal cartilage. The prenasal space is referred to as the foramen cecum when it later becomes surrounded by bone. Inadequate closure of either the fonticulus frontalis or foramen cecum can lead to sinus tracts and/or dermoid formation in this region. Both gliomas and encephaloceles are ectodermal neural tissue of the brain that has remained in the area of the fonticulus frontalis or foramen cecum. Encephaloceles always maintain a connection to the cerebrospinal fluid and are differentiated from gliomas by the presence of a defect in the cranium that allows herniation to occur (as seen in the CT scan shown). If untreated, obstructive hydrocephalus would not cause an isolated frontoethmoid skull defect but would likely present with macrocephaly. A pediatric rhabdomyosarcoma of the orbit would more likely present as an invasive soft-tissue mass causing proptosis.
A 13-year-old girl is brought to the office because of a mass of the tongue that has been growing for 10 years. The patient says she has recently noted ulcers from the mass, and bleeding occasionally occurs. Examination of a specimen obtained on biopsy shows a microcystic lymphatic malformation with microthromboses and chronic inflammation. Photographs are shown. Which of the following is the most appropriate management?
A) Embolization
B) Radiation therapy
C) Resection
D) Sclerotherapy
E) Observation only
The correct response is Option C.
Resection is the most appropriate management for the symptomatic lesion described in the photographs. Oropharyngeal tumors must always be biopsied to assess malignancy potential. If the tumor is then deemed to be benign, appropriate management is determined based on symptoms. This patient presented with a biopsy result and a sizable lesion that is still growing. Typically, an imaging study such as MRI is performed of the head and neck to assess the extent of the disease. For this type of isolated lesion that is ulcerating and interfering with eating, resection is the most appropriate treatment. Observation is not the best option, as the patient is symptomatic. Embolization is not indicated, as this is not a vascular structure. Sclerotherapy yields poor results with a microcystic lesion and would likely result in painful necrosis of the involved tissue. Radiation therapy is not a described treatment for benign lymphatic lesions.
Carbon dioxide laser treatment has been described for these types of lesions, but it often requires multiple treatments and leaves a raw surface for healing following each treatment.
A 9-month-old boy has had the midline nasal mass shown since birth. On the basis of the photographic and CT findings, which of the following is the most likely diagnosis?
(A) Dermoid
(B) Encephalocele
(C) Glioma
(D) Rhabdomyosarcoma of the orbit
(E) Untreated obstructive hydrocephalus
The correct response is Option B.
Nasal dermoids, gliomas, and encephaloceles are congenital midline nasal lesions that share a similar embryopathogenesis. Early in development, a small fontanelle, the fonticulus frontalis, is briefly present between the frontal and nasal bones. A second prenasal space is seen at the same time between the nasal bones and the nasal cartilage. The prenasal space is referred to as the foramen cecum when it later becomes surrounded by bone. Inadequate closure of either the fonticulus frontalis or foramen cecum can lead to sinus tracts and/or dermoid formation in this region. Both gliomas and encephaloceles are ectodermal neural tissue of the brain that has remained in the area of the fonticulus frontalis or foramen cecum. Encephaloceles always maintain a connection to the cerebrospinal fluid and are differentiated from gliomas by the presence of a defect in the cranium that allows herniation to occur (as seen in the CT scan shown). If untreated, obstructive hydrocephalus would not cause an isolated frontoethmoid skull defect but would likely present with macrocephaly. A pediatric rhabdomyosarcoma of the orbit would more likely present as an invasive soft-tissue mass causing proptosis.
A 38-year-old woman has a 2.5-cm squamous cell carcinoma of the tongue. On examination, she has one mobile 2-cm homolateral palpable lymph node; there are no distant metastases. Which of the following is the most appropriate classification of this patient’s tumor?
(A) T1 N0 M1
(B) T1 N1 M0
(C) T2 N1 M0
(D) T2 N2 M0
(E) T3 N2 M1
The correct response is Option C.
In this patient who has a 2.5-cm squamous cell carcinoma of the tongue with involvement of one lymph node only, the tumor is correctly classified as T2 N1 M0. The staging of squamous cell carcinomas of the lip involves three descriptors: T, N, and M. The T descriptor is based on the diameter or surface area of the tumor. The N descriptor describes nodal status. The M descriptor indicates distance of metastasis beyond the neck. This staging criteria allows physicians to predict patient outcomes and choose appropriate therapy based on comparisons with patients in large studies.
A TNM classification table is shown on page below.
Status of Tumor (T)
TX - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor 2 cm or less in greatest dimension
T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 - Tumor more than 4 cm in greatest dimension
T4 (lip) - Tumor invades adjacent structures (eg, through cortical bone, inferior alveolar nerve, floor of mouth, skin of face)
T4 (oral cavity) - Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue, maxillary sinus, skin. Superficial erosion alone of bone/tooth socket by gingival primary tumor is not sufficient to classify as T4).
Stages of Lymph Nodes (N)
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimensions; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a - Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
Status of Metastasis (M)
MX - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
In order to determine the correct clinical staging of this type of tumor, the surgeon must first examine the primary lesion and the lymph nodes in the neck. A CT scan should be obtained to rule out potential invasion of adjacent structures; histologic evaluation of a biopsy specimen of the lesion will best establish and/or confirm the diagnosis. Further evaluation to determine the extent of metastases will include a radiograph of the chest, complete blood cell count, and blood chemistry studies. If the patient’s symptoms are applicable to specific organ systems, other diagnostic tests may be required.
A 50-year-old man with a long-term history of sun exposure is evaluated because of a 2.5-cm biopsy-proven squamous cell carcinoma of the central lower lip. Physical examination shows no enlarged cervical lymph nodes. Which of the following is the most appropriate treatment for this cancer?
A) Combined surgery and radiation
B) Curettage and electrodessication
C) Photodynamic therapy
D) Surgical excision
E) Treatment with 5-fluorouracil for 3 months
The correct response is Option D.
Oral cavity cancers are staged based on the following criteria set forth by the American Joint Committee on Cancer (AJCC):
The cancer described in the scenario is a stage T2N0M0 cancer of the lip. Surgical excision with margin control is the most appropriate and probably the most common treatment for this lesion, although Mohs micrographic surgery may also be an option for surgical removal. Reconstruction would be performed after attaining adequate surgical margins and can be performed utilizing local tissue flaps in most patients.
5-Fluorouracil cream can be used in the treatment of actinic keratosis and superficial basal cell cancers. It is also used in the treatment of some squamous cell cancers, but its efficacy is lower and would not be indicated for a T2 cancer. In curettage and electrodessication, small tumors are scraped off with a curette and electrocautery destroys residual tumor and controls bleeding. It is used for superficial squamous cell cancers without high-risk characteristics in noncosmetically sensitive sites and would not be appropriate for this lesion. Also, surgical margins cannot be evaluated with this technique. Photodynamic therapy involves application of a photosensitizing agent, such as 5-aminolevulinic acid (5-ALA), that is taken up by the cancer cells. The next day, the medicated areas are activated by a strong light. The treatment selectively destroys cancer cells while causing minimal damage to the surrounding tissue. It is used to treat actinic keratosis and is not approved by the Food and Drug Administration for treatment of squamous cell carcinoma, although experience suggests that it is effective for small, superficial cancers. Radiation therapy alone can be used in cosmetically and functionally important sites such as the lip or in patients who are poor candidates for surgery because of medial comorbidities. Given the good functional and cosmetic prognosis of surgical resection and reconstruction in this patient, irradiation would likely be reserved for a recurrent cancer. Combined surgery and irradiation is usually reserved for T4-stage cancers or those with nodal metastases.
A 72-year-old man presents with a 2-cm, nontender, rapidly growing, violaceous intradermal papule of the cheek. Current medications include tacrolimus following renal transplantation. Biopsy of the lesion shows small, round, blue cells with large prominent nuclei that stain positive for cytokeratin 20. Which of the following is the most likely diagnosis?
A) Amelanotic melanoma
B) Basal cell carcinoma
C) Keratoacanthoma
D) Merkel cell carcinoma
E) Squamous cell carcinoma
The correct response is Option D.
Merkel cell carcinoma (MCC) is an uncommon and extremely aggressive cutaneous malignancy that is challenging to diagnose. Up to one half of patients will eventually develop a recurrence or a metastasis. There are approximately 2500 cases of MCC diagnosed per year in the United States. Eighty percent of MCCs are caused by the Merkel cell polyomavirus and the remaining 20% by extensive ultraviolet-mediated damage.
MCC is most common on sun-damaged areas, with half located on the head and neck and nearly 40% on the extremities. They usually present as nontender, rapidly growing, painless, single, red to violaceous, firm intradermal papules or nodules. The epidermis overlying the tumor is usually preserved, but ulceration or crusting is not uncommon. Their doubling time can be as short as 12 days. The clinical features of MCC are summarized in the acronym AEIOU: asymptomatic, expanding, immunosuppressed, older than 50 years, and ultraviolet-exposed fair skin. They are differentiated histologically by the small, round, blue cells that stain positive for cytokeratin 20.
The surgical treatment of MCC consists of wide local excision with one to two centimeter margins, inclusive of the underlying fascia. Management of regional disease is critical with this tumor. A clinically negative nodal basin will be evaluated with a sentinel node biopsy while a patient with a clinically positive nodal basin will be offered a therapeutic complete lymph node dissection. Postoperative radiation is offered to patients with tumors greater than 1 cm, close/positive margins, or nodal involvement.
Melanoma cells stain positive for S100 and HMB-45. Basal cell carcinomas stain positive for Ber-EP4. Squamous cell carcinomas stain positive for AE1/AE3.
A 40-year-old woman has a painless mass at the angle of the left mandible that has been enlarging over the past 10 years; a photograph and CT scan are shown above. Findings on physical examination are otherwise normal. Histologic examination of a biopsy specimen of the tumor shows luminal-type ductal cells mixed with sheets of myoepithelial cells and a mucoid extracellular matrix.
Which of the following is the most likely diagnosis?
(A) Basal cell adenoma
(B) Myoepithelioma
(C) Pleomorphic adenoma
(D) Sjögren’s syndrome
(E) Warthin tumor
The correct response is Option C.
The most likely diagnosis in this patient is pleomorphic adenoma, or mixed tumor. This is the most common benign tumor of the parotid gland, comprising 65% of all salivary gland neoplasms, 55% of all parotid masses, and 80% of all benign parotid tumors. Most pleomorphic adenomas arise from within the superficial lobe of the gland; only 10% are located deep to the facial nerve. These encapsulated tumors contain both epithelial and mesenchymal elements within a stroma, which can vary from mucoid to myxoid to chondroid. Because small lobules of cells may extend beyond the capsule, simple enucleation frequently results in tumor recurrence. Therefore, appropriate management is superficial lobe parotidectomy with preservation of the facial nerve.
Basal cell adenoma is the most common type of monomorphic adenoma found in the minor salivary glands of the upper lip. These tumors rarely occur in the parotid gland. Histologic examination is most likely to show rows of palisading cells with a thickened basement membrane.
Myoepithelioma is a well-circumscribed benign tumor that arises from myoepithelial cells. This tumor is rare and typically affects the parotid gland or palate. Although it is clinically similar to pleomorphic adenoma, histologic examination shows spindle cells.
Sjögren’s syndrome is an autoimmune disease occurring most frequently in women and is characterized by destruction of the exocrine glands due to immune-related mechanisms. When associated with rheumatoid arthritis, it is known as secondary Sjögren’s syndrome. Unilateral or bilateral salivary gland swelling, frequently affecting the parotid gland, is present in 80% of patients with primary Sjögren’s syndrome and 40% of patients with secondary disease. Additional distinguishing findings include xerostomia, interstitial pneumonitis, Raynaud’s phenomenon, lymphadenopathy, purpura, pancreatitis, renal disease, and recurrent parotitis.
Warthin tumor, or papillary cystadenoma lymphomatosum, is a slow-growing multicystic mass most frequently seen in men between the ages of 40 and 70 years. It is almost always localized to the parotid gland and rarely occurs in the submandibular gland. Warthin tumors comprise 10% of all parotid tumors; 10% of affected patients have multicentric lesions, while another 10% have bilateral findings. Histologic examination shows a papillary epithelium containing lymphoid stroma that projects into cystic spaces.
A 53-year-old man is undergoing revision of mandibular reconstruction. An iliac crest osteocutaneous free flap is planned. Which of the following is the main advantage of this flap compared with a free fibula osteocutaneous flap?
A) Bone length
B) Minimal donor site morbidity
C) Pedicle length
D) Reliability with multiple osteotomies
E) Vertical height
The correct response is Option E.
There are many choices for bone grafts, both vascularized and nonvascularized. In this clinical scenario, there is no question that a vascularized bone graft is indicated, given the irradiated field, anterior location, and >6-cm defect.
The choice of vascularized bone grafts include the free fibula, free iliac crest, free scapula, and free radius bone grafts. All have their pros and cons individually, although collectively, vascularized bone free flaps provide 40% more strength, 56% more stiffness, higher complete arthrodesis rate, and superior functional outcomes.
The free fibula flap would be the most common choice for this situation given its long pedicle (6 to 10 cm), the large amount of usable bone (22 to 24 cm), minimal donor site morbidity, ability to accept dental implants, and reliable skin flap (skin island survival rates approaching 100% due to increased anatomical understanding and improvements in harvest techniques). However, its disadvantage is that it doesn’t have the vertical height of the free iliac crest.
An otherwise healthy 19-year-old man is referred to the office for evaluation of two biopsy-proven skin basal cell carcinomas. Physical examination shows an asymmetry of the jaw. His father died of extensive skin cancer at 40 years of age. CT scan of the mandible is shown. Which of the following is the most likely cause of the asymmetry?
A) Ameloblastoma
B) Invasive basal cell carcinoma
C) Metastatic cancer
D) Odontogenic keratocyst
E) Osteosarcoma
The correct response is Option D.
The scenario described, Nevoid Basal Cell Carcinoma Syndrome (Gorlin syndrome, NBCCS), is rare but noteworthy. NBCCS is an autosomal dominant syndrome. Diagnosis of NBCCS is made in the presence of either two major criteria or one major and two minor criteria. The major criteria consist of the following: (1) more than two basal cell carcinomas or one basal cell carcinoma in patients younger than age 20 years; (2) odontogenic keratocysts of the jaw (proven by histologic analysis); (3) three or more palmar or plantar pits; (4) bilamellar calcification of the falx cerebri; (5) bifid, fused, or markedly splayed ribs; and (6) a first-degree relative with NBCCS. Odontogenic keratocysts are seen in 74 to 80% of patients. They usually begin to develop in the first decade (after age 7 years), with the peak incidence in the second and third decades. They are more common in the mandible than in the maxilla. They are usually asymptomatic, but they may cause pathologic fracture, swelling, loose teeth, or displacement of developing permanent teeth. Ameloblastoma has been reported with NBCCS but is very rare. Although other tumors such as fibrosarcoma, rhabdomyosarcoma, and meningioma have been reported to have increased incidence, osteosarcoma and cancers that spread to the mandible have not been reported with increased frequency in patients with NBCCS.
Finally, recognition of syndromic causes of skin cancer allows for proper questions regarding family medical history, as well as the appropriate workup for potentially more threatening occult pathologies. Diagnosis of such a syndrome also sets the stage for appropriate genetic counseling.
A 58-year-old man with a history of base-of-tongue cancer treated with radiation therapy and chemotherapy 3 years ago presents with right jaw pain, severe malocclusion (crossbite), and drainage from a wound in the right cheek. A photograph is shown. CT scan shows a pathologic fracture and bony destruction consistent with osteoradionecrosis of the mandible. A biopsy is negative for recurrent cancer. Which of the following is the most appropriate treatment?
A) Hyperbaric oxygen
B) Open reduction and internal fixation
C) Pentoxifylline and tocopherol
D) Segmental mandibulectomy and osteocutaneous free flap reconstruction
E) Sequestrectomy and treatment with antibiotic oral rinses
The correct response is Option D.
Osteoradionecrosis (ORN) is a complication caused by high-dose radiation therapy to the head and neck, most commonly affecting the mandible. ORN may be painful and can be associated with pathologic fracture, purulent infection, osteomyelitis, and fistula formation. Marx classified ORN into three stages: Stage I, exposed alveolar bone without pathologic fracture that is responsive to hyperbaric oxygen (HBO) therapy; Stage II, disease that does not respond to HBO and requires sequestrectomy and saucerization; and Stage III, full-thickness bone damage or pathologic fracture that usually requires complete resection and reconstruction. In this case, the patient has a pathologic fracture (Stage III) as well as a fistula, and segmental mandibulectomy and osteocutaneous free flap reconstruction are indicated. There is no role for open reduction and internal fixation in most cases of ORN because healing is not likely to occur. Pentoxyifylline and tocopherol (vitamin E) are more recently described treatments that have been shown to be effective in the treatment of early stage ORN.
A 32-year-old man comes to the office because he has had painless swelling of the right side of the jaw for the past 4 months. Examination shows a 6-cm mass over the mandibular angle. Panoramic x-ray study (Panorex) of the mouth is shown. Examination of the specimens obtained on biopsy of the lesion shows palisading odontogenic cells. Which of the following is the most appropriate management?
A ) Curettage and cancellous bone graft
B ) Curettage only
C ) Induction chemotherapy followed by irradiation
D ) Segmental resection and immediate reconstruction with a vascularized bone graft
E ) Segmental resection and nonvascularized bone graft
The correct response is Option D.
This patient has an ameloblastoma, which is a rare cystic tumor involving the mandible. Characteristic findings include a multilocular radiolucent lesion with a ?soap bubble? appearance, usually in association with an impacted molar. X-ray studies show unilocular or multilocular cystic masses associated with thinning of the surrounding bone. Examination of a biopsy specimen shows palisading odontogenic cells.
Appropriate treatment consists of segmental mandibular resection, including a margin of normal bone and any adjacent teeth, and immediate reconstruction. Immediate reconstruction will rapidly restore facial function and improve facial aesthetics. Curettage is inadequate and is associated with a recurrence rate of 50 to 100%.
Ameloblastomas are generally benign. Malignant forms of ameloblastoma may occasionally be treated with adjuvant radiation therapy in addition to surgical resection.
A 60-year-old man is referred for consultation regarding planned reconstruction of a defect that will result after excision of extensive squamous cell carcinoma of the lateral floor of the mouth with mandibular erosion. Preoperative photographs are shown. Which of the following flaps is most appropriate for reconstruction of the defect described?
A) Free latissimus dorsi musculocutaneous flap with the twelfth rib
B) Osteocutaneous fibula free flap
C) Osteocutaneous iliac crest free flap
D) Osteocutaneous radial forearm free flap
E) Osteomuscular dorsal scapular pedicled flap
The correct response is Option B.
This question illustrates the increasing knowledge of perforators and their distribution in flap harvesting. In the case of the fibula, many septo- and musculocutaneous perforators arise from the peroneal artery and can be used to fashion independent skin islands. Because of the experience in understanding vascular territories, safe isolation of bone, skin, and muscle components of the fibula free flap can independently be performed based on their own perforators.
Both the free flap and pedicled latissimus flap have been described for reconstruction of lateral mandibular defects. They allow for a large sheet of skin that can be de-epithelialized and used, albeit bulkily, for through-and-through defects. If more proximal dissection of the thoracodorsal pedicle is used to the subscapular artery, so-called ?mega flaps? of latissimus with scapular bone and/or serratus anterior musculocutaneous components are other options. The iliac crest free flap allows for large components of bone with a skin paddle. The skin, however, is neither pliable nor independent of the bone. With the addition of the internal oblique muscle to line the oral cavity and the skin used for cheek replacement, a through-and-through defect can be reconstructed with this flap.
The osteocutaneous radial forearm flap provides thin and pliable skin that can be de-epithelialized for through-and-through defects. Separate skin paddles have been devised for this flap, but they are hard to center on the bone for such a defect. In addition, the bone is rather thin and cannot accommodate osteointegrated implants. The donor site has to be managed carefully as poor attention to detail (including poor patient selection) could leave the patient at risk for pathologic fracture of the radius remnant.
The osteomuscular dorsal scapular flap is a variant of the pedicled osteocutaneous trapezius flap with a portion of scapular bone and provides an alternative technique for bone and skin defects. Like the latissimus pedicled flap, it provides one skin paddle and transports limited bone, and is generally reserved for patients with smaller defects and severe neck vasculopathy.
Before recent understanding of perforator distribution, the scapular/parascapular free flap with bone was the flap of choice. It, unlike the fibula free flap, requires repositioning of the patient and nonsimultaneous harvesting.
A 70-year-old man is referred for evaluation directly after undergoing excision of recurrent squamous cell carcinoma and Mohs micrographic surgery. A photograph is shown. Pathology shows some extension onto the parotid capsule. Clinical examination shows two enlarged postauricular lymph nodes. Which of the following is the most appropriate management of this patient?
A) Cervical facial flap plus radiation
B) Direct closure alone
C) Superficial parotidectomy and direct closure
D) Superficial parotidectomy, neck dissection, and coverage with a cheek rotation flap
E) Superficial parotidectomy, neck dissection, and direct closure
The correct response is Option D.
Direct closure is being used more commonly in large Mohs facial defects, especially in the elderly, as it minimizes the disruption of skin tension lines. The contraindication in this case to closure alone is the nodal involvement and the extension into the parotid capsule. Given the parotid capsule extension, adequate margins at a minimum will require a superficial parotidectomy. Radiation alone plus flap closure would have a higher recurrence rate because residual disease is left in the capsule. The nodal enlargement requires further evaluation and given the options the best combination is superficial parotidectomy, neck dissection, and a local rotation flap.
A 55-year-old man is evaluated because of right-sided jaw pain, speech problems, and oral dysphagia 5 years after successfully completing a chemoradiation protocol for base-of-tongue cancer. CT imaging shows no signs of recurrence or distant metastatic disease. A panoramic x-ray study (Panorex) is shown. Which of the following is the most appropriate management of this constellation of symptoms?
A) Debridement of mandible
B) Hyperbaric oxygen therapy
C) Open reduction and internal fixation
D) Osteocutaneous fibular free tissue transfer
E) Rib graft
The correct response is Option D.
It is important to note that any patient experiencing pain like this should be worked up for recurrent disease. Nevertheless, this question addresses two issues in head and neck reconstruction. First, most non-oral cavity head and neck cancers are now treated primarily with chemoradiation protocols. This leaves surgery for salvage or for dealing with the morbidities of the therapy. In this case, the patient is now experiencing bilateral osteoradionecrosis with a pathologic fracture on the right. Had this problem stopped with the left side, debridement and letting the mandible sway to the ipsilateral side would be a form of management, although it can be disfiguring.
Secondly, from a reconstructive standpoint, this is a challenging case; but advances in flaps and preoperative modeling allow for managing such situations in one procedure. Given how long the fibular free flap can be fashioned and the ability to remove large central pieces of bone, surgeons can create two osseous segments vascularized off the same pedicle. Since many of these patients have difficult necks from a recipient vessel standpoint, decreasing the number of needed anastomoses is beneficial. Two free flaps can be performed at the same time or sequentially, but this adds increasing morbidity and complexity to the situation. In this case, a single fibular free flap with plates designed using stereolithographic modeling was adequate to restore the patient’s ability to eat and articulate. It also improved his occlusion, and, with debridement, stopped his pain. Postreconstructive imaging is shown.
Now that the right side is involved, simple debridement only would leave the patient potentially an oral cripple. By definition, the bone is of poor quality and simple open reduction and internal fixation will not restore the patient’s function or promote proper healing. Hyperbaric oxygen is used for osteoradionecrosis, but numerous studies now question its benefit in craniofacial bone, and it would not address the pathologic fracture on the right. Hyperbaric oxygen was shown to positively influence the osteoradionecrotic tissues prior to and post-free tissue reconstruction. Finally, a free bone graft in this situation, even with additional soft tissue coverage, would not address the major issue of hypoperfusion to the affected bone.
A 65-year-old woman is evaluated immediately after she underwent subtotal maxillectomy for an adenoid cystic carcinoma. The resulting defect includes the right hemi-palate, maxillary sinus, orbital floor, and nasal lining. A photograph is shown. Which of the following is the most appropriate option for reconstruction?
A) Facial artery musculomucosal flap
B) Obturator
C) Omentum flap
D) Rectus flap
E) Temporalis flap
The correct response is Option D.
This is an extensive subtotal maxillectomy (Type IIIA Cordeiro classification) that requires reconstruction of a number of anatomical structures including the hard palate, the orbital floor, and the nasal lining. In addition, vascularized tissues are required to separate the maxillary sinus content from the orbit. In this case, the rectus flap is the best option because it can provide skin to re-line the maxillary sinus and repair the palatal defect. In addition, the rectus flap has sufficient bulk to obliterate the maxillary sinus and provide vascularized tissue to support the orbital floor reconstruction that is required. The omentum flap usually has enough bulk to obliterate the sinus but will not enable reconstruction of the palatal defect. The obturator will reconstruct the palate but will not provide vascularized tissue to line the orbital floor reconstruction and separate this region from the maxillary sinus. The temporalis flap can be used to cover the orbital floor reconstruction but does not reconstruct the palatal defect. The facial artery musculomucosal flap is a flap based on the facial artery and would not be useful in this reconstruction.
A 54-year-old woman comes to the office for consultation regarding a mass in the mouth that was diagnosed as squamous cell carcinoma. Physical examination shows one ipsilateral 1-cm lymph node. A photograph and CT scan are shown. Which of the following is the most appropriate TNM staging of this patient’s tumor?
(A) I
(B) II
(C) III
(D) IV
The correct response is Option D.
According to the American Joint Committee on Cancer (AJCC) TNM staging, if a tumor invades the mandible through the cortical bone, it is, by definition, a stage IV tumor regardless of size. In this case, considering that there is one node less than 3 cm on the ipsilateral side, the appropriate staging of this tumor is IVA.
Stage II and III tumors do not involve invasion of the mandible or adjacent structures. Stage IVB involves metastasis to a lymph node more than 6 cm in greatest dimension. Stage IVC involves distant metastasis.
Oral Cavity:
T1 Tumor <2 cm
T2 Tumor >2 but <4 cm
T3 Tumor >4 cm
T4 Tumor invades adjacent structures such as cortical bone, tongue, skin, or soft tissues of the neck
N1 One ipsilateral node <3 cm
N2a One ipsilateral node >3 and <6 cm
N2b Multiple ipsilateral nodes <6 cm
N2c Bilateral contralateral nodes <6 cm
N3 Any nodes >6 cm
M0 No distal metastasis
M1 Distal metastasis
A 40-year-old woman comes to the office because of a 5-year history of firm, painless swelling of the upper jaw that has increased progressively in size. CT scan is performed, and the lesion is shown. Resection is performed. Pathologic examination shows odontogenic epithelial islands bordered by palisading columnar cells. No invasion into the surrounding tissues is noted. Which of the following is the most likely diagnosis?
A) Ameloblastoma
B) Fibrous dysplasia
C) Nasopharyngeal angiofibroma
D) Osteosarcoma
E) Squamous cell carcinoma
The correct response is Option A.
Ameloblastomas are benign, locally invasive, odontogenic tumors accounting for 1% of tumors of the jaw and 10% of odontogenic tumors. Approximately 80% occur in the mandible and 20% occur in the maxilla. The peak incidence is in the third and fourth decades but may also arise in children and adolescents. Ameloblastomas may be radiographically found to be unilocular or, more commonly, multilocular with a “soap bubble” or “honeycomb” appearance. Treatment may be with enucleation and curettage or more radical resection. In rare cases, metastatic ameloblastoma and ameloblastic carcinomas have been reported.
Fibrous dysplasia is a benign hamartomatous lesion that has a diffuse, “ground-glass” appearance on x-ray studies. It is usually treated conservatively with shaving and re-contouring of the bone. Squamous cell carcinoma is usually associated with a painful mucosal lesion. Radiographically, bony invasion may be noted in locally advanced cases. Osteosarcomas are aggressive malignancies of mesenchymal origin that exhibit osteoblastic differentiation. They are the most common primary bony cancer. Their radiographic appearance is variable and may include nonspecific destruction of the bone similar to a carcinoma, mottled ossification, similar to fibrous dysplasia, but without well-defined borders, or lamellar ossification (sheets of neo-osteogenesis). Nasopharyngeal angiofibromas are benign but locally invasive vascular tumors that occur almost exclusively in male adolescents. Their symptoms include nasal obstruction but can eventually cause facial asymmetry and eye displacement, as they grow from the region of the sphenopalatine foramen first into the nasopharynx and choanae then into the paranasal sinuses, pterygopalatine and infratemporal fossae, orbit, and even the intracranial cavity. Radiographically, they are nonencapsulated, lobular soft-tissue masses that demonstrate intense uptake of intravenous contrast due to their highly vascular nature. Extensive bony destruction is usually not a feature, but bone may be remodeled or resorbed.
A 32-year-old man is evaluated because of painless swelling of the right cheek 2 months after being assaulted with a knife and sustaining a laceration across the mid cheek. The laceration was sutured by the emergency department physician assistant. Which of the following is the most appropriate management at this time?
A) Drainage of the collection and administration of antisialagogues
B) Open debridement with skin grafting
C) Surgical exploration with reanastomosis of the injured duct
D) Total parotidectomy with facial nerve preservation
E) Ultrasound-guided needle aspiration only
The correct response is Option A.
Any penetrating injury on a line from the tragus to the mid upper lip may injure the parotid duct or gland. The parotid system can be divided into 3 regions:
Region A: gland
Region B: duct superficial to the masseter muscle
Region C: duct from the masseter to where it enters the mouth opposite the 2nd maxillary molar
Additionally, the buccal branch of the facial nerve often runs with the duct. It can cross the superficial layer of the masseter after leaving the parotid gland. Injury manifests as weakness of the upper lip on animation.
Injury not repaired acutely can manifest later as salivary fistulae or sialoceles. Most can be managed conservatively with drainage, pressure, and antisialagogues. Trying to find and repair the duct late after the injury is difficult and may not lead to resolution of the symptoms. This is usually reserved for early injury and repair. If these fail, then a superficial parotidectomy can be considered for recalcitrant salivary collections.
