Head & Neck Flashcards
Anterior to posterior structures
Subclavian vein
Phrenic nerve
Anterior scalene
Subclavian artery
Parotitis
Staph
Elderly, dehydrated
Tx with abx, I&D
Painless mass on roof of mouth
Torus
Leukoplakia vs erythroplakia
Erythoplakia - pre-malignant
Retinoids can reverse leukoplakia nad reduce chance of 2nd head and neck malignancy
Nasopharyngeal SCC features
Drain to posterior neck nodes
EBV
Glottic cancer tx
XRT if cords not fixed
If fixed-surgery + XRT
Lip CA features
lower>upper incidence epidermoid carcinoma tx: <1/2 lip - primary closure >1/2 lip - flaps Radical neck dissection if node +
Tongue CA tx
surgery + XRT
Increased in plummer vinson
Large salivary glands (parotid) sign of?
More likely tumor is benign
MC malignant salivary tumor
mucoepidermoid carcinoma
MC malignant salivary tumor of submandibular /minor salivary glands
adenoid cystic carcinoma
MC benign parotid tumor
Pleomorphic adenoma
Tx of pleomorphic adenoma
Superficial parotidectomy
If malignant - take whole parotid with CN7, if high grade - radical neck dissection
Warthin’s tumor
2 bengin tumor
10% bilateral
70% of bilateral parotid tumors
Tx: superfical parotidectomy
Radical neck dissection takes?
CN XII (most morbid)
SCM
IJ
Submandibular gland
Juvenile nasopharyngeal angiofibroma
Benign in teen males
Presents w/obstruction, epistaxis
Tx-embolize (internal maxillary a, then extirpate)
Frey’s syndrome
Auriculotemporal nerve injury
Gustatory sweating
Tracheo-innominate fistula
massive bleeding from trach
small heraldic bleed
Work up of an enlarged neck node
FNA
Endoscopy/possible open biopsy
Pleomorphic adenoma
Benign parotid mass
Most common benign mass
90% are superficial to facial nerve
Warthin’s tumor
2nd MC benign parotid mass
A/w tobacco use
10% bilateral
Mucoepidermoid carcinoma
MC malignant parotid mass
Treatment of the benign parotid mass
Surgical resection - resect facial nerve if involved
Can usually be enucleated or undergo superifical parotidectomy
Treatment of malignant parotid mass
Superficial lobe without involvement of facial nerve: superficial parotidectomy with adjuvant XRT
Deep lobe: Total parotidectomy
Adjuvant XRT for high grade cancer, neural invasion, invasion into surrounding structures, or mets
Complications of parotidectomy
Frey syndrome: gustatory sweating secondary to parasympathetic damage to auriculotemporal nerve
Facial nerve dysfunction
Recurrence
Salivary fistula
Sensory loss in lower third of external ear (from transecting greater auriculur nerve)
Palpable LN in the neck with unknown primary
FNA
Endoscopy
CT scan
If all negative, proceed with modified radical neck dissection with ipsi XRT
Dx and tx of Frey syndrome
Dx: Minor starch/iodine test
Tx: antiperspirant application to the affected skin
Laryngeal cancer categories and most common presenting symptom
Glottic, subglottic, supraglottic
Otalgia is most common presenting symptom
Le Fort fracture
Separation of maxilla from skull base
Results in mid face mobility on bi-manual exam
Injury to greater auricular nerve is associated with
sensory to preauricular/postauricular area
difficulty shaving, wearing earrings
usually resolves within a few months
Tuberculous lymphadenitis
MC in the cervical LN, MC extra-pulmonary TB form
Most patients have no systemic symptoms and a normal CXR
TB in this form is contagious
Tx: 6 months of TB antibiotic therapy
Intraoperative nerve monitoring or direct visualization of RLN - which is better?
No statistical difference in incidence of RLN palsy with either method
Spinal accessory nerve course
Exits jugular foramen with CN IX and X
Passes anterior to jugular vein
Then enters posterior SCM
Exits cephaled to Erb point (bundle of sensory nerves emerges from SCM posteriorly)
When should emergent cricothyroidotomies be converted to trachs?
Within 24-48hrs to avoid risk of subglottic laryngeal stenosis
At what level should tracheostomies be placed?
2nd or 3rd tracheal ring
Any lower puts patient at risk of erosion of tube or cuff into inominate artery = TI fistula
Bethesda FNA categories
I: insufficient for diagnosis
II: benign, manage according to FNA results alone
III: atypical or follicular lesion of uncertain signficance
IV: follicular neoplasm
V: suspicious for malignancy, manage according to FNA results alone
VI: definitely malignant
Category III and IV: can do gene expression panel assay to predict benign behavior accurately
Inherited non-medullary thyroid cancer syndromes
FAP Cowden Carney Pendred Werner
Cowden syndrome features
Autosomal dominant
Oral hamartomas
Large head circumference
Familial thyroid cancers
First step when TI fistula begins to bleed
Overinflate the cuff
Direct digital pressure towards the sternum
Definitive surgical management: ligate fistulous portion of inominate artery
Recurrence rate after thyroglossal duct cyst excision
10% recurrence rate
Chyle leak management
Low output (<1 L/day): strict fat-free diet, medium chain TG diet, surgical drain should be left in place
High volume or persistent chyle leaks: surgery - open or thoracoscopic ligation of the thoracic duct in the chest, embolization of the thoracic duct by IR
Where does thoracic duct empty?
Left subclavian vein
Risk factors for pharyngeal cancer
HPV (high risk subtype 16) EBV Plummer-Vinson syndrome Metabolic polymorphisms Malnutrition Mutagenic agent exposure
High risk BCC features
Head and neck location, >6 mm
Recurrent tumors
Tumor in area that was previously radiated
Ill-defined borders
Morpheaform
Aggressive growth patterns
Immunocompromised, especially transplant patients (MC malignancy in transplant patients)
Needs wider margins 6 mm or greater
Central neck node dissection borders
Superior: hyoid
Lateral: carotid sheath
Medial: tracheal midline
Inferior: thoracic inlet
What test should be done before excision of thyroglossal duct cyst?
Neck ultrasound to confirm that is not the patient’s only source of thyroid tissue
What cranial nerves are at risk of injury during CEA?
VII, IX, X, XI, XII
MC CN injury during CEA?
Hypoglossal
close to the carotid bifurcation
injury causes tongue deviation to ipsi side
Common nerve injuries during CEA
Hypoglossal: ipsi deviation of the tongue
Vagus/non-recurrent laryngeal nerve: hoarseness, vocal cord palsy
Superior laryngeal nerve: loss of high pitch, projection
Marginal mandibular branch of facial nerve: between platysma and deep carotid fascia - drooping of mouth to ipsi side
Glossopharyngeal: especially during division of posterior belly of digastric and styloid process - impaired swallowing and loss of taste sensation, gag reflex impaired on ipsi side
Spinal accessory: winging of scapula, possibly by traction to SCM
