Head & Neck Tumors/Parotid Flashcards
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.
2018
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.
2018
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.
2018
A 45-year-old man with mucoepidermoid carcinoma of the left parotid gland undergoes parotidectomy. Which of the following complications is most likely in this patient?
A) Gustatory sweating
B) Hyperacusis
C) Loss of taste
D) Tardive dyskinesia
E) Tearing while eating
The correct response is Option A.
Parotidectomy is a surgical procedure performed for benign and malignant tumors of the parotid gland and, uncommonly, for hypersalivation. Specific risks for parotidectomy include facial nerve injury, sialocele formation, and gustatory sweating.
Gustatory sweating (or Frey syndrome) results when there is aberrant innervation of cutaneous sweat glands in the cheek skin overlying the parotid bed resulting in sweating and flushing during eating.
Loss of taste to the anterior two thirds of the tongue results from injury to the chorda tympani, which arises from the facial nerve as it crosses the tympanic cavity and joins with the lingual nerve, not from injury to the facial nerve within the parotid gland.
The stapedius is a small muscle in the middle ear that restricts movement of the stapes bone in response to loud noises. Hyperacusis may occur when the facial nerve is interrupted intracranially, before it exits the stylomastoid foramen and becomes extracranial.
Tearing while eating (crocodile tear syndrome or Bogorad syndrome) is an uncommon consequence of nerve regeneration subsequent to Bell’s palsy in which efferent fibers from the superior salivary nucleus become improperly connected to nerve axons projecting to the lacrimal glands causing tears while smelling foods or eating. Tardive dyskinesia is a disorder resulting in involuntary repetitive movements including grimacing, tongue and lip movements, and excessive blinking that usually occur as side effects of antipsychotic drugs. It is unrelated to facial nerve dysfunction.
2018
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.
2018
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.
2018
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.
2018
A 60-year-old woman undergoes left hemiglossectomy for squamous cell carcinoma of the oral tongue. Reconstruction with which of the following is most likely to achieve the best functional outcome?
A) Pectoralis major myocutaneous pedicled flap
B) Radial forearm fasciocutaneous free flap
C) Rectus abdominis myocutaneous free flap
D) Split-thickness skin graft
E) Temporalis muscle pedicled flap
The correct response is Option B.
Reconstructive strategies for partial and hemiglossectomy reconstruction are different than for subtotal and total glossectomy reconstruction. For partial and hemiglossectomies, the ideal reconstruction preserves the mobility of the remaining tongue, maintaining its ability to manipulate foods, articulate words, and sweep the oral cavity clean. Such defects are best reconstructed with a thin, pliable flap that resists contraction during the healing process. Of the choices listed, the radial forearm fasciocutaneous free flap best fits those requirements.
The pectoralis major myocutaneous pedicled flap is usually too thick to permit ideal movement and can have problems with reach and tethering to the chest as the proximal flap and pedicle contact during healing. The temporalis muscle pedicled flap is unlikely to reach the entire defect and the muscle is likely to contract and stiffen with time, limiting tongue movement. The rectus abdominis myocutaneous free flap is usually too thick to permit unrestricted movement of the remaining hemitongue and is better suited to subtotal and total glossectomy reconstruction, which is best effected with a bulky flap that diverts food and liquids laterally into the pharynx rather than into the larynx. A split-thickness skin graft, while thin, usually contracts substantially, limiting tongue movement. Also, if there is communication into the neck following tongue resection with neck dissection, the skin graft would be at high risk for resulting in a fistula.
2018
A 65-year-old man undergoes microvascular reconstruction with a radial forearm flap following total laryngectomy and partial pharyngectomy for a T4 N3 M0 laryngopharyngeal squamous cell carcinoma. Postoperatively, the patient reports perioral numbness and tingling. Which of the following electrolyte abnormalities is most likely in this patient?
A) Hypercalcemia
B) Hyperkalemia
C) Hypernatremia
D) Hypocalcemia
E) Hyponatremia
The correct response is Option D.
Patients who undergo laryngopharyngectomy often have the thyroid gland removed as part of the operation. Sometimes, the parathyroid glands are removed accidentally or the blood supply is transiently interrupted, causing poor function. The parathyroid glands regulate calcium metabolism, and injury or removal of these glands manifests first as perioral tingling and numbness before more severe symptoms such as tetani.
Hypernatremia is incorrect because, when symptomatic, it causes nausea, vomiting, and confusion. Hyponatremia is incorrect because, when symptomatic, it causes nausea, vomiting, lethargy, and confusion. Hypocalcemia is the correct answer because it is a concern for any patient who has this operation and reconstruction. Perioral tingling and numbness is an early sign of problems. Hypercalcemia is incorrect because, when symptomatic, it causes gastrointestinal issues such as vomiting, diarrhea, constipation, and skeletal muscle pain. Hyperkalemia is most likely to cause EKG changes and metabolism is not associated with parathyroid function.
2018
A 37-year-old man comes to the office for evaluation of whitish papules of the oral mucosa 3 weeks after undergoing successful face transplantation encompassing the maxilla, palate, oral mucosa, and overlying skin. Examination shows that the patient is afebrile and has no leukocytosis. No changes have been made to the initial acute postoperative immunomodulation therapy. Which of the following is the most appropriate initial management of this patient?
A) Apply topical nystatin
B) Biopsy for allograft rejection
C) Increase the dose of tacrolimus
D) Initiate oral amoxicillin therapy
E) Reexamine the patient in 4 weeks
The correct response is Option A.
Post-transplant infections can be divided into three phases: early postoperative infections (0 to 2 months), intermediate (2 to 9 months), and late (greater than 9 months). Because of the variation in tissue type and anatomy between solid organ transplantation and composite tissue allograft transplantation, there are differences between types of infection. In all transplant patients, cytomegalovirus (CMV) infection/reactivation is the most common infectious complication. As a result, the protocol for composite tissue allograft recipients includes CMV prophylaxis.
In this particular scenario, facial transplantation is unique in that there are oral and sinus cavities with colonization with native flora. Candida is the most ubiquitous and most common flora. Treatment is topical nystatin and clotrimazole.
Although there is constant wariness for rejection, this does not occur commonly in the immediate postoperative period. Biopsy would be warranted if there is no improvement with topical antifungals.
As there is no indication of acute rejection, increasing tacrolimus is not an appropriate initial treatment.
Amoxicillin is a bactericidal antibiotic and is not an appropriate treatment for this fungal infection.
2018
A 65-year-old man with Stage II squamous cell cancer at the base of the tongue comes to the office. He has a 30-year history of smoking. Which of the following type of neck dissection is most appropriate for this patient?
A) Modified: levels I to V nodes
B) Radical: levels I to V nodes, CN XI, internal jugular vein, sternocleidomastoid muscle removed
C) Selective (anterior compartment): VI
D) Selective (lateral neck): levels II to IV
E) Selective (supraomohyoid): levels I to III
The correct response is Option E.
Selective removal of nodes in levels I to III is the procedure of choice for N0 and N1 cancers in the oral cavity. Lateral and anterior compartment dissections miss Level I, which is the closest lymphatic level to a base of tongue cancer. Modified neck dissections are indicated for clinically palpable metastatic disease. Radical neck dissections are indicated for involvement of the nerve, vein, or muscle.
2018
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.
2017
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.
2017
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.
2017
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.
2017
A 45-year-old man is evaluated because of a 5-cm mass at the angle of the mandible. A CT scan shows an intraparotid mass. Ultrasound-guided fine-needle aspiration shows benign findings. Which of the following is the most appropriate next step in management?
A) Chemotherapy and superficial parotidectomy
B) Follow-up evaluation in 3 months
C) MRI
D) Superficial parotidectomy only
E) Total parotidectomy
The correct response is Option D.
Most parotid tumors are benign, but they can grow to a large size and produce significant symptoms of discomfort and distortion of anatomy. The differential diagnosis is aided by the use of imaging, CT, or MRI to confirm the location of the mass. Ultrasound-guided fine-needle aspiration is a useful next step in diagnosis of the majority (92%, Sharma, et al). MRI would be superfluous in the present case since imaging is sufficient. Benign neoplasms include pleomorphic adenoma, mucocele, branchial cleft cysts, and lymph nodes. Malignancies include adenocarcinoma.
2017
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.
2017
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.
2017
rm 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. 2017
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.
2017
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.
2017
A 65-year-old man comes to the office because of slow-growing, painless masses within each of the parotid glands. He has smoked 10 cigarettes daily for the past 25 years. Superficial parotidectomies are performed, and pathologic examination shows papillary cysts and mucoid fluid as well as nodules of lymphoid tissue in both tumor specimens. Which of the following is the most likely diagnosis?
A) Adenoid cystic carcinoma
B) Hemangioma
C) Pleomorphic adenoma
D) Squamous cell carcinoma
E) Warthin tumor
The correct response is Option E.
Salivary gland tumors are relatively rare and make up about 3 to 4% of all head and neck neoplasms. The majority of salivary gland tumors (approximately 80%) originate in the parotid gland. Approximately 80% of parotid gland tumors are benign. Facial paralysis may be associated with malignant tumors and are a sign of neural invasion.
Warthin tumor (papillary cystadenoma lymphomatosum) is the second most common tumor of the parotid gland and is benign. Warthin tumors predominantly occur in men of 50 to 70 years of age, most frequently smokers, and are the most common bilateral salivary gland tumors. The histologic appearance of this tumor is very characteristic and is characterized by papillary cysts and mucoid fluid as well as nodules of lymphoid tissue.
Pleomorphic adenoma, also known as benign mixed tumor, is the most common tumor of the parotid gland. This tumor is histologically characterized by epithelial and connective tissue elements, with stellate and spindle cells interspersed within a myxoid background.
Adenoid cystic carcinoma is the second-most common malignancy of the salivary glands after mucoepidermoid carcinoma and exhibits a propensity for perineural invasion. There are three histologic subtypes: cribriform, tubular, and solid. The cribriform pattern has a classic “swiss cheese” appearance with cells arranged in nests separated by round or oval spaces. The tubular pattern has a glandular architecture, while the solid (or basaloid) pattern has sheets of cells with little or no luminal spaces.
Hemangiomas are the most common salivary gland tumors found in children and usually involve the parotid gland. 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 to the skin and aerodigestive tract. It is histologically identical to squamous cell cancers arising from other sites with epithelial cells that form sheets or compact masses, which invade adjacent connective tissue. Round nodules of keratinized squamous cells known as “keratinous pearls” are the hallmark of well-differentiated squamous cell carcinoma.
2017
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.
2017
A 55-year-old man undergoes resection of locally destructive floor-of-mouth cancer including a tooth-bearing segment of the mandible. Immediate reconstruction is performed using a fibula flap. Dental restoration with implants is planned. Which of the following properties of the fibula flap is most likely to ensure the greatest initial stability of the dental implants?
A) Cancellous bone thickness
B) Cortical bone thickness
C) Periosteal thickness
D) Total bone thickness
E) Total bone width
The correct response is Option B.
When dental implants are placed in thicker cortical bone, better initial stability is achieved at the bone implant interface, reducing micromotion during the process of osseointegration. Cortical bone thickness has also been shown to correlate with the amount of torque required to remove a dental implant. No significant correlation has been shown between removal torque and total bone thickness. The presence of osteogenic cells in cancellous bone is responsible for a biologic response, although it is not as important in improving initial stability as thick cortical bone. Periosteal thickness is not relevant to dental restoration.
2017
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.
2017
A 62-year-old woman is evaluated for lower blepharoplasty. On examination, negative vector is noted. Postoperatively, this patient is at increased risk for which of the following conditions?
A) Dystopia
B) Ectropion
C) Enophthalmos
D) Lagophthalmos
E) Proptosis
The correct response is Option B.
The finding of a negative vector places the patient at an elevated risk for lower lid malposition and ectropion. The negative vector refers to the anatomic relationship on lateral view of the maximum projecting point of the globe and the maximum projecting point of the infraorbital malar prominence. If the globe projects less than the malar prominence, a negative vector exists. Conversely, if the malar prominence projects more than the globe, a positive vector exists.
The negative vector finding indicates potentially deficient globe and lid support based on skeletal anatomy. Such patients will often have minor scleral show or lateral lid lag. It is important to recognize these findings prior to blepharoplasty surgery in order to surgically address the risks of ectropion via primary lid suspension during the blepharoplasty. Occasionally, lower lid blepharoplasty may be avoided if a negative vector is present and other conditions such as dry eye exist. Other findings or conditions that are associated with postoperative ectropion and lower lid malposition are: orbicular weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, and eyelid laxity. Excessive or prominent middle lamellar scarring can occur after surgery, which can also lead to lid malposition.
Lagophthalmos is the inability to lower the upper lid fully and is a negative consequence of upper blepharoplasty due to excessive tissue resection or fibrosis. Enophthalmos is interior retraction or displacement of the globe related to increased orbital volume. This is unrelated to lower blepharoplasty surgery. Proptosis is an external displacement of the globe giving the appearance that the eyeball is extruding from the obit. This is most often associated with Graves disease, head trauma, and increased intracranial pressure. It can also be due to a retrobulbar hematoma after blepharoplasty, which is a surgical emergency due to the risk of blindness.
Dystopia refers to malposition of the globe related to skeletal changes of the orbit. This would not be a result of blepharoplasty, but can occur after facial trauma or facial tumor resection.
2016
A 42-year-old man is evaluated because of a 2-cm mass in the anterior floor of the mouth. Examination shows no palpable masses in the neck. In addition to surgical tumor removal, which of the following is the most appropriate additional step in management?
A) Radiation only
B) Radical neck dissection
C) Radical neck dissection and radiation
D) Selective neck dissection
E) Observation
The correct response is Option D.
A 2-cm mass with a clinically negative neck, pT2cN0, merits a supraomohyoid neck dissection because of the high risk of occult spread in this zone. A supraomohyoid dissection removes the lymph nodes in zones I, II, III; a modified neck dissection covers I-IV.
A smaller tumor, pT1N0, can be managed with a “tight ‘wait and watch’” strategy.
A radical neck dissection includes the sternocleidomastoid muscle and is not necessary for a clinically negative neck. Adding radiation therapy to a reflex neurovascular dystrophy is also not necessary for an N0 neck.
2016
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.
2016
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 55-year-old woman is evaluated because of a 2-year history of an enlarging right-sided facial mass. Examination shows a roughly 4-cm firm mass in the right parotid region and a firm lymph node in zone III of the ipsilateral neck. Imaging does not show metastatic disease. Fine-needle aspiration of the mass suggests high-grade mucoepidermoid carcinoma of the parotid gland. Which of the following is the most appropriate treatment in this patient?
A) Neoadjuvant chemoradiation and reassessment of tumor response before additional treatment
B) Superficial parotidectomy with ipsilateral cervical lymph node dissection
C) Superficial parotidectomy with ipsilateral cervical lymph node dissection and postoperative adjuvant radiotherapy
D) Total parotidectomy with ipsilateral cervical lymph node dissection
E) Total parotidectomy with ipsilateral cervical lymph node dissection and postoperative adjuvant radiotherapy
The correct response is Option E.
This patient has T2N1M0 (Stage II) high-grade mucoepidermoid carcinoma, and total parotidectomy with ipsilateral cervical dissection is the appropriate treatment. Because the patient is lymph node positive, both an ipsilateral cervical lymph node dissection and postoperative adjuvant radiotherapy are indicated.
A superficial parotidectomy would perhaps be indicated in a low-grade mucoepidermoid carcinoma, but in a high grade lesion, total parotidectomy is more appropriate. Ipsilateral cervical lymph node dissection and postoperative adjuvant radiotherapy would be indicated in this patient, however.
Although total parotidectomy and ipsilateral cervical lymph node dissection are appropriate, two factors make postoperative adjuvant radiotherapy an important component of treatment: the node positive status of the neck, and the high grade of the tumor.
Chemotherapy remains somewhat controversial in the treatment of mucoepidermoid carcinoma, and, to date, is not a part of standardized therapy.
2016
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.
2016
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. 2016
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.
2016
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.
2016
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.
2014
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.
2019
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.
2022
