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HNNS > HNS37 Common ENT Cancers: Anatomic And Physiologic Appraisal > Flashcards

HNS37 Common ENT Cancers: Anatomic And Physiologic Appraisal Flashcards

1
Q

Treatment of head and neck cancer

A
  1. Surgery
    - Radical excision
    - Reconstruction
  2. Radiotherapy
  3. Chemotherapy (usually adjuvant)
  4. Combined modality

NB: Treatment can affect external appearance (form) unlike other regions (GI surgery)
—> affects psychosocial well being

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2
Q

Function of head and neck

A
  1. Vital sensory functions
    - heading, vision, smell, taste
  2. Breathing
  3. Swallowing
  4. Speech
  5. Facial expression
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3
Q

Ear structure

A
  1. External
  2. Middle ear
    - Ear drum
    - Ossicles
  3. Inner ear
    - Cochlea
    - Semicircular canals

—> Hearing and Balance

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4
Q

Nasopharyngeal cancer and Ear

A

Nasopharyngeal cancer
—> Obstruct Eustachian tube opening
—> Fluid to accumulate in middle ear
—> Conductive deafness

Symptoms of NPC

  • Unilateral hearing loss
  • Unilateral tinnitis
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5
Q

Ear and treatment

A
  1. Removal of external ear —> cosmetic problem

2. Radiation therapy near inner ear can cause damage to cochlear and progressive hearing loss

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6
Q

Nose structure

A
  1. Nasal cavity
  2. Paranasal sinuses
    - frontal, maxillary, ethmoid, sphenoid
  3. Eustachian tube
    - connecting middle ear and nasopharynx

—> Smell and Air passage

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7
Q

***Nose cancers

A
  1. Sinuses
    - deep in skull
    - hidden
    - cancer difficult to detect (although rare)
    - early symptom: blood stained nasal discharge
  2. Lamina papyracea (thinnest bone in body in ethmoid sinus)
    —> cancer can easily spread to ***orbital content
    —> Medial rectus affected (affect vision) / Proptosis
    —> may need to remove eye for tumour clearance
  3. Bones of skull base (e.g. anterior cranial fossa)
    - separates intracranial structures from nasal cavity
  4. Cribriform plate
    - olfactory nerve passing through
    - passage for cancer to invade the brain
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8
Q

Oral cavity, Oropharynx structure

A
  1. Lip, tongue, mandible, teeth, palate, floor of mouth, buccal mucosa
  2. Salivary glands
  3. Tonsils, posterior pharyngeal wall

—> Food passage and Defence
—> Taste and Speech

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9
Q

Oral cavity, Oropharynx treatment

A
  1. Removal of tongue
    —> affects speech and swallowing
    —> <=1/2 removed —> usually ok
  2. Reconstruction of tongue
    —> only provides lining
    —> no muscular function

Functional results depends on residual tongue muscles

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10
Q

Neck pathologies

A
  1. Benign lesion in neck
    - Cysts
    - Neurofibroma (tumour grow within nervous system)
    - Haemangioma (benign tumour of blood vessels)
  2. Lymph nodes
    - neck dissection
    - cancer spreading
  3. Important structures
    - cranial nerves, arteries, veins
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11
Q

Lymphatic drainage of neck

A

Lymphatics: does NOT run within Carotid sheath / Fascial wrappings of neck

Deep lymphatics:
- lies in fascia spaces bound by:
—> Deep investing fascia externally
—> Prevertebral, Carotid, Pretracheal fascia internally

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12
Q

***6 levels of neck LNs

A

Level 1: Submental (A) and Submandibular (B)

Level 2: Upper jugular (divided by CN11 into A + B) (2A: ***Jugulodigastric LN: combined drainage of all upper head and neck)

Level 3: Mid jugular (hyoid to cricoid)

Level 4: Lower jugular (cricoid to clavicle)

Level 5: Posterior triangle (behind SCM, A + B)

Level 6: Pretracheal

Supraclavicular fossa LN: lowest nodes in level 4 and 5

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13
Q

Metastatic neck lymph nodes

A

LNs may be in close association with fascia
—> cancer spread in LN
—> may ***spread into fascia
—> may need remove structures wrapped by fascia for tumour clearance

Structures can be sacrificed:

  • SCM
  • ECA
  • IJV
  • CN11

Structures cannot be sacrificed:

  • Internal / Common carotid artery (in Carotid sheath)
  • CN10 (swallowing) (in Carotid sheath)
  • Phrenic nerve (breathing)
  • Brachial plexus (arm function) (in Posterior triangle)
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14
Q

Pattern of LN spread in head and neck cancer

A

Head and Neck cancer may spread to Neck LN

  • Predictable pattern
  • Skip metastasis uncommon

Cancers from different location spread to different levels first

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15
Q

LN metastasis origin of different levels

A

由邊個structure入去個LN到

Level 1a (Submental):

  • ***lower lip
  • ***anterior floor or mouth
  • mandibular incisors
  • tongue tip

Level 1b (submandibular):

  • lateral oral cavity (buccal)
  • oral tongue
  • ***anterior nasal cavity
  • ***submandibular gland
Level 2 (Upper jugular):
Everywhere (∵ Jugulodigastric LN: combined drainage of all upper head and neck)
- nasal cavity and sinuses
- oral cavity
- oropharynx
- nasopharynx
- supraglottic larynx
- hypopharynx
- parotid and submandibular
- upper thyroid gland

Level 3 (Mid jugular):

  • oral cavity
  • ***oropharynx
  • ***larynx
  • hypopharynx

Level 4 (Lower jugular):

  • hypopharynx
  • ***larynx
  • ***thyroid
  • cervical esophagus

Level 5 (Posterior triangle (behind SCM, A + B)):

  • ***nasopharynx
  • ***oropharynx
  • ***posterior neck and scalp

Supraclavicular fossa LN: lowest nodes in level 4 and 5:

  • drainage from neck above / below clavicle
  • right side: infra-clavicular lesion
  • left side: infra-clavicular lesion / **infra-diaphragmatic lesion (via thoracic duct) —> **Virchow’s node (∵ lower body drains through left side)
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16
Q

Neck dissection

A

Removal of lymphatics in the neck that harbours cancer metastasis

***Radical neck dissection:
Removal of
- Level 1-5 LN (ipsilateral)
- SCM
- IJV
- CN11 (pass through lymphatic layer)
- Cervical plexus (pass through lymphatic layer) (functional deficit but acceptable)

***Modified radical neck dissection:
Modification of radical neck dissection by preserving:
- SCM
- IJV
- CN11
—> Aim: improving functional outcome without jeopardising control of nodal disease

***Selective neck dissection:
Removal of certain areas of LN that has highest chance of occult nodal metastasis
- Oral tongue cancer —> Supraomohyoid neck dissection (Level 1-3) for oral tongue cancer
- Tonsil cancer —> Level 2-4
- Thyroid cancer —> Central compartment dissection (bilateral level 6)
—> usually reserved for patients with no clinical evidence of nodal metastasis but cancer has high chance of occult nodal metastasis

17
Q

Thyroid, Parathyroid glands pathologies

A
  • Benign and malignant tumours
  • Metabolism
  • Calcium level
  • Close proximity:
  1. Recurrent laryngeal nerve (CN10)
    - nerve lies **underneath thyroid gland
    - thyroid cancer may compress nerve —> **    hoarseness
    - surgical injury
  2. Superior laryngeal nerve (CN10)
    - external branch innervates **Cricothyroid muscles
    - injury during dissection of **    upper pole of thyroid
  3. Trachea
18
Q

Benign tumour of Thyroid and Parathyroids

A

Present as a mass

Present with endocrine disturbance
—> Hyperthyroidism in solitary adenoma (Too much Thyroid hormone) —> ipsilateral goitre
—> Hypercalcemia in parathyroid adenoma (Too much PTH) —> ureteric / renal stones

Investigation:
- Nuclear imaging: Special isotope scans to detect physiological abnormalities (functional scan) e.g. Tc99 for parathyroid, I131 for thyroid

19
Q

RLN and SLN injury

A

Unilateral RLN injury

  • ***hoarseness
  • ***choking (∵ cannot close vocal cord: Adductors)

Bilateral RLN injury
- airway obstruction due to ***bilateral vocal cord palsy —> medical emergency (∵ cannot open vocal cord: Abductors)

External branch SLN injury
- unable to sing high pitch (∵ Cricothyroid —> lengthening of cord)

Incomplete bilateral palsy: affect Abductor only —> continue to Adduct —> cannot breathe
Complete bilateral palsy: affect Both —> cord at natural position (open) —> no problem

20
Q

Larynx, pharynx and esophagus pathologies

A
  • Muscle on cartilaginous skeleton
  • Co-ordinated muscular function

3 mains functions

  1. Phonation
  2. Air and food passage
  3. Swallowing
21
Q

Hypopharynx cancer

A

Small cancer
Local excision feasible
—> vocal cord spared
—> good voice

Larger cancer
Cord not moving —> invaded
—> surgical removal: need to remove whole larynx
—> alternative: Chemotherapy + Radiotherapy

22
Q

***Physiological changes after laryngectomy

A

Stoma at trachea to replace nose

  1. Loss of speech
  2. Loss filter function of nose (breathe in cold and dry air)
  3. No smell (∵ bypass nose)
  4. Loss of humidification
  5. Ineffective cough
23
Q

Skin, fascia, muscle etc. reconstruction

A

Head and neck area
—> skin graft, local flaps

Chest wall and other parts of body
—> ***fasciocutaneous flaps, myocutaneous flaps, bone, muscle, bowel

Reconstruction
—> trauma, tumour extirpation

24
Q

Deltopectoral flap (NOT examined)

A
  • Fasciocutaneous flap
  • based on cutaneous perforator of internal mammary artery
  • skin coverage for neck defect

HNNS (58 decks)

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