Neck Disorders Flashcards
Laryngeal cancer
general
Squamous cell carcinoma is the most common subtype
Significant association with tobacco use
Linked to HPV type 16 & 18
More common in oropharyngeal cancer
Nonsmokers
Males aged 50-70 years
laryngeal cancer
S/Sx
Change in voice quality persistent
Most common
Throat pain
Especially with swallowing
Ear pain
Especially with swallowing
Hemoptysis
Dysphagia
Weight loss
Airway compromise
Laryngeal cancer
PE
Full head and neck evaluation
Laryngoscopy
Laryngeal cancer
Laryngoscopy
Evaluate
True fold mobility
Arytenoid fixation
Surface tumor extension
Sometimes, has bronchoscopy or esophagoscopy at same time
Evaluate for synchronous primary tumor
Biopsy
Laryngeal cancer
imaging
CT or MRI neck
Goals
Extent of tumor
Tumor volume
Cartilage sclerosis
Cartilage destruction
Evaluate neck lymph nodes
CT Chest if:
Level IV or VI lymph nodes involved
Concerning chest x-ray
Concerns for metastases
Consider PET/CT if metastases
larygeal cancer
Laboratory Evaluation
Complete blood count
Liver function tests
Laryngeal Cancer
Dx
Biopsy during laryngoscopy
Need pathology of tumor
Mobility of true vocal cords
T1/T2 Glottic tumors with mobile true vocal cords < 5% node involvement
Immobile folds up to 30% nodal involvement
TNM Staging
laryngeal cancer
Tx goals
4
4 Goals
Cure
Preservation of safe and effective swallowing
Preservation of useful voice
Avoidance of permanent tracheostoma
Early glottic/supraglottic cancer
Tx
Radiation therapy is standard of care
>95%/80% cure rates
Significant morbidity
Some tumors may consider partial laryngectomy
Locoregional cure rates 80-90%
Even those with clinical N0 disease benefit from elective limited neck dissection
High risk of neck lymph node involvement, especially supraglottic tumors
Stage III/IV
Chemo Tx
Advanced Stage (III/IV)
Treatment is challenging
Concurrent radiation therapy with Cisplatin based chemotherapy currently utilized most frequently
Superior to either modality alone
Now may consider epidermal growth factor receptor (EGFR) inhibitor Cetuximab (Erbitux)
Lower overall systemic toxicity
Better tolerated
Both systemic agents in combination with XRT are associated with
prolonged gastrostomy-tube dependent dysphagia
Laryngeal stenosis
Select patient may be able to have frontline surgical intervention
Referral to medical oncology, radiation oncology, and surgical oncology (specializing in head and neck dissections-typically tertiary centers)
Laryngectomy
Total laryngectomy
Advanced resectable tumors with
extra laryngeal spread
Cartilage involvement
Persistent tumor following chemoradiation
Recurrence after primary treatment
2nd primary tumor following previous radiation therapy
Speech options
Tracheoesophageal puncture produces successful speech in 75-80%
Indwelling prostheses, changed every 3-6 months
laryngeal cancer
follow up
65% cure rate
3-4% annual second primary rate
Risk for recurrence
Psychosocial Issues
Altered appearance
Work
Social interactions
Medical conditions
Dysphagia
Impaired communication
Vocal Cord Paralysis
Unilateral vocal fold paralysis
Causes
Due to
Lesion
Damage to vagus nerve
Skull base tumors
Damage to recurrent laryngeal nerve
Unilateral
Thyroid surgery
Neck surgery
Anterior discectomy
Carotid endarterectomy
Mediastinal or apical lung cancer involvement
Cricoarytenoid arthritis
Advanced rheumatoid arthritis
Unilateral Vocal Cord Paralysis
general
May be temporary
Up to a year for spontaneous resolution
Surgical intervention for persistent/irrecoverable symptomatic disease
Goals
Medialization of paralyzed vocal fold
Create stable platform for vocal fold vibration
Advancing diet
Improving pulmonary toilet
Cough
Uniulateral Paralysis of vocal folds
Surgical Interventions cont.
Injection laryngoplasty with Teflon, Gel foam, fat, or collagen
Teflon only permanent injectable material
Avoid due to risk of granuloma formation on vocal cords
Formal medialization thyroplasty
For permanent paralysis
Formal medialization thyroplasty
Create a small window in thyroid cartilage
Place implant between the thyroarytenoid muscle and inner table of the thyroid cartilage
Moves the vocal fold medially
Creates a stable platform for bilateral, symmetric mucosal vibration
Bilateral Vocal Cord Paralysis
General
Breathing pattern
Inspiratory stridor with deep inspiration Emergency
Create safe airway with tracheostomy
Minimal reduction in voice quality
Aspiration prevention
Tracheostomy creation
Insidious onset
Asymptomatic at rest
Normal voice
Bilateral Vocal Cord Paralysis
etiology
Etiology
Esophageal cancer
Thyroid surgery
Ventricular shunt malfunction
Cricoarytenoid arthritis
Intubation injuries
Glottic and subglottic stenosis
Laryngeal cancer
Tracheostomy
Indications
Airway obstruction at or above the level of the larynx
Respiratory failure requiring prolonged mechanical ventilation
Most common reason
No consensus on # of days
Life threatening aspiration pneumonia
Improve pulmonary toilet
Related to insufficient clearing of tracheobronchial secretions
Sleep apnea
Tracheotomy Options
Bedside tracheotomy (in ICU)
More cost effective
Percutaneous dilational tracheotomy
Bedside procedure
Tracheotomy with videobronchoscopy in OR
Reduce complications
Tracheostomy
complications
Subglottic stenosis
Extended endotracheal intubation
Dislodging of tracheotomy tube
Tracheotomy
care
Humidified air
Prevent secretions from crusting and occluding inner cannula of the tracheotomy tube
Clean several times per day
Frequent tracheal/bronchia suctioning
Increased bronchial secretions and aspiration of saliva
Elevation of larynx required for swallowing which is limited by tracheotomy
Stoma skin care
Prevent maceration and secondary infections
Cricothyrotomy
general
In emergency situations, secures a faster airway than tracheostomy
Fewer complications
Pneumothorax
Hemorrhage
Cric
Tracheal Foreign Bodies
general
Aspiration of foreign bodies more common in children
Adults at greatest risk are denture wearers and older adults
Diagnosis (if required)
Chest x-ray
Radiopaque foreign body
If radiolucent
Inspiration & expiration film
Air trapping distal to obstruction
Flattened diaphragm
Later, atelectasis and pneumonia
trachea foreign body
Tx
Treatment
Heimlich maneuver
Cricothyrotomy
Rigid bronchoscopy under general anesthesia
Congenital Neck Masses
Branchial Cleft Cysts
Soft cystic mass along anterior border of the sternocleidomastoid muscle
Benign congenital cysts lined by epithelial cells
Seen usually in 20s-30s
May see sudden swelling or infection
Branchial Cleft Cyst
Types
First branchial cysts
High in the neck
May have fistula extending to floor of the external auditory canal
Second branchial cleft cysts
Most common
May communicate with the tonsillar fossa
Third branchial cleft cysts
Rare
Low in the neck
May communicate with the piriform sinus
Branchial Cleft Cyst
Dx
Ultrasound
CT
MRI
Branchial Cleft Cyst
Tx
Treatment
Surgical excision with removal of fistulous tracts
Prevents recurrent infections and possible carcinoma
Thyroglossal Duct Cysts
general
Along the embryologic course of thyroid’s descent from the tuberculum impar of the tongue base in the low neck
Most common before age 20
Can occur at anytime
Midline neck mass usually just below the hyoid bone
Moves with swallowing
Thyroglossal Duct Cysts
Tx
Surgical excision recommended
Prevent recurrent infection
Involves removing
Fistulous tract
Middle portion of hyoid bone
Many fistulas pass through here
Preoperative thyroid ultrasound recommended
Confirm anatomic position of thyroid
Thyroglossal duct cyst
Reactive Cervical Lymphadenopathy
Normal lymph nodes < 1cm
Neck lymphadenopathy can commonly be due to infections involving
Pharynx
Salivary glands
Scalp
Common in HIV patients
Treatment
Directed at underlying source
If suppurates, incision & drainage (I&D) of lymph node
Cervical LAD
when to worry
When to worry
Lymph node > 1.5cm
Lymph node with necrotic center (with no obvious infection)
Especially with history of
Tobacco use
Alcohol use
Prior cancer
Persistent lymphadenopathy
Continued enlargement
cervical LAD
Dx 4
How to evaluate
Ultrasound
Fine needle aspiration (FNA)
Culture
Pathology
Cervical LAD
Causes 3
Tumor
Squamous cell carcinoma
Lymphoma
Metastatic disease from non head & neck area
Infection
Reactive
Mycobacteria
Cat-scratch disease
Autoimmune disease
Kikuchi disease (histiocytic necrotizing lymphadenitis)
Granulomatous Neck Masses
general
Incidence increasing
Both immunocompromised and immunocompetent patients
Typical presentation
Single or matted lymph nodes
May extend to skin and drain externally (late presentation)
Scrofula (mycobacterium adenitis)
Granulomatous Neck Masses
Causes 3
causes
Mycobacterial adenitis
Sarcoidosis
Cat-scratch disease (Bartonella henselae)
Granulomatous Neck Masses
Dx
Diagnosis
FNA (88% sensitivity, 49% specificity)
Cytology
Smear for acid-fast bacilli
Mycobacterial culture
PCR in some cases
Excisional biopsy often required to confirm diagnosis
Tumor Metastases
general
In older adults, 80% of firm, persistent, and enlarging neck masses are metastatic disease
Majority from squamous cell carcinoma of upper aerodigestive tract
Physical exam may reveal source
Consider
Laryngoscopy
Esophagoscopy
Bronchoscopy
Tumpor metastases
Dx
FNA vs. open biopsy
Diagnostic imaging
MRI
PET
Supraclavicular Lymphadenopathy
Source
Lung cancer
Gastric cancer
Esophageal cancer
Breast cancer
Lymphoma
general
10% of lymphomas present in head & neck
Multiple rubbery lymph nodes in young adults
Needs open biopsy (NOT FNA)
