SESAP - H&N Flashcards
Central Neck Borders
Superior - hyoid bone
Lateral - carotids bilaterally
Posterior - superficial and deep layer of the cervical fascia anteriorly
Innominate artery on right
Thyroid cancer
Most likely histologic variant?
Locoregional recurrence rates? LN micromet?
Papillary
25-50% LN micrometastasis
Branchial cleft
First Arch
Structures?
Middle ear, eustachian tube, EA canal.
Branchial cleft
Second Arch
Structures?
MC to hav an anomaly (incomplete obliteration of cleft to result in pouch)
TONSIL!
Branchial cleft
Third Arch
Structures?
Inferior Parathryoid,
Thymus
Branchial cleft
Fourth Arch
Structures?
Superior parathyroid
C-cells
Branchial cleft Second Arch Classification? Workup? What to do?
along Glossopharyngeal NN, hypoglassal nn
b/t int/ext carotic
classified as being superficial, within or adjacent to carotid sheath
ALWAYS FNA to r/o malignancy in adults
ALWAYS EXCISE complete cyst and tract. NOT acutely infected
Spinal accessory nn What cranial nn? Where does it exit? What does it innervate? What action?
CN 11
Jugular foramen through SCM, diagnoally across posterior triangle and into trapezius
trapezius - MOTOR fibers, SCM - MOTOR
Weak shoulder abduction, drooped shoulder
Salivary gland tumors
rule of thumb?
- salivary tumor is dir. proportional to size of gland
- malignant potential is INV proportional to size of gland.
Larger gland - larger tumor - low malignant potential!
Parotid tumor
MC benign tumor?
Workup?
Treatment?
Pleomorphic adenoma
FNA and assess LN
Superficial parotidectomy
Typical patient for Warthin’s
- Bilateral
- Male
- Smoker
Thyroglossal duct cyst
presentation?
w/u?
treatment?
- midline, moves with swallowing.
- remnant tract of migrating thyroid
- U/S and thyroid scan (assess that this is not the only thyroid tissue patient has)
- Sistrunk.
Recurrent laryngeal nerve
location of parathyroids?
Superior - BEHIND lateral
Inferior - In FRONT medial
Intra-operative nerve monitoring - role
Inc cost. Inc time. No utility for routine sx.
ROLE for REPEAT neck procedures to decrease RLN injury.
Parotid injury
Lie of duct?
Parotid duct is anterior along the parotid gland which is by the masseter muscle.
Parotid duct injury
presentation?
Treatment?
- MC - wound infection with salivary drainage.
(also salivary fistula, sialocele, cyst) - earlier repair is better, microsurgery closure. Delated - saliva suppression
FLUS
What Bethesda category?
What do you do next?
- 3
2. repeat FNA with gene expressor to classify risk of malignancy
Bethesda 1 ATA
what is it?
what do you do ?
Nondiagnostic.
Repeat FNA
Bethesda 2 ATA
what is it?
what do you do ?
Benign
Surveillance
Bethesda 4 ATA
what is it?
what do you do ?
FN/FSN
Bethesda 5 ATA
what is it?
what do you do ?
Suspicious
Bethesda 6 ATA
what is it?
what do you do ?
Malignant
Post-intubation tracheal stenosis pathophys? presentation? workup? treatment?
- Transmural ischemia/necrosis of trachea from balloon
- 3-6 weeks after prolonged intubation
- Sx - exertional dyspnea < 10 mm, stridor < 5 mm
- Bronchoscopy with serial dilation was not definitive. Tracheal resection with reconstruction is definitive.
When do you use the laser for for tracheal disease?
laser ablation for intraluminal tumors to get tracheal patency. NOT for circumferential lesions.
Neck dissection
Level 1 borders?
Submental
(drain mouth, ant tongue, ant mand alv ridge, lower lip)
Submand
(mouth, nose, midface, submand gland)
Neck dissection
Level 2 borders?
Level 3?
upper jugular - bleed into level 3 nodes.
A - ANTerior to spinal accessory nerve
B - posterior to nerve
Superior - Inferior: base of skull to hyoid
Medial - lateral: stylohyoid to posterior SCM (upper)
Sup-Inf: inferior edge of Hyoid to Cricoid
Med - lateral: Sternohyoid to posterior SCM
Neck dissection
Level 4?
Lower jugular
Superior - Inferior: Cricoid to Clavicle
Medial - Lateral: sternohyoid to posterior SCM
What is the posterior triangle?
what lymph node level?
LN along lower 1/2 of spinal accessory nn and transverse cervical aa
Apex of triangle: SCM and trapezius meeting
Med - lateral : post SCM to post trapezius
Inf: Clavicle
Level 5 (A: spinal accessory LN, B: along TCA and supraclavicular LN)
What compartment is:
superior - inferior: Hyoid to suprasternal notch
lateral borders: bilateral carotids
What LN are contained?
6! Central
Delphian (pre-cricoid) and paratracheal/pretracheal LN.
Tracheal injuries
when do you not operate?
what is the non-operative treatment?
injuries < 4 cm <1/3 circumference viable tissue without devitalization or displacement No tissue loss. Tissue are apposed. HD stable. No associated injuries, e.g. esophageal.
Voice rest. Abx. PPI. repeat bronchoscopies. (if vented - low tidal volumes)
Surgical approaches to trachea When do you use a collar incision? Median sternotomy? Right posterolateral thoracotomy? Left posterolateral thoracotomy?
- MOST tracheal injuries. Above clavicles.
- injuries that are within 2-3 cm of the clavicle.
- bilateral 2-3 cm from carina
- left sided 2-3 cm from carina
(right side can get to both sides of carina…unless it is really distal injury on the left)
of note, start with the bronch to localize issue and then plan. You have to prep wider then you need with a median sternotomy ALWAY available.
