SESAP - H&N

Question 1

Central Neck Borders

Answer 1

Superior - hyoid bone
Lateral - carotids bilaterally
Posterior - superficial and deep layer of the cervical fascia anteriorly
Innominate artery on right

Question 2

Thyroid cancer
Most likely histologic variant?
Locoregional recurrence rates? LN micromet?

Answer 2

Papillary

25-50% LN micrometastasis

Question 3

Branchial cleft
First Arch
Structures?

Answer 3

Middle ear, eustachian tube, EA canal.

Question 4

Branchial cleft
Second Arch
Structures?

Answer 4

MC to hav an anomaly (incomplete obliteration of cleft to result in pouch)
TONSIL!

Question 5

Branchial cleft
Third Arch
Structures?

Answer 5

Inferior Parathryoid,

Thymus

Question 6

Branchial cleft
Fourth Arch
Structures?

Answer 6

Superior parathyroid

C-cells

Question 7

Branchial cleft 
Second Arch
Classification?
Workup?
What to do?

Answer 7

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

Question 8

Spinal accessory nn
What cranial nn?
Where does it exit?
What does it innervate?
What action?

Answer 8

CN 11
Jugular foramen through SCM, diagnoally across posterior triangle and into trapezius
trapezius - MOTOR fibers, SCM - MOTOR
Weak shoulder abduction, drooped shoulder

Question 9

Salivary gland tumors

rule of thumb?

Answer 9

1. salivary tumor is dir. proportional to size of gland
2. malignant potential is INV proportional to size of gland.

Larger gland - larger tumor - low malignant potential!

Question 10

Parotid tumor
MC benign tumor?
Workup?
Treatment?

Answer 10

Pleomorphic adenoma
FNA and assess LN
Superficial parotidectomy

Question 11

Typical patient for Warthin’s

Answer 11

1. Bilateral
2. Male
3. Smoker

Question 12

Thyroglossal duct cyst
presentation?
w/u?
treatment?

Answer 12

1. midline, moves with swallowing.
2. remnant tract of migrating thyroid
3. U/S and thyroid scan (assess that this is not the only thyroid tissue patient has)
4. Sistrunk.

Question 13

Recurrent laryngeal nerve

location of parathyroids?

Answer 13

Superior - BEHIND lateral

Inferior - In FRONT medial

Question 14

Intra-operative nerve monitoring - role

Answer 14

Inc cost. Inc time. No utility for routine sx.

ROLE for REPEAT neck procedures to decrease RLN injury.

Question 15

Parotid injury

Lie of duct?

Answer 15

Parotid duct is anterior along the parotid gland which is by the masseter muscle.

Question 16

Parotid duct injury
presentation?
Treatment?

Answer 16

1. MC - wound infection with salivary drainage.
   (also salivary fistula, sialocele, cyst)
2. earlier repair is better, microsurgery closure. Delated - saliva suppression

Question 17

FLUS
What Bethesda category?
What do you do next?

Answer 17

1. 3

2. repeat FNA with gene expressor to classify risk of malignancy

Question 18

Bethesda 1 ATA
what is it?
what do you do ?

Answer 18

Nondiagnostic.

Repeat FNA

Question 19

Bethesda 2 ATA
what is it?
what do you do ?

Answer 19

Benign

Surveillance

Question 20

Bethesda 4 ATA
what is it?
what do you do ?

Answer 20

FN/FSN

Question 21

Bethesda 5 ATA
what is it?
what do you do ?

Answer 21

Suspicious

Question 22

Bethesda 6 ATA
what is it?
what do you do ?

Answer 22

Malignant

Question 23

Post-intubation tracheal stenosis
pathophys?
presentation?
workup?
treatment?

Answer 23

1. Transmural ischemia/necrosis of trachea from balloon
2. 3-6 weeks after prolonged intubation
3. Sx - exertional dyspnea < 10 mm, stridor < 5 mm
4. Bronchoscopy with serial dilation was not definitive. Tracheal resection with reconstruction is definitive.

Question 24

When do you use the laser for for tracheal disease?

Answer 24

laser ablation for intraluminal tumors to get tracheal patency. NOT for circumferential lesions.

Question 25

Neck dissection | Level 1 borders?

Answer 25

Submental (drain mouth, ant tongue, ant mand alv ridge, lower lip) Submand (mouth, nose, midface, submand gland)

Question 26

Neck dissection Level 2 borders? Level 3?

Answer 26

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

Question 27

Neck dissection | Level 4?

Answer 27

Lower jugular Superior - Inferior: Cricoid to Clavicle Medial - Lateral: sternohyoid to posterior SCM

Question 28

What is the posterior triangle? | what lymph node level?

Answer 28

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)

Question 29

What compartment is: superior - inferior: Hyoid to suprasternal notch lateral borders: bilateral carotids What LN are contained?

Answer 29

6! Central | Delphian (pre-cricoid) and paratracheal/pretracheal LN.

Question 30

Tracheal injuries when do you not operate? what is the non-operative treatment?

Answer 30

``` 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)

Question 31

``` Surgical approaches to trachea When do you use a collar incision? Median sternotomy? Right posterolateral thoracotomy? Left posterolateral thoracotomy? ```

Answer 31

1. MOST tracheal injuries. Above clavicles. 2. injuries that are within 2-3 cm of the clavicle. 3. bilateral 2-3 cm from carina 4. 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.