Head and Neck 1 Flashcards
What percent of patients require dilatation after gastric pull-up?
0.5
During endoscopic evaluation of a tumor of the hypopharynx, what four questions must be answered?
- Can the larynx be saved?
- Is a partial or total pharyngectomy necessary?
- 3•Is a partial or total esophagectomy necessary?
- 4•Does the tumor extend into the prevertebral fascia?
What are the indications for a supracricoid partial laryngectomy with CHP or CHEP?
- T2 transglottic (TG) or supraglottic (SG) lesions not amenable to SG laryngectomy secondary to ventricular invasion, glottic extension, or impaired 1VC motion.
- T3 TG/SG lesions with 1VC fixation or preepiglottic space involvement.
- 3• T4 TG/SG lesions with limited invasion of thyroid ala without extension through the outer thyroid perichondrium.
- 4• Selected glottic tumors at the anterior commissure with preepiglottic space or SG involvement.
What are the indications for esophageal bypass?
- Complete esophageal stenosis and failure to establish a lumen with dilatation. Irregularity and diverticuli of the esophagus.
- Mediastinitis secondary to dilatation. Fistula formation.
- Inability to maintain a lumen of 40 Fr or greater with dilatation. Patient intolerance of frequent procedures.
What percent of patients with long-term tracheostomies are colonized with Pseudomonas?
>60%.
What are the normal dimensions of the osteotomy in GA?
10 X 20 H1R1.
What is the incidence of stroke and mortality from carotid blowout?
10% stroke and 1% mortality rate if intravascular volume is repleted prior to going to the OR. so% stroke and 25% mortality rate if intravascular volume is not repleted prior to going to the OR.
What is the fistula rate following free jejunal transfer (nonirradiated patients)?
10-20%.
What is the incidence of permanent recurrent laryngeal nerve injury after total thyroidectomy?
1-4%.
What length of jejunum is normally harvested for reconstruction?
15-20 cm.
What is the fistula rate in patients who have had prior irradiation requiring total laryngectomy and partial pharyngectomy?
15-20%.
Which tumors of the pyriform sinus do not necessarily require total laryngectomy?
2 cm or smaller, located at least 1.5 cm superior to the pyriform fossa apex, with normal vocal cord movement, and no invasion into adjacent sites; patients must also have good pulmonary function.
What is the recommended excisional margin for a 3-cm melanoma?
2 cm.
Where on the lid is the implant placed?
2 mm above the lash line.
What is the minimal mandibular height necessary for performing Genioglossus advancement?
25 mm.
What percent of patients with tracheoinnominate fistulae survive?
25%.
What are the treatment options for Frey’s syndrome?
3% scopolamine cream, section Jacobson’s nerve, sternocleidomastoid muscle flap, interpose fascia lata between skin and gland, and botulinum toxin.
What is the minimal time for functional return of the facial nerve after anastomosis or grafting?
4-6 months.
What percent of all instances of tracheal bleeding developing 48 hours or longer after surgery are caused by tracheoinnominate fistulae?
50%.
What is the rate of major complications after gastric pull-up?
50%.
After microneurovascular muscle transfer, what is the maximum muscle power attainable compared with normal?
55%.
What are the recommended margins for excision of basal cell skin cancers (BCCs)?
5mm.
How far from the inferior border of the mandible should the osteotomy for Genioglossus advancement be placed?
8-10 mm.
What problem arises when regional or transplanted skin flaps are used for reconstruction of the hypopharynx when the larynx is preserved?
A large amount of immobile pharyngeal wall interferes with the pharyngeal component of swallowing, making aspiration inevitable.
What is an imbrication laryngectomy?
A through-and-through excision of a horizontal segment of the larynx with anastomosis of the caudal and cephalic laryngeal margins.
When should PEG be performed when done as part of an oncologic resection?
After the primary resection to avoid inadvertent spread of tumor cells to the gastrostomy site.
During placement of a tubed flap, where should the longitudinal suture line uniting the sides of the flap into a tube be placed?
Against the prevertebral fascia.
What factors are associated with the highest likelihood of successful esophageal dilatation for treatment of strictures secondary to caustic ingestion?
Age
What preoperative factor on the patient’s polysomnogram is associated with a positive long-term response to UPPP?
AHI
What are the advantages of this approach?
Allows wide exposure of the nasopharynx with low morbidity.
What should be done preoperatively for retrostyloid malignancies or tumors suspected to be involving the carotid artery?
Angiography with balloon occlusion.
What are the major complications of these procedures?
Aspiration pneumonia, rupture of the pexis, laryngocele, and laryngeal stenosis.
What is the most common and serious complication following supraglottic laryngectomy?
Aspiration pneumonia.
How far apart should the inferior and superior limbs be with the MacFee incision?
At least four fingerbreadths apart.
Where do strictures most often occur after free jejunal transfer?
At the inferior anastomosis between the jejunum and esophagus.
Where do fistulas most often occur after free jejunal transfer?
At the superior anastomosis between the jejunum and pharynx.
What is the absolute contraindication to endoscopic laser resection of supraglottic cancer?
Base of tongue involvement.
What are some adjunctive procedures for patients who do not improve after UPPP?
Base of tongue reduction, mandibular advancement with LeFort I osteotomy and maxillary advancement, genioglossus advancement (GA), and tracheostomy.
What is the plane of dissection for raising flaps during parotidectomy and how can one identify this more easily?
Between the SMAS and the superficial layer of the deep fascia-identify the platysma first and work superiorly.
What happens if the implant is placed too deep?
Can damage the levator muscle, causing ptosis.
What is the most significant early complication of this procedure?
Cervical anastomotic leak (50%).
What is the most significant late complication of this procedure?
Cervical anastomotic stricture (44%).
Which patients are at a higher risk of pneumothorax after tracheostomy?
Children.
What factors are most strongly related to overall speech function 3 months after surgery for oral or oropharyngeal cancer?
Closure type, percentage of oral tongue resected, and percentage of soft palate resected.
What is the most common esophageal bypass procedure?
Colon interposition.
What approach is used for resection of posterolateral tumors?
Combined suprahyoid and lateral pharyngotomy.
What is a functional neck dissection?
Complete cervical lymphadenectomy sparing the sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein.
What is the “first bite syndrome”?
Complication after removal of a carotid body tumor where the patient experiences intense pain with the first bite of food.
What are the signs of a tracheoesophageal fistula after tracheostomy?
Copious secretions, food aspiration, and air leak around the cuff with abdominal distension.
What is CHP / CHEP?
Cricohyoidopexy and cricohyoidoepiglottopexy. Conservation laryngeal procedures performed in concordance with a supracricoid partial laryngectomy. Require preservation of at least one functional cricoarytenoid unit (superior laryngeal nerve, RLN, arytenoid, cricoid, and cricoarytenoid musculature).
How can dynamic rehabilitation be achieved in a patient with a to-year history of facial paralysis following radical parotidectomy?
Cross-facial nerve graft plus microneurovascular muscle transfer.
What should be done during maxillectomy to prevent epiphora postoperatively?
Dacryocystorhinostomy.
What is the most serious complication of this approach and how can it be avoided?
Damage to the hypoglossal and superior laryngeal nerves; can be avoided if the greater horn of the hyoid is left undissected.
Which complication is most likely to be avoided with endoscopic diverticulectomy versus open diverticulectomy?
Damage to the RLN.
What are the advantages of preoperative embolization of carotid body tumors?
Decreased intraoperative blood loss and operative time.
What factors are associated with the development of temporary facial paresis after parotidectomy?
Deep lobe tumor; previous parotid surgery; history of sialoadenitis; addition of a neck dissection to the parotid surgery; increased age; diabetes mellitus; increased operative time; history of parotid irradiation; no EMG monitoring.
Which methods of facial nerve reconstruction have the potential for spontaneous emotional response?
Direct anastomosis and cable grafting.
What sort of gastrointestinal complaints do patients have after gastric pull-up?
Early satiety, emesis, and dumping syndrome.
What can be done to treat or prevent dumping syndrome?
Eating small dry meals, restricting fluid intake during meals, and using octreotide (somatostatin analogue).
What is the differential diagnosis for the etiology of stridor in a patient who has undergone total glossectomy and postoperative radiation therapy?
Edema secondary to altered lymphatics; recurrent tumor; gastroesophageal reflux disease; and superinfection.
What are the treatment options for Tis, microinvasive, and Tt glottic carcinoma?
Endoscopic surgical excision, laser excision, thyrotomy and cordectomy, or radiation.
What technique is most effective in preventing postoperative stenosis afterVPL?
Epiglottopexy.
Which anastomotic technique is preferred by most surgeons?
Epineural anastomosis using three to eight sutures of 8-o or 10-0 synthetic monofilament suture.
What is meant by putting a patient on “carotid blowout precautions”?
Establish IV access with two large bore IVs, type and cross 2 units PRBCs, have an intubation tray at the bedside, and educate nursing staff.
What preoperative symptom best correlates with improvement in AHI after UPPP?
Excess daytime sleepiness.
What is the most serious complication of lateral pharyngotomy?
Excessive retraction on the great vessels leading to thrombosis or embolism.
What is the purpose of vestibulectomy during excision of early glottic cancer?
Excision of the false vocal cord enhances intraoperative and postoperative visualization of the entire vocal cord.
During exploration for primary hyperparathyroidism, three normal parathyroid glands are found but the fourth cannot be identified. “What is the next step in management?
Extend the exploration through the existing incision, to include the central neck compartment between the carotids, posteriorly to the vertebral body, superiorly to the level of the pharynx and carotid bulb, and inferiorly into the mediastinum.
During resection of a carotid body tumor, which vessel can be sacrificed in most cases?
External carotid artery.
True/False: TEP is not effective in patients reconstructed with gastric pull-up.
False, although the voice quality is poor.
True/False: Cricopharyngeal myotomy as an adjunctive procedure to diverticulectomy has been shown to significantly decrease the incidence of recurrence.
False.
What is the greatest advantage of bronchoscopic visualization during percutaneous dilational tracheostomy?
Fewer major complications occur.
What are the contraindications to VPL and laryngoplasty?
Fixed vocal cord, involvement of the posterior commissure, invasion of both arytenoids, bulky transglottic lesions, invasion of the thyroid cartilage, subglottic extension >1 em anteriorly (5 mm posteriorly), and transglottic lesions extending to the supraglottis.
When is a total rhinotomy approach most useful?
For midline tumors where exposure of the cribriform plate and the bilateral ethmoids is necessary.
What are the reconstructive options after total laryngectomy and total pharyngectomy?
Free jejunal interposition graft, U-shaped pectoralis major + split-thickness skin graft (STSG), tubed thin flap (radial forearm or deepithelialized deltopectoral).
When the facial nerve is sacrificed during tumor resection, what must be done prior to reconstruction?
Frozen section confirmation of negative nerve margins.
What are the reconstructive options after total laryngopharyngectomy and cervical esophagectomy?
Gastric pull-up, free jejunal graft.
Which nerve is most often used for facial nerve cable grafting?
Greater auricular nerve.
What is Frey’s syndrome?
Gustatory sweating, secondary to cross-reinnervation of the divided auriculotemporal nerve with cutaneous nerves, after parotidectomy.
What is the advantage of the microneurovascular muscle transfer over the temporalis muscle sling in the treatment of facial paralysis?
Has the potential to restore spontaneous muscle expressions.
What is the most common complication of parotidectomy?
Hematoma.
After primary anastomosis, what is the typical return of facial nerve function?
House grade II or III.
What is the best functional outcome of cable grafting?
House grade III or IV.
What electrolyte problem is disproportionately associated with gastric pull-up?
Hypocalcemia secondary to impaired calcium absorption and inadvertent parathyroid resection during thyroidectomy.
What are the six ways to identify the facial nerve trunk during parotidectomy?
Identification of the tympanomastoid suture line, tragal pointer, posterior belly of the digastric, or styloid process; tracing a distal branch retrograde or tracing the proximal portion forward by drilling out the mastoid segment.
If a tumor-free proximal nerve stump is unavailable for nerve grafting, what method should be used for optimal functional outcome?
If reconstruction is undertaken within 2 years of division, grafting of the proximal portion of another cranial nerve to the distal stump of the facial nerve is the next best choice.
When is total esophagectomy indicated?
If the inferior margin during resection of a postcricoid tumor extends below the mediastinal inlet or if a second primary is present in the distal esophagus.
Your patient has a unilateral vocal cord paralysis after thyroidectomy for goiter. “What are the indications for surgical intervention?
If the paralysis is well tolerated (e.g., no aspiration and voice quality acceptable to the patient), 12 months is allowed for spontaneous recovery before proceeding with surgery. If the symptoms are severe, early surgery, typically a reversible procedure, is indicated.
What is the significance of the Bell’s phenomenon prior to gold weight implantation?
If the patient has a good Bell’s reflex, then the surgeon can be more conservative, choosing a lighter implant to avoid ptosis.
What is the purpose of using an STSG to cover a small defect after excision of a tonsil cancer?
If the pterygoid muscles are exposed during resection, placing an STSG will help prevent muscle fibrosis and trismus.
In which circumstance can a hemilaryngectomy be performed in the presence of vocal cord fixation?
If the tumor does not extend through the cricothyroid membrane or the perichondrium of the thyroid cartilage.
What are the contraindications to percutaneous endoscopic gastrostomy (PEG)?
Inability to perform upper endoscopy safely; inability to transilluminate the abdominal wall; and the presence of ascites, coagulopathy, or intra-abdominal infection.
Why should adenoidectomy be avoided when performing UPPP?
Increases the risk of nasopharyngeal stenosis.
What are the complications of gold weight implantation?
Induced astigmatism, ptosis, migration, extrusion, and persistent inflammation.
How should this flap be modified if reconstruction with a deltopectoral flap is planned?
Inferior incision should be as low as possible.
What type of resection would be best for a tumor confined to the floor of the maxillary antrum?
Infrastructure maxillectomy.
What factors make a tumor of the nose or paranasal sinuses unresectable?
Invasion into the frontal lobe, prevertebral fascia, bilateral optic nerves, or cavernous sinus
What are the contraindications to VPL for treatment of postradiation tumor recurrence?
Involvement of both vocal cords, involvement of body of arytenoid, subglottic extension >5 mm, fixed vocal cord, cartilage invasion, and different tumor type from original primary.
What are the contraindications to laser excision of early glottic carcinoma?
Involvement of the anterior or posterior commissure and subglottic extension.
What are the contraindications to radical maxillectomy?
Involvement of the sphenoid, nasopharynx, middle cranial fossa, or extensive infratemporal fossa; presence of bilateral cervical metastases or distant metastases.
Which cranial nerve is most often grafted to the distal facial nerve?
Ipsilateral hypoglossal.
What is the primary drawback of hypoglossal-facial nerve grafting?
Ipsilateral tongue paralysis.
What is the advantage of the dorsal radial cutaneous nerve?
It branches as it approaches the wrist, making distal separation into bundles for facial nerve branch anastomosis easier.
When performing a thyroid resection, where should the inferior thyroid artery be ligated?
It should not be ligated. Branches of the inferior thyroid artery should be ligated individually at the capsule.
What are the contraindications to percutaneous dilatational tracheostomy?
Large thyroid goiter or other neck mass, marked obesity, coagulopathy, previous neck surgery, neck trauma including burns, and inadequate access to the trachea.
What are other surgical approaches to the nasopharynx?
Lateral rhinotomy with facial disassembly, transpalatal split, lateral cervical approach with mandibular swing, transparotid temporal bone approach, and infratemporal fossa approach.
What are the three basic transfacial approaches to resection of midface tumors?
Lateral rhinotomy, total rhinotomy, and midface degloving.
What happens if the orbital septum is violated during resection of a sinonasal tumor?
Lid shortening and ectropion.
What is the primary limitation of the midface degloving approach?
Limited exposure of the skull base and anterior ethmoid sinuses.
What is the Weber-Ferguson incision?
Lip-splitting extension of the lateral rhinotomy incision that permits exposure for a radical maxillectomy.
Patients with supraglottic cancer who undergo both surgery and radiation therapy (vs. surgery alone) are at a significantly higher risk for what?
Long-term gastrostomy feeding.
Which neck dissection incision results in the best cosmetic outcome?
MacFee incision.
What is the initial treatment for a chyle leak diagnosed 3 days after neck dissection?
Maintain drains and begin medium-chain triglyceride tube feedings.
What are the possible complications of GA?
Mandible fracture; dental injury; failure to advance; infection; anesthesia of lower lip, gums, and chin; and bleeding/hematoma.
Which branch of the facial nerve is most commonly paretic after parotidectomy?
Marginal mandibular.
What are the available treatments for cricopharyngeal dysphagia?
Mechanical dilation, pharyngeal plexus neurectomy, cricopharyngeal myotomy, or botulinum toxin.
What is the best surgical approach to resection of JNAs?
Medial maxillectomy via lateral rhinotomy or midface degloving approach.
What is the gold standard of treatment for inverting papillomas?
Medial maxillectomy via lateral rhinotomy.
What are the four basic surgical procedures used to resect tumors of the midface?
Medial maxillectomy, suprastructure maxillectomy, infrastructure maxillectomy, and radical maxillectomy.
What are other indications for free muscle transposition surgery for facial reanimation?
Mobius syndrome or destruction of muscles secondary to trauma.
What are the indications for Mobs surgery?
Morpheaform BCC, recurrent BCC, and BCC in cosmetically sensitive locations.
What can be done to prevent functional dysphagia due to neuromuscular incoordination?
Myotomy of the jejunal musculature.
What precaution should be taken for a patient with a tracheostomy undergoing general anesthesia?
Nitrous oxide should be avoided, as it diffuses into the cuff and can increase the pressure by up to 40 mm Hg. If it is used during induction, the cuff should be deflated temporarily.
What are the indications for prophylactic central neck dissection in patients with well-differentiated thyroid cancer?
No definite indications. The American Thyroid Association advises that it may be performed for advanced, large, or invasive T3 or T4 tumors.
If a marginal mandibulectomy is performed and the bony margin is positive, does one irradiate the remaining bone?
No, as bone is relatively hypoxic and cannot generate many free radicals with radiation therapy; the patient should be taken back to the operating room for mandibulectomy.
What is the primary limitation of the gastric pull-up?
Obtaining enough length to achieve a tension-free closure.
When a carotid body tumor is embolized preoperatively, communication between the external and internal carotid circulation may occur through which vessel?
Occipital artery.
What are the advantages of transorallaser resection of early supraglottic cancer?
Oncologically sound, no tracheostomy or feeding tube is usually necessary, early discharge, rapid resumption of deglutition, and more cost effective.
What are five adjunctive procedures to the above dissections?
Orbital exenteration, infratemporal fossa dissection, craniotomy, contralateral maxillectomy, and rhinectomy.
A patient with an advanced sinonasal tumor has significant diplopia secondary to tumor invasion of the periorbital muscles. What procedure should be done in addition to maxillectomy?
Orbital exenteration.
What structures are preserved with an infrastructure maxillectomy that would be resected with a total maxillectomy?
Orbital floor and sometimes the infraorbital nerve.
What is the success rate of uvulopalatopharyngoplasty (UPPP) for the treatment of obstructive sleep apnea syndrome (OSAS) in adults?
Overall, 50% experience a 50% reduction in the apnea-hypopnea index (AHI) or in the amount of oxyhemoglobin desaturation.
What are the general indications for performing tracheostomy on patients with OSAS?
Oxygen saturation
What is a major contraindication to this procedure?
Paralysis of IX or X.
What procedure is performed for resection of these lesions?
Partial laryngopharyngectomy.
What effect does tracheostomy have on the incidence of pneumonia?
Patients on a ventilator are at a higher risk of pneumonia after tracheostomy and also tend to develop more serious pneumonias (Pseudomonas) secondary to antibiotic resistance.
What are the risk factors for innominate artery rupture after tracheostomy?
Placement of tracheostomy below the third ring; aberrant course of the innominate artery; use of a long, curved tube; over hyperextension of the neck during the procedure; prolonged pressure by inflated cuff; and tracheal infection.
What is the most common cause of mortality in patients < 1year of age who undergo tracheostomy?
Plugging or accidental decannulation.
What can happen if the free jejunal graft is too long?
Pooling of secretions and dysphagia.
What are the contraindications to craniofacial resection?
Poor surgical candidate, presence of multiple distant metastases, invasion of the prevertebral fascia, cavernous sinus (by a high-grade tumor), carotid artery (in a high-risk patient), or bilateral optic nerves/optic chiasm.
What are the contraindications to surgical resection of juvenile nasopharyngeal angiofibromas (JNAs)?
Poor surgical risk, recurrent tumor that has proved refractory to previous excisions, and involvement of vital structures.
In which subsite of the hypopharynx is cancer more common in females?
Postcricoid area.
What area of the sinonasal tract is better visualized via endoscopy as opposed to medial maxillectomy?
Posterior ethmoid cells, particularly those lateral to the sphenoid sinus and around the optic nerve.
When must the facial nerve be sacrificed during parotidectomy?
Preoperative facial nerve weakness or paralysis; adenoid cystic carcinoma abutting the nerve; malignant tumor infiltrating the nerve.
What are the contraindications to surgical resection of esophageal tumors?
Presence of distant metastases; involvement of prevertebral fascia, trachea, or carotid arteries.
What is the primary advantage of the midline mandibular osteotomy for resection of oropharyngeal tumors compared with the lateral mandibulotomy?
Preservation of the inferior alveolar and lingual nerves.
What are the reconstructive options after partial pharyngectomy?
Primary closure (if 3 or more em of tissue is available), skin graft, sternocleidomastoid flap, radial forearm free flap, or deltopectoral flap with a deepithelialized pedicle.
What are the reconstructive options after total laryngectomy and partial pharyngectomy?
Primary closure if more than 40% of the pharyngeal circumference is left in situ, regional flap (pectoralis major, deltopectoral), radial forearm free flap, gastric patch, free jejunal patch, tongue base rotation flap.
What maneuvers help facilitate preservation of olfaction after total laryngectomy?
Rapid facial or buccal movements, clicking” of the palate, and movement of the olfactory source.
What are the most common complications of gastric pull-up?
Regurgitation, cervical dysphagia, stricture, and anastomotic leak.
What is felt to be the safest way to address severe esophageal strictures with dilatation?
Retrograde technique using Tucker dilators over a guide string.
What are the advantages of the uvulopalatal flap?
Reversible; less pain and less incidence of dehiscence than UPPP.
What is the blood supply to the gastric pull-up?
Right gastroepiploic and right gastric arteries.
What does continuous facial nerve monitoring during parotidectomy prevent?
Short-term paresis.
What factor is most important regarding the risk of surgical complications in patients undergoing Zenker’s diverticulectomy?
Size of the diverticulum.
What are the primary limitations to endoscopic diverticulectomy?
Size of the sac; difficult to perform in very small or large sacs (10 em); and limitations in access due to anatomic factors (i.e., inability to extend the neck or limited jaw excursion).
What are some other options for improvement of function after facial paralysis?
Static facial slings, dynamic muscle slings, free muscle transfers, gold weight upper lid implants, lid-tightening procedures, and brow lift.
Which reconstructive options restore facial nerve function most quickly?
Static slings, gold weights, and tarsorrhaphies.
What are the incisions used for the midface degloving approach?
Sublabial; intercartilaginous; and complete transfixion.
Into which plane is a gold weight placed?
Suborbicularis.
