Chapter 19: Head and Neck Flashcards Preview

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Flashcards in Chapter 19: Head and Neck Deck (152):
1

Anterior neck triangle

Sternocleidomastoid, sternol notch, inferior border of the digastric muscle; contains the carotid sheath

2

What does the anterior triangle contain?

Carotid sheath

3

Posterior neck triangle

Posterior border of the SCM, trapezius muscle, and the clavicle; contains the accessory nerve (innervates SCM, trapezius, and platysma) and the brachial plexus

4

What does the posterior neck triangle contain?

Accessory nerve (innervates SCM, trapezius, and platysma) and the brachial plexus

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Secrete mostly serous fluid

Parotid glands

6

Secrete mostly mucin

Sublingual glands

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50/50 serous / mucin

Submandibular glands

8

Where are the false vocal cords?

In the larynx, the false vocal cords are superior to the true vocal cords

9

Has U-shaped cartilage and a posterior portion that is membranous

Trachea

10

Where does the vagus nerve run?

Between internal jugular vein and carotid artery

11

Runs on top of the anterior scalene muscle

Phrenic nerve

12

Runs posterior to the middle scalene muscle

Long thoracic nerve

13

Branches of the trigeminal nerve

Ophthalmic, maxillary, and mandibular branches

14

Gives sensation to most of the face

Trigeminal nerve

15

Taste to anterior 2/3 of tongue, floor of mouth, and gingiva

Mandibular branch of trigeminal nerve

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Branches of facial nerve

Temporal, zygomatic, buccal, marginal mandibular, and cervical branches

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Motor function to face

Facial nerve

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Taste to posterior 1/3 tongue

Glossopharyngeal nerve

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- Motor to stylopharyngeus
- Injury affects swallowing

Glossopharyngeal nerve

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Motor to all of tongue except palatoglossus

Hypoglossal nerve

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Where does tongue go in hypoglossal nerve injury?

Same side

22

Innervates all of larynx except cricothyroid muscle

Recurrent laryngeal nerve

23

Innervates the cricothyroid muscle

Superior laryngeal nerve

24

Occurs after parotidectomy; injury of auriculotemporal nerve that then cross-innervates with sympathetic fibers to sweat glands of skin
- Symptom: gustatory sweating

Frey's syndrome

25

What composes the thyrocervical trunk?

STAT
- Suprascapular artery
- Transverse cervical artery
- Ascending cervical artery
- Inferior thyroid artery

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What bases the trapezius flap?

Transverse cervical artery

27

1st branch of external carotid artery?

Superior thyroid artery

28

What bases the pectoralis major flap?

Based on either thoracoacromial artery or the internal mammary artery

29

Congenital bony mass on upper palate of mouth
- Tx: nothing

Torus palatini

30

Congenital bony mass on lingual surface of mandible
- Tx: nothing

Torus mandibular

31

What does modified radical neck dissection (MRND) involve?

- Omohyoid
- Submandibular gland
- Sensory nerves C2-C5
- Cervical branch of facial nerve
- Ipsilateral thyroid

32

Mortality: modified radical neck dissection (vs) radical neck dissection

No mortality difference compared with RND

33

What does radical neck dissection (RND) involve?

- Omohyoid
- Submandibular gland
- Sensory nerves C2-C5
- Cervical branch of facial nerve
- Ipsilateral thyroid
- Accessory nerve
- SCM
- Internal jugular resection (rarely done anymore)

34

Morbidity: radical neck dissection

Most morbidity occurs from accessory nerve resection

35

MC cancer of oral cavity, pharynx, and larynx

Squamous cell cancer

36

Biggest risk factors: squamous cell CA of oral cavity

Tobacco and alcohol

37

Considered more premalignant than leukoplakia

Erythroplakia

38

What does the oral cavity include?

Mouth floor.
Anterior 1/3 tongue.
Gingiva.
Hard palate.
Anterior tonsillar pillars.
Lips.

39

MC site for oral cavity CA

Lower lip (more common than upper lip due to sun exposure

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Why is survival rate lowest for hard palate tumors?

Hard to resect

41

Glossitis.
Cervical dysphagia from esophageal web.
Spoon fingers.
Iron-deficiency anemia.

Plummer-Vinson syndrome (oral cavity cancer increased in patients)

42

Tx: oral cavity cancer

- Wide resection (1 cm margins)
- MRND for tumors > 4cm, clinically positive nodes, or bone invasion)
- Postop XRT for advanced ( > 4cm, positive margins, or nodal/bone involvement)

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When MRND in oral cavity cancer?

Tumors > 4cm, clinically positive nodes, or bone invasion

44

When Post op XRT for oral cavity XRT?

Advanced lesions
- >4 cm
- Positive margins
- Nodal / bone involvement

45

When do you need flaps in lip cancer?

May need flaps if more than 1/2 of the lip is removed

46

Most aggressive lesions: lip CA

Lesions along the commissure are the most aggressive

47

Oral cavity cancer: commando procedure

Tongue CA - can still operate with jaw invasion

48

Well-differentiated SCCA; often found on the cheek; oral tobacco
- Not aggressive, rare metastasis
Treatment?

Verrucous ulcer
- Tx: full cheek resection +/ flap; no MRND

49

Tx: cancer of maxillary sinus

Tx: maxillectomy

50

- ETOH, tobacco, males
- SCCA most common
- Asymptomatic until large
- 80% have lymph node metastases at time of diagnosis

Tonsillar cancer

51

Treatment: tonsillar cancer

Tonsillectomy best way to biopsy; wide resection with margins after that

52

- EBV
- Chinese
- Presents with nose bleeding or obstruction.

Where does it go?

Nasopharyngeal SCCA

Goes to posterior cervical neck nodes

53

Tx: nasopharyngeal cancer

XRT primary therapy (very sensitive; give chemo XRT for advanced disease- no surgery)

54

Do you do surgery in nasopharyngeal carcinoma?

NO.
Super sensitive to XRT.

55

#1 cause tumor of nasopharynx in children
- Treatment?

Lymphoma.

Tx: chemotherapy

56

MC benign neoplasm of nose / paranasal sinuses

Papilloma

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- Neck mass, sore throat
- Goes to posterior cervical neck nodes

Oropharyngeal SCCA

58

Tx: oropharyngeal SCCA

XRT for tumors 4 cm, bone invasion, or nodal invasion)

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- Hoarseness, early metastases
- Goes to anterior cervical nodes

Hypopharyngeal SCCA

60

Tx: hypopharyngeal SCCA

- XRT for tumors 4 cm, bone invasion or nodal invasion)

61

- Benign tumor
- Presents in males

Nasopharyngeal angiofibroma

62

Hoarseness, aspiration, dyspnea, dysphagia
- Try to preserve larynx

Laryngeal cancer

63

Tx: laryngeal cancer

XRT (if vocal cord only) or chemo-XRT (if beyond vocal cord)
- Surgery is not the primary treatment, try to preserve larynx
- MRND needed if nodes clinically positive
- Take ipsilateral thyroid lobe with MRND

64

Most common benign lesion of larynx

Papilloma

65

Where can salivary gland cancers occur?

Parotid, submandibular, sublingual and minor salivary glands

66

Can present as a neck mass or swelling in the floor of the mouth

Submandibular or sublingual tumors

67

Mass in large salivary gland

More likely mass is benign

68

Mass in small salivary gland

More likely mass is malignant, although th operated gland is the most frequent site from malignant tumor

69

Most frequent site for malignant tumor of salivary glands

Parotid gland

70

Often present as a painful mass but can also present with facial nerve paralysis or lymphadenopathy

Salivary gland malignant tumors

71

Lymphatic drainage of salivary gland malignant tumors

Intra-parotid and anterior cervical chain nodes

72

#1 malignant tumor of the salivary glands

Mucoepidermoid CA
- Wide range of aggressiveness

73

#2 malignant tumor of salivary glands

Adenoid cystic CA
- Long, indolent course; propensity to invade nerve roots
- Very sensitive to XRT

74

Tx: mucoepidoermoid CA, adenoid cystic CA

Resection of salivary gland (e.g., total parotidectomy), prophylactic MRND, and post XRT if high grade or advanced disease
- If in parotid, need to take whole lobe; try to preserve facial nerve

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Often present as painless mass

Benign tumors of salivary glands

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#1 benign tumor of the salivary glands
- Malignant degneration in 5%

Pleomorphic adenoma

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Tx: pleomorphic adneoma

Superficial parotidectomy

78

Tx: malignant degeneration pleomorphic adenoma

Total parotidectomy

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#2 benign tumor of the salivary glands
- Males, bilateral in 10%

Warthin's tumor

80

Tx: Warthin's tumor

Superficial parotidectomy

81

MC injured nerve with parotid surgery

Greater auricular nerve (numbness over lower portion of the ear)

82

What do you need to find in submandibular gland resection?

Need to find mandibular branch of facial nerve, lingual nerve, and hypoglossal nerve

83

MC salivary gland tumor in children

Hemangiomas

84

Ear: need suture through involved cartilage in laceration

Pinna laceration

85

Undrained hematoma that organize and calcify, need to be drained to avoid this

Cauliflower ear

86

Epidermal inclusion cyst of ear; slow growing but erode as they grow; present with conductive hearing loss and clear drainage form ear

Cholesteatoma

87

Tx: cholesteatoma

Surgical excision

88

Vascular tumor of middle ear (paraganglionoma)

Chemodectomas
- Tx: surgery +/ XRT

89

CNVIII, tinnitus, hearing loss, unsteadiness; can grow into cerebellar / pontine angle

Acoustic neuroma

Tx: craniotomy and resection; XRT is alternative to surgery

90

Tx: acoustic neuroma

Craniotomy and resection
- XRT is alternative to surgery

91

20% metastasize to parotid gland

Ear SCCA

92

Tx: Ear SCCA

Resection and parotidectomy
- MRND for positive nodes or large tumors

93

MC childhood aural malignancy (although rare) of the middle or external ear

Rhabdomyosarcoma

94

When do you set nasal fractures?

Set after swelling decreases

95

Management septal hematoma?

Need to drain to avoid infection and necrosis of septum

96

What is CSF rhinorrhea usually secondary to?

Cribiform plate fracture (CSF has tau protein)

97

Tx: CXF rhinorrhea

Repair of facial fractures may help leak; may need contrast study to help find leak.
- Tx: conservative 2-3 weeks; try epidural catheter drainage of CSF; may need transethmoidal repair

98

Treatment: anterior epistaxis

90% are anterior. Can be controlled with packing.

99

Treatment: posterior epistaxis

Consider internal maxillary artery or ethmoid artery embolization for persistent posterior bleeding despite packing / balloon

100

Inflammatory cyst at the root of the teeth; can cause bone erosion; lucent on XR

Radicular cyst

- Tx: local excision or curettage

101

Slow-growing malignancy of odontogenic epithelium (outside portion of teeth); soap bubble appearance on XR

Ameloblastoma

Tx: wide local excision

102

Poor prognosis
- Tx: multimodality approach that includes surgery

Osteogenic sarcoma

103

Tx: maxillary jaw fractures

Most treated with wire fixation

104

Tx: TMJ dislocations

Treated with closed reduction

105

Cause lower lip numbness

Inferior alveolar nerve damage (branch of mandibular nerve)

106

Management: Stensen's duct laceration

Repair over catheter stent
- Ligation can cause painful parotid atrophy and facial asymmetry

107

Duct from which saliva gets to mouth from parotid gland

Stensen's duct

108

Usually in elderly patients; occurs with dehydration; staph most common organism

Suppurative parotitis

109

Tx: suppurative parotitis

Fluids, salivation, antibiotics; drainage if abscess develops or patient not improving
- Can be life threatening

110

Acute inflammation of a salivary gland related to a stone in the duct; most calculi near orifice

Sialoadenitis

111

Where does sialoadenitis most frequently occur?

80% of the time affects the submandibular or sublingual glands

112

Cause of recurrent sialoadenitis

Due to ascending infection from the oral cavity

113

Tx: sialoadenitis

Incise duct and remove stone
- Gland excision may eventually be necessary for recurrent disease

114

- Older kids (> 10 years)
- Symptoms: trismus, odynophagia; usually does not obstruct airway

Peritonsillar abscess

115

Tx: peritonsillar abscess

Needle aspiration 1st, then drainage thru tonsillar bed if no relief in 24 hours (may need to intubate to drain; will self-drain with swallowing once opened)

116

Younger kids (

Retropharyngeal abscess

117

Tx: retropharyngeal abscess

Tx: intubate the patient in a calm setting; drainage thru posterior pharyngeal wall; will self-drain with swallowing once opened

118

All age groups; occurs with dental infections, tonsillitis, pharyngitis

Parapharyngeal abscess

119

What causes morbidity in parapharyngeal abscess?

Morbidity comes from vascular invasion and mediastinal spread with prevertebral and retropharyngeal spaces

120

Tx: parapharyngeal abscess

Drain through lateral neck to avoid damaging internal carotid and internal jugular veins; need to leave drain in

121

Acute infection of the floor of the mouth, involves mylohyoid muscle
- May rapidly spread to deeper structures and cause airway obstruction

Ludwig's angina

122

MCC dental infection of the mandibular teeth

Ludwig's angina

123

Tx: ludwig's angina

Airway control, surgical drainage, antibiotics

124

All lumps near ear

Parotid tumors until proven otherwise

125

Diagnosis preauricular tumors

Diagnosis is usually made after superficial lobectomy

126

80s of parotid tumors

80% salivary gland tumors are in parotid.
80% of parotid tumors are benign.
80% of benign parotid tumors are pleomorphic adenomas.

127

MC distant metastases for head and neck tumors

Lung

128

If no obvious malignant epithelial tumor, considered to have Hodgkin's lymphoma until proven otherwise.
Need FNA or open biopsy.

Posterior neck masses

129

Neck mass workup

1. H&P, laryngoscopy, FNA (best test for dx); can consider antibiotics for 2 wks with re-eval if though to be inflammatory.
2. Nondx? panendoscopy with multiple random biopsies, neck and chest CT
3. Still no? Excisional biopsy (prepare for MRND)

130

What does adenocarcinoma neck mass suggest?

Breast, GI, or lung primary

131

Work up: epidermoid CA (SCCA variant) found in cervical node without known primary

1. panendoscopy to look for primary; get random biopsies
2. CT scan
3. Still cannot find primary -> ipsilateral MRND, ipsilateral tonsillectomy (MC location for occult head / neck tumor), bilateral XRT

132

MC location for occult head / neck tumor

Tonsils

133

Dysphagia; most just below the cricopharynxgeus (95%)
- Dx and Tx: rigid EGD under anesthesia

Esophageal foreign body

134

What dictates risk of perforation in esophageal foreign body?

Length of time in the esophagus

135

Fever and pain after EGD for foreign body?

Gastrografin followed by barium swallow to rule out perforation

136

Laryngeal foreign body - coughing
- Treatment?

Emergent cricothyroidotomy as a last resort may be need to secure airway

137

Associated with MIs, arrhythmias and death

Sleep apnea

138

More common in obese and those with micrognathia / retrognathia -> have snoring and excessive daytime somnolence

Sleep apnea

139

Tx: sleep apnea

CPAP, uvulopalatopharyngoplasty (best surgical solution) or permanent trach

140

Can lead to subglottic stenosis.

Prolonged intubation

141

Treatment: subglottic stenosis after prolonged intubation

Tracheal resection and reconstruction

142

Consider in patients who will require intubation for > 7-14 days

Tracheostomy

143

Why tracheostomy for patients with prolonged intubation?

Decreases secretions, provides easier ventilation, decreased pneumonia risk

144

Failure of tongue fusion.
- Tx: none necessary

Median rhomboid glossitis

145

When can cleft lip (primary palate involve)?

Involves lip, alveolus or both

146

- Repair at 10 weeks, 10 lb, 10 Hgb.
- Repair nasal deformities at same time
- May be associated with poor feeding

Cleft lip (primary palate)

147

Involves hard and soft palate; may affect speech and swallowing if not closed soon enough; may affect maxillofacial growth if closed too early -> repair at 12 months

Cleft palate (secondary palate)

148

MC benign head and neck tumor in adults

Hemangioma

149

Infection of the mastoid cells; can destroy bone
- Rare; results as a complication of untreated acute supportive otitis media
- Ear is pushed forward

Mastoiditis

150

Tx: mastoiditis

Antibiotics, may need emergency mastoidectomy

151

- Rare since immunization against H. influenza type B
- Mainly in children aged 3-5
- Symptoms: stridor, drooling, leaning forward position, high fever, throat pain, thumbprint sign on lateral neck film
- Can cause airway obstruction

Epiglottitis

152

Tx: epiglottitis

Early control of the airway, antibiotics