Flashcards in Chapter 19: Head and Neck Deck (152):
Anterior neck triangle
Sternocleidomastoid, sternol notch, inferior border of the digastric muscle; contains the carotid sheath
What does the anterior triangle contain?
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
What does the posterior neck triangle contain?
Accessory nerve (innervates SCM, trapezius, and platysma) and the brachial plexus
Secrete mostly serous fluid
Secrete mostly mucin
50/50 serous / mucin
Where are the false vocal cords?
In the larynx, the false vocal cords are superior to the true vocal cords
Has U-shaped cartilage and a posterior portion that is membranous
Where does the vagus nerve run?
Between internal jugular vein and carotid artery
Runs on top of the anterior scalene muscle
Runs posterior to the middle scalene muscle
Long thoracic nerve
Branches of the trigeminal nerve
Ophthalmic, maxillary, and mandibular branches
Gives sensation to most of the face
Taste to anterior 2/3 of tongue, floor of mouth, and gingiva
Mandibular branch of trigeminal nerve
Branches of facial nerve
Temporal, zygomatic, buccal, marginal mandibular, and cervical branches
Motor function to face
Taste to posterior 1/3 tongue
- Motor to stylopharyngeus
- Injury affects swallowing
Motor to all of tongue except palatoglossus
Where does tongue go in hypoglossal nerve injury?
Innervates all of larynx except cricothyroid muscle
Recurrent laryngeal nerve
Innervates the cricothyroid muscle
Superior laryngeal nerve
Occurs after parotidectomy; injury of auriculotemporal nerve that then cross-innervates with sympathetic fibers to sweat glands of skin
- Symptom: gustatory sweating
What composes the thyrocervical trunk?
- Suprascapular artery
- Transverse cervical artery
- Ascending cervical artery
- Inferior thyroid artery
What bases the trapezius flap?
Transverse cervical artery
1st branch of external carotid artery?
Superior thyroid artery
What bases the pectoralis major flap?
Based on either thoracoacromial artery or the internal mammary artery
Congenital bony mass on upper palate of mouth
- Tx: nothing
Congenital bony mass on lingual surface of mandible
- Tx: nothing
What does modified radical neck dissection (MRND) involve?
- Submandibular gland
- Sensory nerves C2-C5
- Cervical branch of facial nerve
- Ipsilateral thyroid
Mortality: modified radical neck dissection (vs) radical neck dissection
No mortality difference compared with RND
What does radical neck dissection (RND) involve?
- Submandibular gland
- Sensory nerves C2-C5
- Cervical branch of facial nerve
- Ipsilateral thyroid
- Accessory nerve
- Internal jugular resection (rarely done anymore)
Morbidity: radical neck dissection
Most morbidity occurs from accessory nerve resection
MC cancer of oral cavity, pharynx, and larynx
Squamous cell cancer
Biggest risk factors: squamous cell CA of oral cavity
Tobacco and alcohol
Considered more premalignant than leukoplakia
What does the oral cavity include?
Anterior 1/3 tongue.
Anterior tonsillar pillars.
MC site for oral cavity CA
Lower lip (more common than upper lip due to sun exposure
Why is survival rate lowest for hard palate tumors?
Hard to resect
Cervical dysphagia from esophageal web.
Plummer-Vinson syndrome (oral cavity cancer increased in patients)
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)
When MRND in oral cavity cancer?
Tumors > 4cm, clinically positive nodes, or bone invasion
When Post op XRT for oral cavity XRT?
- >4 cm
- Positive margins
- Nodal / bone involvement
When do you need flaps in lip cancer?
May need flaps if more than 1/2 of the lip is removed
Most aggressive lesions: lip CA
Lesions along the commissure are the most aggressive
Oral cavity cancer: commando procedure
Tongue CA - can still operate with jaw invasion
Well-differentiated SCCA; often found on the cheek; oral tobacco
- Not aggressive, rare metastasis
- Tx: full cheek resection +/ flap; no MRND
Tx: cancer of maxillary sinus
- ETOH, tobacco, males
- SCCA most common
- Asymptomatic until large
- 80% have lymph node metastases at time of diagnosis
Treatment: tonsillar cancer
Tonsillectomy best way to biopsy; wide resection with margins after that
- Presents with nose bleeding or obstruction.
Where does it go?
Goes to posterior cervical neck nodes
Tx: nasopharyngeal cancer
XRT primary therapy (very sensitive; give chemo XRT for advanced disease- no surgery)
Do you do surgery in nasopharyngeal carcinoma?
Super sensitive to XRT.
#1 cause tumor of nasopharynx in children
MC benign neoplasm of nose / paranasal sinuses
- Neck mass, sore throat
- Goes to posterior cervical neck nodes
Tx: oropharyngeal SCCA
XRT for tumors 4 cm, bone invasion, or nodal invasion)
- Hoarseness, early metastases
- Goes to anterior cervical nodes
Tx: hypopharyngeal SCCA
- XRT for tumors 4 cm, bone invasion or nodal invasion)
- Benign tumor
- Presents in males
Hoarseness, aspiration, dyspnea, dysphagia
- Try to preserve larynx
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
Most common benign lesion of larynx
Where can salivary gland cancers occur?
Parotid, submandibular, sublingual and minor salivary glands
Can present as a neck mass or swelling in the floor of the mouth
Submandibular or sublingual tumors
Mass in large salivary gland
More likely mass is benign
Mass in small salivary gland
More likely mass is malignant, although th operated gland is the most frequent site from malignant tumor
Most frequent site for malignant tumor of salivary glands
Often present as a painful mass but can also present with facial nerve paralysis or lymphadenopathy
Salivary gland malignant tumors
Lymphatic drainage of salivary gland malignant tumors
Intra-parotid and anterior cervical chain nodes
#1 malignant tumor of the salivary glands
- Wide range of aggressiveness
#2 malignant tumor of salivary glands
Adenoid cystic CA
- Long, indolent course; propensity to invade nerve roots
- Very sensitive to XRT
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
Often present as painless mass
Benign tumors of salivary glands
#1 benign tumor of the salivary glands
- Malignant degneration in 5%
Tx: pleomorphic adneoma
Tx: malignant degeneration pleomorphic adenoma
#2 benign tumor of the salivary glands
- Males, bilateral in 10%
Tx: Warthin's tumor
MC injured nerve with parotid surgery
Greater auricular nerve (numbness over lower portion of the ear)
What do you need to find in submandibular gland resection?
Need to find mandibular branch of facial nerve, lingual nerve, and hypoglossal nerve
MC salivary gland tumor in children
Ear: need suture through involved cartilage in laceration
Undrained hematoma that organize and calcify, need to be drained to avoid this
Epidermal inclusion cyst of ear; slow growing but erode as they grow; present with conductive hearing loss and clear drainage form ear
Vascular tumor of middle ear (paraganglionoma)
- Tx: surgery +/ XRT
CNVIII, tinnitus, hearing loss, unsteadiness; can grow into cerebellar / pontine angle
Tx: craniotomy and resection; XRT is alternative to surgery
Tx: acoustic neuroma
Craniotomy and resection
- XRT is alternative to surgery
20% metastasize to parotid gland
Tx: Ear SCCA
Resection and parotidectomy
- MRND for positive nodes or large tumors
MC childhood aural malignancy (although rare) of the middle or external ear
When do you set nasal fractures?
Set after swelling decreases
Management septal hematoma?
Need to drain to avoid infection and necrosis of septum
What is CSF rhinorrhea usually secondary to?
Cribiform plate fracture (CSF has tau protein)
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
Treatment: anterior epistaxis
90% are anterior. Can be controlled with packing.
Treatment: posterior epistaxis
Consider internal maxillary artery or ethmoid artery embolization for persistent posterior bleeding despite packing / balloon
Inflammatory cyst at the root of the teeth; can cause bone erosion; lucent on XR
- Tx: local excision or curettage
Slow-growing malignancy of odontogenic epithelium (outside portion of teeth); soap bubble appearance on XR
Tx: wide local excision
- Tx: multimodality approach that includes surgery
Tx: maxillary jaw fractures
Most treated with wire fixation
Tx: TMJ dislocations
Treated with closed reduction
Cause lower lip numbness
Inferior alveolar nerve damage (branch of mandibular nerve)
Management: Stensen's duct laceration
Repair over catheter stent
- Ligation can cause painful parotid atrophy and facial asymmetry
Duct from which saliva gets to mouth from parotid gland
Usually in elderly patients; occurs with dehydration; staph most common organism
Tx: suppurative parotitis
Fluids, salivation, antibiotics; drainage if abscess develops or patient not improving
- Can be life threatening
Acute inflammation of a salivary gland related to a stone in the duct; most calculi near orifice
Where does sialoadenitis most frequently occur?
80% of the time affects the submandibular or sublingual glands
Cause of recurrent sialoadenitis
Due to ascending infection from the oral cavity
Incise duct and remove stone
- Gland excision may eventually be necessary for recurrent disease
- Older kids (> 10 years)
- Symptoms: trismus, odynophagia; usually does not obstruct airway
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)
Younger kids (
Tx: retropharyngeal abscess
Tx: intubate the patient in a calm setting; drainage thru posterior pharyngeal wall; will self-drain with swallowing once opened
All age groups; occurs with dental infections, tonsillitis, pharyngitis
What causes morbidity in parapharyngeal abscess?
Morbidity comes from vascular invasion and mediastinal spread with prevertebral and retropharyngeal spaces
Tx: parapharyngeal abscess
Drain through lateral neck to avoid damaging internal carotid and internal jugular veins; need to leave drain in
Acute infection of the floor of the mouth, involves mylohyoid muscle
- May rapidly spread to deeper structures and cause airway obstruction
MCC dental infection of the mandibular teeth
Tx: ludwig's angina
Airway control, surgical drainage, antibiotics
All lumps near ear
Parotid tumors until proven otherwise
Diagnosis preauricular tumors
Diagnosis is usually made after superficial lobectomy
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.
MC distant metastases for head and neck tumors
If no obvious malignant epithelial tumor, considered to have Hodgkin's lymphoma until proven otherwise.
Need FNA or open biopsy.
Posterior neck masses
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)
What does adenocarcinoma neck mass suggest?
Breast, GI, or lung primary
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
MC location for occult head / neck tumor
Dysphagia; most just below the cricopharynxgeus (95%)
- Dx and Tx: rigid EGD under anesthesia
Esophageal foreign body
What dictates risk of perforation in esophageal foreign body?
Length of time in the esophagus
Fever and pain after EGD for foreign body?
Gastrografin followed by barium swallow to rule out perforation
Laryngeal foreign body - coughing
Emergent cricothyroidotomy as a last resort may be need to secure airway
Associated with MIs, arrhythmias and death
More common in obese and those with micrognathia / retrognathia -> have snoring and excessive daytime somnolence
Tx: sleep apnea
CPAP, uvulopalatopharyngoplasty (best surgical solution) or permanent trach
Can lead to subglottic stenosis.
Treatment: subglottic stenosis after prolonged intubation
Tracheal resection and reconstruction
Consider in patients who will require intubation for > 7-14 days
Why tracheostomy for patients with prolonged intubation?
Decreases secretions, provides easier ventilation, decreased pneumonia risk
Failure of tongue fusion.
- Tx: none necessary
Median rhomboid glossitis
When can cleft lip (primary palate involve)?
Involves lip, alveolus or both
- Repair at 10 weeks, 10 lb, 10 Hgb.
- Repair nasal deformities at same time
- May be associated with poor feeding
Cleft lip (primary palate)
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)
MC benign head and neck tumor in adults
Infection of the mastoid cells; can destroy bone
- Rare; results as a complication of untreated acute supportive otitis media
- Ear is pushed forward
Antibiotics, may need emergency mastoidectomy
- 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