Fiser Chapter 19 HEAD AND NECK Flashcards Preview

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Flashcards in Fiser Chapter 19 HEAD AND NECK Deck (92):
1

Anterior neck triangle

SCM, sternal notch, inferior border of digastric muscle

Contains carotid sheath

2

Posterior neck triangle

SCM posterior border, trapezium, clavicle

Contains accessory nerve (to SCM, trap, platysma) and brachial plexus

3

Parotid vs sublingual vs. submandibular gland secretions

Parotid -> serous

Sublingual -> mucin

Submandibular -> 50/50

4

False versus true vocal cords

False are superior to true in larynx

5

Location of vagus nerve in neck

Between carotid and IJ

6

Location of phrenic nerve in neck

On top of anterior scalene muscle

7

Location of long thoracic nerve in neck

Posterior to middle scalene muscle

8

Sensory nerve to face

Trigeminal with ophthalmic, maxillary, mandibular branches

Mandibular branch also gives taste to anterior 2/3 of tongue, floor of mouth, gingiva

9

Motor nerve to face

Facial nerve with temporal, zygomatic, buccal, marginal mandibular, cervical branches

10

Taste nerves

Trigeminal anterior 2/3 of tongue
Glossopharyngeal posterior 1/3 of tongue

11

Swallowing nerve

Glossopharyngeal (motor to stylopharyngeus, also taste posterior 1/3 tongue)

12

Motor nerve to tongue

Hypoglossal (motor to all of tongue except palatoglossus): tongue deviates toward same side of injury

13

Laryngeal muscle innervation

Superior laryngeal nerve innervates cricothyroid muscle

Recurrent laryngeal nerve innervates all the rest

14

Gustatory sweating after parotidectomy

Frey's syndrome: injury to auriculotemporal nerve, that then cross-innervates with sympathetic fibers to sweat glands of skin

15

Thyrocervical trunk branches

STAT:

Suprascapular artery
Transverse cervical artery
Ascending cervical artery
inferior Thyroid artery

16

External carotid artery branches

STAPLF (like staple) OPAMST

1. Superior thyroid artery
2. Ascending pharyngeal
3. Lingual
4. Facial
5. Occipital
6. Posterior auricular
7. Maxillary
8. Superficial temporal

17

Trapezius flap blood supply

transverse cervical artery

18

Pectoralis major flap blood supply

Either thoracoacromial artery or internal mammary artery

19

Torus palatine and Toru mandibular

Congenital bony mass on upper palate of mouth, or on lingual surgace of mandible
Tx: Nothing

20

Radical versus modified radical neck dissection

Radical: takes accessory nerve, SCM, IJ, omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, ipsilateral thyroid

Modified: leaves accessory nerve, SCM, IJ

No mortality difference between them. Most morbidity occurs from accessory nerve resection

21

Most common cancer of oral cavity, pharynx, and larynx; risk factors

Squamous cell carcinoma

Risk factors tobacco and EtOH

22

Erythroplakia versus leukoplakia

Erythroplakia more premalignant

23

Oral cavity borders

Mouth floor, anterior 1/3 of tongue, gingiva, hard palate, anterior tonsillar pillars, lips

24

Most common site for oral cavity CA

Lower lip (more common than upper lip d/t sun exposure)

25

Oral cancer location with lowest survival rate

Hard palate (hard to resect)

26

Risk factor for oral cavity cancer

-Plummer-Vinson synrome (glossitis, cervical dysphagia from esophageal web, spoon fingers, iron-deficiency anemia)

27

Oral cavity cancer treatment

-Wide resection (1 cm margins)

-MRND: tumors >4 cm, clinically positive nodes, or bone invasion

-Postop XRT: advanced lesions (>4 cm, positive margins, or nodal/bone involvement)

28

Lip cancer, most common site, site where most aggressive, and when flaps needed

Lower lip

Along commissure

Flaps if > 1/2 lip removed

29

Tongue cancer with jaw invasion, can you still operate?

Yes (commando procedure)

30

Verrucous ulcer

Well-differentiated SCCA often found on the check, associated with oral tobacco; not aggressive, rare metastasis

Tx: full cheek resection +/- flap; NO MRND

31

MRND indications

Oral cancer > 4 cm, or if node/bone invasion

32

Maxillary sinus cancer tx

Maxillectomy

33

Tonsillar CA risk factors, type, tx

EtOH, tobacco, males

SCCA most common

Asymptomatic until large, 80% have node mets at dx

Tx: Tonsillectomy to bx, wide resection with margins afterward

34

Nasopharyngeal SCCA risk factors, presentation, metastasis, tx, types

-EBV
-Chinese

Presents: nose bleeding or obstruction

Goes to: posterior cervical neck nodes

Tx: XRT primary therapy (very sensitive; give chemo-XRT for advanced disease; NO SURGERY)

Types: is lymphoma in children, give chemotherapy
Papilloma is most common benign neoplasm of nose/paranasal sinuses

35

Treatment of nasopharyngeal cancer

XRT

Chemo for advanced disease

No surgery!

36

Oropharyngeal cancer presentation, mets, tx

Presents: neck mass and sore throat

Goes to: posterior cervical neck nodes

Tx: XRT for tumors < 4 cm and no node/bone invasion
Otherwise surgery, MRND, XRT

37

Hypopharyngeal SCCA presentation, mets, tx

Presents: hoarseness, early mets!

Goes to: anterior cervical nodes

Tx: XRT for tumors < 4 cm, no node/bone invasion
Otherwise surgery, MRND, XRT

38

15yo male with epistaxis and nasal obstruction

Nasopharyngeal angiofibroma - benign tumor

Extremely vascular

Tx: Angiography and embolization (usually internal maxillary artery), followed by resection

39

Where do the different types of pharyngeal cancer metastasize to, and what is tx for each?

Nasopharyngeal SCCA: posterior cervical neck nodes
Tx: XRT, chemo-XRT for advanced, NO surgery

Oropharyngeal SCCA: posterior cervical neck nodes
Tx: XRT as long as < 4cm and no node/bone invasion
otherwise surgery, MRND, XRT

Hypopharyngeal SCCA: anterior cervical neck nodes
Tx: XRT as long as < 4 cm and no node/bone invasion
otherwise surgery, MRND, XRT

40

Hoarseness, aspiration, dyspnea, dysphagia

Laryngeal cancer, if benign then papilloma

Tx: XRT if vocal cord only, otherwise chemo-XRT
Try to preserve larynx, surgery is not primary tx
MRND (with ipsilateral thyroid) if nodes clinically positive

41

Neck mass and swelling in the floor of the mouth

Salivary gland cancer

Painless mass, benign

Pain and facial nerve paralysis or LAD: malignant

80% of salivary tumors are in parotid

80% of parotid tumors are benign

80% of benign parotid tumors are pleomorphic adenomas

42

Most frequent SITE for malignant salivary tumor

Parotid

Mass in large salivary gland more likely benign
Mass in small salivary gland more likely malignant

43

Most frequent malignant salivary tumor

1. Mucoepidermoid cancer, wide range of aggressiveness

2. Adenoid cystic cancer: long, indolent course, propensity to invade nerve roots, very sensitive to XRT

44

Salivary gland cancer lymphatic drainage

Intra-parotid and anterior cervical chain nodes

45

Tx of salivary gland cancer

Resection of salivary gland (total parotidectomy), prophylactic MRND, postop XRT if high grade or advanced
If in parotid, need to take whole loe, try to preserve facial nerve

46

Benign salivary gland tumors

1. Pleomorphic adenoma: Tx superficial parotidectomy; if malignant degeneration (occurs in 5%), need total parotidectomy

2. Warthin's tumor: males, bilateral in 10%, tx superficial parotidectomy

47

Most common injured nerve with parotid surgery

Greater auricular nerve (numbness over lower portion of ear)

Facial nerve branches course between superficial and deep lobes

48

Submandibular gland resection, which nerves must be identified?

Facial nerve mandibular branch, lingual nerve, hypoglossal nerve

49

Most common salivary gland tumor in children

Hemangiomas

50

Most common nasopharyngeal tumor in children

Lymphoma, tx chemo

51

Ear pinna lacerations, how to suture

through involved cartilage

52

Cauliflower ear

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

53

Epidermal inclusion cyst of ear; slow growing but erode as grow; present with conductive hearing loss and clear drainage from ear (dx and tx)

Cholesteatoma

Tx: Surgical excision

54

Paraganglionoma (vascular tumor of middle ear, dx and tx)

Chemodectoma

Tx: Surgery and XRT

55

Tinnitus, hearing loss, unsteadiness, tumor in cerebellar/pontine angle

Acoustic neuroma (CN VIII)

Tx: craniotomy and resection, XRT is alrternative

56

Ear SCCA metastasis and tx

Goes to: parotid gland

Resection and parotidectomy, MRND for positive nodes or large tumor

57

Most common childhood aural malignancy of middle or external ear

Rhabdomyosarcoma (though rare)

58

Nasal fracture tx

Set after swelling decreases

59

Septal hematoma tx

Drain to avoid infection and septum necrosis

60

CSF rhinorrhea tx

Usually due to cribriform plate fracture
Dx: CSF has tau protein, may need contrast study to help find leak and any facial fractures

-Conservative 2-3 weeks; try epidural catheter drainage of CSF; may need transethmoidal repair

61

Epistaxis tx

90% are anterior and can be controlled with packing

Consider internal maxillary artery or ethmoid artery embolization for persistent posterior bleeding

62

Radicular cyst of tooth

Inflammatory cyst at root of teeth, can cause bone erosion, lucent on X ray, tx local excision or curettage

63

Ameloblastoma of tooth

Slow-growing malignancy of odontogenic epithelium (outside portion of teeth); soap bubble appearance on X ray, tx wide local excision

64

Osteogenic sarcoma of jaw

Poor prognosis

Tx: multimodality approach including surgery

65

Maxillary jaw fracture tx

Wire fixation

66

TMJ dislocation tx

Closed reduction

67

Lower lip numbness, underlying nerve

Inferior alveolar nerve damage (branch of mandibular nerve)

68

Stensen's duct laceration (parotid duct) tx

Repair over catheter stent

Ligation can cause painful parotid atrophy and facial asymmetry

69

Suppurative parotitis tx

-Occurs in eldery patients with dehydration, staph most common organism, can be life-threatening

-Tx: fluids, salivation, antibiotics, drainage if abscess develops or not improving

70

Sialoadenitis

Acute inflammation of a salivary gland related to stone in duct; most calculi near orifice; 80% submandibular or sublingual glands

Recurrent d/t ascending infection from oral cavity

Tx: Incise duct and remove stone; gland excision may eventually be necessary for recurrent disease

71

15yo kid with trismus, odynophagia, airway fine

Peritonsillar abscess

Tx: Needle aspiration first, then drainage through tonsillar bed if no relief in 24hrs (may need to intubate to drain, will self-drain with swallowing once opened)

72

5yo kid with fever, odynophagia, drooling

Retropharyngeal abscess, AIRWAY EMERGENCY

Can also occur in elderly with Pott's disease

Tx: Intubate patient in calm setting, drainage through posterior pharyngeal wall, will self-drain with swallowing once opened

73

Parapharyngeal abscess, morbidity is from what; tx

Occurs with dental infections, tonsillitis, pharyngitis

Morbidity from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spaces

Tx: Drain through lateral neck to avoid damaging internal carotid and IJ; leave drain in

74

Acute infection of floor of mouth involving mylohyoid muscle

Ludwig's angina

MCC dental infection of mandibular teeth

May rapidly spread to deeper structures and cause airway obstruction

Tx: airway control, surgical drainage, abx

75

Preauricular tumor

Parotid tumor until proved otherwise

76

Most common distant mets for head and neck tumors

Lung

77

Posterior neck mass

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

78

Neck mass workup

1. H&P, laryngoscopy, FNA (best test for dx); can consider abx for 2 week with re-eval if seems inflammatory

2. Panendoscopy with multiple random biopsies, neck and chest CT

3. Perform excisional biopsy; need to be prepared for MRND

79

Adenocarcinoma on bx of head and neck cancer

Suggests breast, GI, or lung primary

80

Epidermoid CA (SCCA variant) found in cervical node without known primary -> what do you do?

1. Panendoscopy with random biopsies

2. CT scan

3. If still cannot find primary, ipsilateral MRND, ipsilateral tonsillectomy (most common location for occult head/neck tumor), bilateral XRT

81

Dysphagia, found to have esophageal foreign body (most just below cricopharyngeus) -> dx and tx?

Rigid EGD under anesthesia

Perforation risk increases with length of time in esophagus

82

Fever and pain after EGD for foreign body -> next step

Gastrografin followed by barium swallow to rule out perforation

83

Coughing, found to have laryngeal foreign body

May need emergent cricothyroidotomy as last resort to secure airway

84

Sleep apnea associated with what

MIs, arrhythmias, death

Most common in obese and those with micrognathia/retrognathia

85

Sleep apnea tx

CPAP

Uvulopalatopharyngoplasty (best surgical solution)

Or permanent trach

86

Prolonged intubation complication and tx

Subglottic stenosis

Tx: Tracheal resection and reconstruction

87

Indication for tracheostomy

Patients who will require intubation for > 7-14 days

Decreases secretions, provides easier ventilation, decreases PNA risk (???)

88

Median rhomboid glossitis

Failure of tongue fusion

Tx: none necessary

89

Cleft lip (primary palate) tx

Involves lip, alveolus, or both

May be associated with poor feeding

Tx: Repair at 10 weeks, 10 lb, Hgb 10
- Repair nasal deformities at same time

90

Most common benign head and neck tumor in adults

Hemangioma

91

Mastoiditis

Infection of mastoid cells, can destroy bone, rare

Results as complication of untreated ACUTE SUPPURATIVE OTITIS MEDIA

Ear is pushed forward

Tx: Abx, may need emergency mastoidectomy

92

4yo with stridor, drooling, leaning forward, high fever, throat pain, thumbprint sign on lateral neck film

Epiglottitis

Rare since HiB vaccine

Tx: early control of airway, abx