Head and Neck Flashcards

Question

Oral cavity T staging

Answer 1

T1: tumor < 2cm in greatest dimension, and DOI ≤ 5 mm T2: tumor ≤ 2 cm, DOI > 5 mm and ≤ 10 mm or tumor > 2 cm and ≤ 4 cm and DOI ≤ 10 mm T3: > 4cm or any tumor with DOI > 10 mm T4a: Tumor invades adjacent structures only (e.g., through cortical bone of mandible or maxilla, or involves the maxillary sinus or skin of the face; for lip it invades through the cortical bone, inferior alveolar nerve, floor of mouth or skin of face) T4b: Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid artery

Answer 2

Clinical assessment: NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, ≤ 3 cm and ENE- N2a: Metastasis in a single ipsilateral lymph node > 3 cm and ≤ 6 cm and ENE N2b: Metastases in multiple ipsilateral lymph nodes, ≤ 6 cm and ENE- N2c: Metastases in bilateral or contralateral lymph nodes, ≤ 6 cm and ENE- N3a: Metastasis in a lymph node > 6 cm and ENE- N3b: metastasis in any lymph node(s) with ENE+ clinically Pathologically remainder of above is the same except for - N2a: Metastasis in a single ipsilateral lymph node, ≤ 3 cm and ENE+; or metastasis in a single ipsilateral lymph node > 3 cm and ≤ 6 cm and ENE- N3b: Metastasis in a single ipsilateral node larger than 3 cm in greatest dimension and ENE+; or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE+; or a single contralateral node of any size and ENE+

Answer 3

- Mucosal space between third mandibular molar and maxillary tuberosity - Continuous with buccal mucosa, hard and soft palate, anterior tonsillar pillar, maxillary tuberosity and upper and lower alveolar ridges Borders: superior - maxillary tuberosity; anterior: posterior aspect of second mandibular molar; lateral - buccal mucosa; medial- anterior tonsillar pillar

Answer 4

- Palatine tonsils - Base of tongue (posterior to circumvallate papillae)/ lingual tonsils - Soft palate and uvula - Anterior and posterior tonsillar pillars - Posterior pharyngeal wall - Vallecula

Answer 5

T1: Tumor ≤ 2 cm T2: Tumor > 2 cm and ≤ 4 cm T3: Tumor > 4 cm or extension to lingual surface of the epiglottis T4: Moderately advanced local disease; tumor invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible or beyond

Answer 6

Clinical- NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 One or more ipsilateral lymph nodes ≤ 6 cm N2 Contralateral or bilateral lymph nodes ≤ 6 cm N3 Lymph node(s) > 6 cm Pathologic - pNX Regional lymph nodes cannot be assessed pN0 No regional lymph node metastasis pN1 Metastasis in 4 or fewer lymph nodes pN2 Metastases in more than 4 lymph nodes

Answer 7

squamous epithelium -> superficial lamina propria -> intermediate lamina propria -> deep lamina propria -> vocalis muscle

Answer 8

Supraglottis Glottis Subglottis

Answer 9

Epiglottis AE folds Arytenoid cartilages False vocal folds

Answer 10

True vocal folds Anterior commissure Posterior commissure Ventricle

Answer 11

- Quadrangular membrane (for supraglottis) - Conus elasticus (for glottis and subglottis) - Cricothyroid membrane - Thyrohyoid membrane - Inner perichondrium

Answer 12

1. Broyle's tendon: vocalis tendon inserted into thyroid cartilage 2. Preepiglottic space 3. Paraglottic space

Answer 13

T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2: Tumor invades mucosa of more than one adjacent subsite* of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, or medial wall of pyriform sinus) without fixation of the larynx T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex) T4a: Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Answer 14

T1: Tumor limited to the vocal cord(s), which may involve anterior or posterior commissure, with normal mobility T1a: Tumor limited to one vocal cord T1b: Tumor involves both vocal cords T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility T3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex) T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Answer 15

T1: Tumor limited to the subglottis T2: Tumor extends to vocal cord(s) with normal or impaired mobility T3: Tumor limited to larynx with vocal cord fixation T4a: Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Answer 16

- Can be done for T1, T2 and limited T3 tumors of the supraglottis - Remove epiglottis, AE folds, false cords, preepiglottic space, portions of hyoid and thyroid cartilage - Spares the arytenoids and true cords

Answer 17

- Can be done for select T3/T4 glottic and supraglottic cancers - Must not have arytenoid fixation, cricoid cartilage contact/incision, major preepiglottic space involvement, invasion of thyroid cartilage, perichondrum, hyoid and posterior arytenoid mucosal involvement - Remove entire thyroid cartilage, bilateral true and false vocal cords, one arytenoid and the paraglottic space - Spare cricoid, hyoid and at least one arytenoid

Answer 18

- Can be done for T1 glottic cancers located in the mid third

Answer 19

- Can be done for T1 glottic cancers located in the mid third

Answer 20

- Done for T1-T2 glottic cancers if the tumor does not extend beyond one third of the opposite cord; < 10mm anterior subglottic extension; <5mm posterior subglottic extension; no posterior commissure, cricoarytenoid joint, AE fold, posterior surface of arytenoids or paraglottic space involvement; FEV1 > 50% - remove one vocal fold from the arytenoid cartilage to vocal process, false cord, ventricle, paraglottic space and overlying thyroid cartilage - Vertical height of the larynx is maintained by the retained contralateral thyroid ala

Answer 21

- Fixed TVF - > 10mm anterior subglottic extension or > 5 mm posterior subglottic extension - Involvement of posterior commissure - Bulky transglottic lesions - Lesions invading thyroid cartilage - Poor pulmonary function

Answer 22

- Cricoid or thyroid cartilage invasion - Arytenoid mucosa involvement - Posterior or anterior commissure involvement - Impaired TVC motion - Impaired base of tongue motion - BOT invasion < 1cm from circumvallate papillae - Invasion of FOM via vallecular involvement

Answer 23

- Arytenoid fixation - > 1.5cm extension anteriorly (cricothyroid membrane) and > 0.5cm posterolaterally - Cricoid involvement - Extensive preepiglottic space invasion with bulging beneath the vallecular or extension to the thyrohyoid membrane - Hyoid bone involvement - External perichondrial thyroid cartilage involvement or extralaryngeal spread

Answer 24

- Fixed cords - Cartilage invasion - Subglottic extension - Interarytenoid invasion - Subglottic invasion - Cervical metastasis (relative contraindication)

Answer 25

- T3/T4 tumors with thyroid cartilage destruction - Posterior commissure or bilateral arytenoid involvement - Circumferential submucosal disease - Subglottic extension with cricoid cartilage involvement - RT or chemoradiation failures - Hypopharygneal tumors that spread to the postcricoid mucosa - Thyroid tumors that invade both sides of the larynx - Radiation necrosis of the larynx - Severe irreversible aspiration

Answer 26

- Bevel tracheal cuts - Minimize tracheal tension - Cut medial heads of SCM - Minimize suctioning - Minimize lary tube use

Answer 27

- Early complications: drain failure, hematoma, infection, pharyngocutaneous fistula, wound dehiscence, hypoglossal nerve injury - Late complications: stomal stenosis, pharyngoesophageal stenosis or stricture, hypothyroidism

Answer 28

Plummer Vinson (dysphagia, iron deficiency anemia, hypopharyngeal webs) - Can see an increased risk in nonsmoking women in their 3rd-5th decades of life - Most commonly associated with hyopharyngeal cancers in the postcricoid region

Answer 29

- Pyriform sinuses - Postcricoid space - Posterior pharyngeal wall

Answer 30

Medial border: AE fold Lateral border: thyroid cartilage Superior border: glossoepiglottic fold Inferior border: cricopharyngeus muscle/ esophageal introitus Posterior border: lateral pharyngeal wall Anterior: junction of pyriform sinuses in postcricoid region

Answer 31

Superior border: posterior arytenoid cartilages Inferior border: esophageal introitus Lateral border: tracheoesophageal groove

Answer 32

Anterolateral: thyroid cartilage Inferiomedial: conus elasticus Medial: ventricle and quadrangular membrane Posterior: pyriform sinus

Answer 33

- Specifically associated with postcricoid SCC - Primarily affects post menopausal women (85%) - Dysphagia, iron deficiency anemia, hypopharyngeal/esophageal webs, atrophic gastritis, angular stomatitis - Chronic irritation from webs progresses to carcinoma - Syndrome etiology likely the result of nutritional deficiency

Answer 34

- Cancer involves postcricoid mucosa - Cancer extends beyond the midline - Advanced cancer or the posterior hypopharyngeal wall

Answer 35

- Genetics: 15-20% of nasopharyngeal carcinoma pt have a first degree family member with NPC, HLA-b,c and D haplotypes associated with increased risk - Environment: high nitrosamine diet of salted fish, eggs and vegetables - EBV - Male sex 3:1 ratio

Answer 36

Stage I: tumor confined to nasopharynx Stage II: tumor extends to nasal cavity or sphenoid Stage III: tumor involves maxillary sinus, ethmoid sinus, infratemporal fossa, orbit, cheek and cavernous sinus Stage IV: tumor is intracranial

Answer 37

T1: Tumor confined to the nasopharynx, or extension to oropharynx and/or nasal cavity without parapharyngeal involvement T2: Tumor with extension to parapharyngeal space, and/or adjacent soft tissue involvement (medial pterygoid, lateral pterygoid, prevertebral muscles) T3: Tumor with infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses T4: Tumor with intracranial extension, involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive soft tissue infiltration beyond the lateral surface of the lateral pterygoid muscle

Answer 38

N1: Unilateral metastasis in cervical lymph node(s) and/or unilateral or bilateral metastasis in retropharyngeal lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage N2: Bilateral metastasis in cervical lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage N3: Unilateral or bilateral metastasis in cervical lymph node(s), larger than 6 cm in greatest dimension, and/or extension below the caudal border of cricoid cartilage

Answer 39

- Maxillary sinus (50-70%) - Nasal cavity (15-30%) - Ethmoid sinus (10-20%)

Answer 40

- Wood dust exposure (adenocarcinoma) - Leather related occupational exposure (adenocarcinoma) - Smoking (SCC) - Nickel exposure (SCC)

Answer 41

Kadish A: confined to the nasal cavity Kadish B: extends to the paranasal sinuses Kadish C: extends beyond the nasal cavity and paranasal sinuses Kadish D: lymph node or distant metastasis

Answer 42

1. Paranasal sinuses 2. Nasal cavity 3. Anterior cranial fossa 4. Pterygopalatine fossa 5. Infratemporal fossa 6. Orbital cavity

Answer 43

Epithelial: SCC, adenocarcinoma, adenoid cystic carcinoma Nonepithelial: lymphoma, esthesioneuroblastoma, sinonasal undifferentiated carcinoma, mucosal melanoma

Answer 44

- Facial soft tissue extension - Anteriolateral frontal sinus involvement - Palate involvement - Dural involvement beyond midpupillary line - Mandible involvement - Orbital extension

Answer 45

- 70% in parotid (75% benign) - 22% in submandibular gland (57% benign) - 8% minor salivary gland (85% malignant)

Answer 46

Decreased gag reflex (CN IX and X) Aspiration (CN IX and X) Asymmetric palate elevation (CN X) Hoarseness (CNX) Dysphagia (CNX) Shoulder weakness (CN XI) Tongue atrophy/paresis (CN XII) Ptosis (sympathetic chain)

Answer 47

- Bilateral high T2 signal that does not enhance: more likely Warthin's tumor - Unilateral high T2 signal that enhances: more likely pleomorphic adenoma - Intermediate to low T2 signal: more likely malignant

Answer 48

- Most common salivary gland malignancy (adult and pediatric) - Can look similar to necrotizing sialometoplasia (hard palate) and adenosquamous carcinoma on FNA - Grading: low, intermediate, high (higher component of squamous cells to mucus cells) - Grading correlates to clinical aggressiveness and adjuvant treatment - MECT1-MAML2 t(11;19) (q21;p13) translocation

Answer 49

- Second most common salivary malignancy in the parotid gland. Most common malignant tumor of submandibular gland or minor salivary galnd - Patterns: tubular, cribiform, solid (shows groups of cuboidal cells) - Slowly progressive, infiltrative growth with distant mets developing over years - Tendency for perineural invasion - MYB-NFIB t(6;9) translocation - Good 5 year, poor 10 year survival

Answer 50

- Arises mainly from minor salivary glands; most commonly from hard/soft palate junction - Second most common minor salivary gland carcinoma - Low grade malignancy with excellent prognosis

Answer 51

- Arises mainly in the parotid gland (90% of cases) - Second most common childhood salivary gland malignancy - Low grade malignancy but 33% will recur - 10-15% will develop regional or distant mets

Answer 52

- One of the most aggressive salivary gland cancers - Generally presents with rapidly growing parotid mass - Minority present with facial nerve paresis - High grade by definition (30-40% develop local recurrence, 50-75% develop distant mets) - Significant minority positive for ERBB2 (Her2/neu) receptors - Typically negative for estrogen and progesterone receptors

Answer 53

- Tragal pointer (1-1.5cm deep and inferior) - Tympanomastoid suture line (6-8mm deep) - Retrograde dissection (marginal mandibular branch at mandible superficial to facial vessels; buccal branch deep to parotidomasseteric fascia, parallel to parotid duct) - Posterior belly of digastric

Answer 54

- Seroma - Hematoma - Facial nerve paresis/paralysis - Frey syndrome - First bite syndrome - Salivary fistula

Answer 55

Gustatory sweating - Aberrant cross innervation between postganglionic secretomotor parasympathetic fibers (parotid) to postganglionic sympathetic fibers (sweat glands to the skin) - Estimated incidence 35-60% - Diagnosis: minor starch/iodine test - Treatment: antiperspirant, glycopyrrolate, tympanic neurectomy, botox

Answer 56

- Most common after deep lobe parotidectomy with instrumentation in parapharyngeal space - Characterized by severe cramping or spasm int he parotid with first bite of a meal - Likely because of loss of sympathetic innervation, causing denervation supersensitivity activated by parasympathetic hyperactivation - Stimulates exaggerated myoepithelial cell contraction through the parotid - Treatment: pain meds, acupuncture, botox, time

Answer 57

- Rare overall (<4%) but makes up >50% of desmoplastic melanomas occur in head and neck - Features: majority are amelanotic, locally aggressive and highly infiltrative, up to 50% with local recurrence, perineural and endoneural infiltration, greater tumor thickness at time of diagnosis - Pure and mixed variants

Answer 58

- Superficial spreading (70%) - Nodular (15-30%) - Lentigo maligna - Desmoplastic (4%) - Unknown primary (2-8%)

Answer 59

- Recommend complete excisional biopsy with 1-2 mm margins - If can't do excisional then punch or incisional biopsy through thickest or darkest portion - FNA, shave biopsy, frozen section not recommended (prevents evaluation of tumor thickness which dictates treatment)

Answer 60

T1: <1mm thickness T2: > 1-2mm thickness T3: > 2-4mm thickness T4: > 4mm thickness a - no ulceration b- ulceration present

Answer 61

Defined as a nest of metastatic tumor > .05mm in diameter that is separate from the primary lesion by <2cm

Answer 62

Defined as a metastatic tumor that is separate from the primary lesion by > 2cm but not in the lymph node basin

Answer 63

N1: one node N2: 2-3 nodes N3: Four + notes a: microscopic (clinically occult) b: macroscopic (clinically detected) c: presence of satellite or intransit mets

Answer 64

- T2-T4 melanomas - Some patients with T1b

Answer 65

- S100 - Melan-A (MART-1) - HMB-45

Answer 66

- Exits vagus nerve at base of neck - Loops around right subclavian artery - Returns deep to innominate artery and back to thyroid bed diagonally - Non-recurrent RLN may rarely occur on right side and enter from lateral course, associated with aberrant retroesophageal subclavian artery

Answer 67

- Exits vagus nerve at level of aortic arch and ligamentum arteriosum, lateral to the obliterated ductus arteriosus - Returns to thyroid bed along tracheoesophageal groove at a more medial and vertical course than right RLN - Crosses deep to inferior thyroid artery 70% of time

Answer 68

- Superior parathyroid glands: at the level of the cricoid cartilage, medial/cranial to the intersection of the RLN and inferior thyroid artery - Inferior parathyroid glands: lateral or posterior surface of lower thyroid pole Superior glands are deep to the RLN and inferior glands are superficial to the RLN

Answer 69

Inferior thyroid artery (branch of the thyrocervical trunk) Superior thyroid artery (branch of the external carotid artery) Superior, middle and inferior thyroid veins (drain to the internal jugular or innominate veins)

Answer 70

Papillary (RET, BRAF, RAS) - BRAF V600E is specific for PTC and found in 70-80% of tall cell variants, RET/PTC arrangements can be seen commonly in pts with history of radiation Follicular (RAS, PPARG) Poorly differentiated (RAS, BRAF, TP53) Anaplastic (TP53, RAS, BRAF, PIK3CA) Medullary (RET 95% in MEN2)

Answer 71

T1: Tumor ≤ 2 cm in greatest dimension limited to the thyroid T1a: Tumor ≤ 1 cm in greatest dimension limited to the thyroid T1b: Tumor > 1 cm but ≤ 2 cm in greatest dimension limited to the thyroid T2: Tumor > 2 cm but ≤ 4 cm in greatest dimension limited to the thyroid T3*: Tumor > 4 cm limited to the thyroid or gross extrathyroidal extension invading only strap muscles T3a*: Tumor > 4 cm limited to the thyroid T3b*: Gross extrathyroidal extension invading only strap muscles (sternohyoid, sternothyroid, thyrohyoid or omohyoid muscles) from a tumor of any size T4: Includes gross extrathyroidal extension into major neck structures T4a: Gross extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea, esophagus or recurrent laryngeal nerve from a tumor of any size T4b: Gross extrathyroidal extension invading prevertebral fascia or encasing carotid artery or mediastinal vessels from a tumor of any size

Answer 72

N0: No evidence of regional lymph node metastasis N0a*: One or more cytologic or histologically confirmed benign lymph nodes N0b*: No radiologic or clinical evidence of locoregional lymph node metastasis N1*: Metastasis to regional nodes N1a*: Metastasis to level VI or VII (pretracheal, paratracheal, prelaryngeal / Delphian or upper mediastinal) lymph nodes; this can be unilateral or bilateral disease N1b*: Metastasis to unilateral, bilateral or contralateral lateral neck lymph nodes (levels I, II, III, IV or V) or retropharyngeal lymph nodes

Answer 73

Differentiated thyroid cancer: Age at diagnosis < 55 years Stage I: any T any N M0 Stage II: any T any N M1 Anaplastic thyroid cancer: staging automatically starts at IVa

Answer 74

Kidney, breast, lung, skin (melanoma and SCC)

Answer 75

- Loss of fatty hilum - Increased vascularity - Round nodule configuration - Solid nodule with hypoechogenicity - Microcalcifications

Answer 76

- Thyroglobulin level monitoring - Routine neck ultrasound monitoring - Elective lateral neck dissection not recommended until N+ disease documented - Central neck disection recommended for N+ disease, palpable or visualized disease during surgery

Answer 77

- Cervical lymphadenopathy less common than PTC - Classically hematogenous spread - Distant mets more common than PTC - FNA cannot distinguish between follicular adenoma and carcinoma

Answer 78

- Arises from parafollicular C cells and secretes calcitonin - Distant mets present in 50% of patients on presentation - 30% are familial - Workup: calcitonin, RET mutation testing (if negative don't need to test for MEN), serum calcium to test for hyperparathyroidism, 24hr urinary metanephrines and catecholamines and abdominal MRI to assess for pheo - Surgery: any pheo should be removed first, total thyroidectomy, central neck dissection strongly considered with lateral neck if central +, when primary lesion >1cm ipsilateral lateral neck strongly considered because 60% will have nodal mets - Surveillence: calcitonin - RAI no effective

Answer 79

MEN2A - MTC, pheochromocytoma, hyperparathyroidism MEN2B: MTC, pheochromocytoma, mucosal neuromas, Marfanoid body habitus

Answer 80

- TSH suppresion: goal TSH of <0.1 for intermediate to high risk patients, goal TSH of 0.1-0.5 for low risk - RAI: for higher risk PTC and FTC. Indications include any primary tumor >4cm, extrathyroidal extension, distant mets, high risk features. Need TSH elevated > 30ml/L since RAI uptake stimulated by TSH

Answer 81

- Half life of 3-5 minutes - Cleared by liver and kidney - Increase resportion of calcium and decreases resorption of phosphorus - Converts 25 hydroxyvitamin d3 (calcifediol) to 1,25 OH D3 (calcitriol) - Stimulates osteoclast activity via osteoblast modulation - Increases calcium absorption through vitamin D

Answer 82

- Secreted by parafollicular cells in thyroid gland - Inhibits bone resoption

Answer 83

- Cricothyroid junction approximately 1cm cranial to the juxtaposition of the RLN and inferior thyroid artery - Paraesophageal location in 1% of cases - Embyrologically deep to RLN

Answer 84

- Inferior pole of thyroid along the thyrothymic ligament - Migratory pathway into the anterior superior mediastinum (where up to 33% of missed parathyroid glands are found) - More variable position compared to superior glands

Answer 85

- Inferior thyroid artery supply 80% of inferior and posterior glands - Additional vascularization from plexus of vessels - Superior thyroid artery may provide dominant arterial supply for superior glands in 10-20% of patients

Answer 86

- High calcium - Elevated PTH - Normal creatinine - Low or low normal phosphate - Urinary calcium > 125mg/ 24hrs - Normal 25 OH vitam D and 1,25 OH vitamin D

Answer 87

- Nephrolithiasis, urolithiasis (most stones are calcium oxalate) - Osteitis fibrosis cystica (bone pain, pathologic fractures, cystic bone change), osteoporosis (spares trabecular bone) - Muscle weakness, fatigue - Anxiety, psychosis, depression, deafness, dysphagia, - Peptic ulcer, pancreatitis, cholelithiasis - Hypertension

Answer 88

- Parathyroid adenoma - Parathyroid lipoadenoma - Parathyroid hyperplasia - Parathyroid carcinoma

Answer 89

- Insufficient calcium intake, decreased calcium absorption, vitamin D deficiency - Renal insufficiency or failure

Answer 90

Long standing renal insufficiency or failure leading to autonomous parathyroid hyperfunctioning

Answer 91

- PTH related protein secretion (lung, esophagus, head and neck, renal cell, ovarian, bladder, pancreatic) - Ectopic PTH secretion by small cell lung cancer, small cell ovarian cancer, squamous cell lung cancer - Ectopic 1,25 OH production by B cell lymphoma and Hodgkin disease - Lytic bone mets (multiple myeloma, lymphoma, breast cancer and sarcoma) - Tumor cytokines

Answer 92

- Autosomal dominant disorder - Inactivating mutations in the calcium sensing receptor of the parathyroid gland - Low 24 hour urine calcium relative to their hypercalcemia

Answer 93

- Serum calcium >1mg/dL above the upper limit of normal - Creatinine clearance reduced > 60ml/min - Age < 50 - Surgery requested by patient and patient unsuitable for surveillence

Answer 94

- Mediastinum and thymus - Retroesophageal - Intrathyroidal - Carotid sheath

Answer 95

- Hydration - Furosemide - Bisphosphonates - Estrogen - Calcitonin - Calcimimetics (sensitizes PTH receptor to calcium)

Answer 96

G0: resting state G1: preparation for cell division; increase in transcription/translation and doubling of macromolecules S: synthesis phase, replication of chromosomes G2: continued cellular growth M: mitosis phase, chromosomes are separated and two daughter cells result

Answer 97

G1/S checkpoint: prevent entry into S phase, rate limiting step Intra S phase checkpoint: halt progression of S phase if damaged DNA is detected G2/M checkpoint: prevent entry into M phase M checkpoint: ensure correct replication of DNA and avoid mitotic exit if errors exist

Answer 98

Recruitment of DNA repair effector complexes Temporary cell cycle arrest, which can lead to senescence or apoptosis depending on the cell and the lesion

Answer 99

p53 (activates p21-> inhibits cyclin and cyclin dependent kinase (CDK) complexes)

Answer 100

- Cdks: catalytic subunit, require cyclin for activation; result in phosphorylation (activates/inactivates molecules necessary for progression through the cell cycle) - Cyclines: regulatory subunit that activates Cdk molecules when bound to form a heterodimer

Answer 101

E2F factors

Answer 102

p16 and p19, G1 phase

Answer 103

Interphase

Answer 104

Prophase: condensation of chromatin, polarization of centrosomes and initiation of mitotic spindle formation Prometaphase: nuclear envelope breaks down, mitotic spindle microtubules attach to chromosomes Metaphase: alignment of chromosomes at metaphase plate Anaphase: separation of sister chromatids Telophase: cytoplasmic division into two daughter cells; chromatid decondensation

Answer 105

20-25 years

Answer 106

Term used to describe histopathologic changes seen in mucosa surrounding invasive carcinoma and result in an increased incidence of second primary tumors. Thought to be due to abnormal and genetically unique clones that form independently at multiple sites due to exposure to similar environmental changes or due to a single tumoral clone that forms and subsequently migraes via lateral movement through the mucosa.

Answer 107

It may decrease the effectiveness of both local and systemic detoxification enzymes (cytochrome P450)

Answer 108

- Loss of p16 (normally inhibits cyclin D) - upregulation of cyclin D - loss of p53 (normally inhibits cell cycle progression and promotes apoptosis) - upregulation of EGFR (enhances mitogenic signaling) - upregulation of COX-2 (increased angiogenesis, decreased apoptosis) - increased chromosomal instability (increased aneuploidy)

Answer 109

- Fanconi anemia (autosomal recessive, DNA repair gene mutation) - Cowden syndrome (autosomal dominant, TPEN hematoma tumor syndrome; PTEN is a tumor suppressor gene) - Mutations in cyp P450 enzymes

Answer 110

E: regulate transcription of viral DNA L: encode capsid proteins involved in viral spread

Answer 111

- E6/E7: onco genes - E1/E2: transcriptional regulators

Answer 112

Loss of regulation of E6 and E7 and subsequent transcription of these viral genes

Answer 113

E6. Results in progressiong though G1 checkpoint and inhibition of apoptosis.

Answer 114

E7. Results in releast of pRb inhibition of E2F, activation of cell cycle related transcription and progression through the G1 checkpoint.

Answer 115

p16. Normally inhibitics Cdk4/6, but with the loss of p53, pRb, does not meaningfully result in cell cycle control. Can be used as a biomarker of HPV activity.

Answer 116

- EBV (nasopharyngeal carcinoma) - HIV (increased risk of all head and neck cancers) - merkel cell polyomavirus (merkel cell carcinoma) - Human T lymphotrophic virus (HTLV-1, human T cell lymphoma/leukemia) - Kaposi sarcoma associated herpesvirus (Kaposi sarcoma)

Answer 117

- Cellular growth and proliferation - Apoptosis - Angiogenesis - Invasion - Metastasis

Answer 118

Increased expression and amplification are related to decreased recurrence free survival and cancer specific survival rates.

Answer 119

- Tyrosine kinase inhibitors (geftinib) - Monoclonal antibodies inhibiting dimerization (cetuximab) - Antisense oligodeoxynucleotide or small interfering mRNA inhibition of mRNA expression

Answer 120

Prostaglandins as a result of the upregulation of COX-1 and 2

Answer 121

CN V3, IX (via Jacobsons nerve), X (via Arnold nerve), and VII as well as branches of C2 and C3 through the great auricular nerve.

Answer 122

Leukoplakia

Answer 123

Erythroplakia

Answer 124

- Size > 1cm - Evidence of central necrosis (~100% specificity) - Spherical shape (suggestive) - Nodal grouping in the predicted drainage pathway, with nodes > 1cm

Answer 125

- Soft tissue tumor - Intracranial extension or skull base involvement - Paranasal sinus disease - Nasopharyngeal tumors - Temporal bone - Assessment of perineural invasion

Answer 126

- Well differentiated thyroid cancer - Medullary thyroid cancer - Indolent lymphomas - Neuroendocrine tumors - Teratomas - Soft tissue sarcomas

Answer 127

- Infection - Normal physiologic activity (brain, kidneys) - Inflammation (after radiation, surgical resection, aspiration/biopsy) - Osteoradionecrosis - Granulomatous disease - Patient movement

Answer 128

It is unreliable for lesions <1cm in diameter

Answer 129

Cytokeratin

Answer 130

- Neuron specific enolase (NSE) - Chromogranin - Synaptophysin

Answer 131

- Leukocyte common antigen (LCA/CD45) - CD 20 -> B cell specificity - CD2 -> T cell specificity

Answer 132

Vimentin -> sarcomas, lipomas, myomas Desmin -> sarcomas, myomas

Answer 133

- Basaloid carcinoma - Despite early regional mets, these tumors are failry sensitive to tx and therefore have better prognosis than conventional SCC

Answer 134

Also called carcinosarcoma or pseudosarcoma because it includes a squamous cell lesion on the surface and a more notable underlying malignant spindle cell component. Currently it is thought it arises from epithelial cells and undergoes mesenchymal differentiation

Answer 135

- Contains a superficial squamous cell lesion and a deeper malignant spindle cell component - Stain positive for both cytokeratin (epithelial cells) and vimentin (mesenchymal cells) - Arises from epithelial cells and then undergoes mesenchymal differentiation

Answer 136

Mucoep doesn't include a mucosal component. Adenosquamous carcinoma has a predominant mucosal squamous cell component and a deeper adenocarcinoma component.

Answer 137

- Verrucous carcinoma - Focal areas of high grade SCC

Answer 138

- lungs (66%) - bone (22%) - liver (10%) - less often skin, mediastinum and bone marrow

Answer 139

Regional nodal disease

Answer 140

- Presence of nodal disease - Increasing nodal size - Extracapsular spread - Bilateral neck disease - Matted lymph nodes - Disease in levels IV and V - "Skipped" levels - Invasion of local structures by nodal disease - Confluence of primary disease and nodal disease - Total number of involved lymph nodes

Answer 141

- EGFR amplification and overexpression - HPV status - Loss of heterozygosity (suggests loss of tumor suppressor gene function) - Aneuploidy

Answer 142

Treatment approaches uses chemotherapy and or radiation therapy before definitive therapy

Answer 143

Aka concomitant therapy, uses chemo and radiation together as primary treatment modality

Answer 144

Treatment apporahc that uses radiation therapy with or without chemoptheray after primary surgical management

Answer 145

- Phase I: defines maximum tolerated dose or safety of a drug or invasive medical device - Phase II: includes more patients than phase I; assess the efficacy and side effects or toxicity associated with the intervention of interest - Phase III: randomized prospective trial comparing the intervention of interest with standard of care

Answer 146

6-9 months

Answer 147

Year 1: see every 1-3 months Year 2: see every 2-4 months year 3-5: see every 4-6 months > 5 years: see 6-12 months Imaging: within 6 months of treatment end for T3-4 or N2-3 cancers of oropharynx, hypopharynx, glottic/supraglottic larynx and nasopharynx. Additional imaging based on concerning signs and symptoms

Answer 148

If the neck was irradiated check every 6-12 months

Answer 149

Physiologic: cardiorespiratory fitness, coag status, immune status, weight loss Anatomical: surgical acess to subsite of interest Oncologic: ability to achieve surgical margins, acceptable morbidity with complete resection

Answer 150

Failure to identify origin results in significant decrease 5 year overall survival and results in the need for wide field radiation therapy with increase in associated morbidity

Answer 151

Radiosensitive: M phase and G2 Radioresistant: S phase

Answer 152

Radiation therapy produces intracellular ionization -> breaks chemical bonds, creates free radicals -> DNA damage -> cell death. Double strand breaks are the most important and deadly injury imposed by radiation

Answer 153

Mitotic cell death. This is why tumors do not shrink immediately after radiation and may take weeks to demonstrate the full effects of radiation treatment.

Answer 154

- Mucositis - Dermatitis - Xerostomia - Hoarseness - Odynophagia - Dysphagia - Weight loss

Answer 155

- Xerostomia - Dental caries/decay - Osteoradionecrosis, chondronecrosis - Fibrosis - Hypothyroidism - Neurologic damage

Answer 156

Alkylating agents

Answer 157

Nephrotoxicity, ototoxicity, neurotoxicity, nausea/vomting, electrolyte disturbances, myelotoxicity

Answer 158

Carboplatin

Answer 159

Binds to dihydrofolate reductase which is necessary for de novo synthesis of thymidine and purine synthesis

Answer 160

-Doxorubicin - results in intercalation between base pairs - Bleomycin: form complexes with iron, thus reducing oxygen to superoxide and hydroxyl radicals which result in DNA strand breaks - Mitomycin: results in DNA cross linking, alkylation and oxygen radiacals

Answer 161

Alkaloids - VincristingL binds irreversibly to microtubules and spindle proteins in S phase and interferes with the mitotic spindle -> arrest in metaphase - Vinblastine: binds to tubulin and inhibits microtubule formation, disrupts mitotic spindle -> arrest in M phase

Answer 162

Taxanes - Docetaxel - Paclitaxel

Answer 163

Bevacizumab

Answer 164

- Positive surgical margins - Extracapsular extension - T3/T4 primary - Higher nodal stage - Perineural invasion - Angiolymphatic invasion - Involvement of level IV or V lymph nodes

Answer 165

Posterior edge of the submandibular gland

Answer 166

Posterior border of the internal jugular vein

Answer 167

Spinal accessory nerve (CN XI)

Answer 168

Superior: skull base Inferior: carotid bifurcation

Answer 169

Radiographic: inferior border of the hyoid bone Surgical: carotid bifurcation

Answer 170

Superior: inferior border of hyoid Inferior: inferior border of cricoid

Answer 171

Radiographic: inferior border of cricoid cartilage Surgical: omohyoid muscle

Answer 172

A horizontal plane from the inferior border of the cricoid cartilage Level VA includes spinal accessory nodes, VB includes transverse cervical nodes and supraclavicular nodes. Just inferior to the clavicle lies the sentinel node or Verchow node

Answer 173

Hyoid bone superiorly, suprasternal notch inferiorly, common carotid arteries laterally

Answer 174

- Glottic and subglottic - Pyriform sinus - Cervical esophagus - Thyroid gland

Answer 175

Superficial cervical fascia Deep cervical fascia: superficial (investing), middle (visceral) and deep layers

Answer 176

Superficial cervical fascia

Answer 177

Superficial layer of the deep cervical fascia

Answer 178

Muscular division: surrounds infrahyoid strap muscles, attached superiorly to the hyoid bone and thyroid cartilage and inferiorly to the sternum Visceral division: surrounds the thyroid, trachea and esophagus and extends into the mediastinum to connect with the fibrous pericardium. Superiorly, the fascia may blend with the buccopharyngeal fascia (controversial)

Answer 179

Inner: pharyngobasilar fascia Outer: buccopharyngeal fascia

Answer 180

Prevertebral fascia: fuse to the transverse processes of the vertebral bodies with extension medially to cover the prevertebral musculature and vertebral bodies. Continues posteriorly to cover the extensor muscles and insert onto the vertebral spinous processes. Alar fascia: located between the prevertebral fascia and the visceral division of the middle layer of the deep cervical fascia

Answer 181

The superficial (investing), middle (visceral) and deep layers of the deep cervical fascia

Answer 182

- Two muscles (SCM and trapezius) - Two glands (parotid and submandibular gland) - Two spaces (posterior triangle, suprasternal space of Burns)

Answer 183

Innervation: cervical branch of the facial nerve (VII) Arterial supply: submental branch of the facial artery and suprascapular artery

Answer 184

Innervation: spinal accessory nerve (CN XI), ventral rami of C2-4 Arterial supply: occipital and posterior auricular arteries, superior thyroid artery, suprascapular artery

Answer 185

Innervation: anterior belly -> mylohyoid branch of inferior alveolar nerve (V3); posterior belly -> facial nerve Arterial supply: anterior belly -> submental branch of facial artery; posterior belly -> posterior auricular and occipital arteries

Answer 186

Innervation: ansa cervicalis (C1-3) Arterial supply: superior thyroid artery and lingual artery

Answer 187

Anterior scalene muscle

Answer 188

Ventral rami of C2-4 -Lesser occipital nerve (C2): posterior scalp and ear -Greater auricular nerve (C2,C3): anterior branch -> skin over parotid gland; posterior branch -> mastoid area, lower ear and lobule -Transverse cutaneous nerve (C2, C3): Ascending/descending branches ->anterolateral neck skin -Supraclavicular nerve (C3, C4): Medial, intermediate and lateral (posterior) branches -> supraclavicular skin from second rib to shoulder

Answer 189

Erb's point - The spinal accessory nerve (CN XI) passes approximately 1cm superior and deep to the SCM muscle and Erb's point.

Answer 190

- Phrenic nerve (C3-C5) - Inferior branch of ansa cervicalis (C1-3) - Segmental branches including cervical branches of the spinal accessory nerve (C1-4)

Answer 191

Phrenic nerve

Answer 192

Hypoglossal and lingual nerves

Answer 193

Longus colli

Answer 194

Branches off vagus at approximately T1-2, wraps around the subclavian artery from anterior to posterior, ascends in the neck along the tracheoesophageal groove, generally posterior to the inferior thyroid artery, and enters the larynx at a 30-45 degree angle by passing under the inferior constrictor muscle and through the cricothyroid joint space

Answer 195

Wraps around the aortic arch before passing superiorly in the neck in the tracheoesophageal groove to enter the larynx at 0-30 degree angle by passing under the inferior constrictor muscle and through the cricothyroid

Answer 196

50%: nerve passes deep to artery 25%: nerve passes between arterial branches 25%: nerve passes anterior to artery This relationship is extremely variable and may not represent a reliable landmark for identifying the nerve

Answer 197

- Right nonrecurrent inferior/recurrent laryngeal nerve - Left nonrecurrent inferior/ recurrent laryngeal nerve

Answer 198

Galen anastamosis (aka ramus anastomaticus)

Answer 199

Innominate (brachiocephalic) artery

Answer 200

Vertebral artery

Answer 201

- Vertebral artery - Thyrocervical trunk - Inferior thoracic artery

Answer 202

- Inferior thyroid artery - Suprascapular artery - Superficial/transverse cervical artery

Answer 203

- Deep cervical artery - Superior intercostal artery

Answer 204

C3-C4 (at the level of the superior border of the thyroid cartilage)

Answer 205

Styloid process

Answer 206

- Superior thyroid - Ascending pharyngeal - Lingual - Facial - Occipital - Posterior auricular - Internal maxillary artery - Superficial temporal

Answer 207

Infrahyoid, superior laryngeal, cricothryoid and SCM arteries

Answer 208

Pharyngeal, inferior tympanic, meningeal arteries

Answer 209

suprahyoid, dorsal lingual, sublingual arteries

Answer 210

Ascending palatine, tonsillar, submental, labial arteries

Answer 211

upper and lower branches to the SCM

Answer 212

Stylomastoid artery

Answer 213

Frontal and parietal branch

Answer 214

Arises at the level of the greater cornu of the hyoid bone from the external carotid, runs deep to the posterior belly of the digastric muscle and stylohyoid muscle, turns at the middle constrictor to follow the posterior boundary of the submandibular gland and medial border of the medial pterygoid muscle and then winds around the mandible at the level of the facial notch

Answer 215

Occipital artery

Answer 216

- First part: mandibular portion - arises between the ramus of the mandible and sphenomandibular ligament, passes posterior to the lateral pterygoid muscle - Second part: pterygoid portion - within the lateral pterygoid muscle - Third part: pterygopalatine portion - peterygopalatine fossa

Answer 217

- deep auricular - anterior tympanic - middle meningeal - accessory meningeal - inferior alveolar - mylohyoid artery

Answer 218

- anterior deep temporal artery - posterior deep temporal - pterygoid branches - masseteric artery - buccinator/buccal artery

Answer 219

- posterior superior alveolar artery - infraorbital artery - sphenopalatine artery - artery of the ptergoid canal - pharyngeal artery

Answer 220

- Carotid sinus -> internal carotid artery, baroreceptor, glossopharyngeal, vagus and sympathetics - Carotid body -> posterior or between carotid bifurcation, chemoreceptor, same innervation as carotid sinus

Answer 221

- Retromandibular vein and postauricular vein - Drains scalp and face - Drains into subclavian vein

Answer 222

Anterior jugular veins

Answer 223

Cranial nerves IX, X and XI, inferior petrosal sinus

Answer 224

Subclavian vein -> brachiocephalic vein

Answer 225

Thoracic duct

Answer 226

Right sided only - 4% Bilateral - 12-15%

Answer 227

> 90%, most common inflammatory

Answer 228

- Upper aerodigestive tract - Head and neck skin - Major and minor salivary glands - Thyroid gland

Answer 229

- Lung - Thoracic esophagus - Ovary - Prostate - Kidney

Answer 230

Oropharynx (tonsil and tongue base)

Answer 231

- Palpable neck mass - Symptoms resulting from compression (dysphagia, dysphonia) - Symptoms resulting from invasion (RLN paralysis, accessory neuropathy, pain)

Answer 232

Thyroid nodule

Answer 233

Excisional lymph node biopsy, commonly in the OR

Answer 234

patients younger than 45

Answer 235

- Extracapsular spread (may not be true for HPV+ tumors) - skipped nodal levels - Involvement of IV and V - Number of involved nodes - Size of involved nodes - Bilateral nodal disease - Matted lymph nodes

Answer 236

Levels 1-3 at a minimum with level IV for oral tongue cancers. Bilateral dissection should be considered with floor of mouth, ventral tongue or midline tongue involvement in those undergoing elective ipsilateral neck dissection with no plans for postop radiation

Answer 237

Levels II-IV. Bilateral dissection considered for base of tongue tumors, posterior oropharynx tumors and those that cross midline. Dissecting level IIB in cN0 necks is controversial

Answer 238

Levels II-IV and occasionally VI

Answer 239

Immediate: ~20%. Permanent: <5% HB grade II-III/VI

Answer 240

Shoulder syndrome: denervation of trapezius muscle resulting in destabilization of scapula and inability to abduct the shoulder >30 degrees, pain and shoulder girdle deformity. Injury from dissection around spinal accessory nerve in levels IIB and VA may also result in shoulder syndrome.

Answer 241

Phrenic nerve

Answer 242

Coverage with vascularaized tissue, preferably a mycutaneous flap

Answer 243

Facial and cerebral edema, increased intracranial pressure, AMS, SIADH, abducens palsy and blindness have all been associated

Answer 244

1-3%. Most are in left neck, but 25% have been reported in right neck.

Answer 245

2-4L/day. Fat (chylomicrons, long chain fats), protein, electrolytes and lymphocytes

Answer 246

Hypovolemia, electrolyte disturbances, hypoalbuminemia, coagulopathy, immunosuppression, infection, peripheral edema, chylothorax

Answer 247

- Chylomicrons - Triglycerides - Sudan III stain positive

Answer 248

- Low fat, medium chain fatty acid only diet - Pressure dressing - Suction wound drainage

Answer 249

Radical neck dissection results in significantly worse shoulder function and a tend toward increased pain. No difference in subjective appearance, activity, recreation, chewing, swallowing or speech.

Answer 250

Anterior: vermillion border of the lip Posterior/superior: Hard and soft palate junction Posterior/inferior: Circumvallate papillae Lateral: Anterior tonsillar pillars and glossotonsillar folds

Answer 251

- Alveolar ridges - Retromolar trigone

Answer 252

Anterior "deep lobe" of the submandibular gland -> between the lingual and hypoglossal nerves over the hyoglossus muscle -> anterior and superior ascent between the genioglossus and sublingual glands -> over the lingual nerve -> sublingual papilla just lateral to the lingual frenulum

Answer 253

External carotid artery - Lingual arter -> oral tongue - Greater palatine artery -> hard palate - Superior alveolar arteries -> gingiva of the maxilla, alveolar ridge, teeth, buccal mucosa - Transverse facial artery (superficial temporal artery) -> buccal mucosa - Facial artery -> lips (labial arteries) - Buccal artery (maxillary a) -> buccal mucosa - Inferior alveolar artery: mandible and mandibular teeth - Ascending pharyngeal artery + lesser palatine arteries -> retromolar trigone, posterior floor of mouth - Submental (facial artery) and sublingual (lingual artery) arteries -> floor of mouth

Answer 254

From superficial to deep (or lateral to medial) - Mylohyoid muscle - Hypoglossal nerve and lingual vein - Hypoglossus muscle - Lingual artery - Genioglossus

Answer 255

- Upper lip: infraorbital (V2) - Lower lip: mental nerve (V3)

Answer 256

- Lesser palatine nerves - Glossopharyngeal nerve

Answer 257

- Anterior two thirds: general sensory - lingual nerve (V3), special sensory - chorda tympani via the lingual nerve - Posterior 1/3: general and special sensory - Cn IX

Answer 258

Lingual nerve

Answer 259

Nasopalatine nerve (V2) via the incisive canal

Answer 260

Intrinsic: vertical, transverse, superior longitudinal, inferior longitudinal Extrinsic: genioglossus, hyoglossus, palatoglossus, styloglossus

Answer 261

Palatoglossus, innervated by pharyngeal branch of vagus

Answer 262

Denied medially by the buccinator muscle and its facia, the mandible inferiorly, the zygomatic arch superiorly, the risorius, zygomaticus major and levator labii superior muscles laterally, the orbicularis oris muscle anteriorly, and the anterior border of the masseter muscle and the parotid gland posteriorly

Answer 263

Defined by the layers of the deep cervical fascia as the split around the mandible and come back together at the ventral and dorsal borders of the mandibular ramus, thus enclosing the lateral pterygoid muscle and by the fascia surrounding the medial pterygoid, masseter and temporalis muscle

Answer 264

Levels I-III

Answer 265

- Submandibular lymph nodes (level IB) -> upper and lower lip - Submental lymph nodes (level IA) -> lower lip, primarily midline lesions - Preauricular, parotid, perifacial -> upper lip

Answer 266

- Tip -> submental lymph nodes (level IA) - Ventral tongue -> submental and submandibular lymph nodes (Level IA and IB) - Lateral tongue -> submandibular (level IB), jugulodigastric nodes (level IIA), directly to levels III and IV) - Laterality of the lymphatic drainage of the oral tongue due to the lack of lymphatic anastomoses across the fibrous lingual septum is unique from the base of tongue

Answer 267

Upper jugular nodes (level IIA)

Answer 268

Anterior -> level IA and IB (often bilateral) Posterior -> level IIA (ipsilateral)

Answer 269

Levels IA and IB

Answer 270

Levels I and II

Answer 271

Parotid gland originates at the site of the eventual duct orifice and grows in posterior direction. The facial nerve develops in an anterior direction and eventually becomes surrounded by parotid gland tissue.

Answer 272

- Serous acinis: found in the parotid - Mucinous acini: in the sublingual gland and minor salivary glands - Mixed acini: in the submandibular gland

Answer 273

An acinus is the main secretory component that is composed of a central lumen surrounded by acinar cells that produce saliva. Intercalated ducts form early connections between acini. Both acini and intercalated ducts are lined with myoepithelial cells that helps contract and propel saliva foraward. Intercalated ducts feed into larger striated ducts and then into exrectory ducts. 4 main parts of the salivary duct system (AISE) - acinar cells, intercalaed ducts, striated ducts, exretory ducts

Answer 274

Lymph nodes develop within the pseudocapsule of the parotid gland leading to intraparotid lymph nodes. No other salivary gland has intraglandular lymph nodes. Most lymph nodes lie within the superficial lobe but can be present in both superficial and deep lobes.

Answer 275

Originates from the superficial portion of the parotid gland, travels anteriorly on the masseter muscle and buccinator fat pad and then travels medially to pierce the buccinator muscle. Duct empties lateral to the second maxillary molar.

Answer 276

Parotid fascia is continuous with the superifical layer of the deep cervical fascia.

Answer 277

It is just superficial

Answer 278

The parasympathetic nervous system suuplies the parotid via CN IX (lesser petrosal nerve). The sympathetic nervous system supplies the gland via the superior cervical ganglion

Answer 279

Parasympathetics that are part of glossopharyngeal nerve (tympanic branch) enter middle ear through tympanic canaliculus as Jacobsons nerve. They exit middle ear cavity and travel through middle cranial fossa as lesser petrosal nerve which exits the skull base through the foramen ovale and travels to the otic ganglion. After synapsing in the otic ganglion postsynaptic fibers are carried via the auciculotemporal nerve to the parotid gland.

Answer 280

There is an increase in adipose cells in the parotid parenchyma with age

Answer 281

The chorda tympani via the lingual nerve

Answer 282

Parasympathetic contribution of facial nerve (nervus intermedius) via the chorda tympani

Answer 283

- Sarcomatoid carcinoma - Basaloid carcinoma - Verrucous carcinoma

Answer 284

- Lymphoma - Minor salivary gland tumors - Sarcoma - Melanoma

Answer 285

- A premalignant lesion - White plaque that cannot be wiped off - lower risk of malignancy (<30%)

Answer 286

- A premalignant lesion - Red plaque not associated with obvious cause - Higher risk of malignant conversion compared to leukoplakia (<60%)

Answer 287

- Premalignant lesion - Lacy white pattern on mucosa or atrophic lesions (red and smooth) or errosive lesions (depressed margins, covered with fibrinous exudate) - More common in women - <1% 10 year conversion rate

Answer 288

Necrotizing sialometaplasia

Answer 289

Pseudoepitheliomatous hyperplasia

Answer 290

Buccal mucosa

Answer 291

Posterolateral oral tongue

Answer 292

Adjacent to the third mandibular molar

Answer 293

Consider for stage III-IV disease

Answer 294

- Tumor thickness (>5mm= increased risk of occult nodal disease, decreased recurrence free and overall survical rates) - Differentiation - Angiolymphatic invasion

Answer 295

Upper lip cancer tends to be more aggressive and to have early metastatic potential

Answer 296

- Stepwise mandibulotomy: provides better alignment and stability - Paramedian: minimizes trauma to the genioglossus, geniohyoid, and digastric muscles

Answer 297

6 weeks or less (often around 3-4 weeks). Ideally all treatment will be completed within 12 weeks from diagnosis.

Answer 298

- Primary site: 60-66 Gy daily M-F for 6 weeks - N+ levels: 60-66 Gy - N- levels: 44-64 Gy

Answer 299

- Less than one third: primary closure - One third to two thirds: Abbe Estlander flap - More than two thirds: Karapandzic flap, Webster-Bernard flap or radial forearm free flap with palmaris longus tendon

Answer 300

Facial artery musculomucosal (FAMM) flap

Answer 301

Tethered tongue

Answer 302

Skin graft or free tissue transfer

Answer 303

Free tissue transfer with vascularized bone (i.e fibula free flap)

Answer 304

Stylopharyngeus muscle, styloglossus muscle, stylohyoid ligament, glossopharyngeal nerve

Answer 305

buccopharyngeal fascia

Answer 306

Mucosa -> superior pharyngeal constrictor muscle -> buccopharyngeal fascia -> retropharyngeal space (contains lateral fat pads and retropharyngeal nodes) -> alar fascia -> prevertebral fascia -> prevertebral muscles (laterally)/anterior longitudinal ligament (medially) -> vertebral bodies

Answer 307

- Superior pharyngeal constrictor muscle (CN IX, X) - Palatoglossus muscle (CN X) - Palatopharyngeus muscle (CN X) - Tensor veli palatini muscle ( CN V3) - Levator veli palatini muscle (CN X) - Uvular muscle (CN X)

Answer 308

Tonsillar branch of the ascending pharyngeal artery, descending palatine artery, tonsillar branch of the facial artery (primary arterial supply), dorsal lingual artery, ascending palatine artery

Answer 309

Lingual artery and its branches

Answer 310

Lesser palatine artery (primary arterial supply), ascending pharyngeal artery, tonsillar branches from the dorsal lingual artery, ascending palatine artery

Answer 311

- Posterolateral to the lateral oropharyngeal wall - Separated from tonsil by superior constrictor and buccopharyngeal fascia - On average, it is 1.4cm from the tonsillar fossa in a 1 year old and 2.5cm in an adult

Answer 312

- Tonsil: tonsillar and pharyngeal plexus, lingual and facial veins - Base of tongue: lingual and retromandibular veins - Soft palate: pharyngeal and pterygoid plexus, external palatine vein - Posterior pharyngeal wall: pharyngeal venous plexus All drain to the jugular venous system

Answer 313

CN X, CN IX and sympathetic fibers from the superior cervical ganglion

Answer 314

Levels II, III and IV most commonly

Answer 315

Retropharyngeal nodes

Answer 316

Precollecting lymphatic channels on each side cross the midline to drain to the contralateral side (up to 30% at presentation). Level II is at highest risk for bilateral disease

Answer 317

- Medial -> middle one third of the jugular chain (level III) - Lateral -> retropharyngeal nodes - Anterior -> hard palate -> submental and submandibular nodes (levels IA and IB) Uvular lymphatics drain primarily to level IIA

Answer 318

Retropharyngeal nodes (up to 44%), levels II and III

Answer 319

Lymphoepithelial carcinoma

Answer 320

Non-Hodgkin lymphoma. Diffuse large B cell lymphomas are the most common subtype

Answer 321

Mucosal melanoma

Answer 322

Odynophagia, dysphagia, bleeding, painless neck mass, globus, otalgia, bleeding

Answer 323

Soft palate. They generally occur on the anterior oropharyngeal surface of the soft palate

Answer 324

- Invasion of skull base - Invasion or encasement of great vessels - Invasion of the mandible - Confluent primary tumor and neck metastasis - Tumor extension potential necessitating

Answer 325

T1: tumor ≤2 cm in greatest dimension T2: tumor >2 cm and ≤4 cm T3: tumor >4 cm, or tumor extension to lingual surface of epiglottis T4: moderately or very advanced T4a: moderately advanced local disease in which tumor invades any of the following: larynx (except lingual surface of epiglottis), extrinsic muscles of the tongue (except palatoglossus within the oropharynx), medial pterygoid muscle, hard palate, mandible T4b: very advanced local disease in which tumor encases carotid artery or invades any of the following: lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base

Answer 326

Intensity modulated radiation therapy (IMRT)

Answer 327

- Lateral pharyngotomy - Transhyoid pharyngotomy - Lingural release and pull through technique

Answer 328

None. The wound is allowed to heal by secondary intention

Answer 329

Velopharyngeal insufficiency with nasopharyngeal reflux and hypernasal speech

Answer 330

"Marginal area": Lateral wall of the aryepiglottic folds

Answer 331

Killian triangle

Answer 332

- External carotid artery - Superior laryngeal artery (primary blood supply) - Branches of the lingual artery - Branches of the ascending pharyngeal artery

Answer 333

Through the pharyngeal plexus, adjacent names veins and jugular system

Answer 334

- Sensory: Cn IX and X via the pharyngeal plexus; sympathetics from the pharyngeal plexus may also contribute - Motor: CN X via the pharyngeal plexus

Answer 335

Hypopharynx (~70%)

Answer 336

Primarily drain to levels II-IV, also level VI (especially with inferior hyopharyngeal and post cricoid disease). Retropharyngeal nodes are also at risk

Answer 337

- Lymphoma - Sarcoma - Adenocarcinoma

Answer 338

Minor salivary glands or ectopic gastric mucosa

Answer 339

Sensory fibers from the SLN and Arnold nerve both synapse within the jugular ganglion

Answer 340

T1: tumor limited to one subsite of hypopharynx (left or right pyriform sinuses, posterior hypopharyngeal wall, or postcricoid region), and/or tumor ≤2 cm in greatest dimension T2: tumor extends into adjacent subsite of hypopharynx or adjacent site (larynx, oropharynx), and/or tumor >2 cm and ≤4 cm without fixation of hemilarynx T3: tumor >4 cm, or clinical fixation of hemilarynx, or extension to esophageal mucosa T4: moderately advanced and very advanced local disease T4a: moderately advanced local disease in which tumor invades one or more of the following: thyroid cartilage, cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle, central compartment soft tissue (prelaryngeal strap muscles and subcutaneous fat) T4b: very advanced local disease in which tumor encases carotid artery or invades one or more of the following: mediastinal structures, prevertebral fascia

Answer 341

Hypopharynx (20-47%)

Answer 342

Select neck dissection levels II-IV with inclusion of level VI in pyriform apex tumors and retropharyngeal lymph nodes in pharyngeal wall tumors

Answer 343

Comprehensive neck dissection including levels I-V, inclusion of levels IV with pyriform apex tumots and retropharyngeal lymph nodes with pharyngeal wall tumors

Answer 344

- Tumor extension to more than one wall of pyriform sinus - Involvement of pyriform apex - Involvement of larynx including medial wall of pyriform sinus

Answer 345

Medial wall pyriform sinus tumors

Answer 346

- Thyroid or circoid cartilage invasion - Pyriform apex involvement - Postcricoid region involvement - Impared vocal cord mobility

Answer 347

- Tubed fasciocutaneous free flap - Gastric transposition (gastric "pull up") - Colonic transposition - Jejunal free flap

Answer 348

- Superior: cricopharyngeus muscle - Inferior: thoracic inlet (sternal notch)

Answer 349

- Squamous epithelium - Submucosa - Inner circular muscle layer - Outer longitudinal muscle layer - Adventitia

Answer 350

- Upper one third: striated - Middle one thrid: mixed - Lower one third: smooth

Answer 351

- Posterior surface of the thyroid and cricoid cartilage - Hyoid bone - Cricopharyngeus muscle - Inferior constrictor muscle (thyropharyngeus muscle) - Cervical esophageal muscles - Extends 3-4cm in total The UES is tonically contracting via the vagus nerve

Answer 352

- Upper esophageal sphincter and cervical esophagus: inferior thyroid artery - Thoracic esophagus: aortic esophageal arteries, terminal bronchial arteries - Distal esophagus and lower esophageal sphincter: left gastric artery, branch of the left phrenic artery

Answer 353

Submucosal plexus -> superior vena cava

Answer 354

- Sensory: CN X, IX and spinal afferent nerves - Motor: CN X, parasympathetic and sympathetic nerves - Intrinsic innervations: Auerbach plexus (between the inner circular and outer longitudinal muscle layers), Meissner plexus (submucosa)

Answer 355

Primarily levels II-IV, also drains to level VI, retroesophageal, retropharyngeal and superior mediastinal nodes (level VII)

Answer 356

- Cervical: SCC - Distal: adenocarcinoma

Answer 357

15cm to less than 20cm

Answer 358

Human epidermal growth factor receptor (HER-2)

Answer 359

Deep to the submandibular gland. With inferior retraction of the gland and anterior rectraction of the mylohyoid muscle, the lingal nerve and submandibular ganglion can be exposed.

Answer 360

The nerve courses from posteriolateral to anteriomedial position, passing inferior to Wharton duct

Answer 361

Facial vein is found on the lateral surface of the submandibular gland; the facial artery is located on the posterior surface of the gland and is often ligated on both the superior and inferior aspect of the gland during the submandibular gland excision.

Answer 362

The gland drains into the mouth via smaller duct of Rivinus (which empties into the floor of the mouth or into submandibular duct) and larger duct of Bartholin (empties into submandibular duct)

Answer 363

Bordered by the mandible, genioglossus muscle and mylohyoid muscle

Answer 364

The hard palate mucosa harbors most of the mouth's minor salivary glands

Answer 365

- Lubrication of food - Buffering and prevention of carries - Mineralization of teeth - Antibacterial and bactericidal function - Digestion - Taste

Answer 366

Usually at least 3.5cm

Answer 367

The parotid gland

Answer 368

Staph aureus

Answer 369

The submandibular gland is the most common as a result of increased calcium concentration, higher pH, more mucinous saliva and potential anatomical factors (length, gravity)

Answer 370

Submandibular stones. 80% of parotid stones are radiolucent.

Answer 371

Patients with chronic sialadenitis are at an increased risk for salivary duct carcinoma

Answer 372

Urinary retention, increased body temperature, decreased persipiration, tachycardia, xerostomia, vision changes, confusion, respiratory suppression, mydriasis, constipation

Answer 373

Pilocarpine, a parasympathomimetic drug that acts on M3 acetylcholine muscarinic receptor

Answer 374

Bilateral salivary gland swelling that is not associated with another systemic disease. Specially, it is distinct from salivary swelling associated with Sjogren syndrome

Answer 375

Ranulas are mucoceles that develop from the sublingual gland

Answer 376

Often appear as bluish, translucent mass on floor of mouth.

Answer 377

A ranula that extends inferior to the mylohyoid muscle into the neck

Answer 378

The mumps virus

Answer 379

Paramyxovirus (RNA)

Answer 380

Children between the ages of 5-10 with nonspecific symptoms of headache, fever, myalgia, anorexia, followed by bilateral parotid gland swelling

Answer 381

Autoimmune destruction of exocrine glands

Answer 382

Primary: involves only exocrine glands Secondary: involves exocrine glands and additional connective tissue disease

Answer 383

Sjogren syndrome

Answer 384

SS-A and SS-B in addition to ANA, RF and ESR

Answer 385

Diffuse lymphadenopathy, salivary gland swelling (parotid or submandibular), red cutaneous nodules on the head and neck as well as pigmented, coarse, pruritic skin overlying glandular swelling

Answer 386

Young males in their 20-30s from Southeast Asia

Answer 387

Eosinophils (both peripheral eosinophilia and intralesional eosinophilia)

Answer 388

BUN, creatinine, urinary protein to rule out nephrotic syndrome.

Answer 389

Ulcer on the posterior hard palate. The lesions of necrotizing sialometaplasia heal spontaneously in 5-9 weeks so treatment is supportive care only.

Answer 390

Sarcoidosis

Answer 391

Uveuoparotid fever presents with uveitis, non suppurative parotitis and in 50% of patients facial palsy. Treatment consists of systemic steroids and eye care.

Answer 392

5-7% of sarcoid patients have salivary gland enlargement

Answer 393

Hemangiomas or pleomorphic adenomas

Answer 394

Pleomorphic adenomas

Answer 395

Surgical excision with a cuff of normal salivary tissue

Answer 396

1.5% in first 5 years and 10% after 15 years

Answer 397

Warthin tumor of parotid gland

Answer 398

Mitochondria

Answer 399

Minor salivary glands of the upper lip

Answer 400

A term that refers to a set of rare salivary gland tumors. includes basal cell adenoma, canalicular adenoma, clear cell adenoma, glycogen rich adenoma, myoepithelioma

Answer 401

Mucoepidermoid carcinoma

Answer 402

Radiation exposure, history of head and neck cancer, EBV, HIV, Hodgkin disease, industrial exposure to rubber manufacturing or nickel compound, employment in a beauty salon

Answer 403

Adenoid cystic carcinoma. 30-50% of patients develop metastasis most commonly in the lungs

Answer 404

A male in his 60s-70s with a long standing parotid mass that suddenly increases in size over several months

Answer 405

High grade ductal carcinoma of the breast

Answer 406

Mucoepidermoid carcinoma is most common malignant salivary gland tumor, followed by adenoid cystic carcinoma and then adenocarcinoma

Answer 407

Low grade is more cystic with little atypia and low mitotic activity. High grade is more solid.

Answer 408

Low grade requires removal of salivary gland with margin of healthy tissue, elective neck dissection is not necessarily required. High grade requires total excision and elective or therapeutic neck dissection and often adjuvant radiation.

Answer 409

Carcinoma ex pleomorphic adenoma and carcinosarcoma

Answer 410

An asymptomatic mass of the hard palate present for months to years

Answer 411

Slow growth, indolent behavior, almost exclusively involves minor salivary glands with an infiltrative growth pattern and perineural invasion

Answer 412

Other primary (skin) with mets to parotid. This is more common than primary SCC of parotid gland.

Answer 413

Selective neck dissection levels I-IV for a parotid primary and level I-III for submandibular primaries

Answer 414

Cases of advanced stage positive margins after resection, high grade tumor, perineural invasion, or bony invasion

Answer 415

- Gastric transposition (gastric "pull-up") - Colonic transposition

Answer 416

- High morbidity and mortality - Inability to close some defects with oropharyngeal or nasopharyngeal extension - Frequent pulmonary complications - Risk of hypoparathyroidism - Gastric dumping syndrome - Gastric outlet obstruction - Regurgitation

Answer 417

- Gastric transposition - Colonic transposition - Jejunal vascularized free flap - Tubed fasciocutaneous vascularized free flap

Answer 418

-Superior: oropharynx; tip and lateral borders of the epiglottis -Inferior: Trachea, plane passing through the inferior limit of cricoid cartilage -Posterior/lateral: hypopharynx; laryngeal surface of the aryepiglottic folds, arytenoid region, interarytenoid space, mucus membrane covering posterior surface of cricoid cartilage -Anterior: anterior/lingual surface of the suprahyoid epiglottis, thyrohyoid membrane, anterior commissure, thyroid cartilage, cricothyroid membrane, anterior arch of thyroid cartilage

Answer 419

-Supraglottis - Glottis superior and inferior surface of TVF - Subglottis: inferior margin of glottis to inferior border of cricoid cartilage

Answer 420

Supraglottis

Answer 421

Glottis and subglottis

Answer 422

- 2nd: lesser horn and upper portion of hyoid bone - 3rd: greater horn and lower portion of hyoid bone

Answer 423

- arytenoid cartilages - suprahyoid epiglottis - infrahyoid epiglottis - aryepiglottic fold - false vocal fold

Answer 424

TVFs (superior and inferior surface), including the anterior and posterior commissures

Answer 425

There are none

Answer 426

- Pseudostratified columnar respiratory epithelium - Lateral surface of the aryepiglottic folds and epiglottis are stratified squamous epithelium - Numerous mucinous glands are present

Answer 427

Stratified squamous epithelium

Answer 428

- Stratified squamous epithelium - Superficial lamina propria (Reinke space) - Vocal ligament (intermediate and deep lamina propria) - Thyroartenoid muscle

Answer 429

Pseudostratified columnar epithelium

Answer 430

- Quadrangular membrane - Conus elasticus - Thyrohyoid membrane (aperture for superior laryngeal neurovascular bundle allows spread) - Laryngeal cartilages - Hyoepiglottic ligament - Anterior commissure tendon - Cricothyroid membrane

Answer 431

Sheet of fibroelastic tissue stretching from the epiglottis to the arytenoid and corniculate cartilages, contributes to AE fold superiorly and defines free margin of false cord inferiorly

Answer 432

Sheet of fibroelastic tissue stretching from vocal ligament to superior margin of cricoid laterally and inferior margin of thyroid cartilage anteriorly (where it forms the cricothyroid membrane)

Answer 433

Aka Broyles ligament. A fibrous tissue band that connects the vocal ligament to midline of thyroid cartilage and is associated with a lack of perichondrium at the insertion point and serves as a barrier to spread of laryngeal cancer

Answer 434

Funnel shaped space formed by thyrohyoid membrane and thyroid cartilage anteriorly, epiglottis posteriorly, hyoepiglottic ligament, valecula and hyoid bone superiorly, and thyroepiglottic ligament inferiorly. Communicates laterally with the paraglottic spave and acts as an avenue for tumor spread.

Answer 435

Paired spaces definied by thyroid cartilage laterally, conus elasticus inferiomedially, ventricle medially, quadrangular membrane superiomedially, and pyriform sinus mucosa posteriorly. Avenue of spread of laryngeal cancer and communicates anteriorly with pre-epiglottic space.

Answer 436

Fenestrations

Answer 437

- Directly crossing the ventricle - Crossing at the anterior commisure - Via the paraglottic space - Spread along thyroid cartilage to the posterior ventricle

Answer 438

The supraglottis is formed from a single structure (i.e. no midline fusion) and therefore lymphatics cross midline allowing bilateral spread of disease.

Answer 439

Inferior false vocal fold (barrier is the quadrangular membrane)

Answer 440

II, III, IV with bilateral disease common

Answer 441

Along the superior laryngeal neurovascular bundle

Answer 442

The "marginal zone"; suprahyoid epiglottis and superior aspect of the AE folds

Answer 443

up to 40%. Increases with increasing T stage

Answer 444

They are formed by paired structures that fuse in midline. Lymphatics within this subsite are minimal and do not communicate across the midline.

Answer 445

18%. Increases with T stage

Answer 446

II, II, IV and VI

Answer 447

Level IV. Commonly present with contralateral or bilateral disease and mediastinal lymphadenopathy below level VII

Answer 448

- Males (3.8:1) - Tobacco exposure - Age younger than 40

Answer 449

Alcohol and smoking

Answer 450

- Hyperplasia - Keratosis - Dysplasia - Carcinoma in situ

Answer 451

- 11% for mild - 30% for severe or CIS - May take up to 10 years for malignant conversion but average of 3 years

Answer 452

- Verrucous - Spindle cell (aka sarcomatoid carcinoma, carcinosarcoma, pseudosarcoma) - Adenoid basaloid SCC - clear cell carcinoma - adenosquamous carcinoma - giant cell carcinoma - lymphoepithelial carcinoma

Answer 453

Characterized by proliferation of the squamous mucosa, elongated rete ridges that appear worrisome for carcinoma and show no evidence of cytologic abnormalities consistent with malignancy. Can be associated with infection, trauma, granular cell tumor, chronic irritation. Easily mistaken for SCC.

Answer 454

Necrotizing sialometaplasia

Answer 455

Verrucous carcinoma. The larynx is the second most common site in the head and neck behind oral cavity.

Answer 456

Basaloid SCC

Answer 457

Spindle cell carcinoma

Answer 458

Minor salivary glands

Answer 459

Mucoep and adenoid cystic

Answer 460

They occur three time more commonly in women than in men - this tumor type is very rare and usually lethal with a 2 and 5 year survival rate of 16% and 5%

Answer 461

Chondrosarcomas

Answer 462

Kidney, skin (melanoma), breast, lung, prostate, GI tract

Answer 463

Dysphagia. Can also manifest with dysphonia, odynophagia, otalgia, stridor, dyspnea, hemoptysis and neck mass

Answer 464

Dyspnea and stridor

Answer 465

Ulceration, sessile lesion, polpoid lesion, submucosal fullness, exophytic friable mass

Answer 466

T1-weighed gadolinium enhanced MRI with fat suppression. High negative predictive value. False positive results are caused by inflammation

Answer 467

- 64% - glottic (79%) > supraglottic (47%) > subglottic (30-50%)

Answer 468

Inadequate recognition of deep extension

Answer 469

- T3 or T4 tumors - Subglottic tumor extension

Answer 470

- Subglottic extension (>5mm) - Postcricoid extension - Pyriform sinus invasion - Cartilage invasion - Tongue base involvement

Answer 471

- Supraglottic - Extended supraglottic - Supracricoid

Answer 472

An embryologic boundary exists between the false and true vocal folds resulting in independent drainage pathways. A subset of T1/T2 supraglottic tumors that do not extend into neighboring structures may benefit from horizontal supraglottic hemilaryngectomy.

Answer 473

Lung and mediastinum (not including level VII)

Answer 474

Supraglottis

Answer 475

Levels II-IV, VI when appropriate

Answer 476

Remove the ETT, then irrigate with water, reintubate and perform bronchoscopy to survey the injury

Answer 477

The larynx is divided in the midline with entry at the anterior commissure

Answer 478

- residual or recurrent locoregional disease - Chondroradionecrosis - Severe aspiration - Laryngeal stenosis - Pharyngoesophageal stenosis

Answer 479

Cricopharyngeal myotomy

Answer 480

- Running Connell stitch followed by one or two layers of interrupted 3.0 vicryl to imbricate the overlying layers - Flood the mouth to ensure closure is water right

Answer 481

Candida colonization

Answer 482

- Superior: sphenoid bone - Anterior: choana - Posterior: clivus, C1 and C2 - Inferior: soft palate - Lateral: torus tubarius and Rosenmueller fossa

Answer 483

- Foramen lacerum (greater petrosal and deep petrosal nerves travel through this)

Answer 484

- Parapharyngeal space

Answer 485

- Masticator space

Answer 486

The ICA lies immediately posterolateral to this space

Answer 487

Passavant ridge

Answer 488

- Ascending pharyngeal artery (from the ECA) - Sphenopalatine (internal maxillary artery) - Vidian artery (internal maxillary artery)

Answer 489

Pharyngeal plexus -> jugular system

Answer 490

- CN IX - V2

Answer 491

Lateral wall Posterior wall Soft palate

Answer 492

- Retropharyngeal nodes and levels II and VA - Bilateral disease is common

Answer 493

Lateral retropharyngeal lymph nodes; highest neck nodes, draines the sinuses and nasopharynx, enlargement can cause Vernet's syndrome

Answer 494

Pseudostratified columnar respiratory epithelium. It is carried for life by the infected person

Answer 495

- Lymphadenopathy (60%) - Blood tinged saliva/sputum, more common than epistaxis - Conductive hearing loss from serous otitis media - Epistaxis - Nasal obstruction - Tinnitus - Cranial nerve palsy

Answer 496

Tumor invasion of skull base with involvement of CN III-VI resulting in facial pain and diplopia

Answer 497

A notochord remnant presenting as a benign cystic mass in the nasopharynx

Answer 498

Vidian nerve

Answer 499

Vernet syndrome - Refers to paralysis of the IX, X, and XI cranial nerves traversing the jugular foramen.

Answer 500

Prestyloid

Answer 501

Temporal lobe necrosis

Answer 502

Hypopituitarism

Answer 503

Lateral nasal wall just posterior to the end of the middle turbinate

Answer 504

Greater palatine

Answer 505

Ohngren line. Tumor limited to the anterior inferior portion portends better prognosis.

Answer 506

A pyramidal space beneath the orbit that is bounded anterior by the posterior wall of the maxillary sinus and posteriorly by the pterygoid plates

Answer 507

sphenopalatine, lesser and greater palatine nerves, vidian nerve, internal maxillary artery

Answer 508

Maxillary sinus

Answer 509

Sphenoid sinus

Answer 510

Upper jugulodigastric

Answer 511

Adenoid cystic carcinoma (cribiform is the most common type and has the best prognosis)

Answer 512

Lateral nasal wall including turbinates

Answer 513

- S100+ - Homer Wright rosettes - Flexner Winter rosettes

Answer 514

- Esthesioneuroblastoma - Rhabdomyosarcoma - Sinonasal undifferentiated carcinoma - Small cell carcinoma - Neuroendorine carcinoma - Plasmacytoma - Poorly differentiated and nonkeratinizing SCC - Lymphoma - Mucosal melanoma

Answer 515

- Small cell with scan cytoplasm and round hyperchromatic nuclei with absent or poorly visualized nucleoli - Cells grow in clusters and commonly display extensive necrosis and hemorrhage

Answer 516

Rhabdomyosarcoma

Answer 517

t(2;13)(q35;q14), PAX3-FKHR gene fusion

Answer 518

Extracapillary pericytes (of Zimmerman)

Answer 519

Soft, slow growing tumors typically arising in the nasal cavity that occasionally metastasize. Most common presentation is nasal obstruction and epistaxis.

Answer 520

Nasal cavity

Answer 521

Renal cell carcinoma

Answer 522

- Diffuse large B cell (Western) - NK/T cell lymphoma (Asian)

Answer 523

- Results in diplopia, decreased visual acuity and numbness above the eye - Involves CN II, III, IV, V1 and VI

Answer 524

- results in ophthalmoplegia, periorbital numbness, ptosis, proptosis and fixed dilated pupil - CN III, IV, V and VI are affected

Answer 525

All are considered T3 or T4 reflecting the aggressive behavior

Answer 526

Chondrosarcoma

Answer 527

Mucosal melanoma

Answer 528

Minor salivary gland tumors

Answer 529

Epiphora or recurrent dacrocystitis from division of the nasolacrimal duct

Answer 530

Mandible and maxilla

Answer 531

Sinonasal cavity

Answer 532

The oral cavity

Answer 533

Sinonasal cavity

Answer 534

Li Fraumeni syndrome

Answer 535

- Embryonal - Alveolar (worst prognosis) - Mixed - Anaplastic (previously pleomorphic)

Answer 536

Chemotherapy typically used with radiation as an induction agent and then concurrently. Typically vincristine as main agent used with two other agents

Answer 537

Liposarcoma

Answer 538

Hypopharynx and retropharynx

Answer 539

T1: tumor <5cm in greatest dimensions (T1a superficial, T1b deep) T2: tumor > 5cm in greatest dimensions (T2a superficial, T2b deep)

Answer 540

Unexplained bruising of the forehead or scalp, may progress in a rapid fashion in an elderly patient.

Answer 541

A rapidly enlarging, red, ulcerated lesion within the field of prior radiation treatment - Management is with simple surgical excision. Nodal involvement is rare

Answer 542

20% of patients will have GI tract involvement

Answer 543

Non Hodgkin lymphoma

Answer 544

Hashimoto thyroiditis

Answer 545

CD20, CD22, CD79a

Answer 546

Hypocalcemia, hyperkalemia, hyperuricemia, hyperphosphatemia, acute renal failure days after initiation of chemotherpay for aggressive lymphoma

Answer 547

A monoclonal antibody against CD20

Answer 548

Positive surgical margins, distant mets, extranodal extension

Answer 549

Lip - 10% (don't routinely do neck dissection) Tongue - 40% (Neck dissection for T1 with depth of invasion greater than 4mm or T2+) FOM - 30-50% Alevolar ridge: 32% in lower and 14% in upper Hard palate- 10-25% RMT - 35-50% (behaves more like oropharyngeal sites) Typically recommend neck dissection if liklihood of neck metastasis is grester than 20%

Answer 550

Abscess, forieng body, cancer, distal obstruction, epithelialization

Answer 551

Superior: skull base Inferior: hyoid Lateral: mandibular ramus and angle Medial: superior constrictors, tonsil, eustachian tube

Answer 552

Internal maxillary artery, V3, salivary gland, muscle and connective tissue

Answer 553

Carotid, CN IX-XII, sympathetic chain, lymph nodes in the periphery

Answer 554

ascending pharyngeal

Answer 555

Carotid body tumor and glomus vagale. Carotid body tumor will show splaying of the internal and external carotid arteries (lyre sign)

Answer 556

- Can help determine if it is tonsillar or paraphayrngeal (which side of the superior constrictor is the mass on) - Deep lobe of the parotid vs minor salivary gland - Intracranial extension - Vascular (flow voids) vs non vascular (can have a false negative)

Answer 557

Contain the most mitochondria and are important for electrolyte activity. The richest in oxyphilic staining (deep red)

Answer 558

Acinar cells: acinic cell carcinoma Intercalated ducts: pleomorphic adenoma Striated ducts: warthins or oncocytoma Excretory ducts: SCCA and mucoepidermoid carcinoma

Answer 559

Will have negative SSa and SSB but + HLA. Commonly have another autoimmune disease

Answer 560

Warthin's and oncocytoma (because of the high amount of mitochondria)

Answer 561

Sural: Advantage - length; Disadvantage - second site incision, anatomy, expertise Great auric: Advantage - same site access, reasonable size match; Disadvantage- some length and size discrepancy (theoretical risk of adenoid cystic great auric carcinoma recurrence, if used when removing parotid for ACC)

Answer 562

- Mycobactal TB - Atypical TB - Sarcoid - Deep fungal infection - Actino and cat scratch can appear like granulomatous diseases on FNA due to their intense inflammatory processes but aren't true granulomatous diseases

Answer 563

- Often presents with hilar lymphadenopathy - ACE levels are elevated - In the head and neck lymphadenopathy is the most common manifestation - Non caseating granulomas

Answer 564

follicular hyperplasia

Head and Neck Flashcards

(621 cards)