Head & Neck

Question 1

Subclavian structures from anterior to posterior

Answer 1

Subclavian vein
Phrenic nerve
Anterior scalene
Subclavian artery
Brachial plexus
Middle scalene

Question 2

Recurrent laryngeal innervates everything but this muscle?

What innervates this muscle?

Answer 2

Cricothyroid muscle.

Superior laryngeal nerve. Affects voice tone, high pitches

Question 3

Treatment strategy for oral squamous cell CA based on size

Answer 3

> 4cm or node involvement -> WLE, modified radical neck dissection, adjuvant XRT

Question 4

Salivary gland tumors.

• Most common malignant tumor? #2 most common malignant?
• MC benign tumor?
• Treatment for malignant salivary gland tumor? What if it’s invading the facial nerve?

Answer 4

• Most common malignant: mucoepidermoid. #2: adenoidcystic
• Most common benign: pleomorphic adenoma
• Rx: total parotidectomy with facial n. preservation, ipsilateral modified radical neck dissection, post-op XRT. If it involves the facial, you can get away with XRT only

Question 5

Palpable node in the neck. Bx shows cancer. Unkn primary.

• What to do next?
• What is the most common site for unknown h&n primary?
• what is the treatment?

Answer 5

FNA of regional nodes
CT of head neck, chest +/-PET
OR for direct laryngoscopy, directed biopsies

• tonsil, followed by base of the tongue.
• have to take pt to OR regardless. Do ipsilateral modified radical neck dissection, bilateral XRT

Question 6

Most common site for oral cavity cancer. Why.

When to do flap reconstruction

Answer 6

Lower lip. Sun exposure.if over half of the lip is resected then reconstruct

Question 7

Painless protuberance in the bony part of the mouth. Treatment?

Answer 7

Torus peletinus. Do nothing

Question 8

Ebstein barr associated with what head and neck cancer? Treatment?

Answer 8

Nasopharyngeal squamous cell cancer

Radiation

Question 9

What is Frey syndrome? Why/how does it happen?

Answer 9

Auriculotemporal nerve injury. Interacts with the sympathetics

Question 10

Post-op lap CCY. High fevers and big swelling at the angle of the jaw. What is it? What organism? Treatment?

Answer 10

Suppurative parotiditis. Staph aureus

Abx, supportive care. I&D if collection

Question 11

What is the most common original of the brachial cleft cyst?

Answer 11

2nd arch

Question 12

The tract of the brachial cleft cyst goes over or under cranial nerve 12?

Over or under cranial nerve 9?

Relation to internal and external carotid?

Relation to SCM?

Ultimately goes into what structure?

Answer 12

Over CN12
Over CN9
Between the bifurcation
Anterior to SCM
ultimately goes into the tonsil

Question 13

The entire thyroid gland rises from the thyroglossal duct tract except for what part?

Answer 13

The tubercle of zuckerkandl which rises from the 4th pouch along with the superior paras

Question 14

Sarcoidosis is caseating or non-caseating granulomatous changes?

Answer 14

Non-caseating.

Caseating: TB

Question 15

If you biopsy a head and neck lymphadenopathy and see metastatic cancer? What is the most likely primary?

Answer 15

Squamous cell CA of upper aerodigestive tracts

Question 16

What is the T staging for any head and neck tumors?

Answer 16

T1: <2 cm
T2: 2-4 cm
T3: >4 cm
T4: any that invades adjacent structures

Question 17

Treatment regimen for head and neck cancer based on T staging?

Given that the pt doesn’t have any physical exam or CT findings of nodes, what do you do with neck for each of the T stages?

Answer 17

T1 - T2: surgery

T3 - T4: surgery with post-op radiation or chemo

Only T2 lesions needs b/l neck dissection.

T1: low chance of nodal disease
T2: 30% chance of nodal disease
T3-T4: you’re giving post-op radiation anyway

Question 18

What is the main complication from radiation to face/mouth cancer?

Answer 18

Osteoradionecrosis. Bone becomes necrotic. Gets infected

Question 19

CT size cutoff for neck nodes

Answer 19

N1: < 3 cm
N2: 3-6 cm
N3: >6 cm

N2a: 3-6cm single node
N2b: multiple nodes
N2c: contralateral node

Question 20

What does the accessory nerve innervate?

Answer 20

Trapezius and SCM

Question 21

Which type of thyroid cancer most likely to be when there’s calcifications in the thyroid?

Answer 21

Papillary

Question 22

80% of parotid tumors are benign or malignant?

What is the most common benign tumor?

What is the most common malignant tumor?

Answer 22

80% of parotid is benign

Most common benign: pleomorphic adenoma

Most common malignant: mucoepidermoid carcinoma

Question 23

Do cystic hygromas carry any malignancy risk?

Can they be diagnosed on prenatal ultrasound?

Answer 23

No

Yes

Question 24

Which organ do you need to take out when removing a 3rd and 4th branchial remnant?

What about 2nd remnant?

Answer 24

3rd and 4th: thyroid

2nd: tonsil

Question 25

T/F: acutely infected branchial cleft cyst needs immediate operation The incision should be (transverse/longitudinal) over the cyst

Answer 25

F. Abx for several weeks first Transverse incision will improve cosmesis

Question 26

What are the borders of the submental triangle

Answer 26

Anterior belly of the digadtrics Hyoid bone Symphysis menti floor: mylohyoid

Question 27

"pushing edges" on the histological exam rather than invading

Answer 27

Verrucous carcinoma. It's a variant of the sq cell ca

Question 28

Most common site of minor salivary gland malignancies?

Answer 28

Palate. 50% of all minor salivary gland malignancy

Question 29

Why should you never do a cric in kids?

Answer 29

Cricoid cartilage is the narrowest part of the airway in kids. It'll cause airway stenosis >12yo you can do it

Question 30

What the F is frey syndrome? How do you treat it?

Answer 30

Sweating and flushing of a patch of skin near the ear that occurs when someone is eating It occurs due to inappropriate regrowth of the parasympathetic auriculotemporal nerve into the sweat glands overlying the parotid gland Apply antiperspirant to involved skin

Question 31

What innervates the sensation over the skin behind ears?

Answer 31

Greater auricular nerve

Question 32

Parathyroid cancer carries worse prognosis for - men vs women? - young age vs old age at diagnosis?

Answer 32

- men are worse | - old age at diagnosis is worse

Question 33

What are the borders of the submandibular triangle?

Answer 33

Anterior belly, posterior belly of the digadtrics, Mandible. This is the triangle right next to the submantle triangle Hyoid bone Anterior digadtrics

Question 34

What is the most common incision for parotid surgery?

Answer 34

Modified Blair incision Starts in the preauricular skin and extends around the lobule over the mastoid tip then curves around down the neck

Question 35

What is the second most common benign parotid gland

Answer 35

Monomorphic adenoma aka warthin tumor

Question 36

Open trach vs perc trach. Difference in icu los? Cost? Infection rate?

Answer 36

Only difference is lower infection rate in perc trach

Question 37

What is the N staging for head and neck cancer?

Answer 37

N1: single ipsilateral node < 3cm N2: single ipsilateral node 3 - 6cm OR multiple ipsilateral nodes or bilateral N3: > 6cm

Question 38

Enlarging parotid gland mass with facial droop. Is it pleomorphic adenoma?

Answer 38

No. When it's enlarging and facial droop think cancer. Mucoepidermoid is most common

Question 39

Most common morbidity after radical neck dissection?

Answer 39

Shoulder dysfunction because of accessory nerve Denervated trapezius. Frozen shoulder

Question 40

What forms the floor of the submental triangle?

Answer 40

Mylohyoid muscle

Question 41

Typically where is the facial nerve trunk in relation to Tragal pointer? Tympanomastoid suture line?

Answer 41

1cm inferior to the tragal pointer 6-8mm below the tympanomastoid suture line at the lvl of the belly of the posterior digastric muscle.

Question 42

For parotidectomy, what is the rate of facial nerve dysfunction? What is the prognosis once you get facial nerve dysfunction? What is the rate of permanent dysfunction?

Answer 42

20-40%. Very common Prognosis: most recover within a year. Permanent dysfunction only 4%