CHAPTER 19- HEAD AND NECK.txt

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CHAPTER 19- HEAD AND NECK.txt
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  1. Anterior neck triangle:
    • 1) sternocleidomastoid muscle, sternal notch, inferior border of the digastric muscle
    • 2) contains carotid sheath
  2. Posterior neck triangle
    • 1) posterior border of sternocleidomastoid muscle, trapezius muscle, and clavicle
    • 2) contains spinal accessory nerve and brachial plexus
  3. Where is the phrenic nerve
    on anterior scalene muscle
  4. What type of secretions do the following glands produce:
    Parotid:
    Sublingual:
    Submandibular:
    • Parotid glands- secrete mostly serous fluid
    • Sublingual glands- secrete mostly mucinous
    • Submandibular glands- 50/50
  5. How are the true and false vocal cords arranged in the larynx?
    In larynx, the false vocal cords are superior to the true vocal cords
  6. Describe the trachea:
    Trachea has U-shaped cartilage and a posterior portion that is membranous
  7. Where does the vagus nerve run
    the vagus nerve runs between the internal jugular and carotid arteries
  8. Trigeminal nerve
    • 1) opthalmic, maxillary, mandibular branches
    • 2) gives sensation to most of the face
    • 3) mandibular branch- taste to anterior 2/3 of tongue, floor of mouth, gingiva
  9. Facial nerve
    motor function to the face.

    • 1) temporal
    • 2) zygomatic
    • 3) buccal
    • 4) marginal mandibular
    • 5) cervical branches
  10. Glossopharyngeal nerve
    • 1) sensory to posterior tongue
    • 2) motor to stylopharyngeus
    • 3) injury affects swallowing
  11. Hypoglossal nerve
    • 1) motor to all to the tongue except palatogossus
    • 2) tongue deviates to side of injury
  12. Recurrent laryngeal nerve
    innervates all of the larynx except the cricothyroid muscle
  13. Superior laryngeal nerve
    innervates the cricothyroid muscle
  14. Frey's syndrome:
    • 1) occurs after a parotidectomy; injury of auriculotemporal nerve that then cross innervates with sympathetic fibers to sweat glands of the skin
    • 2) symptom: gustatory sweating
  15. Thyrocervical trunk:
    • STAT:
    • 1) suprascapular artery
    • 2) transverse cervical artery
    • 3) ascending cervical artery
    • 4) inferior thyroid artery
  16. What is the first branch of the external carotid artery
    superior thyroid artery
  17. Trapezius flap
    • 1) spinal accessory nerve, shoulder shrug
    • 2) based on transverse cervical artery
  18. Pectoralis major
    based on thoracoacromial artery
  19. Torus palatini
    • congenital bony mass on upper palate of mouth
    • Tx: nothing
  20. Torus mandibular
    1) similar to torus palantini but on the anterior lingual surface of the mandible
  21. Radical neck dissection (RND)
    • Takes:
    • 1) accessory nerve (CN XI)
    • 2) sternocleidomastoid
    • 3) internal jugular
    • 4) omohyoid
    • 5) submandibular gland
    • 6) sensory nerves C2-C5
    • 7) cervical branch of facial nerve
    • 8) ipsilateral thyroid
  22. Modified radical neck dissection (MRND)
    • Takes:
    • 1) omohyoid
    • 2) submandibular gland
    • 3) sensory nerves C2-C5
    • 4) cervical branch of facial nerve
    • 5) ipsilateral thyroid

    no mortality difference compared with RND
  23. Progressive signs and symptoms indicating head + neck cancer:
    • odynophagia
    • dysphagia
    • weight loss
    • loose dentition
    • oral fetor
    • trismus
    • otalgia
    • neck mass
    • serous otitis media
    • nasal obstruction
    • epistaxis
    • facial pain
    • cranial neropathies
    • secondary infections
    • aspiration
    • fistulization
    • hemorrhage
    • airway obstruction
  24. What is the most common cancer of the oral cavity, pharynx, and larynx?
    Whats the biggest risk factor?
    • 1) squamous cell cancer
    • 2) tobacco and EtOH
  25. Which is considered more premalignant, erythroplakia or leukoplakia?
    erythroplakia is considered more premalignant than leukoplakia
  26. What does the oral cavity include:
    • 1) mouth floor
    • 2) anterior 1/3 of tongue
    • 3) gingiva
    • 4) hard palate
    • 5) anterior tonsillar pillars
    • 6) lips
  27. What is the most common site for oral cavity cancer?
    lower lip
  28. which oral cancer has the lowest survival rate and why:
    survival rate lowest for hard palate tumors- hard to resect
  29. Plummer-Vinson Syndrome
    1) increased oral cavity cancer in patients with plummer-vinson syndrome

    • 1- glossitis
    • 2- cervical dysphagia from esophageal web
    • 3- spoon fingers
    • 4- iron deficiency anemia
  30. Treatment for oral cavity cancer:
    • 1) wide resection of tumor if <2 cm (T1), need 1-2 cm margins
    • 2) MRND for tumors >2cm or if clinically positive nodes
    • 3) post-op XRT for advanced lesions (>2cm, positive margins, nerve/vascular/lymphatic invasion)
  31. Lip Ca
    • 1) lower lip Ca more common than upper due to sun exposure
    • 2) may need flaps if more than 1/2 of the lip is removed
    • 3) lesions along the commissure are most aggressive
  32. Tongue Ca
    can still operate with jaw invasion
  33. Verrucous ulcer
    • 1) well-differentiated tumor of the cheek
    • 2) not aggressive
    • 3) Tx: full cheek resection +/- flap; no MRND
  34. Cancer of the maxillary sinus
    Tx: maxillectomy
  35. Nasopharyngeal squamous cell carcinoma
    • 1) EBV
    • 2) chinese
    • 3) presents with nose bleeding or obstruction
    • 4) goes to posterior (deep) cervical lymph nodes
    • 5) Treatment:
    • 1- XRT primary
    • 2- MRND for tumors >2cm or clinically positive nodes
    • 3- post-op chemo for advanced stage
  36. Tumors in the nasopharynx in children:
    • 1) lymphoma is the #1 tumor of the nasopharynx
    • 2) Tx: chemotherapy
  37. What is the most common benign neoplasm of nose/paranasal sinuses?
    papilloma
  38. oropharyngeal squamous cell carcinoma
    • 1) neck mass, sore throat
    • 2) goes to posterior (deep) cervical neck nodes
    • 3) Tx: XRT or surgery; MRND for tumors >2cm or if clinically positive nodes
  39. Tonsillar cancer
    • 1) EtOH, tobacco, males
    • 2) squamous cell cancer most common
    • 3) asymptomatic until large
    • 4) 80% have LN metastases at time of diagnosis
    • 5) Tx: tonsillectomy best way to biopsy; XRT mainstay
  40. Hypopharyngeal squamous cell carcinoma
    • 1) hoarseness
    • 2) early metastases
    • 3) goes to anterior cervical nodes
    • 4) tx:
    • 1- usually surgery (laryngectomy)
    • 2- MRND
    • 3- postop XRT
  41. Nasopharngeal angiofibroma
    • 1) benign tumor
    • 2) presents in males <20 (obstruction or epistaxis)
    • 3) extremely vascular
    • 4) Tx: angiography and embolization (usually internal maxillary artery), followed by resection
  42. Laryngeal cancer
    • 1) hoarseness, aspiration, dyspnea, dysphagia
    • 2) can preserve larynx in some cases of cancer (glottis free of tumor and mobile)
    • 3) take ipsilateral thyroid lobe with MRND
    • 4) papilloma- most common benign lesion of the larynx
  43. Supraglottic squamous cell carcinoma
    • 1) early nodal spread to submental/submandibular areas
    • 2) Small- tx: XRT or conservative surgery
    • 3) large- Tx: laryngectomy, MRND, postop XRT
  44. Glottic squamous cell carcinoma
    • 1) nodal spread to anterior cervical chain
    • 2) small- tx: XRT or laser, chordectomy with recurrence
    • 3) large-tx: laryngectomy, MRND, postop XRT
    • 4) Fixed cords require laryngectomy
  45. Subglottic squamous cell carinoma
    • 1) early nodal to anterior cervical chain and metastatic spread
    • 2) small- tx: XRT or conservative surgery
    • 3) large- Tx: laryngectomy, MRND, postop XRT
  46. What glands can be affected in salivary gland cancers?
    • 1) parotid
    • 2) submandibular
    • 3) sublingual
    • 4) minor salivary glands
  47. How can submandibular and sublingual tumors present?
    submandibular or sublingual tumors can present as a neck mass or swelling in the floor of the mouth
  48. What is a mass in a large salivary gland most likely:
    more likely mass is benign
  49. Mass in small salivary gland is more likely:
    mass in small salivary gland is more likely malignant, although the parotid gland is the most frequent site for malignant tumor
  50. Malignant tumors of salivary gland
    • 1) Mucoepidermoid cancer-
    • 1- #1 malignant tumor of the salivary glands
    • 2- wide range of aggressiveness

    • 2) Adenoid cystic cancer-
    • 1- #2 malignant tumor of the salivary glands
    • 2- #1 malignant salivary tumor of the minor salivary glands
    • 3- long indolent course; propensity to invade nerve roots
  51. How do salivary gland cancers present:
    often present as a painful mass but can also present with facial nerve paralysis or lymphadenopathy
  52. Where is lymphatic drainage to?
    • lymphatic drainage to the:
    • 1) intraparotid nodes
    • 2) anterior cervical chain nodes
  53. Treatment for mucoepidermoid and adenoid cystic cancer:
    • 1) resection of salivary gland (parotidectomy)
    • 2) prophylactic MRND
    • 3) postop XRT if high grade or SCCA
    • 1- if in partoid, need to take the whole lobe; try to preserve facial nerve
    • 2- other tumors- adenocarcinoma, scca, lymphoma
  54. General principles for surgical treatment of salivary gland malignancies:
    • 1) malignant tumors of the parotid gland warrant total parotidectomy
    • 2) the facial nerve should be sacrified only for direct tumor invasion or for preexisting facial paralyses
    • 3) patients with high-grade tumors should undergo elective neck dissection if there is no clinical neck disease or a modified neck dissection for palpable adenopathy
    • 4) postoperative radiotherapy is indicated for all high-grade tumors; close margins; recurrent disease; skin, bone, nerve, or extraparotid involvement; positive nodes; or unresectable disease
  55. Pleomorphic adenoma
    • 1) mixed tumor
    • 2) #1 benign tumor of the salivary glands
    • 3) malignant degeneration in 5%
    • 4) Tx: superficial parotidectomy
    • 5) if malignant degeneration, need total parotidectomy; if high grade also need MRND
  56. Warthin's tumor
    • 1) #2 benign tumor of the salivary glands
    • 2) males, bilateral in 10%
    • 3) Tx: superficial parotidectomy
    • 4) often presents as a painless mass
  57. What is the most common injured nerve with parotid surgery:
    greater auricular nerve (numbness over lower portion of auricle)
  58. What do you need to find for submandibular gland resection:
    • need to find:
    • 1) mandibular branch of facial nerve
    • 2) lingual nerve
    • 3) hypoglossal nerve
  59. What is the most common salivary gland tumor in children
    hemangiomas
  60. Cauliflower ear
    undrained hematomas that organize and calcify; need to be drained to avoid this
  61. Chemodectomas
    • 1) vascular tumor of the middle ear (paraganglionoma)
    • 2) Tx: surgery +/- XRT
  62. Acoustic neuroma
    • 1) CN VIII
    • 2) tinnitus
    • 3) hearing loss
    • 4) unsteadiness
    • 5) can grow into cerebellar/pontine angle
    • 6) Tx: craniotomy and resection
    • 7) XRT is alternative to surgery
  63. Cholesteatoma
    • 1) epidermal inclusion cyst of the ear
    • 2) slow growing but erode as they grow
    • 3) present with conductive hearing loss and clear drainage from ear
    • 4) Tx: surgical excision
  64. Pinna lacerations
    need suture through involved cartilage
  65. Ear squamous cell carcinoma
    • 1) 20% metastasize to parotid gland
    • 2) Tx: parotidectomy, MRND for positive nodes or large tumors, XRT
  66. What is the most common childhood aural malignancy:
    1) Rhabdomyosarcoma is the most common childhood aural malignancy (although rare) of the middle or external ear
  67. Nasal fractures:
    set after swelling decreases
  68. Septal hematoma
    need to drain to avoid infection/necrosis of the septum
  69. CSF rhinorrhea
    • 1) usually a cribriform plate fracture (CSF has tau protein)
    • 2) repair of facial fractures may help leak; may need contrast study to help find leak
    • 3) Tx: conservative 2-3 weeks; try epidural catheter, may need transethmoid repair
  70. Epistaxis
    • 1) 90% anterior and can be controlled with packing
    • 2) consider internal maxillary artery or ethmoid artery ligation (direct or angiographically) for persistant posterior bleeding despite packing or balloon.
  71. Neck + Jaw cards to follow..
  72. Radicular cyst
    • 1) local excision or curettage
    • 2) lucent on xray
  73. Ameloblastoma
    • 1) slow-growing malignancy
    • 2) soap bubble appearance on x-ray
    • 3) can have metastases
    • 4) Tx: wide local excision
  74. Osteogenic sarcoma
    • 1) poor prognosis
    • 2) multimodal approach that includes surgery
  75. Maxillary jaw fractures
    most treated with wire fixation
  76. TMJ dislocations
    treated with closed reduction
  77. lip numbness
    damage to inferior alveolar nerve
  78. Stensen's duct laceration
    • 1) repair over catheter stent
    • 2) ligation can cause painful parotid atrophy and facial asymmetry
  79. Suppurative parotitis
    • 1) usually in elderly patients
    • 2) occurs with dehydration
    • 3) staph most common organism
    • 4) Tx: fluids, salivation, antibiotics; drainage if abscess develops or patient not improving
    • 5) can be life-threatening
  80. Sialoadenitis
    • 1) actue inflammation of the salivary gland related to a stone in the duct; most calculi near orifice
    • 2) recurrent sialoadenitis is thought to be due to ascending infection from the oral cavity
    • 3) gland excision may eventually be necessary for recurrent disease
    • 4) 80% of the time affects submandibular or sublingual glands
    • 5) Tx: incise duct and remove stone
  81. Peritonsillar abscess
    • 1) older kids (>10years)
    • 2) symptoms: trismus, odynophagia
    • 3) usually doesn't obstruct airway
    • 4)Tx:
    • 1- needle aspiration 1st
    • 2- then drainage through tonsillar bed if no relief in 24hrs
    • 5) may need to intubate to drain; will self-drain with swallowing once opened
  82. Retropharyngeal abscess
    • 1) younger kids (<10years)
    • 2) symptoms: fever, odynophagia, drool; is an airway emergency
    • 3) can occur in elderly with Pott's disease
    • 4) will self drain with swallowing once opened
  83. Ludwig's angina
    • 1) acute infection of the floor of the mouth
    • 2) involves mylohyoid muscle
    • 3) most common cause is dental infection of the mandibular teeth
    • 4) may rapidly spread to deeper structures and cause airway obstruction
    • 5) Tx:
    • 1- airway control
    • 2- surgical drainage
    • 3- antibiotics
  84. Preauricular tumors
    • 1) all lumps near ear are parotid tumors until proved otherwise
    • 2) diagnosis is usually made after superficial lobectomy
    • 3) 80% of all salivary tumors are in parotid
    • 4) 80% of parotid tumors are benign
    • 5) 80% of benign parotid tumors are pleomorphic adenomas - 5% malignant degeneration
  85. Most common distant metastases for head and neck tumors:
    • 1) lung
    • 2) tx: chemotherapy
  86. Posterior neck masses
    • 1) if no obvious malignant epithelial tumor, considered to have hodgkin's lymphoma until proved otherwise
    • 2) need FNA or open biopsy
  87. Neck mass work-up:
    • 1st- history and exam, laryngoscopy, antibiotics if thought to be inflammatory, FNA is hard
    • 2nd- panendoscopy with multiple random biopsies, neck and chest CT
    • 3rd- still cannot figure it out--> perform excisional biopsy; need to be prepared for MRND
  88. What does adenocarcinoma finding on neck mass biopsy suggest?
    adenocarcinoma suggests breast, GI, or lung primary lesion
  89. Epidermoid Ca found in cervical node without known primary:
    • 1st- panendoscopy with random biopsies
    • 2nd- CT scan
    • 3rd- still cannot find primary --> ipsilateral MRND, ipsilateral tonsillectomy, bilateral XRT
  90. Esophageal foreign body
    • 1) dysphagia
    • 2) most just below the cricopharyngeous (95%)
    • 3) Dx: rigid EGD under anesthesia
    • 4) perforation risk increases with length of time in the esophagus
  91. What do you do if pt has fever + pain after EGD for foreign body?
    CXR and gastrographin followed by barium swallow to rule out perforation
  92. Laryngeal foreign body
    • 1) coughing
    • 2) emergent cricothyroidectomy as a last resort may be needed to secure airway
  93. Lip lacerations
    • 1) apposition of the vermillion border is key
    • 2) layered closure is preferred
  94. Sleep apnea
    • 1) associated with MIs, arrhythmias, and death
    • 2) more common in obese and those with micrognathia/retrognathia--> have snoring and excessive daytime somnolence
    • 3) Tx:
    • 1- CPAP
    • 2- uvulopalatopharyngogplasty
    • 3- hyoid suspension
    • 4- permanent trach
  95. Prolonged intubation
    • 1) can lead to subglottic stenosis
    • 2) subglottic stenosis is treated with:
    • 1- laser
    • 2- dilatation
    • 3- possible excision
  96. Tracheostomy
    • 1) consider in patients who will require intubation for >7-14 days
    • 2) decreases secretions, provides easier ventilation, decreases pneumonia risk
  97. Tracheoinnominate fistula
    • 1) occurs after tracheostomy
    • 2) can have rapid exanguination
    • 3) Tx:
    • 1- place finger in trach hole and hold pressure
    • 2- median sternotomy
    • 3- this complication is avoided by keeping tracheostomy above the 3rd tracheal ring
  98. Median rhomboid glossitis
    • 1- failure of tongue fusion
    • 2- tx: none necessary
  99. Cleft lip:
    • 1) primary palate
    • 2) Involves lip, alveolus, or both
    • 3) Repair at:
    • 1- 10 weeks
    • 2- 10lb
    • 3- Hgb 10
    • 4) repair nasal deformities at same time
    • 5) may be associated with poor feeding
  100. Cleft palate
    • 1) secondary palate
    • 2) involves soft and hard palates
    • 3) may affect speech and swallowing if not closed soon enough
    • 4) may affect maxillofacial growth if closed too early
    • 5) repair at 12 months
  101. What is the most common bengin head and neck tumor in adults?
    hemangioma
  102. Mastoiditis
    • 1) infection of the mastoid cells
    • 2) can destroy bone
    • 3) rare; resuts as a complication of untreated acute supportive otitis media
    • 4) ear pushed forward
    • 5) Tx:
    • 1- antibiotics
    • 2- may need emergency mastoidectomy
  103. Epiglottitis
    • 1) rare since immunization against H. influenza type B
    • 2) mainly in children aged 3-5
    • 3) symptoms:
    • 1- stridor
    • 2- drooling
    • 3- leaning forward position
    • 4- high fever
    • 5- throat pain
    • 6- thumbprint sign on lateral neck film
    • 4) can cause airway obstruction
    • 5) early control of the airway; antibiotics
  104. Kaposi's sarcoma
    • 1) oral and pharyngeal mucosa are the most common sites
    • 2) can get odynophagia and dysphagia; bleeding
    • 3) primary goal usually is palliation
    • 4) most common neoplasm in patients with AIDS
    • 5)Tx:
    • 1- XRT
    • 2- Intratumor vinblastine

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