CHAPTER 19- HEAD AND NECK.txt

• 1) sternocleidomastoid muscle, sternal notch, inferior border of the digastric muscle
• 2) contains carotid sheath

• 1) posterior border of sternocleidomastoid muscle, trapezius muscle, and clavicle
• 2) contains spinal accessory nerve and brachial plexus

on anterior scalene muscle

• Parotid glands- secrete mostly serous fluid
• Sublingual glands- secrete mostly mucinous
• Submandibular glands- 50/50

In larynx, the false vocal cords are superior to the true vocal cords

Trachea has U-shaped cartilage and a posterior portion that is membranous

the vagus nerve runs between the internal jugular and carotid arteries

• 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

motor function to the face.

• 1) temporal
• 2) zygomatic
• 3) buccal
• 4) marginal mandibular
• 5) cervical branches

• 1) sensory to posterior tongue
• 2) motor to stylopharyngeus
• 3) injury affects swallowing

• 1) motor to all to the tongue except palatogossus
• 2) tongue deviates to side of injury

innervates all of the larynx except the cricothyroid muscle

innervates the cricothyroid muscle

• 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

• STAT:
• 1) suprascapular artery
• 2) transverse cervical artery
• 3) ascending cervical artery
• 4) inferior thyroid artery

superior thyroid artery

• 1) spinal accessory nerve, shoulder shrug
• 2) based on transverse cervical artery

based on thoracoacromial artery

• congenital bony mass on upper palate of mouth
• Tx: nothing

1) similar to torus palantini but on the anterior lingual surface of the mandible

• 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

• 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

• 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

• 1) squamous cell cancer
• 2) tobacco and EtOH

erythroplakia is considered more premalignant than leukoplakia

• 1) mouth floor
• 2) anterior 1/3 of tongue
• 3) gingiva
• 4) hard palate
• 5) anterior tonsillar pillars
• 6) lips

lower lip

survival rate lowest for hard palate tumors- hard to resect

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

• 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)

• 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

can still operate with jaw invasion

• 1) well-differentiated tumor of the cheek
• 2) not aggressive
• 3) Tx: full cheek resection +/- flap; no MRND

Tx: maxillectomy

• 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

• 1) lymphoma is the #1 tumor of the nasopharynx
• 2) Tx: chemotherapy

papilloma

• 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

• 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

• 1) hoarseness
• 2) early metastases
• 3) goes to anterior cervical nodes
• 4) tx:
• 1- usually surgery (laryngectomy)
• 2- MRND
• 3- postop XRT

• 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

• 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

• 1) early nodal spread to submental/submandibular areas
• 2) Small- tx: XRT or conservative surgery
• 3) large- Tx: laryngectomy, MRND, postop XRT

• 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

• 1) early nodal to anterior cervical chain and metastatic spread
• 2) small- tx: XRT or conservative surgery
• 3) large- Tx: laryngectomy, MRND, postop XRT

• 1) parotid
• 2) submandibular
• 3) sublingual
• 4) minor salivary glands

submandibular or sublingual tumors can present as a neck mass or swelling in the floor of the mouth

more likely mass is benign

mass in small salivary gland is more likely malignant, although the parotid gland is the most frequent site for malignant tumor

• 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

often present as a painful mass but can also present with facial nerve paralysis or lymphadenopathy

• lymphatic drainage to the:
• 1) intraparotid nodes
• 2) anterior cervical chain nodes

• 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

• 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

• 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

• 1) #2 benign tumor of the salivary glands
• 2) males, bilateral in 10%
• 3) Tx: superficial parotidectomy
• 4) often presents as a painless mass

greater auricular nerve (numbness over lower portion of auricle)

• need to find:
• 1) mandibular branch of facial nerve
• 2) lingual nerve
• 3) hypoglossal nerve

hemangiomas

undrained hematomas that organize and calcify; need to be drained to avoid this

• 1) vascular tumor of the middle ear (paraganglionoma)
• 2) Tx: surgery +/- XRT

• 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

• 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

need suture through involved cartilage

• 1) 20% metastasize to parotid gland
• 2) Tx: parotidectomy, MRND for positive nodes or large tumors, XRT

1) Rhabdomyosarcoma is the most common childhood aural malignancy (although rare) of the middle or external ear

set after swelling decreases

need to drain to avoid infection/necrosis of the septum

• 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

• 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.

• 1) local excision or curettage
• 2) lucent on xray

• 1) slow-growing malignancy
• 2) soap bubble appearance on x-ray
• 3) can have metastases
• 4) Tx: wide local excision

• 1) poor prognosis
• 2) multimodal approach that includes surgery

most treated with wire fixation

treated with closed reduction

damage to inferior alveolar nerve

• 1) repair over catheter stent
• 2) ligation can cause painful parotid atrophy and facial asymmetry

• 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

• 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

• 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

• 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

• 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

• 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

• 1) lung
• 2) tx: chemotherapy

• 1) if no obvious malignant epithelial tumor, considered to have hodgkin's lymphoma until proved otherwise
• 2) need FNA or open biopsy

• 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

adenocarcinoma suggests breast, GI, or lung primary lesion

• 1st- panendoscopy with random biopsies
• 2nd- CT scan
• 3rd- still cannot find primary --> ipsilateral MRND, ipsilateral tonsillectomy, bilateral XRT

• 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

CXR and gastrographin followed by barium swallow to rule out perforation

• 1) coughing
• 2) emergent cricothyroidectomy as a last resort may be needed to secure airway

• 1) apposition of the vermillion border is key
• 2) layered closure is preferred

• 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

• 1) can lead to subglottic stenosis
• 2) subglottic stenosis is treated with:
• 1- laser
• 2- dilatation
• 3- possible excision

• 1) consider in patients who will require intubation for >7-14 days
• 2) decreases secretions, provides easier ventilation, decreases pneumonia risk

• 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

• 1- failure of tongue fusion
• 2- tx: none necessary

• 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

• 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

hemangioma

• 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

• 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

• 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