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HEAD AND NECK. A 50 YO M has a 1 cm mass anterior to the ear. The mass causes pain and a facial droop. CT of the head shows the tumor is involved in the.

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Presentation on theme: "HEAD AND NECK. A 50 YO M has a 1 cm mass anterior to the ear. The mass causes pain and a facial droop. CT of the head shows the tumor is involved in the."— Presentation transcript:

1 HEAD AND NECK

2 A 50 YO M has a 1 cm mass anterior to the ear. The mass causes pain and a facial droop. CT of the head shows the tumor is involved in the deep and superficial portions of the gland. This most likely represents: A. Mucoepidermoid carcinoma B. Adenoid cystic carcinoma C. Pleomorphic adenoma D. Warthin's Tumor

3 A 50 YO M has a 1 cm mass anterior to the ear. The mass causes pain and a facial droop. CT of the head shows the tumor is involved in the deep and superficial portions of the gland. This most likely represents: A. Mucoepidermoid carcinoma B. Adenoid cystic carcinoma C. Pleomorphic adenoma D. Warthin's Tumor There are two features that make the parotid tumor almost certainly malignant. The first is that it invades both the superficial and deep glands (unusual for benign tumors) and the second is that the facial nerve is affected (facial droop) Given that this tumor is almost certainly malignant, you have to go with the most common malignant tumor of the parotid, which is mucoepidermoid carcinoma

4 Treatment of mucoepidermoid carcinoma will most likely involve: A. Superficial parotidectomy B. Total parotidectomy C. Chemo-XRT only D. Chemotherapy only

5 Treatment of mucoepidermoid carcinoma will most likely involve: A. Superficial parotidectomy B. Total parotidectomy C. Chemo-XRT only D. Chemotherapy only Initial treatment is total parotidectomy including the facial nerve (b/c it's already out). Also need to figure out whether or not it is low grade If it is low grade you are done If it is high grade or any other cell type you should perform a prophylactic modified radical neck dissection and give post op XRT

6 The tumor most likely to involve B/L parotid glands at the time of presentation is: A. Mucoepidermoid carcinoma B. Adenoid cystic carcinoma C. Pleomorphic adenoma D. Warthin's tumor

7 The tumor most likely to involve B/L parotid glands at the time of presentation is: A. Mucoepidermoid carcinoma B. Adenoid cystic carcinoma C. Pleomorphic adenoma D. Warthin's tumor The tumor most likely to involve B/L parotid glands at the same time is Warthin's tumor

8 Treatment of most benign parotid tumors involves: A. Superficial parotidectomy B. Total parotidectomy C. Chemo-XRT D. Chemotherapy

9 Treatment of most benign parotid tumors involves: A. Superficial parotidectomy B. Total parotidectomy C. Chemo-XRT D. Chemotherapy Treatment of most benign parotid tumors involves superficial parotidectomy

10 The most common benign tumor is: A. Mucoepidermoid carcinoma B. Adenoid cystic carcinoma C. Pleomorphic adenoma D. Warthin's tumor

11 The most common benign tumor is: A. Mucoepidermoid carcinoma B. Adenoid cystic carcinoma C. Pleomorphic adenoma D. Warthin's tumor The most common benign tumor is pleomorphic adenoma

12 Following a parotidectomy, a pt. has gustatory sweating. This is most likely caused by: A. Recurrent tumor B. Cross-innervation of the vagus and sympathetic nerves to the skin C. Cross-innervation of the auriculotemporal nerve and sympathetic nerves to the skin D. Cross-innervation to the glossopharyngeal nerve and sympathetic nerves to the skin

13 Following a parotidectomy, a pt. has gustatory sweating. This is most likely caused by: A. Recurrent tumor B. Cross-innervation of the vagus and sympathetic nerves to the skin C. Cross-innervation of the auriculotemporal nerve and sympathetic nerves to the skin D. Cross-innervation to the glossopharyngeal nerve and sympathetic nerves to the skin Post op gustatory sweating is caused by cross innervation of the auriculotemporal nerve and the sympathetic nerves of the skin Usually goes away but if refractory and alloderm graft can be placed b/t the auriculotemporal and skin nerves

14 What is this syndrome called? A. Stewart-Treves Syndrome B. Ratatouille Syndrome C. Foster-Kennedy syndrome D. Sheehan's syndrome E. Frey's syndrome

15 What is this syndrome called? A. Stewart-Treves Syndrome B. Ratatouille Syndrome C. Foster-Kennedy syndrome D. Sheehan's syndrome E. Frey's syndrome

16 Match the cervical lymph node level with the corresponding anatomic description Level I Level II Level III Level IV Level V Level VI Level VII Prelaryngeal, pretracheal, and paratracheal Upper jugulodigastric Posterior triangle Submental/submandibular Middle jugulodigastric Upper mediastinal Lower jugulodigastric

17 Level I is bounded by the anterior and posterior bellies of the digastric muscle, mandible superiorly and hyoid inferiorly Level II extends from base of skull superiorly, hyoid inferiorly, posterior belly of digastric medially, and posterior border of SCM laterally Level III extends from hyoid superiorly to cricoid inferiorly Level IV extends from cricoid superiorly to clavicle inferiorly; levels III and IV share same lateral border (posterior margin of SCM) Level V is posterior and lateral to II,III, and IV, and consists of the posterior triangle Level VI is the anterior compartment nodes from hyoid superiorly, sternal notch inferiorly, and laterally to medial borders of carotid sheaths Level VII contains upper mediastinal lymph nodes inferior to suprasternal notch

18 The nerve most likely injured with submandibular resection is: A. Vagus B. Hypoglossal C. Auriculotemporal D. Marginal mandibular

19 The nerve most likely injured with submandibular resection is: A. Vagus B. Hypoglossal C. Auriculotemporal D. Marginal mandibular The nerve most commonly injured w/ resection of the mandibular gland is the marginal mandibular nerve This nerve supplies the lower lip and chin

20 Massive bleeding 7 days after tracheostomy is most likely from: A. Tracheo-carotid fistula B. Erosion of tracheostomy into external jugular vein C. Tracheo-jugular fistula D. Tracheo-innominate fistula

21 Massive bleeding 7 days after tracheostomy is most likely from: A. Tracheo-carotid fistula B. Erosion of tracheostomy into external jugular vein C. Tracheo-jugular fistula D. Tracheo-innominate fistula The most common case of massive bleeding following tracheostomy is a tracheo-innominate fistula Place finger through tracheostomy site and try to compress the innominate artery against sternum Then go to OR for median sternotomy Ligate and divide innominate artery (can place graft but at high risk of infection) Ligation of innominate artery proximal to takeoff of right subclavian usually does not result in neurologic dysfunction due to collaterals

22 A 35 YO F comes in w/ CC of tinnitus and hearing loss. You order a head MRI and there is a tumor at the cerebello-pontine angle. The most likely diagnosis is: A. Glioma B. Glioma multiforme C. Neuroma D. Meduloblastoma

23 A 35 YO F comes in w/ CC of tinnitus and hearing loss. You order a head MRI and there is a tumor at the cerebello-pontine angle. The most likely diagnosis is: A. Glioma B. Glioma multiforme C. Neuroma D. Meduloblastoma An acoustic neuroma has the classic symptoms of unsteadiness, tinnitus, and hearing loss. A tumor at the cerebellopontine angle almost ensures the diagnosis

24 A 10 YO boy presents w/ a cyst and a cyst tract near the angle of his mandible. This cyst has had recurrent infections in it. This cyst most likely connects to the: A. External auditory canal B. The tonsilar pillar C. The nasal septum D. Thoracic duct

25 A 10 YO boy presents w/ a cyst and a cyst tract near the angle of his mandible. This cyst has had recurrent infections in it. This cyst most likely connects to the: A. External auditory canal B. The tonsilar pillar C. The nasal septum D. Thoracic duct Type I branchial cleft cysts extend from the angle of the mandible to the external auditory canal

26 A 10 YO boy presents with a cyst in his lateral neck medial to the anterior border of the sternocleidomastoid muscle. This cyst most likely connects to the: A. External auditory canal B. The tonsillar pillar C. The nasal septum D. Thoracic duct

27 A 10 YO boy presents with a cyst in his lateral neck medial to the anterior border of the sternocleidomastoid muscle. This cyst most likely connects to the: A. External auditory canal B. The tonsillar pillar C. The nasal septum D. Thoracic duct Type II branchial cleft cysts extend from the anterior border of the SCM, through the carotid bifurcation, to the tonsillar pillar

28 The most common branchial cleft cyst is: A. Type I B. Type II C. Type III D. Type IV

29 The most common branchial cleft cyst is: A. Type I B. Type II C. Type III D. Type IV The most common branchial cleft cyst is type II

30 Treatment of branchial cleft cysts involves: A. Antibiotics B. Resection C. XRT D. Chemotherapy

31 Treatment of branchial cleft cysts involves: A. Antibiotics B. Resection C. XRT D. Chemotherapy Treatment of branchial cleft cysts involves resection

32 All branchial remnants are present at the time of birth In children, fistulas > external sinuses > cysts; In adults, cysts predominate Clinical presentation may range from continuous mucoid drainage from a fistula/sinus to a cystic mass that may become infected. Dermal pits or skin tags may also be evident. 1st branchial remnants are typically located in front/back of the ear, or in upper neck in the region of the mandible. Fistulas typically course through the parotid gland, deep, or through branches of the facial nerve, and end in the external auditory canal Remnants from the 2nd branchial cleft are the most common. The external ostium of these remnants is located along the anterior border of the SCM, usually in the vicinity of the upper half to lower third of the muscle. The course of the fistula must be anticipated preoperatively because stepladder counterincisions are often necessary to excise the fistula completely. Typically, the fistula penetrates the platysma, ascends along the carotid sheath to the level of the hyoid bone, and then turns medially to extend between the carotid artery bifurcation. The fistula then courses behind the posterior belly of the digastric and stylohyoid muscles to end in the tonsillar fossa. 3 rd branchial remnants usually do not have associated sinuses/fistulas and are located in the suprasternal notch or clavicular region. These most often contain cartilage and present clinically as a firm mass or as a subcutaneous abscess.

33 A 5 YO F presents w/ a midline anterior neck mass that moves w/ tongue protrusion and swallowing. This most likely represents: A. Thyroid cancer B. Branchial cleft cyst Type I C. Branchial cleft cyst Type II D. Thyroglossal duct cyst

34 A 5 YO F presents w/ a midline anterior neck mass that moves w/ tongue protrusion and swallowing. This most likely represents: A. Thyroid cancer B. Branchial cleft cyst Type I C. Branchial cleft cyst Type II D. Thyroglossal duct cyst A midline anterior neck mass in a child that moves w/ tongue protrusion and swallowing is classic for a thyroglossal duct cyst. Thyroid CA would appear more lateral as would branchial cleft cysts

35 Resection of this cyst involves: A. Removal of the cyst only B. Removal of the cyst and total thyroidectomy C. Removal of the cyst along with the hyoid bone D. Post-op XRT

36 Resection of this cyst involves: A. Removal of the cyst only B. Removal of the cyst and total thyroidectomy C. Removal of the cyst along with the hyoid bone D. Post-op XRT You need to resect the hyoid bone (or atleast a central portion of it) when resecting these cysts so that they do not recur. This is called the Sistrunk procedure

37 Thyroglossal duct cysts most commonly present in preschool-aged children. Thyroglossal remnants produce midline masses extending from the base of the tongue (foramen cecum) to the pyramidal lobe of the thyroid gland Complete failure of thyroid migration results in a lingual thyroid (US or radionuclide imaging may be useful to identify the presence of a normal thyroid gland w/in the neck) May be located in the midline of the neck anywhere from the base of the tongue to the thyroid gland but most are found at or just below the hyoid bone Indications for surgery include increasing size, the risk for cyst infection, or the presence (1%-2%) of carcinoma The classic treatment involves complete excision of the cyst in continuity with its tract, the central portion of the hyoid bone, and the tissue above the hyoid bone extending to the base of the tongue; Failure to remove these tissues will result in a high risk for recurrence because multiple sinuses have been histologically identified in these locations

38 Regarding oropharyngeal abscesses, which one of the following statements is true? A. Peritonsillar, parapharyngeal, and retropharyngeal abscesses occur with approximately equal frequency among children <10 yrs. of age B. Parapharyngeal and retropharyngeal abscesses can progress rapidly to cause airway obstruction C. Drainage of peritonsillar, parapharyngeal, and retropharyngeal abscesses is best accomplished through the pharyngeal wall D. As with abscesses in other locations in the body, small drains should be placed into transpharyngeally drained abscesses to promote continued evacuation of the abscess cavity

39 Regarding oropharyngeal abscesses, which one of the following statements is true? A. Peritonsillar, parapharyngeal, and retropharyngeal abscesses occur with approximately equal frequency among children <10 yrs. of age B. Parapharyngeal and retropharyngeal abscesses can progress rapidly to cause airway obstruction C. Drainage of peritonsillar, parapharyngeal, and retropharyngeal abscesses is best accomplished through the pharyngeal wall D. As with abscesses in other locations in the body, small drains should be placed into transpharyngeally drained abscesses to promote continued evacuation of the abscess cavity

40 Peritonsillar abscess are rare in children <10 yrs. of age; treated w/ abx and needle aspiration of abscess (if no response in 24 hrs. repeat aspiration or I and D); rarely causes airway obstruction Retropharyngeal abscesses occur in infants, young children, and the elderly (although rare after age 10); Loss of airway is a potential hazard; Abx and drainage through posterior pharyngeal wall or neck are treatments of choice; drains not necessary (drains w/ swallowing) Parapharyngeal abscesses occur in all age groups and may be due to dental infection, pharyngitis, or tonsillitis; B/C these abscesses occur more laterally drainage through oropharynx is hazardous (close to ICA and jugular veins); Should be drained through lateral neck with a drain left in place Greatest morbidity is from IJ thrombosis, vascular erosion, or spread into mediastinum/abdomen via prevertebral or retropharyngeal spaces.

41 Regarding epistaxis, which one of the following statements is false? A. In most cases, epistaxis occurs from the anteroinferior part of the nasal septum B. Properly applied anteroposterior packing controls bleeding in 95% of cases C. Hypoxemia is a potential complication of nasal packing D. Ligation of the internal maxillary artery is ineffective for controlling epistaxis and should be avoided

42 Regarding epistaxis, which one of the following statements is false? A. In most cases, epistaxis occurs from the anteroinferior part of the nasal septum B. Properly applied anteroposterior packing controls bleeding in 95% of cases C. Hypoxemia is a potential complication of nasal packing D. Ligation of the internal maxillary artery is ineffective for controlling epistaxis and should be avoided

43 Approximately 90% of cases of epistaxis arise from Kiesselbach's plexus (anteroinferior part of the nasal septum); in most cases it is easily controlled w/ digital pressure (can be cauterized chemically/electrically; occasionally anterior nasal packing required) In 10% of cases the source is posterior (Woodruff's plexus); frequently occurs in pts. w/ arteriosclerosis and HTN; initial attempt should be anterior or ant/post packs which is successful in 95% of cases (give abx to prevent sinusitis and otitis media) Air exchange is frequently hindered by packing (supplemental O2) Posterior epistaxis that can not be controlled w/ packing can be treated with transantral or transnasal endoscopic ligation of internal maxillary artery (If bleeding high on lateral nasal walls anterior ethmoid artery should be ligated)

44 Regarding acute suppurative parotitis, which one of the following statements is false? A. It usually occurs in elderly or debilitated pts. B. Dehydration is a major contributing factor C. Immediate surgical drainage is mandatory D. The numerous vertically oriented fascial septa of the parotid space lead to multiloculated abscesses when infection progresses E. S. aureus is the most frequent causative organism

45 Regarding acute suppurative parotitis, which one of the following statements is false? A. It usually occurs in elderly or debilitated pts. B. Dehydration is a major contributing factor C. Immediate surgical drainage is mandatory D. The numerous vertically oriented fascial septa of the parotid space lead to multiloculated abscesses when infection progresses E. S. aureus is the most frequent causative organism

46 Acute suppurative parotitis is a severe, life threatening infection most often seen in dehydrated elderly or debilitated pts. W/ poor oral hygiene Its pathogenesis is thought to be related to stasis w/in the salivary ducts as a result of increased viscosity S. aureus is the usual causative organism Initial treatment includes IV hydration, warm packs, sialagogues, and abx; If no improvement in 12 hrs surgical treatment is warranted Drainage is performed through a preauricular incision, w/ elevation of the skin to expose the parotid capsule and vertical incisions through the gland in a direction parallel to the branches of the facial nerve

47 Regarding neck dissections, which one of the following statements is true A. In a classical radical neck dissection, the internal jugular vein, spinal accessory nerve, phrenic nerve, and SCM are routinely resected en bloc w/ the specimen B. B/L simultaneous radical neck dissections are well tolerated and should be performed in cases of midline lesions that have or may have metastasized to both sides of the neck C. The term modified radical neck dissection refers to the dissection of all but the posterior triangle portion of the classic radical neck dissection D. Sentinel lymph node biopsy w/ selective neck dissection is now the standard of care for clinically N0 squamous cell carcinomas of the oral cavity E. Preservation of the spinal accessory nerve significantly reduces the morbidity of neck dissection

48 Regarding neck dissections, which one of the following statements is true A. In a classical radical neck dissection, the internal jugular vein, spinal accessory nerve, phrenic nerve, and SCM are routinely resected en bloc w/ the specimen B. B/L simultaneous radical neck dissections are well tolerated and should be performed in cases of midline lesions that have or may have metastasized to both sides of the neck C. The term modified radical neck dissection refers to the dissection of all but the posterior triangle portion of the classic radical neck dissection D. Sentinel lymph node biopsy w/ selective neck dissection is now the standard of care for clinically N0 squamous cell carcinomas of the oral cavity E. Preservation of the spinal accessory nerve significantly reduces the morbidity of neck dissection

49 Classical radical neck dissection is designed to remove lymph nodes that accompany the great vessels w/in the carotid sheath as well as the submandibular and posterior cervical triangles It involves removal of SCM, IJ, spinal accessory nerve, submandibular gland, and associated lymph nodes; branches of external carotid, sensory branches of anterior roots C2-C4, and cervical branch of facial nerve can sacrificed (phrenic, lingual, hypoglossal nerves preserved) B/L radical neck dissection significantly increases surgical morbidity (facial, pharyngeal, orbital edema, changes in MS from increased CNS venous pressure); prophylactic or elective B/L simultaneous neck dissections should be avoided Modified radical neck dissection involves removal of a nodal tissue w/ preservation of 1 or more of the following: SCM, IJ, and/or spinal accessory nerve Sentinel lymph node Bx is accepted for selected melanomas of the head and neck, but still investigational for for squamous cell CA Syndrome of shoulder droop, scapular displacement, discomfort, and weakness from loss of spinal accessory nerve is major source of morbidity from radical neck dissection.


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