Head - Neck

1. Head - Neck Hashmi

2. Anatomy - Physiology • Ant Triangle  SCM, Sternal Notch, Inf border of digastric muscle – contains carotid sheath • Post Triangle  Post border SCM, trapezius, clavicle – contains CN XI + brachial plexus • Phrenic nerve  lies on Ant scalene muscle • Vagus  Runs btwn IJ and Carotid • Trigeminal N  ophthalmic, maxillary, mandibular branches. Sensory to face. Mandibular give taste to Ant 2/3rd of tongue • Facial N  temporal, zygomatic, bucal, marginal mandibular, cervical branches. Motor to face • Glossopharyngeal  sensory to post tongue. Motor to stylopharyngeus, injury affects swallowing • Hypoglossal  motor to tongue. Injury: tongue deviates to side of injury • RLN  larynx except cricothyroid muscle (sup laryngeal n)

3. Anatomy - Physiology • Parotid  secretes mostly serous fluid • Sublingual  secretes mainly mucin • Submandibular  50/50 serous and mucin • Frey Syndrome  after parotidectomy, injury to auriculotemporal n that cross reinnervate with sympathetic fibers to sweat glands of skin: gustatory sweating • Torus palatini  congenital bony mass on upper palate of mouth. TX: nothing • Torus mandibular congenital bony mass on ant lingual surface of the mandible • RND  CN XI, SCM, IJ, omohyoid, submandibular gland, sens C2-5, cervical branch of facial n, and ipsilateral thyroid • MRND  RND minus CN XI, SCM, IJ

4. Oral Cavity Cancer • Most common  Squamous cell cancer • Risk factor  tobacco and etoh • Erythroplakia is considered more premalignant than leukoplakia • Lower lip most common site for oral cavity cancer secondary to sun exposure • Nodal spread unusual, however to submental and submandibular chains first • Ant tongue tumors spread to cervical chain • Survival rate lowest for hard palate tumors  hard to resect • Oral cavity cancer increased in Plummer-Vinson  glossitis, cervical dysphagia from esophageal web, spoon fingers, iron-deficiency anemia • Treatment: Wide resection if <2cm (need 1-2cm margin) MRND if >2cm or +nodes Postop XRT for >2cm, +margins, nerve/lymph/vasc invasion

5. Pharyngeal Cancer • Nasopharyngeal: SCCA  EBV, Chinese; presents with nose bleeding/obstruction. Deep cervical neck nodal spread Tx: XRT primary, MRND for >2cm or +nodes, Postop chemo for advanced stages. Children: Lymphoma #1 Tx: Chemo Papilloma most common benign neoplasm • Oropharyngeal: SCCA  presents as neck mass, sore throat Deep cervical neck nodal spread Tx: XRT or surgery, MRND for >2cm or +nodes • Tonsillar: SCCA  etoh, tobacco, males, asymptomatic, 80% +nodes @ dx Tx: Tonsillectomy, XRT • Hypopharyngeal: SCCA  hoarseness, early mets Ant cervical nodes Tx: Laryngectomy, MRND, Post XRT • Angiofibroma: Benign; extremely vascular, presents as obstruction/epistaxis Usually internal maxillary artery Tx: angiography and embolization followed by resection.

6. Laryngeal Cancer • Hoarseness, aspiration, dysnea, dysphagia • Take ipsilateral thyroid lobe with RND • Papilloma most common benign lesion • Supraglottic: SCCA; early nodal spread to submental/submandibular Small  XRT Large  Laryngectomy, MRND, Postop XRT • Glottic: SCCA; nodal spread to anterior cervical chain Small  XRT or laser, chordetomy w/recurrence Large  Laryngectomy, MRND, Postop XRT Fixed cords  Laryngectomy +XRT • Subglottic: SCCA; nodal spread to ant cervical chain and early mets Small  XRT Large  Laryngectomy, MRND, Postop XRT

7. Salivary Gland Cancer • Parotid, submandibular, sublingual, minor salivary glands • Malignant tumor: #1 Mucoepidermoid, #2 Adenoid Cystic Painful mass, lymphadenopathy, facial nerve paralysis Tx: resection; MRND and postop XRT if high grade or SCCA Parotid: Take whole lobe preserving facial n • Benign tumor: #1 Pleomorphic adenoma (mixed) – Malignant degenerationin 5% Tx: Superficial parotidectomy, total if malignant. MRND - high grade #2 Warthin’s tumor males; bilateral in 10% Tx: Superficial parotidectomy • Parotid surgery injury most common - greater auricular n • Submandibular resection - identify: mandibular branch of facial, lingual, hypoglossal n • Hemangioma – most common salivary gland tumor in children

8. Abscesses • Peritonsillar: Older kids (>10yr), does not obstruct airway Tx: Needle aspiration 1st, then drain through tonsillar bed (intubate) Self-drain with swallowing once opened • Retropharyngeal: Younger kids (<10yr), airway emergency Tx: Intubate, drain through post pharyngeal wall Self-drain with swallowing once opened • Parapharyngeal: Any age; occurs with dental infxn, tonsillitis, pharyngitis Vascular invasion, mediastinal spread via prevertebral and retropharyngeal space Tx: Drainage through lateral neck, leave drain. Avoid carotid – IJV • Ludwig’s Ang: Infxn of floor of mouth, involving myelohyoid muscle. Usually after dental infxn of mandibular teeth. Possible airway obst. Tx: Airway control, drainage, antibiotics

9. Miscellaneous • Suppurative parotiditis: Elderly pt, dehydration, Staph most common. Tx: Fluids, salivation, antibiotics, drainage • Sialodenitis: Acute inflammation of salivary duct related to stone Tx: incise duct and remove • Cleft lip (primary palate): Repair @ 10wk, 10 lbs, 10 Hgb. Repair nasal deformity. • Cleft palate (secondary): Involves hard/soft palate. Repair at 12 months • Cauliflower ear: Calcified hematomas • Chemodectoma: Vascular tumor of middle ear (paraganglionoma). Tx: Sg +/- XRT • Acoustic neuroma: CN VIII, tinnitus, hearling loss, unsteadiness. Tx: Sg or XRT • Cholesteatoma: Epidermal inclusion cyst of ear • CSF rhinorrhea: Cribiform plate fx. CSF has tau protein • Amelioblastoma: Malignancy of neck/jaw. Soap bubble on x-ray. Tx: WLE • TMJ dislocation: Closed reduction • Epiglottitis: Child. HI-B. stridor-drooling-leaning-thumbprint sign Tx: airway/abx • Kaposi’s sarcoma: Oral/pharyngeal mucosa. AIDS pt. Tx: XRT, intratumor vinblastine • TI fistula: Replace trach, inflate balloon  OR & Ligate