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Head - Neck. Hashmi. 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

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anatomy physiology
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)
anatomy physiology3
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
oral cavity cancer
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

pharyngeal cancer
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.

laryngeal cancer
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

salivary gland cancer
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
abscesses
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

miscellaneous
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