Head And Neck

High Yield Anatomy

Name the structures of the thoracic outlet from anterior to posterior

• Anterior to posterior - Subclavian Vein → Phrenic Nerve → Anterior Scalene → Subclavian Artery (SCA) → Middle Scalene ‘'’The phrenic nerve travels from lateral to medial on top of the anterior scalene as it courses into the chest.’’’

  Name the boundaries and contents of the anterior and posterior neck triangles

• Anterior neck triangle
  • Anterior boundary— Midline of the neck
  • Posterior boundary — Sternocleidomastoid (SCM)
  • Inferior (Apex) — Sternal notch
  • Superior (Base) — Lower border of the body of the mandible
  • Contents: Carotid Sheath
• Posterior Neck Triangle
  • Anterior boundary — Posterior border of SCM
  • Posterior boundary — Trapezius muscle
  • Base — Middle 3rd of Clavicle
  • Apex — Intersection of SCM and Trapezius
  • Contents: Spinal Accessory Nerve
• Anterior/Posterior triangles are broken up into smaller triangles, but these are not commonly tested

  What muscles does the recurrent laryngeal nerve (RLN) innervate? How does the anatomy differ on the right side versus the left side?

• RLN branches off vagus nerve and innervates muscles of larynx (except for cricothyroid muscle, which is innervated by Superior Laryngeal Nerve)

• Right side: Vagus passes anterior to SCA and the RLN loops behind SCA and travels superiorly in Tracheoesophageal (TE) groove
• Left side: Vagus passes anterior to aortic arch between Left Common Carotid Artery and SCA and RLN then loops behind aortic arch and travels superiorly in TE groove The superior laryngeal nerve innervates the cricothyroid muscle, all other laryngeal muscles are innervated by the recurrent laryngeal nerve

Head and Neck Cancers

What is the most common head and neck cancer?

• Squamous cell cancer (SCC)
• 5th most common Cancer overall; Men affected more than women 5:1
• Risk Factors: Alcohol and tobacco (Synergistic Effect), HPV
• Each subsite (e .g . oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, nose, paranasal sinus, and salivary gland) has its own staging system and treatment recommendations . However, IN GENERAL:
• Stage I and II - Local disease (No regional or distant Mets)
• Stage III and IV - Either locally aggressive or distant mets
• Surgery or Radiation acceptable for stage I-II . Surgery vs . radiation will depend on location and morbidity of resection (e .g . WLE for intraoral lesions vs radiation for vocal cord lesions) .
• Multimodality required for Stage III-IV. Usually surgery (WLE + MRND) followed by radiation +/- chemotherapy
• Oral SCC >4cm (or + nodes/bone invasion) needs resection with MRND followed by postop radiation

  Are large or small salivary gland tumors more likely to be malignant, and what are the subtypes of the most common salivary malignant tumors?

• Tumors of small salivary glands more likely to be malignant than larger glands (i .e . sublingual > submandibular > parotid)
• Malignant Tumors
• Mucoepidermoid Cancer - Most common
  • Treatment → Resection (total parotidectomy with facial nerve preservation if parotid) with MRND, +/- postop XRT
• Adenoid Cystic Cancer
  • Slow growing with tendency to locally invade (particularly nerves)
  • Tx: resection (total parotidectomy with facial nerve preservation if parotid) with MRND, +/- postop XRT
  • Don’t need to aggressively resect Adenoid Cystic Cancer if it would result in high morbidity as it is very sensitive to XRT

    What are the principles of management of an unknown primary head and neck cancer tumor (i .e . regional metastasis to node without known primary)?

     1. Thorough head and neck exam - included fiberoptic exam of nasopharynx and larynx
     2. FNA of regional node or excisional biopsy
     3. CT scan Head/Neck/Chest +/- PET
     4. OR for direct laryngoscopy, esophagoscopy, and ipsilateral tonsillectomy, + biopsies directed by previous work-up
    

• Most common site of unknown primary is tonsil followed by base of tongue
• If no primary identified - will still need ipsilateral MRND and bilateral XRT

  How do you diagnose and treat a melanoma of the head and neck?

• Diagnose with full-thickness biopsy (excisional, incisional, or punch) - NO SHAVE BIOPSY!

• Staged like melanoma at other sites (See melanoma section)

• Treatment: Resection with the same margins as other sites if possible (1cm for lesions <1mm in depth and 2cm for those >2mm in depth)
• Tumor margins can be adjusted if abutting critical structures
• Branches of facial nerve should be preserved unless clinically involved
• Confirm negative margins prior to reconstruction
• Moh’s surgery also an option, especially if resection would result in morbidity
• Lymphadenectomy is required if regional nodes are clinically positive .
• If clinically node negative → Sentinel Lymph Node (SLN) for >1mm depth
• How to determine lymph node basin for melanoma of head/ neck → Primary lesions anterior to imaginary line from one tragus to the other will drain anteriorly through the parotid basin
• For anterior lesions → superficial parotidectomy and selective anterior neck dissection
• For posterior lesions → Selective posterior neck dissection
• Adjuvant therapy for melanoma is currently undergoing rapid advancement and recommendations may change in near future
  • Adjuvant interferon alpha has been showed survival benefit in advanced disease, however it has many side effects and poorly tolerated
  • Adjuvant radiation therapy may help with regional control, however has no survival benefit
  • Ongoing trials for targeted therapies (monoclonal antibodies, oncogene inhibitors) are showing a lot of promise

Quick Hits

Painless mass on roof of the mouth?

• Torus Palatinus (overgrowth of cortical bone)
• Treatment? Do Nothing (resect if interfering with denture fit)

  Most common site for oral cavity cancer?

• Lower lip (related to sun exposure)
• Will need flap reconstruction if > ½ lip resected

  EBV related H&N Cancer?

• Nasopharyngeal SCC
• Treatment? → XRT

  MC malignant salivary gland tumor?

• Mucoepidermoid carcinoma

  MC benign salivary gland tumor? And what is the treatment?

• Pleomorphic adenoma
• Superficial Parotidectomy (Do not enucleate this lesion)

  Gustatory sweating following parotidectomy? What is the cause of this?

• Frey’s syndrome
• Injury to auriculotemporal nerve that then cross innervates with sympathetic fibers

  Elderly patient with postop fever, pain, and swelling at angle of jaw? What is the organism and what is the treatment?

• Suppurative parotiditis
• Staphylococcus
• Hydration and antibiotics; I&D if abscess is present

  Management of bleeding at tracheostomy site?

• Small amount → Bronchoscopy to rule out Tracheoinnominate fistula
• Large amount → Place finger into tracheostomy, hold manual pressure against sternum and go to OR emergently for median sternotomy and resection of innominate artery . Close tracheal side primarily and cover with strap muscle (do NOT put synthetic interposition graft . It will get infected and blow out) .

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