Head & Neck Surgery 2024 Summary (Part 2) PDF

# Head & Neck Surgery 2024 Summary (PART 2) ## Chapter 4: Neck Mass ### Appropriate Initial Assessment | Age | Presentation | | ------------------------ | ----------------------------------------------- | | Children (Pediatric) | Inflammator...

# Head & Neck Surgery 2024 Summary (PART 2) ## Chapter 4: Neck Mass ### Appropriate Initial Assessment | Age | Presentation | | ------------------------ | ----------------------------------------------- | | Children (Pediatric) | Inflammatory - congenital - malignant | | Young adult | Congenital - inflammatory - congenital - malignant | | >40 | Malignant - inflammatory | **Rule of 80 of Neck Masses** - 80% are neoplastic. - 80% are malignant. - 80% are metastatic. **Physical Examination** - Location of the mass in the neck, Triangles/level - Level 1 neck mass: LN, oral cavity, Skin - Level II: LN, oropharynx - Level III: LN, Larynx, Hypopharynx, thyroid - Level IV: LN, thyroid - Level V: LN, Nasopharynx **Excisional/Incisional biopsy may be necessary for:** - Sub-classification of lymphoma - Persistently non-diagnostic FNAB - Facilitating diagnosis of poorly differentiated carcinoma ### Imaging: Appropriate Use and Interpretation The commonest imaging modalities: 1. Ultrasonography (US). 2. Computed tomography (CT): Preferred mainly 3. Magnetic resonance imaging (MRI) 4. Positron emission tomography (PEM) ## Non-Malignant Neck Lumps ### Cystic Hygroma (Lymphangioma) - Congenital lesion, usually present within the first year of life. - It occurs in the posterior triangle. - Soft, cystic, multilocular, partially compressible. - Brilliantly trans-illuminant - Treatment of lymphangiomas: - Injection with picibanil OR - Excision for easily accessible lesions or those affecting vital functions ### Branchial Cleft Cyst - Remnant of branchial cleft (2nd) - Most commonly occur in the second or third decades - Pain +/- (severe throbbing pain) - Smooth, fluctuant non-tender (tender), non-trans-illuminant mass - Lies underlying the anterior border of the SCM muscle. - Treatment: Control of infection by antibiotics, followed by surgical excision. ### Thyroglossal Cyst - This is a common congenital midline neck mass. - Elevates on protrusion of the tongue. - Treatment: - Control of infection by antibiotics, followed (Sistrunk's procedure) = Midportion of the body of the hyoid bone ### Lipoma - Lipomas are the most common benign soft tissue neoplasms in the neck. - Diagnosis is made clinically. ### Sebaceous Cyst - Skin overlying the mass is adherent. - Punctum - Excisional biopsy confirms the diagnosis. ### Cervical Lymphadenopathy - Acute Lymphadenitis - Tender swelling ### Tuberculous (TB) Cervical Lymphadenitis - Upper and middle deep cervical lymph nodes (LNs) - Mass: firm, matted, fluctuate! - Temperature is normal (cold abscess) - Treatment: Anti-TB drugs for 6-9 months. ## Carotid Body Tumor - Rare tumor of chemo-receptors (Structures sensitive to changes in arterial PO2) - Pulsating lump. - Symptoms of transient cerebral ischemia! - Also known as potato tumor (hard, non-tender) - Angiography is the investigation of choice - Surgical removal is based on patient factors and symptoms. ## Pharyngeal Pouch - Diverticulum through gap between - Horizontal fibers of the crico-pharyngeus muscle below - Lowermost oblique fibers of the inferior constrictor muscle above. - Halitosis and regurgitation of food + gurgling sounds - Treatment: cricopharyngeal myotomy ## Ludwig"s Angina - CT infection of the floor of the mouth - Mostly due to dental infections. - Treatment: drainage of pus + antibiotic to cover aerobes with anaerobes ## Malignant Neck Lumps ### Lymphoma - Painless lump, non-tender, smooth, and discrete - Weight loss, hepato-splenomegaly - Mediastinal mass (superior vena caval [SVC] syndrome) - Treatment: according to stage (radio-sensitive) ### Metastatic Lymph Nodes - Upper cervical lymph nodes (upper aero-digestive tract). - Accessory chain of nodes in posterior triangle (Naso-pharyngeal malignancies). - Most common sites of Occult primary: Tonsil, base of tongue, naso-pharynx and pyriform sinus. - Virchow's LN (Troisier 's sign): abdominal and thoracic malignancies - Painless, non-tender, and hard masses ## Chapter 5: Salivary gland ### Boundaries of parotid region: 1. Superiorly: zygomatic arch (lower border). 2. Anteriorly: over the masseter muscle 3. Posteriorly: curves behind the ear till mastoid process. 4. Inferiorly: just below and behind angle of the mandible. ### The parotid duct (Stensen's duct): - Pierce the buccinator muscle… Open 2nd upper molar tooth. ### Branches of facial nerve in parotid gland (serous): 1. Temporal 2. Zygomatic 3. Buccal 4. Marginal mandibular 5. Cervical which supplies the platysma muscle ### Important relations in the parotid gland: 1. 3 important structures pass through gland from lateral to medial; - Facial nerve. - Retro-mandibular vein (drains to internal jugular vein - IJV) - External carotid artery (ECA). ### The Submandibular Gland - Type: mixed (serous (Predominant+ mucin) →70% of daily saliva. - Mylohyoid separates it into superficial & deep lobes. - Submandibular (Wharton's) duct: - It opens into anterior floor of the mouth just at sublingual papillae - Acute suppurative parotitis → parotid abscess. ### Etiology: - Staph. Aureus. ### Clinical Picture: - Tenderness & Temperature: very tender and hot + throbbing pain. - Consistency: Brawny ### Surgical Treatment: - Decompression of the parotid (Hilton's method): Do not wait for fluctuation. - Under general anesthesia, a vertical incision in the skin - The capsule in incised transversely. - Pus is evacuated, a drain is put in the lower part, then closure is achieved. ### Autoimmune diseases - **Mikulicz syndrome:** Enlargement of salivary glands + lacrimal gland. - **Sjogren syndrome:** Similar to Mikulicz syndrome + dryness of mouth and eyes. ### Cysts of the salivary glands - **Mucocoele:** Retention cyst of salivary glands - **Ranula:** - Def: Mucocoele of the sublingual salivary gland. - C/P: - Large bluish swelling at the floor of mouth. Displaces the tongue. - Positive translucent test. - Usually one side, if from both sides →hourglass ranula. - Can also be plunging into the neck - **Treatment:** - It is better treated by **marsupialization** by - Suturing the edges to the floor to prevent recurrence. - **DDX with dermoid:** - Dermoid occurs in mid line. - Negative translucence test. ### Submandibular stones - **WHY stones are commoner in submandibular gland > other gland?** - Viscid Secretions - The drainage is less dependant - The opening of the submandibular gland is at the floor of the mouth and food particles can precipitate in it, obstructing it. - **Clinical picture:** Acute or chronic submandibular calculous sialadenitis. - Pain and swelling of the gland on eating, or on seeing food + fever - Gland can be felt bidigitally. ### MCQ: How to differentiate between submandibular gland and submandibular LN: bidigital examination - The submandibular salivary gland stones lies in one of 4 sites: - Meatal - Intraductal - Juxtaglandular - Intraglandular ### Imaging - **Plain X-ray:** - 85% are radio-opaque due to high content of calcium in submandibular stones - 10-15% are radio-opaque in Parotid stone due to saliva has lower conc of ca. - **Ultrasonography** highlights most stones + anatomical details of the gland. ### Treatment | Location | Treatment | | --------------------- | --------------------------------------------------------------------- | | Meatal stone | Only meatotomy and extraction | | Intraductal stone | Open the ductal at the floor of the mouth: Extract the stone and leaving the incision open. Done local or general anaesthesia | | Juxtaglandular stone | Submandibular sialadenectomy | | Intraglandular stone | Submandibular sialadenectomy | ### Submandibular Gland Surgery - Important structures taken into consideration when planning for excision - Facial artery and vein. - Marginal mandibular nerve (MMN) (branch of the facial nerve). - Lingual & hypoglossal nerves. #### The MMN - To avoid injury to this the following steps are taken: - Incision is made 3-4 cm below the inferior margin of the mandible - Platysma is incised at this low point #### The lingual nerve: - It first lies lateral, then inferior, then medial to Wharton's duct. ## Chapter 6: Oral Lesions and Jaw Swellings ### Lesions of the Oral Cavity - **Aphthous Stomatitis:** - Small, multiple, painful ulcers. - Associated with stress or decreased immunity. - Normally heals within 10-14 days. - May be associated with syndromes as Behcet's or Reiter's syndromes - **Behcet's syndrome:** Multiple oral cavity ulcers, Conjunctivitis, Genital lesions - **Reiter's syndrome:** Multiple oral cavity ulcers, Conjunctivitis, Urethritis., Arthritis, Polyarteritis nodosa (PAN) - **Ranula:** - NB (ranula = little frog) - It is a bluish translucent cyst of the sublingual salivary gland - Treatment: - Excision of the cyst with gland intra-orally. - If it is plunging, excision intra-orally with insertion of a drain from the floor of the mouth down into the neck cavity. - If complete excision is not possible, marsupialization is performed. - **Lingual and sublingual Dermoid Cyst:** - R: excision through a vertical incision from tip of tongue to the frenum. - **Treatment:** - Wide local excision + LN neck dissection + post-operative radiotherapy (sine qua non) - Reconstruction of the buccal mucosa: - Split thickness skin graft. - Pedicled flap (delto pectoral or forehead flap). - Free flap e.g. sandwich TRAM, or radial forearm flap ### 4. The Tongue - **Hyperkeratosis & Leukoplakia:** - Hyperkeratosis reverses back to normal once the offending agent is stopped - Leukoplakia: does not revert back & offending agent is not usually known. - Causes: Smoking, spices, sepsis, spirits, sharp teeth, syphilis, candida - **Tongue Ulcers:** - **Dental:** - **Viral:** Coxsackie, Herpes - **Bacterial:** Acute (Pertussis), Chronic (TB [tip] AND syphilis [middle]. - **Fungal:** - **Aphthous** - **Neoplastic:** - **SCC** ### Incidence and Site - **Tongue Cancer:** - Gender: Males, Mostly on the lateral margin of anterior 2/3 (47%) - Never in the midline ### Etiology - **Risk factors:** 6s + 1c. - **Premalignant lesion:** Leukoplakia, erythroplakia, oral submucous fibrosis. ### Pathology - Microscopically: SCC (most common) - Grossly: Ulcer (most common) ### Clinical picture - Malignant ulcer: Everted edges are characteristic - Excessive salivation, Ankyloglossia., Inability to articulate well, Fetor - Lump in the neck ### Investigations - **Biopsy:** - Excisional (for small lesion under local anesthesia) - Incisional (for a large lesion) ### Classification and Staging | Stage | Description | | ------ | ------------------------------------------------------------ | | Tx | Primary tumor cannot be assessed | | TO | No evidence of primary tumor | | Tis | Carcinoma in-situ. | | T1 | Tumor <2 cm (in greatest dimension). | | T2 | Tumor 2 but <4 cm | | T3 | Tumor >4 but <6 cm. | | T4 | Tumor invades adjacent structures (e.g. mandible, skin). | | Stage | Description | | ------ | ------------------------------------------------------------ | | Nx | Regional LNs cannot be assessed | | NO | No regional LN metastases. | | N1 | Metastasis in a single ipsilateral LN <3 cm (in greatest dimension) | | N2a | Metastasis in a single ipsilateral LN >3 cm but not > 6 cm. | | N2b | Metastasis in multiple ipsilateral LN, none > 6 cm. | | N2c | Metastasis in bilateral or contralateral LNs, none > 6 cm. | | N3 | Metastasis in any LN>6 cm | | Stage | Description | | ------ | ------------------------------------------------- | | MO | No evidence of distant metastases. | | M1 | Evidence of distant metastases. | ### Treatment - Wide local excision with a 2-cm safety margin. - If LNs are +ve: Unilateral Modified Radical Neck Dissection (MRND) - If LNs are -ve: selective supra-omohyoid neck dissection (on same side of tumor) - Post-operative radiotherapy (RT) (sine qua non) - Reconstruction: Radial forearm free flap or pedicled-flap (pectoralis major or forehead) ### Swellings of the Jaw #### 1. Congenital #### Odontomes (developmental abnormalities of the teeth) - **Ameloblastoma (Adamantinoma):** - Origin: from dental lamina, commonest tumor of the lower jaw. - **Clinical picture:** - 4th or 5th decade of life, more common in females. - 3rd molar region, a multilocular cyst, which is the commonest presentation. - It is locally malignant. - **X-ray:** - Honeycomb or fine soap & bubble appearance - **Treatment:** - Excision with 1 cm safety margin with reconstruction using bone grafts. - If not adequately removed, to lung metastasis (no lymph node metastasis). - It is not radio-sensitive (i.e. it is radio-resistant). - **Odotogenic Myxoma:** - Similar to ameloblastoma, but it has myxomatous stroma. #### 2. Traumatic: Mandible fractures - **Site: most common** 1. Body (29%). #### 3. Inflammatory - **Alveolar Abscess:** - Definition: Abscess in alveolar ridge of the jaw, - **Osteomyelitis of the Mandible** #### 4. Neoplastic - **Epulides:** - Definition: Swellings from muco-periosteum (lumps on gums). - **Types:** - Fibrous epulides: The commonest form - Giant cell epulides DD from osteoclastoma, situated peripherally in the mandible. - Pregnancy epulides - Cause: ↑ estrogen level during pregnancy and bad oral hygiene. - Denture induced granuloma - **Osteoclastoma (Giant Cell Tumor):** - It is a rare locally malignant tumor of the jaw. - It has a central predilection (i.e. arises near the symphysis menti). - Complete surgical resection is required for adequate treatment as incomplete resection leads to recurrence in about 70% of cases - It is radiosensitive. - **Squamous Cell Carcinoma (SCC):** - **Treatment:** segmental resection of the mandible + together with adjacent involved tissues + modified radical neck dissection + post-operative radiotherapy. - **Burkitt's Lymphoma:** - Etiology: Epstein-Barr (EB) virus is the most likely etiological factor. - Diagnosis: Plain X-ray or CT: multiple osteolytic deposits with bone destruction. - **Treatment:** the tumor is sensitive to chemotherapy. #### 5. Others (Cysts) - **Dentigerous Cyst:** from the crown of a non-erupted tooth. - Treatment: enucleation. - **Dental Cyst:** - Similar to dentigerous, but arises from the apex of the tooth. - Treatment: enucleation.