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Tumors of Head and Neck

Upper Aerodigestive tract:

Oral cavity
Pharynx
Larynx
Nasal cavity/ paranasal sinus

STAGING:

Recommended at initial evaluation of all patients with primary cancers of the upper aerodigestive tract

May involve:
o
Direct laryngoscopy
o
Rigid/ flexible esophagoscopy
o
Rigid/ flexible bronghoscopy panednoscopy- some surgeons argue against the use of bronchoscopy because of the low yield of the
examination in asymptomatic patients with a normal CXR
o
Barium swallow- used instead of esophagoscopy as a preoperative evaluation

Primary Tumor
TX
Unable to assess primary tumor

T0

No evidence of primary tumor

Tis

Carcinoma in situ

T1

Tumor is <2cm in greatest dimension

T2

Tumor >2cm and <4cm in greatest dimension

T3

Tumor >4cm in greatest dimension

T4
(lip)

Primary tumor invading cortical bone, inferior alveolar


nerve, floor of mouth, or skin of face

T4a
(oral)

Tumor invades adjacent structures

T4b
(oral)

Tumor invades masticator space, pterygoid plates, or


skull base and/or encases the internal carotid artery

Regional Lymphadenopathy
NX

Unable to assess regional lymph nodes

N0

No evidence of regional metastasis

N1

Metastasis in a single ipsilateral lymph node, 3cm or


less in greatest dimension

N2a

Metastasis in single ipsilateral lymph node, >3cm


and <6cm

N2b

Metastasis in multiple ipsilateral lymph nodes, all


nodes <6cm

N2c

Metastasis in bilateral or contralateral lymph nodes,


all nodes <6cm

N3

Metastasis in a lymph nodes >6cm in greatest


dimension

MX
M0
M1

Unable to assess for distant metastases


No distant metastases
Distant Metastases

Distant Metastases

I. ORAL CAVITY
-regional spread: lymphatics of the submandibular and upper jugular region (levels 1,2 and 3)
- >90% SCC

1. Lips
Anatomy
Epidemiology

Risk factors
Clinical Findings

Negative prognostic
factors

Prognosis

Treatment

- Cancer of the lip is commonly seen in white men


- 50-70y.o.
- can be seen in younger patients, particularly those with fair complexion
- histology: usually SCC
- Lower lip (88-98%)
- upper lip (2-7%)
- oral commissure (1%)
**basal cell carcinoma presents more frequently in the upper than the lower lip
- prolonged exposure to sunlight, fair complexion, immunosupression and tobacco use
- ulcerated lesion on the vermilion or cutaneous surface
- careful palpation is important in determining the actual size and extent
- presences of paresthesia in the area adjacent to lesion may indicate mental nerve involvement
- perineural invasion
- involvement of underlying maxilla/ mandible
- presentation on the upper lip or commisure
- regional lymphatic mestastasis
- age younger than 40y.o. at onset
- results in fewer than 200 deaths annually and is stage dependent
- early diagnosis coupled with adequate treatment results in high likelihood of disease control
- 5-year cure rate: 90% and drops to 50% in the presence of a neck mass
- determined by overall health of patient, size of primaray lesion and presence of regional metastasis
a. small primary lesions

Surgery or radiation

Surgical excision with histologic confirmation of tumor-free margins is the preferred modality
b. presence of clinically evident metastasis

Neck dissection is indicated


- after tumor excision: reconstruction of lip defects

Realignment of vermilion border

Resection with primary closure

Burows triangle

Karapandzic flap

Lip switch (Abbe-Estlander) flap- micorsotomia is a potential complication

Webster or Bernard type

2. Oral Tongue
Anatomy

Epidemiology
Treatment

- muscular structure with overlying nonkeratinizing squamous epithelium


- posterior limit: circumvallate papillae
- ventral portion: contiguous with anterior floor of mouth
- composed of four intrinsic and four extrinsic muscles
- regional lymphatics: submandibular space and upper cervical lymph nodes
- lingual nerve and hypoglossal nerve innervate the tongue (if invaded: ipsilateral paresthesia and deviation of tongue on protrusion
with fasciculations and eventual atrophy)
- commonly seen on the lateral and ventral surface
a. Small primary tumors (T1-T2)
- wide local excision with either primary closure or healing by secondary intention
- CO2 laser may be used
- partial glossectomy removes significant portions of lateral tongue and permits reasonably effective postoperative function
b. Larger tumors of the tongue that can invade deeply
- use of soft, pliable fasciocutaneous free flaps
- prosthetic augmentation
** treatment of regional lymphatics is typically performed with the same modality used to address primary site

If surgery was used: MRND or SND is used

3. Retromolar trigone
Retromolar trigone- tissue posterior to the posterior inferior alveolar ridge and ascends over the inner surface of the ramus of the mandible

Early involvement of the mandible is common d/t lack of intervening soft tissue in the region.

Trismus- involvement of the muscles of mastication and may indicate spread to the skull base

Tumors may extend:


posteriorly into the oropharyngeal anatomy or laterally to invade the mandible
marginal or segmental mandibulectomy with a soft-tissue and/or osseous reconstruction - to maximize a patient's postoperative ability for speech and
swallowing
Ipsilateral neck dissection - risk of metastasis to the regional lymphatics

4. Alveolar ridges
Alveolar mucosa- overlies the bone of the mandible and maxilla
from the gingivobuccal sulcus to the mucosa of the floor of mouth and hard palate
posterior limits: pterygopalatine arch and the ascending portion of the ramus of the mandible
tx of lesions requires resection of the underlying bone (d/t the tight attachment of the alveolar mucosa to the mandibular and maxillary periosteum)

Marginal resection of the mandible- for tumors of the alveolar surface that present with minimal bone invasion (anterior mandibulotomy)

Transoral and pull-through procedure- if a coronal or sagittal marginal mandibulotomy is performed

Segmental mandibulectomy- for extensive tumors that invade into the medullary cavity

Preoperative radiographic evaluation of the mandible determine the type of bone resection required
Panorex views (demonstrate gross cortical invasion)
MRI best modality for demonstrating invasion of the medullary cavity of the mandible
Sectional CT scanning with bone settings optimum modality for imaging subtle cortical invasion

5. Floor of mouth
-

Mucosally covered semilunar area that extends from anterior tonsillar pillar posteriorly to the frenulum anteriorly and from the inner surface of the
mandible to the ventral surface of the oral tongue.
Genioglossus, mylohyoid and hyoglossus muscles comprises the muscular floor of mouth and prevents the spread of disease, with invasion results
decrease tongue mobility and poor articulation
Invasion to the salivary ducts can lead to direct extension into the sublingual space.
Anterior or lateral extension to the mandibular periosteum is of primary importance in the preoperative assessment. MRI,CT and Panorex Radiography
helpful in determining invasion
Bimanual palpation to assess adherence or fixation to adjacent bone is essential, its absence indicates that mandible sparing procedure is feasible.
Resection of large tumor of the floor of mouth may require a lip-splitting incision and immediate reconstruction. Its goal is to obtain watertight closure and
avoid tongue tethering.

6. Buccal mucosa
Buccal mucosa- all of the mucosal lining from the inner surface of the lips to the line of attachment of mucosa of the alveolar ridges and pterygomandibular raphe

Etiologies of malignancies:
lichen planus
chronic dental trauma
habitual use of tobacco and alcohol

Tumors - propensity to spread locally and to metastasize to regional lymphatics


Resection of the alveolar ridge of the mandible or maxilla if with local intraoral
Small lesions: excised surgically
Advanced tumors: combined surgery and postoperative radiation
Deep invasion into the cheek: through-and-through resection
Reconstruction aimed at providing both internal and external lining may be accomplished with a folded fasciocutaneous free flap or a combination of
pedicled and free tissue techniques

Lymphatic drainage:
Facial
Submandibular nodes (level I)

7. Hard palate
Hard palate- semilunar area between the upper alveolar ridge and the mucous membrane covering the palatine process of the maxillary palatine bones
extends from the inner surface of the superior alveolar ridge to the posterior edge of the palatine bone

Most squamous cell carcinomas caused by habitual tobacco and alcohol use
chronic irritation from ill-fitting dentures also may play a causal role
treated surgically
advanced staged tumors- adjuvant radiation

Necrotizing sialometaplasia - butterfly-shaped ulcer


tx is symptomatic and biopsy confirms its benign nature

Torus palatini - bony outgrowths of the midline palate


no surgical treatment unless symptomatic

Squamous cell carcinoma and minor salivary gland tumors most common malignancies of the palate

Minor salivary gland tumors:


adenoid cystic carcinoma, mucoepidermoid carcinoma, adenocarcinoma and polymorphous low-grade adenocarcinoma
tend to arise at the junction of the hard and soft palate
Direct infiltration of bone leads to extension into the floor of the nasal cavity and/or maxillary sinus

Mucosal melanoma - presents as a nonulcerated, pigmented plaque

Kaposis sarcoma of the palate- most common intraoral site for this tumor

Tumors may present as either:


Ulcerative
Exophytic
Submucosal mass

Periosteum of the palate- can act as a barrier to spread of tumorso


very superficial lesions: mucosal excision is adequate
involvement of the periosteum: requires removal of a portion of the bony palate
Larger lesions involving the palate or maxillary antrum: Partial palatectomy of infrastructure maxillectomy

Malignancies may extend along the greater palatine nerve making biopsy important for identifying neurotropic spread

II. Pharynx
Anatomy

Metastasis

Oropharynx
- extends from soft palate to the supereior
surface of the hyoid bone
- includes: base of the tongue, inferior
surface of the soft palate and uvula, anterior
and posterior tonsillar pillars, glossotonisillar
sulci, tonsils and lateral and posterior
pharyngeal walls
Direct extension: spread into parapharyngeal
space; ascending ramus of mandible can be
involved when tumors invde the medial
pterygoid muscle
Regional metastasis: high (ipsilateral or
bilateral nontender cervical
lymphadenopathy is a common presenting
sign)

Epidemiology

Lymph node metastasis: most commonly


occurs in subdigastric or level 2
: also found in 2,3 and 4 in addition to
retropharyngaeal and parapharyngeal lymph
nodes
- histology of tumors SCC
- incidence increased, attributed to HPV (HPV
16) related development of malignancy

Diagnosis

Clinical Findings

Treatment

Hypopharynx and Cervical esophagus


- extend form the vallecula to the lower
border of the cricoids cartilage
- includes the pyriform sinuses, the lateral
and posterior pharyngeal walls and the
postcricoid region

Nasopharynx
- extends in a plane superior to the hard
palate from the choana to the posterior nasal
cavity to the posterior pharyngeal wall
- includes: the Rosenmuller, the Eustachian
orifices, and the site of the adenoid pad

Direct extension: to the larynx, may result in


vocal cord paralysis and may lead to airway
compromise

Lymphatic spread: To posterior cervical,


upper jugular and retropharyngeal nodes

Regional metastasis: bilateral metastatic


adenopathy in the paratracheal chain is
common and majority of patients present
with nodal disease at the time of diagnosis

Distant metastasis is present ini 5%


** indications of perinueral spread:

CT- erosion or enlargement of


neural foramina

MRI- enhancement of cranial


nerves
** worse prognosis

- SCC frequently presents at the advanced


stage

Flexible fiberoptic laryngoscopy


Barium swallow
CT and/or MRI
- ulcerative lesions or exophytic mass
- tumor fetor from necrosis is common
-hot potato voice in large tonghu base
tumors
- dysphagia and weight loss are common
symptoms
- referred otalgia, mediated by tympanic
branches of CN9 and CN10
- trismus may indicate advanced disease and
usually results from involvement of pterygoid
muscles
- Approximately 50% of patients have
metastases at the time of presentation
- bilateral mets are common from tumors in
the base of tongue and soft palate

- neck mass
- muffled or hoarse voice
- referred oatalgia
- dysphagia
- weight loss
- a common symptom is dysphagia, starting
with solids and progressing to liquids, leaving
patients malnourished at the time of
presentation

Goals: maximizing survival and preserving


fuction
- tumors in this region are radiosensitive

Surgery with postoperative radiation therapy


improves locoregional control

- tumors are usually SC origin


- risk factors: area of habitation, ethnicity and
tobacco use
- related to EBV infection
Flexible or rigid fiberoptic endoscope
CT with contrast for determining bone
destruction
MRI for intracranial and soft- tissue extension
-nasal obstruction
- level 5/ posterior neck mass
- epistaxis, headache, serous otitis media
with hearing loss, and otalgia
- CN involvement is indicative of skull base
extension and advance disease

Poor survival rates than other sites of head


and neck because of advanced stage and LN
metastasis at presentation
5 year survival rate: <20%

definitive radiation therapy- limited to


T1 tumors

concomitant chemoradiation- generally


used for T2 and T3

a. Early stage lesions- monomodality with


radiation
b. later stages (3,4)- concomitant
chemoradiation

Bilateral regional metastatic spread is


common

Total laryngectomy is often required

resection of primary tumor and


surrounding tissue is performed en bloc

bilateral neck dissection- frequently


indicated
Laryngopharyngectomy
Cervial esophageal cancers- may be managed
surgically or aby concomitant
chemoradiation,

total esophagectomy because of


tendency for multiple primary
tumors and skip lesions

Standard: chemoradiation

III. Larynx
- Laryngeal carcinoma is a diagnosis typically entertained in individuals with prominent smoking histories and the complaint of a change in vocal quality
- borders span from the epiglottis superiorly to the cricoids inferirorly
- Lateral limits are the aryepiglottic folds

Anatomy

Histology
Minor salivary glands
Lymphatic drainage
Lymphatic spread
Clinical Findings

Diagnosis

Treatment

Supraglottic
Glottis
Subglottis
- includes the epiglottis, aryepiglottic
- includes: true vocal cords, anterior and
- inferior surface of the glottis to the lower
folds, arytenoids, and ventricular bands
posterior commissures
margin of the cricoids cartilage
(false vocal folds)
- inferior border: ventricles of morgani
PCCE that covers the false vocal cords
Nonkeratinized stratified squamous
PCCE
Present
Absent
Present
Pierce the thyroid membrane to the
Prelaryngeal node (delphian node), paratracheal LN, and deep cervical LN
subdigastric and superior jubgular nodes
Common (30-50%)
Limited (1-4%)
Common (40%)
- chronic sore throat, dysphonia (hot
- hoarseness is an early symptom (in contrast
- relatively uncommon and typically present
potato voice), dysphagia or neck mass
to supraglottic)
with compromise vocal cord paralysis
secondary to regional metastasis
- airway obstruction is usually a late
(usually unilateral) and or/or airway
- may cause vocal cord fixation by inferior
symptom and is the result of tumor bulk or
extension or by direct invasion of the
impaired vocal cord mobility
-40% present with regional adenopathy and
cricoarytenoid joint
special attention must be directed to the
- referred otalgia or odynophagia is
treatment of paratracheal lymph nodes
encountered with advanced supraglottic
cancers
Staging classification

includes assessment of vocal cord mobility as well as local tumor extension

clinical staging requires: flexible fiberoptic endoscopy and direct microlaryngoscopy or bronchoscopy

key areas to note for extension: the vallecula, base of tongue, ventricle, arytenoids, and anterior commisure
Severe dysplasia with carcinoma in situ
- total laryngectomy

complete removal of involced mucosa with microlaryngostomy


Limited involvement of arytenoids or anterior commissure

best candidates for good posttreatment voice quality (after microlaryngostomy)


Early stages of glottis and suproglottis

radiation therapy provides excellent disease control and preservation of voice


quality
small glottis cancers

partial laryngectomy ( voice quality may vary)


supraglottic CA without artenoid or vocal cord extension:

standard supraglottic laryngectomy


For advanced tumors with extension beyond the endolarynx:

total laryngectomy with postoperative radiation


in this setting reconstruction by means of pectoralis major flap or free flap reconstruction is
required for lesion with pharyngeal extension

IV. Nose and Paranasal Sinus


-

Site for a great deal of infection and inflammatory pathology


Dx usually made after unsuccessful tx for recurrent sinusitis
Associated symptoms include chronic nasal obstruction, facial pain, headache, epistaxis, and facial numbness. Nonspecificity leads to an advanced stage
upon presentation.
Orbital invasion - proptosis, diplopia, epiphora, and vision loss.
Pterygopalatine fossa or skull base invasion - paresthesia within the distribution of CN V2; poor prognostic factor
Maxillary sinus tumors loose dentition indicating erosion of the alveolar and/or palatal bones
Tumors found to arise posterior to Ohngren's line - worse prognosis than more anteriorly based lesions
Variety of benign lesions are present
o
Herniation of intracranial contents into the nasal cavity can occur with the erosion of the anterior skull base with the resultant presentation of a
sinonasal mass on clinical examination
Malignant tumors of the sinuses are predominantly squamous cell carcinomas
Metastases from the kidney, breast, lung, and thyroid may also present as an intranasal mass. Regional metastasis uncommon.
Diagnosis of an intranasal mass is made with the assistance of a headlight and nasal speculum or nasal endoscopy:
o
Site of origin
o
Structures involved
o
Vascularity

meningocoele and encephalocoele presents as a unilateral pulsatile mass


o
Skull base foramen perineural invasion
o
Cavernous sinus extension, cribriform plate erosion, and dural enhancement respectability and type of surgical approach
*Biopsy of a unilateral nasal mass should be deferred until imaging studies are obtained.
Untimely biopsy can result in a CSF leak.
*Benign processes frequently present as slow-growing expansile tumors with limited erosion of surrounding bone, as compared to the lytic destruction typically
associated with malignancies.
The standard treatment for malignant tumors of the paranasal sinuses is surgical resection with postoperative radiation therapy.
o
medial wall of the maxillary sinus medial maxillectomy
o
advanced tumors multispecialty approach
o
vascular tumors - preoperative embolization performed within 24 hours
Prognosis is dependent on tumor location and extension to the surrounding anatomy.
o
Infrastructure maxillectomy which includes removal of the hard palate and the lower maxillary sinus - inferiorly based tumors of the maxillary
sinus.
o
Complete maxillectomy (including removal of the orbital floor) - for tumors in the upper portion of the maxillary sinus.
o
Exenteration of the orbital contents - invasion of the orbital fat
o
For tumors involving the ethmoid sinuses, the integrity of the cribriform plate is assessed with preoperative imaging.

Complete sphenoethmoidectomy or medial maxillectomy - localized to the lateral nasal wall.

Anterior craniofacial resection - erosion of the cribriform plate


* Paranasal sinus malignancies that are deemed unresectable are those with bilateral optic nerve involvement, massive brain invasion, or caroti dencasement.
* Combined treatment with surgery and postoperative radiotherapy for squamous cell carcinoma of the sinuses results in survival superior to either radiation or
surgery alone.
*Chemotherapy has a limited application and may be used for specific indications (ie. Rhabdomyosarcoma follow up radiation)
*Surgery is reserved for persistent disease after chemoradiation (ie. Sinonasal undifferentiated carcinoma)
-

V. Others: Salivary Gland Tumors


Submandiblar and Sublingual

MAJOR
Parotid

MINOR

Anatomy
Malignancy

- 50% of tumors are malignant

Epidemiology
Diagnosis

o
o

Types

- majority are benign


- most common histology is pleomorphic
adnenoma (benign mixed tumor)
- 85% of salivary gland neoplasm

- found throughout the aerodigestive tract


- highest density in the palate
- 75% of tumors are malignant

MRI
most sensitive study to determine soft-tissue extension and involvement of adjacent structures
FNA
provide an accurate preoperative diagnosis in 70 to 80% of cases
help the operative surgeon with treatment planning and patient counseling
surgical excision
confirms the final histopathologic diagnosis

BENIGN
Epithelial
- pleomorphic adenoma (80%)
- monomorphic adenoma
- Warthins tumor
- oncocytoma
- sebaceous neoplasm
Nonepithelial
- hemangioma
- neutral sheath tumor
- lipoma

MALIGNANT
a. Mucoepidermoid
- Low- grade (predominantly mucin-secreting)
- High- grade (perdominanlty epidermoid)
- most common malignant epithelial neoplasm of salivary gland
b. Adenoid cystic carcinoma
- has pa propensity for neural invasion
- second most common malignancy in adults
- skip lesion along nerves are common and lead to treatment failure
- high incidence of distant metastasis, but display indolent growth
- poor survival rate
**the most common malignancies in the pediatric population are
the mucoepidermoid and acinic cell carcinoma.
** for minor salivary glands: the most common are adenoid cystic,
mucoepidermoid and low grade polymorphous adenocarcinoma

Treatment

o
o
o

o
o

surgical excision of the affected gland


parotid, excision of the superficial lobe with facial nerve
dissection and preservation.
Superficial parotidectomy with preservation of the facial
nerve minimal surgical procedure for neoplasms of the
parotid
Enucleation of the tumor mass is not recommended because
of the risk of incomplete excision and tumor spillage
Tumor spillage of a pleomorphic adenoma during removal can
lead to problematic recurrences

*Carcinoma ex pleoporphic adenoma- is an aggressive malignancy


Surgical excision

Basic principles: en bloc removal of the involved gland with


preservation of all nerves unless directly invaded by tumor

superficial parotidectomy with preservation of CN VII


parotid tumors that arise in the lateral lobe

total parotidectomy with nerve preservation tumor


extends into the deep lobe of the parotid

If the nerve is encased by tumor and preservation would


result leaving gross residual disease, nerve sacrifice should be
considered

Radical resection
- tumors that invade the mandible, tongue, or floor of mouth

Therapeutic removal of the regional lymphatics


- clinical adenopathy or when the risk of occult regional
metastasis exceeds 20% (i.e. high-grade mucoepidermoid
carcinomas)

sacrifice of the nerve with retrograde frozen section biopsies


- gross nerve invasion is found (lingual or hypoglossal)
** skip metastases in the nerve with adenoid cystic carcinoma
makes recurrence common with this pathology
Postoperative Radiotherapy
Indications: extraglandular disease, perineural
invasion, direct invasion of regional structures,
regional metastasis, and high- grade histology

OTHERS: NECK AND UNKOWN PRIMARY

Diagnostic evaluation of a neck mass requires a planned approach that does not compromise the effectiveness of future treatment options.
o
Complete history
o
Full head and neck exam
In children, most neck masses are INFLAMMATORY or CONGENITAL
In adults, mass >2cm has a >80% probability of being malignant
Fine-needle aspiration can provide valuable info for early Tx planning
Imaging (CT or MRI) evaluate the anatomic relationships of the mass and the surrounding anatomy of the neck.
Lesions may be benign or may be metastases from distant sites evaluate potential primary sites
Open biopsy may be necessary if findings of FNA and imaging are inconclusive

Patterns of Lymph Node Metastasis

Regional lymphatic drainage of the neck is divided into 7 levels


o
PURPOSE: for a standardized format for radiologists, surgeons, pathologists, and radiation oncologists to communicate concerning specific sites
within the neck

Level Isubmental and submandibular nodes


Level IasubMENTAL nodes
Level IbsubMANdibular nodes and gland

Medial to the anterior belly of the digastric muscle bilaterally

Posterior to the anterior belly of digastrics

Symphysis of mandible superiorly

Anterior to the posterior belly of digastrics

Hyoid inferiorly

Inferior to the body of the mandible


Level II UPPER JUGULAR chain nodes
Level IIajugulodigastric nodes
Level IIbSubMUSCULAR recess

Deep to sternocleidomastoid (SCM) muscle

Superior to spinal accessory nerve to the level of the skull base

Anterior to the posterior border of the muscle

Posterior to the posterior aspect of the posterior belly of digastrics

Superior to the level of the hyoid

Inferior to spinal accessory nerve (CN XI)


Level IIIMIDDLE JUGULAR chain nodes
o
Inferior to the hyoid
o
Superior to the level of the cricoids
o
Deep to SCM muscle from posterior border of the muscle to the strap muscles medially
Level IVLOWER JUGULAR chain nodes
o
Inferior to the level of the cricoids
o
Superior to the clavicle
o
Deep to SCM muscle from posterior border of the muscle to the strap muscles medially
Level Vposterior triangle nodes
Level Valateral to the posterior aspect of the SCM muscle
Level Vblateral to the posterior aspect of SCM muscle

INFERIOR & MEDIALto splenius capitis and trapezius

Medial to trapezius

SUPERIOR to the spinal accessory nerve

Level VIanterior compartment nodes


o
Inferior to the hyoid
o
Superior to suprasternal notch
o
Medial to the lateral extent of the strap muscles bilaterally
Level VIIparatracheal nodes

Inferior to the suprasternal notch in the upper mediastinum

Inferior to the spinal accessory nerve


Superior to the clavicle

BENIGN NECK MASS

Thyroglossal duct cysts


o
midline or paramedian cystic mass adjacent to the hyoid bone
o
vestigial remainder of the tract of the descending thyroid gland from the foramen cecum, at the tongue base, into the lower anterior neck during
fetal development
o
enlarge/infected after an upper respiratory infection
o
MANAGEMENT:
1. UTZ to identify if normal thyroid tissue exist
2. Lab assay to assess if px is euthyroid
3. Excision of thyroglossal duct cyst, including th, tract, central portion of the hyoid bone (Sistrunk procedure), and portion of the tongue base up to
the foramen cecum

Congenital branchial cleft remnants


o
TYPES (accdg to their corresponding embryologic branchial cleft):
A. First BC cysts and sinuses associated intimately with the EAC and parotid gland
B. Second BC cysts - Third BC cysts along the anterior border of the SCM mucscle; produce drainage via a sinus tract to the neck skin
o
Removal of branchial cleft cysts and fistula requires removal of the fistula tract to the point of origin to decrease the risk of recurrence
o
Second branchial cleft remnant tract - courses between the internal and external carotid arteries and proceeds into the tonsillar fossa
o
Third branchial cleft remnant - courses posterior to the common carotid artery, ending in the pyriform sinus region.
o
Cystic metastasis from squamous cell carcinoma of the tonsil or tongue base to a cervical lymph node - confused for a branchial cleft cyst in an
asymptomatic patient
o
Dermoid cysts - present as midline masses and represent trapped epithelium originating from the embryonic closure of the midline

Lymphatic malformations
A. lymphangiomas
B. cystic hygromas
o
mobile, fluid-filled masses
o
removal is challenging due to their predisposition to track extensively into the surrounding soft tissues
o
newborns and infants require tracheostomy
DEEP-NECK FASCIAL PLANES

provide boundaries

determine the pathway of spread of infection

3 LAYERS
1. superficial layer of the deep cervical fascia

forms a cone around the neck and spans from skull base and mandible to the clavicle and manubrium

surrounds the SCM muscle and covers the anterior and posterior triangles of the neck.
2. pretracheal fascia

within the anterior compartment, deep to the strap muscles and surrounds the thyroid gland, trachea, and esophagus

infections in this region may track along the trachea or esophagus into the mediastinum.
3. prevertebral fascia

from the skull base to the thoracic vertebra and covers the prevertebral musculature and cervical spine

ionfectious extension into this space is complicated because this region extends from the skull base to the mediastinum

Unknown Primary Tumors


When patients present with cervical nodal metastases without clinical or radiologic evidence of an upper aerodigestive tract primary tumor, they are referred to as
having an unknown primary.

Patient considered to have previous unknown primary tumor


o
Ipsilateral tonsillectomy, direct laryngoscopy with base of tongue and pyriform biopsies, examination of the nasopharynx, and bimanual
examination

Primary site cannot be ascertained


o
empiric treatment of the mucosal sources of the upper aerodigestive tract at risk (from nasopharynx to hypopharynx) and the cervical
lymphatics with concomitant chemoradiation is advocated

For patients with advanced neck disease (N2a or greater) or with persistent lymphadenopathy after radiation

a postradiation neck dissection may be necessary


Long term manangement and rehabilitation

Palliative treatment- aim at improving a patients symptom


o
May include: radiation, chemotherapy, pain specialist
o
Hospice- also an option for patients with limited outlook.

Follow up Care
o
Aimed at monitoring recurrence and side effects of therapy.
o
Worsening of dyspahgia- maybe presenting symptom of parhygeal stricture
o
Patient may also develop hypothryroidism years after treatment
Post treatment
1st year
2nd year
3rd year
4th year
5th year and after

Follow-up Period
Every 3-4 mo
Every 2-3 mo
Every 3-6 mo
Every 4-6 mo
Every 12 mo