S U R G E R Y IITOPIC 14.
DISORDERS OF THE HEAD AND NECK
Dr. Winston Jake P. Etalin ● October 27, 2021 ● 1st Semester (Midterms)
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TOPIC OUTLINE
I. BENIGN CONDITIONS OF THE HEAD AND NECK
II. BENIGN CONDITIONS OF THE LARYNX
III. TRAUMA OF THE HEAD AND NECK
IV. TEMPORAL BONE FRACTURES
V. TUMORS OF THE HEAD AND NECK
VI. REFERENCES AND CITATIONS
I. BENIGN CONDITIONS OF THE
HEAD AND NECK
A. EAR INFECTIONS
 Infectious processes of the ear may be considered by their
location (external, middle, or inner ear), their time course
(acute or chronic), and the presence of complications.
 The external ear or pinna consists of a cartilaginous
framework, perichondrium, and a relatively thin layer of
skin.
 Erysipelas (St Anthony’s Fire) or impetigo are causes of
external ear infection affecting the dermis or hypodermis of
the auricle, typically caused by Streptococcus pyogenes or
Staphylococcus aureus, respectively, that may be
encountered posttraumatically or related to ear piercing.
 Treatment is oral antibiotic therapy targeting these organisms.
History and clinical features such as presence of bullae and
golden crusting distinguish erysipelas and impetigo from other
benign entities causing erythema and edema of the auricle,
such as relapsing polychondritis, which is typically diffuse,
lobule-sparing, and steroid-responsive.
a. Otitis externa
 Infection of the skin of the external auditory canal.
 Acute otitis externa/―swimmer’s ear‖ moisture that persist after
swimming initiates the process which leads to skin maceration
and itching
 Subsequent trauma to the canal skin by scratching (i.e.,
instrumentation with a cotton swab or fingernail), erodes the
normally protective skin/ cerumen barrier. Hearing aid use
and comorbid dermatologic conditions such as eczema or
other forms of dermatitis may similarly serve as predisposing
factors. The milieu of the external ear canal—dark, warm,
humid—is ideal for rapid microbial proliferation.
o P. aeruginosa (most common offending organism)
o Treatment: topical antimicrobials such as Neomycin or
quinolone containing eardrop. The topical steroid
component of these drops (e.g., hydrocortisone or
dexamethasone) addresses swelling and, as a result,
decreases the often intense pain associated with this
infection.
 Symptoms and signs of otitis externa include itching during
the initial phases and pain with marked swelling of the canal
soft tissues as the infection progresses.
 Patients with otitis externa should also be instructed to keep
the ear dry. Systemic antibiotics are reserved for those with
severe infections, diabetics, and immunosuppression.
MALIGNANT OTITIS EXTERNA
 Very common in diabetics, elderly, & immunocompromised
patients are susceptible
 Fulminant necrotizing infection of the otologic soft tissues &
osteomyelitis of the temporal bone
 Classic finding during physical examination – granulation
tissue along the floor of the external auditory canal
1 | 13 Trans No. 14 Associate Editors
 Symptoms include persistent otalgia for longer than one
month and purulent otorrhea
 Treatment included medical and surgical: IV antibiotics to
cover Pseudomonas,
 Surgical debridement for refractory cases
 Can progress to brain abscess, meningitis & death (severe
cases)
b. Otitis media
 Infection of the middle ear
 It is divided into 3: acute otitis media, subacute otitis media
and chronic otitis media
 For the sign and symptoms, basically they are the same
except for the duration.
 For the treatment of acute and subacute otitis media,
basically it is more on medical management such as oral
antibiotic and otic drops.
 For chronic, may use surgery specially what being called as
Tympanoplasty or the surgical closure of the ear drum.
Acute otitis media (AOM)
 Typically implies a bacterial infection of the middle ear.
 Most common bacterial infection of childhood.
 Most cases occur before 2 years of age and are secondary to
immaturity of the Eustachian tube. Well-recognized
contributing factors include upper respiratory viral infection
and daycare attendance, as well as craniofacial conditions
affecting Eustachian tube function, such as cleft palate
 Signs and symptoms of infectious otitis media occurring for <3
weeks denote AOM. In this phase, otalgia and fever are the
most common symptoms and physical exam reveals a
bulging, opaque tympanic membrane.
 If the process lasts 3 to 8 weeks, it is deemed subacute.
Chronic otitis media, lasting more than 8 weeks, usually
results from an unresolved acute otitis media.
 The most common organisms responsible: Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis.
Otitis media with effusion (OME)
 Denotes uninfected serous fluid accumulation within the
middle ear space.
 In children not already considered ―at risk‖ for developmental
difficulties, OME is generally observed for resolution for a
period of 3 months.
 Age-appropriate hearing testing should be performed when
OME persists for ≥3 months or at any time when language
delay, learning problems, or a significant hearing loss is
suspected.
Table 1. Otitis media
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Disorders of the Head and Neck
Complications of otitis media
 Complications of otitis media with or without cholesteatoma
may be grouped into two categories: intratemporal
(otologic) and intracranial. Fortunately, complications are
rare in the antibiotic era, but mounting antibiotic resistance
necessitates an increased awareness of these conditions.
 Divided into intracranial and intratemporal complication
1. Intratemporal
 Intratemporal complications of otitis media are managed by
myringotomy tube placement in addition to appropriate IV
antibiotics.
 In acute coalescent mastoiditis and petrositis, mastoidectomy
is also performed as necessary to drain purulent foci.
 Mastoiditis
o In acute coalescing mastoiditis, destruction of the bony
lamellae by an acute purulent process results in severe
pain, fever, and fluctuance behind the ear.
o The mastoid air cells coalesce into one common space
filled with pus.
o Mastoid infection may also spread to the petrous apex,
causing retro-orbital pain and sixth-nerve palsy. These
diagnoses are confirmed by computed tomographic scan.
 Petrositis
 Facial nerve paralysis
o due to the course of the nerve on the temporal bone which
is susceptible to infection
o may also occur secondary to an acute inflammatory
process in the middle ear or mastoid.
o caused by herpes simplex, so treat w/ acyclovir
 Ramsey-Hunt syndrome
o Wanting to note about which is cause by reactivated
varicella zoster virus characterized by severe otalgia Figure 1. Cholesteatoma
followed by eruption of the vesicles of the external ear and This shows Cholesteatoma which grows although it is benign
condition and cause destruction of the bone within the middle ear.
the soft palate. Treatment is similar to Bell’s palsy, but full
recovery is only seen in approximately two-thirds of cases. B. SINUS INFLAMMATORY DISEASE
 Labyrinthitis  Rhinosinusitis is a symptomatic inflammation of the nasal
o inflammation of the inner ear sec. to viral infections of the cavity and paranasal sinuses. Rhinosinusitis is preferred over
endolymphatic space sinusitis because sinusitis almost always is accompanied by
o Treatment: antibiotics & myringotomy tube placement. inflammation of the contiguous nasal mucosa.
 Rhinosinusitis is the 5 most common diagnosis responsible
th
o The patient experiences vertigo together with sensorineural
hearing loss, and symptoms may smolder over several for antibiotic prescription
weeks.  Rhinosinusitis may be broadly classified based on duration of
o Labyrinthitis associated with middle ear infection may be symptomatology
serous or suppurative.  Divided into 3 groups under Sinus inflammatory disease:
o The goal of management of inner ear infection, which acute, subacute and chronic sinusitis.
occurs secondary to middle ear infection, is to ―sterilize‖ the
middle ear space with antibiotics and the placement of a a. Acute Rhinosinusitis (ARS)
myringotomy tube.  Symptoms lasting < 4 weeks
2. Intracranial  Acute rhinosinusitis most commonly occurs in the setting of a
 Meningitis viral upper respiratory tract infection (URI).
o most common complication caused by H. influenzae type B  The most common viruses involved in ARS include rhinovirus,
in children influenza virus, and parainfluenza virus.
o Other intracranial complications include epidural abscess,  Viral infection leads to mucosal edema with sinus ostium
subdural abscess, brain abscess, otitic hydrocephalus, and obstruction, mucus stasis, tissue hypoxia, ciliary dysfunction,
sigmoid sinus thrombophlebitis. In these cases, the and epithelial damage, which may enhance bacterial
otogenic source must be urgently treated with antibiotics adherence.
and myringotomy tube placement. Mastoidectomy and  The symptomatic criteria used to define ABRS include up to 4
neurosurgical consultation may be necessary. weeks of purulent nasal drainage accompanied by nasal
3. Cholesteatoma obstruction, facial pain with pressure and fullness, or both.
 Benign condition in the ear  If it is bacterial in origin, treat with oral antibiotics.
 Epidermoid cyst of the middle ear & mastoid w/c causes bone  The management of ABRS is heavily dependent on
destruction secondary to its expansile nature & enzymatic antibiotics.
destruction  Other treatments include topical and systemic decongestants,
 Result of Eustachian tube immaturity & chronic otitis media nasal saline spray, topical nasal steroids, and oral steroids in
 Treatment: mastoidectomy for chronic mastoiditis w/ selected cases.
cholesteatoma.  In the acute setting, surgery is reserved for complications or
 Technically the management is surgical removal of the pending complications, which may include extension to the
Cholesteatoma eye (orbital cellulitis or abscess) or the intracranial space
(meningitis or intracranial abscess).

2 | 13 Trans No. 14 Associate Editors ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ
Disorders of the Head and Neck
b. Chronic Rhinosinusitis (CRS)
 Characterized by symptomatic inflammation of the nose and
paranasal sinuses lasting over 12 weeks
 Exhibit mucosal edema, ostial obstruction, ciliary dysfunction,
and an abhorrent inflammatory milieu.
 Two of the following symptomatic criteria must be present to
diagnose CRS: purulent nasal drainage, nasal obstruction,
facial pain-pressure-fullness, and decreased sense of smell.
 Nasal endoscopy is a critical element of the diagnosis of
CRS. Abnormalities that may confirm the diagnosis of CRS
include:
o Purulent mucus in the middle meatus or anterior ethmoid
region
o Edema in the middle meatus or ethmoid region
o Polyps in nasal cavity or the middle meatus
 Medical management of CRS is heavily dependent on topical
intranasal therapy. Nasal irrigation and topical nasal steroids
are common.
 For treatment, long term antibiotics for 3-6 weeks.
Table 2. Sinusitis
C. PHARYNGEAL AND ADENOTONSILLAR
DISEASE
a. Pharyngeal mucosa
 Contains significant concentrations of lymphoid tissue w/c
predisposes it to inflammatory changes
b. Waldeyer’s ring
 Composed of the following:
o Adenoid
o 2 tubal tonsils
o 2 palatine
o Lingual
 There is also a Waldeyer’s fascia which is seen in the rectum.
 Waldeyer’s ring consists of the palatine tonsils between the
anterior and posterior tonsillar pillars, the lingual tonsils
(lymphoid tissue in the base of tongue), and the adenoid
located in the nasopharynx.
 These are all considered mucosa-associated lymphoid tissue
(MALT).
 These tissues react to inflammatory disease, infection,
trauma, acid reflux, and radiotherapy..
Figure 2. Waldeyers Ring of Lymphoid Tissue
3 | 13 Trans No. 14
c. Common disorders
1. Acute Adenotonsilitis
 Acute infection is typically viral in origin but secondary
bacterial invasion may initiate chronic disease.
 Viruses do not cause chronic infections; however, Epstein-
Barr Virus (EBV) can cause significant hypertrophy.
2. Chronic or recurrent adenotonsilitis
 Most commonly cause by Group A beta-hemolytic strep
(Strep pyogenes), S. pneumonia, & group C & G strep
 Worst part of tonsillitis technically its Complications of S.
pyogenes pharyngitis::
o Rheumatic fever
o Glomerulonephritis
o Scarlet fever
 due to production of enterotoxin by the streptococci
 Presence of punctate rash first appearing on the trunk &
spreads distally sparing the palms & soles
 Strawberry tongue (pathognomonic sign of Scarlet fever)
o Peritonsillar abscess
 common complication that is treated in an ambulatory
setting through a transoral approach after appropriate
topicalization and local anesthetic.
o Deep neck space infections
 rare from pharyngitis but can occur from odontogenic and
salivary gland infections. These typically require a
transcervical approach for incision and drainage.
o Treatment:
 tonsillectomy after > 3 infections per year has occurred
 Adenoidectomy – first line treatment for children w/
chronic sinusitis
 Candida albicans: most common fungi to cause
pharyngitis (fungal pharyngitis)
3. Adenotonsillar hypertrophy
 Acute adenoiditis typically presents with purulent rhinorrhea,
nasal obstruction, and fever and can be associated with otitis
media, particularly in the pediatric population.
 Recurrent acute adenoiditis is defined as four or more
acute infections in a 6-month period
 Chronic adenoiditis presents with persistent nasal
discharge, halitosis, chronic congestion, and postnasal drip.
Chronic infection can be treated with antibiotics, although this
often does not lead to a full resolution of symptoms.
 Adenoidectomy is indicated for recurrent and chronic
infections that have failed conservative management. These
infections are not limited to the adenoid bed but also involve
the sinuses and the middle year.
 Adenoidectomy with a myringotomy and ventilation tube
placement is beneficial for recurrent or chronic otitis media in
children because the adenoid functions as a reservoir for
bacteria that can enter the middle ear through the Eustachian
tube.
 Adenoidectomy is also the first line of surgical management
for children with chronic sinusitis because the adenoid can
obstruct mucociliary clearance from the sinonasal tract into
the choana and ultimately into the pharynx.
4. Tonsils and Tonsillectomy
 Patients with acute tonsillitis present with sore throat, fever,
dysphagia, and tender cervical nodes with erythematous or
exudative tonsils.
 First-line treatment is with penicillin or a cephalosporin;
however, in those with an allergy, a macrolide can be
considered.
II. BENIGN CONDITIONS OF THE LARYNX
 Hoarseness is the most common presenting symptom for
patients with a voice complaint.
 Other complaints include breathiness, weakness/hypophonia,
aphonia, and pitch breaks.
Associate Editors ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ
Disorders of the Head and Neck
 Voice disorders affect a large range of patient ages,
occupations, and socioeconomic statutes and affect both
genders equally.
 They can be associated with dysphagia, globus sensation,
laryngopharyngeal reflux (LPR) disease ad rarely, airway
obstruction.
 Smoking can both cause and aggravate preexisting benign
laryngeal conditions and raises the suspicion of malignancy
often requiring a biopsy to exclude this diagnosis.
A. RECURRENT RESPIRATORY
PAPILLOMATOSIS (RPR)
 Most commonly cause by HPV types 6 & 11 secondary to
vaginal acquisition during vaginal delivery. LPR and herpes
simplex virus type 2 are risk factors of adult onset RRP.
o The disorder typically presents in early childhood
secondary to HPV acquisition during vaginal delivery;
however children born by cesarean section are also at risk
for the disease.
o Adult onset RRP is less severe and is more likely to involve
extra laryngeal subsites
 hoarseness characteristic
 diagnosed by endoscopy
 Supportive treatment only. There is no cure for RRP. Surgery
excision is used to improve to improve voice and airway
symptoms in a palliative fashion.
B. LARYNGEAL GRANULOMA
 occurs on the posterior pharynx on the arytenoid mucosa
 due to voice abuse, reflux, throat clearing & intubation
 These lesions are typically multifactorial: chronic throat
clearing, phonotrauma, endotracheal intubation,
compensatory supraglottic squeeze from vocal fold paralysis,
and LPR.
Management and Treatment
 Conservative management – rest the voice, anti-reflux
therapy, voice therapy, oral steroids, inhaled steroids, and
proton pump inhibitors.
 Surgical excision if there’s suspicion for malignancy or if it
causes obstruction
 Botulinum toxin of thyroarytenoid and lateral cricoarytenoid
muscles can be used as first-line treatment in patients who
prefer a chemically activated voice rest regiment.
 Surgery is rarely required.
o Infantile Hemangiomas
C. POLYPOID CORDITIS/ REINKE’S EDEMA
 Reinke’s Edema characterized by edema in the superficial
lamina propria of the vocal cord. Edema is thought to arise
from injury to the capillaries that exist in this layer, with
subsequent extravasation of fluid.
 The etiology is multifactorial: smoking, LPR, hypothyroidism,
and vocal misuse.
 This pathology is more common in women (because they
present early due to a deep vocal pitch change in their voice)
and heavy smokers.
 The physical examination findings are typically bilateral.
 Vocal recovery
 Affects the superficial lamina propria of the vocal cord.
 Rough low-pitched voice
 Treatment: cessation of smoking. However, smoking
cessation and surgery do not fully reverse the structural
abnormalities due to the presence of possible structure
alterations in fibroblasts caused by the toxicity of cigarette
components, resulting in uncontrolled production of fibrous
matrix in the lamina propria, thus preventing complete
 Surgery – Cold Steel or CO2 Laser. Surgery typically involves
microlaryngoscopy with removal of the gelatinous debris in
Reinke’s space with trimming of the excess mucosa.
4 | 13 Trans No. 14 Associate Editors
D. VOCAL CORD CYST
 Seen on the mucous secreting glands of the laryngeal
mucosa usually in supraglottis.
 It is an encapsulated lesion within the subepithelial or
ligamentous space and is associated with reduces mucosal
wave.
 Causes hoarseness if found in the true vocal cords.
 Diagnosed by video stroboscopic laryngoscopy.
 Treatment: marsupialization w/ cold steel or CO2 laser. It
typically does not resolve with vice therapy.
E. VOCAL CORD PARALYSIS
 Iatrogenic in origin, following surgery to the thyroid,
parathyroid, carotid, spine through an anterior approach, or
cardiothoracic structures.
 Affects the left RLN (recurrent laryngeal nerve) due to its
longer course extending to the thoracic cavity.
 The right RLN is affected commonly during anterior neck
approaches because it courses lateral to the
tracheoesophageal groove or the ligament of berry which
behind of the trachea.
 Bilateral nerve injury – cords are paralyzed on paramedian
direction causing obstruction mandating tracheostomy intraop
During tracheostomy operation, one of the pitfalls is the
dissection of the thyroid is the identification of left and right
laryngeal nerve which courses on the tracheoesophageal
groove or the ligament of berry. During dissection, always try
to isolate the laryngeal nerves and if worst comes to worst of
do ligate the bilateral laryngeal nerve, it will necessitate to do
tracheostomy because post-op patient will not breath.
 Unilateral nerve injury– only changes in voice which can do
Management: speech therapy
F. VASCULAR LESIONS
a. Hemangiomas
o most common during infancy & childhood proliferated
during the first year then involutes
o can do conservative management as long as there is no
st
obstruction or bleeding specially during the 1 year
because hemangiomas most commonly involutes or
decrease in size.
o Surgery is done after 3-4 years for non involution if it
persist.
o Nd:YAG lase
 Present largely within the first few weeks of life.
 Initially they proliferate (2 weeks to 1 year), and then they
begin to involute (1–7 years) until they have fully involuted,
leaving the child with redundant skin, scar, or a fatty lesion.
Congenital Hemangiomas
 Differ from infantile hemangiomas in that they reach their
maximal size at birth and do not have a proliferative phase.
 There are two subtypes: rapidly involuting (RICH), which
typically disappears by 1 of age with minimal fatty appearance
upon resolution, and noninvoluting (NICH).
b. Vascular malformations
 slowly enlarges with the body & never involutes
 Technically the differences between hemangiomas and
vascular malformations is for hemangioma, can do
conservative management with watchful waiting while for
vascular malformations which never involutes perform
surgery.
 Vascular malformations, in contrast to infantile hemangioma,
are always present at birth, although they may not be
apparent for a few months. Although they do not have a
proliferative phase, they grow with the patient, have hormonal
growth spurts and do not involute.
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Disorders of the Head and Neck
 Capillary, Venular (Port-Wine Stains), Lymphangiomas or AV
Malformations
o Capillary malformations arise from the cutaneous
superficial plexus and are made up of capillary and
postcapillary venules with a pink, red, or purple macular-
papular appearance
o Venous malformation Arise from dilated vascular channel
lined by normal endothelium; therefore, they are soft,
compressible, and nonpulsatile. If they are superficial, they
will increase in size with Valsalva or dependent positioning.
They can grow suddenly with trauma or in association with
hormonal changes.
o Lymphatic malformations Typically present at birth with
the majority (90%) being identified by 2 years of age. They
can be macrocystic (>2 cm), microcystic (≤2 cm), or a
combination.
o Infrahyoid Lesions Tend to be macrocystic, well
circumscribed, and discrete and can be totally excised, Figure 4. Tranverse Buttresses
whereas suprahyoid lesions are typically microcystic, Three Classic patterns of more extensive midface
infiltrative, and excision is usually incomplete. fractures
 Nd:YAG laser  During trauma specially on the face, Lefort fractures occur.
Table 3. LeFort
III. TRAUMA OF THE HEAD AND NECK
A. MANDIBLE
 most commonly fractured bone
• most common sites condyle (36%), body (21%) and angle
angle of the mandible (20%).
• The vector forces from the muscles of mastication, vertical
from the masseter and horizontal from the pterygoid muscles, In LeFort III, it is the separation of skull and the face
can cause a fracture to be favorable or unfavorable
depending on the angle of the fracture line.
• Diagnosis: Panorex views & CT scan
• Treatment:
o Favorable fractures - closed reduction & 6 week period of
intermaxillary fixation (IMF)
 Displaced, comminuted, unfavorable fracture – ORIF (done
most commonly by ENT surgeons) + IMF
B. MIDFACE FRACTURES
 Note these Buttresses, Doc might ask in the exam.
3 vertical buttress:
o nasofrontal-maxillary
o frontozygomaticomaxillary
o pterygomaxillary
o 5 horizontal buttress (weaker)
5 horizontal buttress (weaker):
o frontal bone
o nasal bones
o upper alveolus
o zygomatic arches
o infraorbital region

Figure 5. LeFort Fracture Classification

Most severe is the LeFort III.

IV. TEMPORAL BONE FRACTURES

 Longitudinal
o most common (80%) but affects the facial nerve 20% cases
 Transverse
o only 20% but the facial nerve is affected by more than 50%
of the time
Figure 3. Vertical Buttresses o This has been largely replaced by the more relevant otic
capsule sparing or involving classification given that most
fractures are oblique.
5 | 13 Trans No. 14 Associate Editors ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ
Disorders of the Head and Neck
 Consider the status of the facial nerve.
o Delayed or partial paralysis will resolve spontaneously but
immediate paralysis w/out recovery within 1 week should
undergo nerve decompression.
o Patients with facial nerve paralysis of any etiology &
absence of blink reflex w/c causes corneal drying &
abrasion, must protect the eye with artificial tears.
V. TUMORS OF THE HEAD AND NECK
A. ETIOLOGY AND EPIDEMIOLOGY
 Tobacco & alcohol are the most common preventable risk
factors for the development of head & neck carcinomas
o nonsmokers presented more on the oral cavity, oral tongue,
buccal mucosa & alveolar ridge
o smokers it is common in the larynx, hypopharynx & floor of
the mouth.
 40% of tonsillar carcinomas are due to HPV types 16 & 18.
These HPV type 16 and 18 are more towards to malignancy
while HPV type 6 and 11 are more on the benign side. Figure 7. Anatomy of the Pharynx

B. ANATOMY AND HIDTOPATHOLOGY D. LARYNX

 Oral cavity is divided in to 7 subtypes which are the following:  Subdivided into 3 groups: supraglottis, glottis and subglottis.
lip, buccal mucosa, retromolar trigone, hard palate, gingiva,  Always consider the lymphatic drainages.
tongue and floor of the mouth. Table 5. 3 Anatomic Groups of the Larynx
 extends from the vermilion border of the lip to the junction of
the hard/soft palate superiorly, circumvallate papillae inferiorly
& anterior tonsillar pillars laterally
 7 subsites
 Regional metastatic spread: from submandibular & upper
jugular/cervical lymphatics (Levels I, II, III)

Figure 8. The Larynx

 Carcinogenesis
o Point mutations in p53 associated in 45% of head & neck
carcinomas.
Second Primary tumors in the Head & Neck
 Patients with head and neck squamous cell carcinoma
(NSCC) are at increased risk for the development of a second
primary malignancy (SPM), which is defined as a second
malignancy that presents either simultaneously or after the
diagnosis of an index tumor.
Figure 6. Seven Subsites  14%- rate of secondary tumors
C. PHARYNX (3 REGIONS)  Synchronous
o < 6 months after diagnosis of primary tumor
 Subdivided into 3 regions.
o Accounts for only 3-4%.
Table 4. Regions of the Pharynx  Metachronous
o > 6 months of initial diagnosis & accounts for 80% of
second primaries.
 Tumors in oral cavity & pharynx
nd
o 2 lesion in the cervical esophagus
 Tumors in the larynx
nd
o 2 lesion in the lung
E. UPPER AERODIGESTIVE TRACT
Lip
 Vermilion border - represents a transition zone from external
skin to internal mucous membrane
 function of the lip is created by activation of the circumferential
musculature of the orbicularis oris, a critical structure in lip form and
It is very important when dealing with neck and neck is the lymphatics. function.

6 | 13 Trans No. 14 Associate Editors ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ
Disorders of the Head and Neck
 Risks factors:
o Sun exposure
o Tobacco
o fair complexion
o immunosuppression
 Most common site: lower lip 88-98% due to its increased
protrusion and increased sun exposure
 Other sites: upper lip (2-7%) but basal cell carcinoma & oral
commissure (1%)
Histology
 SCCA (squamous cell carcinoma)
 Basal cell CA
o commonly affects upper lip
o Fx ulcerated lesion on the vermilion or cutaneous surface
of lip
o Poor prognosis:
 perineural invasion
 maxilla/mandible involvement Figure 10. Tumor of the Tongue
 lymph nodes metastasis (submandibular & submental
nodes) 2. Floor of Mouth
 age < 40 years  The floor of mouth is a mucosal-covered semilunar area that
extends from the anterior tonsillar pillar posteriorly to the frenulum
a. Oral Cavity – Mostly SCCA (90%) anteriorly, and from the inner surface of the mandible to the ventral
 Tumors of the oral cavity metastasize to the submandibular, surface of the oral tongue.
submental, and upper cervical nodes and are almost always  Contains the ostia of the sublingual & submaxillary glands
treated with a supraomohyoid neck dissection at the time of (anterior floor) & if there’s direct invasion, there’s a need to
primary resection with a few rare exceptions (T1 oral tongue resect such glands.
lesions that have less than 4 mm depth of invasion).  The muscular floor of mouth is composed of the sling-like
1. Oral tongue genioglossus, mylohyoid, and hyoglossus muscles, which
 Tumors of the tongue typically start along the epithelial serve as a barrier to the spread of disease. Invasion into
surface and can be endophytic or exophytic with or without these muscles can result in decreased tongue mobility and
ulceration and are typically seen on the lateral and ventral poor articulation.
surfaces of the tongue.  It begins just below the lingual surface of the mandibular
 Ulcerated or exophytic mass alveolus and ends at the ventral tongue where the frenulum
 MC site: lateral tongue border & ventral surface connects the floor of mouth to the tongue along the midline
o Lesions on the dorsal aspect of the tongue, particularly and at the anterior tonsillar pillars posteriorly.
along the midline, are less likely to be malignant.  lingual nerve (a branch of V3) provides sensory innervation.
 Lymphatics: submandibular & upper cervical nodes (Levels  The contiguity of the floor of mouth mucosa with the lingual
I, II & III, IV) surface of the mandible can lead to mandibular invasion.
 Always remember in neck and neck disorder, the treatment  Panorex or MRI: assess invasion to the mandible
is surgical with good margins and good lymphatic  Involves levels I, II & III
dissection  Treatment: Surgery: WLE (wide local excision)
 Treatment: SURGERY: WLE (wide local excision) / /Mandibulectomy (if the mandible is invaded) +RT (always
Glossectomy (if the whole mouth is affected) + RT do radiotherapty)
(radiotherapy)Lymphatics: submandibular & upper cervical  Lymphatics: Supraomohyoid neck dissection/MRND
nodes (Levels I, II & III, IV)
 Treatment: SURGERY: WLE/ Glossectomy + RT
 Lymphatics: Supraomohyoid neck dissection for selective
neck dissection /MRND (modified radical neck dissection)

Figure 11. Mass on X mark

Figure 8. Supraomohyoid

7 | 13 Trans No. 14 Associate Editors ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ
Disorders of the Head and Neck
Figure 12. Tumor of the Floor of the Mouth
3. Alveolus / Gingiva
 Usually invades the mandible or maxilla
 The alveolar mucosa overlies the bone of the mandible and
extends from the gingivobuccal sulcus to the mucosa of the
floor of mouth to the second and third molar, which is the
anterior border of the retromolar trigone subsite
 MRI: best modality to demonstrate invasion to the
medullary cavity of the mandible
 Treatment: Surgery +RT
o Treatment of these lesions requires at the very least
marginal resection of the mandibular bone given the
proximity and early invasion of the periosteum in this
region.
o A marginal resection is acceptable if there is only very early
bony invasion. If the inferior alveolar canal or the medullary
cavity is invaded on physical examination or preoperative
imaging, a negative locoregional prognostic factor, a
segmental resection is recommended with appropriate
reconstruction
 Lymphatics: Supraomohyoid neck dissection even if (-)
nodes
Figure 13. Tumor of the Gingiva
4. Retromolar trigone
 It is bordered medially by the anterior tonsillar pillar,
anteriorly by the second or third molar, posteriorly by the
maxillary tuberosity, inferiorly by the posterior mandibular
alveolus, superiorly by the coronoid process of the
mandible, and laterally by the buccal mucosa.
 Early involvement of the mandible as with alveolar lesions
 These tumors are aggressive. Infiltration into the masticator
space and bony invasion (maxilla more often than
mandible) significantly worsens the prognosis
 Levels I, II & III
 Treatment: Surgery +RT
 Lymphatics: Ipsilateral Supraomohyoid neck dissection
 Chemotherapy is seldom done for head and neck. Radiotherapy is
most commonly done.
8 | 13 Trans No. 14 Associate Editors
Figure 14. Tumor of the Floor of the Retromolar Trigone
5. Buccal Mucosa
 includes 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.
 includes the parotid (Stenson’s) duct opening adjacent to
the first and second maxillary molars
 Etiologies:
o lichen planus
o Chronic dental trauma
o Alcohol
o Tobacco
 Tends to metastasize to facial & submandibular nodes
(Level 1)
 Treatment: Surgery + RT
 Reconstruction aimed at providing both an internal and
external lining may be accomplished with a folded
fasciocutaneous free flap or a combination of a local flap for
the external component and a free flap for the internal
component. Marginal bone resection is often required in
tumors that extend to the mandibular or maxillary alveolus.
 Lymphatics: Supraomohyoid neck dissection
Figure 15. Tumor of the Floor of the Buccal Mucosa
6. Palate
 The greater palatine nerve and foramen can be a pathway
for neuropathic spread, and it is important to identify
perineural invasion on these tumors in the biopsy
specimen.
 MC malignancies: SCCA & minor salivary gland tumors
o Although SCC continues to be the primary malignant
pathology at this subsite, minor salivary gland tumors
such as adenoid cystic carcinoma, mucoepidermoid
carcinoma, and adenocarcinoma can also present in this
location. Minor salivary gland tumors tend to arise at the
junction of the hard and soft palate
ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ
Disorders of the Head and Neck
 Common site: junction between the hard & soft palate
 Treatment: Surgery + RT
o Treatment is symptomatic as these lesions typical
disappear with time; however, a biopsy is warranted to
confirm the diagnosis. A torus palatine is a benign bony
outgrowth seen on midline of the hard palate. This does
not require biopsy to confirm the diagnosis and only
requires treatment to relieve symptoms.
 Lymphatics: Supraomohyoid neck dissection
Figure 16. Malignancy in the Palate
F. NASOPHARYNX
 Includes Fossa of Rosenmuller, Eustachian tube orifice
 Usually SCCA
 Associated with EBV
 Note that surgery is NOT done in nasopharyngeal carcinoma.
It is the only part of the head and neck wherein surgery is not
performed.
 Chemoradiotherapy should be done.
G. OROPHARYNX
 The borders of the oropharynx start at the soft palate
superiorly, the hyoid (vallecular root) inferiorly, the anterior
tonsillar pillar anterolaterally, and the cricumvallate papilla at
the junction between the anterior two-thirds and posterior third
of the tongue.
 There are five subsites in the oropharynx:
o tonsillar region that includes the anterior and posterior
tonsillar pillars
o soft palate
o posterior pharyngeal wall
o lateral pharyngeal wall
o base of tongue
 Tumors at this subsite can have direct extension laterally in
the parapharyngeal space, posteriorly into the
retropharyngeal space, anteriorly into the oral cavity,
superiorly into the nasopharynx, or inferiorly into the
supraglottic larynx.
 Mostly are SCCA minor salivary gland tumors can present as
submucosal lesions in the soft palate or tongue base, and
lymphoma can present in the tonsils as an asymmetric
enlargement, underlying the importance of a tissue diagnosis
before treatment.
 Includes base of tongue, soft palate & uvula
 Signs & Symptoms:
o hot potato voice due to large tongue tumors
o dysphagia
o Oropharyngeal cancers, other than those on the soft palate
or tonsils, are often not obvious on oral cavity exam
inspection; therefore, a high degree of suspicion should
exist in patients with a muffled voice as would be
experienced in tongue base tumors, patients with
dysphagia and weight loss, or referred otalgia from the
tympanic branches of CN IX and X.
9 | 13 Trans No. 14 Associate Editors
o Trismus
 Involvement of pterygoid musculature
 Advanced disease
o otalgia – CN IX & X involvement
 High risk of metastasis to subdigastric area of Level II; others
include levels III, IV & V
 Radiosensitive tumors
 Treatment:
o RT alone/ Surgery + ChemoRT
o Management of squamous cell cancers of this region
includes single modality (surgery or radiotherapy alone)
treatment for early stage disease (stage I/II) and
multimodality treatment for advanced stage (stage III/IV)
disease (surgery followed by postoperative radiotherapy or
concurrent chemoradiotherapy).
H. HYPOPHARYNX
 includes pyriform sinus & post cricoid region
 extends from the vallecular to the lower border of the
cricoid cartilage
 has three subsites; the pyriform sinuses, the lateral and
posterior pharyngeal walls, and the post cricoid space
 SCCA typically presents with progressive dysphagia, first to
solids then to liquids, followed by weight loss.
 Similar to oropharyngeal tumors, patients can also present
with voice change, referred otalgia or a neck mass. Rarely,
when the larynx is involved, patients may present with stridor
and airway compromise necessitating an urgent tracheotomy.
 Treatment: RT alone/ Surgery + ChemoRT
 Bilateral neck dissections of levels II to IV is indicated
o High risk of node metastasis
o Predilection to paratracheal & upper mediastinal nodes
 Poorer survival rates compared to other lesions of the head &
neck due to advance primary stage & lymph node metastasis
at time of presentation.
 Palliative care is most commonly done for patients especially
in the Philippine setting. They are seldom diagnosed early.
I. LARYNX
 SCCA in smokers & with hoarse voice
 The larynx is divided into the supraglottis, glottis, and
subglottis as previously described. The larynx starts
superiorly at the epiglottis and ends inferiorly at the inferior
border of the cricoid cartilage of the larynx span from the
epiglottis superiorly to the cricoid cartilage inferiorly. Laterally,
it is separated from the hypopharynx by the aryepiglottic folds
 The larynx functions to (a) phonate, (b) protect the airway
during swallowing, and (c) maintain airway patency.
 Patients with laryngeal tumors can present with dysphonia
(hot potato voice in supraglottic tumors and hoarseness in
glottic tumors), dysphagia, and airway concerns. These
patients can also present with dysphagia, weight loss,
referred otalgia, and a neck mass.
 Diagnosed via
o Direct laryngoscopy is beneficial in the assessment of
laryngeal tumors to assess the local extent of tumor spread
 This is particularly important in assessing vallecula and
base of tongue as there can be direct extension to the
oropharynx.
 Provides information about the best possible site of entry
into the pharynx.
o Esophagoscopy assess second primary tumors
o Bronchoscopy to
 Stage the tumor
 Rule out synchronous lesions
o Ct scan & MRI for evaluation of other structures not seen
during endoscopy.
 Erosion or invasion of the thyroid and cricoid cartilage can
significantly impact outcomes and treatment as can extension
into the preepiglottic or paraglottic spaces.
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Disorders of the Head and Neck
 Prognostic factors includes:
o Tumor size
o Nodal metastasis
o Perineural invasion
o Extracapsular spread to cervical lymphatics
 Supraglottis
o Includes epiglottis, aryepiglottic folds, arytenoids & false
vocal cordS
o Drains to subdigastric & superior jugular nodes (levels I &
II)
o drains through the neurovascular bundle to the thyrohyoid
membrane, mainly draining to the upper and lateral cervical
nodes (levels II–IV)
o Inc risk of lymph spread (50%)
o Treatment: surgery/RT/ surgery + postop RT
 Glottis
o Includes true vocal cords, anterior & posterior commissures
o drains in prelaryngeal (Delphian Node), paratracheal nodes
& deep cervical nodes along the inferior thyroid artery
o Treatment: surgery/RT/surgery + RT or ChemoRT
 Subglottis
o Uncommon
o 40% lymph node metastasis
o Treatment: Total laryngectomy plus bilateral lateral neck
dissection plus thyroidectomy
J. NASAL & PARANASAL SINUSES
 Cancers of the nasal cavity and paranasal sinuses are
exceedingly rare, and pathology in this anatomic subsite is
dominated by infectious and inflammatory sources.
 SCCA. Beyond squamous cell carcinoma, the next two most
common malignancies at this site include adenoid cystic
carcinoma and adenocarcinoma
 A concerning history is one that involves a slow progression
and worsening of symptoms, which may include nasal
obstruction, facial pain, headache, epistaxis, and facial
numbness
 Tumors posterior to Ohngren’s line are associated with worst
prognosis. Most tumors at this site present with advanced
stage given the inevitable delay in diagnosis.
 Numbness in the V2 distribution suggests invasion of
pterygopalatine fossa, and V3 distribution numbness can be
an indication of extension to the infratemporal fossa and skull
base invasion to foramen ovale.
 Regional metastasis is uncommon (14-16%) Treatment:
Surgery plus post-op RT
o standard of care includes surgical resection followed by
adjuvant radiotherapy
o Extent of surgery and prognosis is dependent on the tumor
location and extension. For tumors limited to the hard
palate and lower maxillary sinus, an infrastructure
maxillectomy is sufficient. A total maxillectomy without
removal of the orbital floor may be warranted for more
extensive tumors limited to the maxillary sinus.
o Tumors originating in the ethmoid sinuses may require
excision of the cribriform plate and repair of subsequent
skull base defect if the tumor originates or invades through
the bony skull base.
o Tumors are deemed to be unresectable if both optic nerves
are involved, if there is carotid artery invasion, or if there is
extensive intracranial extension.
K. NASOPHARYNX & MEDIAN SKULL BASE
 The anatomic borders of the nasopharyx are superiorly the
adenoid patch, superolaterally the fossa of Rosenmüller and
the Eustachian tube orifices (torus tubarius), inferiorly the
plane of the hard palate from the choana, anteriorly the
posterior nasalcavity, and posteriorly the posterior pharyngeal
wall
 Mostly SCCA
10 | 13 Trans No. 14 Associate Editors
 Includes Fossa of Rosenmuller, Eustachian tube orifice
 Advanced disease can present with cranial neuropathies,
particularly of the cranial nerves, which run in the cavernous
sinus (CN V1, V2, III, IV, VI).
 Bilateral regional disease spread is common, and the
lymphatic level involved include the posterior neck (level V),
as well as the upper (level II) cervical nodes and
retropharyngeal nodes.
 Associated with EBV
 Lymphatics:Level II, III, IV, V & retropharyngeal nodes
 bilateral metastasis is common
 Treatment: ChemoRT/ Salvage Surgery
 Salvage Surgery is done especially in cases of airway
obstruction.
 Staging includes a thorough physical examination using
either a flexible or rigid endoscope to assess the mucosal
extent of the disease.
L. EAR & TEMPORAL BONE
 < 1% of head & neck tumor
 Subsites in this head and neck site from lateral to medial
include the pinna (external ear), external auditory canal,
middle ear, mastoid, and petrous portion of the temporal
bone.
 Although the typical pathology at this site is
squamous cell carcinoma, minor salivary gland tumors such
as adenocarcinoma and adenoid cystic carcinoma can also
present here.
 MC aural lesion: Rhabdomyosarcoma. These tumors typically
present with an advanced stage, and resection with clear
margins and functional preservation is challenging because of
the close proximity of vital structures, namely the facial nerve
and the external auditory canal.
 MC site: external auditory canal
 Histology: SCCA
 for tumors in the pinna – both basal cell & SCCA
 Treatment:
o Small lesions simple excision w/ primary closure or Moh’s
surgery
o Advanced lesions – surgery + RT
o Tumors involving the EAC and middle ear require different
management, including a sleeve resection of the external
auditory canal, a lateral temporal bone resection, or a
subtotal temporal bone resection.
M. NECK
 Children
o inflammatory or congenital
 Adult
o mass > 2 cm, 80% malignant
 FNAB provides a valuable tool in early treatment planning that
provides less oncologic disruption to a tissue mass than an
open biopsy
N. PATTERNS OF LYMPH NODE SPREAD
LEVELS
 The patient’s age, social history, including alcohol and
smoking history, preceding illness history, and synchronous
upper aerodigestive tract physical examination findings can
significantly impact the differential diagnosis and the
investigation to work up a neck mass.
 Ia– submental nodes medial to the anterior belly of the
digastric muscle bilaterally, symphysis of mandible superiorly,
and hyoid inferiorly; this level does not have any laterality as it
includes both right and left sides
 Ib - submandibular nodes and gland; posterior to the
anterior belly of digastric, anterior to the posterior belly of
digastric, and inferior to the body of the mandible
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Disorders of the Head and Neck
 II– upper jugular chain nodes
o Level IIa—upper jugular chain nodes; anterior to the
posterior border of the sternocleidomastoid (SCM) muscle,
posterior to the posterior aspect of the posterior belly of
digastric, superior to the level of the hyoid, inferior to spinal
accessory nerve (CN XI)
o Level IIb—submuscular recess; superior to spinal
accessory
nerve to the level of the skull base
 III– middle jugular chain nodes inferior to the hyoid,
superior to the level of the cricoid, deep to SCM muscle from
posterior border of the muscle to the strap muscles medially
 IV– lower jugular chain nodes inferior to the level of
the cricoid, superior to the clavicle, deep to SCM muscle from
posterior border of the muscle to the strap muscles medially
 V– posterior triangle nodes
Level Va—lateral to the posterior aspect of the SCM
muscle,
inferior and medial to splenius capitis and trapezius,
superior
to the spinal accessory
Level Vb—lateral to the posterior aspect of SCM muscle,
medial to trapezius, inferior to the spinal accessory nerve,
superior to the clavicle
 VI– anterior compartment nodes, inferior to the hyoid,
superior to suprasternal notch, medial to the lateral extent of
the strap muscles bilaterally
 VII– paratracheal nodes, inferior to the suprasternal notch in
the upper mediastinum
Figure 17. Patterns of Lymph Node Spread
O. PATTERNS OF TUMOR SPREAD
 Oral cavity & lip: levels I, II & III
 Oropharynx, hypopharynx & larynx:levels II, III & IV.
 Nasopharynx & thyroid: posterior lymph nodes & jugular chain
nodes; levels II, III, IV & V
 Hypopharynx, cervical esophagus & thyroid: level VII
 Advanced tumors of glottis & subglottis:Delphin node (a
pretracheal node)
 Lateral tongue: can have skip metastasis to levels III & IV
P. CONTROL OF CERVICAL METASTASIS
 Radical neck Dissection (RND)
o removes levels I-V nodes plus the SCM, CN XI and internal
jugular vein
o Pioneered by Dr. George Washington Crile
o Classical radical neck dissection is also known as Crile’s
Procedure.
 Modified Radical Neck Dissection (MRND) or Functional
Neck Dissection
o preserves non lymphatics (SCM, CN XI & IJV)
o TREATMENT OF CHOICE for clinically positive nodes
11 | 13 Trans No. 14
Figure 18. MRND
nerve  Selective Neck Dissection (SND)
o Supraomohyoid neck dissection – used with oral cavity
primaries and removes levels I-III.
o Lateral neck dissection – used for laryngeal tumors and
removes levels II-IV
o Anterorolateral neck dissection – used with thyroid CA
and removes levels II-V
Figure 19. Selective Neck Dissection (SND)
Remove high risk lymph node groups based on tumor site.
 Clinically negative neck (NO)
o risk of metastasis risk >20% treatment of the nodes is
warranted
 elective irradiation
 SND.
o not applicable for glottic cancers
 Clinically Positive Neck (N+)
o RND or MRND
o (+) poor prognostics factors
 multiple nodes
 extracapsular spread
 perineural & vascular invasion- RT
 Advance neck disease (N2a or greater)
 Partial response to RT
o For patients subjected to radiotherapy neoadjuvant or prior
to surgery.
o ND, 6-8 weeks after completion of treatment.
 Surgical debulking of metastasis does not improve survival
 In high-stage patients, there is no point in doing surgery
especially if R0 cannot be attained, might as well do palliative
treatment. Radiotherapy is given to patients instead of
subjecting them to surgery which is more invasive.
Q. PARAPHARYNGEAL SPACE MASSES
 Potential space from the skull base to the hyoid
 The differential diagnosis for parapharyngeal masses is very
much dependent on the anatomy and contents of this space
which is divided into the pre- and poststyloid spaces
by the tensor-styloid fascia.
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Disorders of the Head and Neck
 Subdivided into two by the styloid process  Prevertebral fascia – covers the cervical spine, covers the
o prestyloid space prevertebral musculature and space and extends down to the
 contains the parotid, fat & lymph nodes thoracic vertebra and diaphragm
 comprises 40-50% of the tumors and are of salivary  CLINICAL CORRELATION:
gland in origin o Infections of the prevertebral space between this fascia and
o poststyloid space the prevertebral musculature are considered to be in the
 contains the CN IX-XII, carotid space contents, cervical prevertebral space and can extend all the way down to the
sympathetic chain, fat & lymph nodes. sacrum. Therefore, neck infections can extend to the
 More emphasis on nerves mediastinum or beyond and need to be treated
 Comprises 20-25% of the tumors & composed of aggressively.
paragangliomas, schwannomas & neurofibromas
T. SALIVARY GLAND TUMORS
 Lymphatic origin masses such as lymphoma and lymph node
metastases represent 15% of tumors at this subsite.  < 2% of all H&N malignancies
Therefore, most prestyloid lesions are considered of salivary  minor salivary gland malignancies can present anywhere in
gland origin, whereas poststyloid lesions are typically vascular the upper aerodigestive tract, particularly on the palate;
or neurogenic. however, the major salivary glands are the parotid,
 Tumors of the parapharyngeal space can displace the lateral submandibular, and sublingual gland
pharyngeal wall medially into the oropharynx and can thus  The majority of tumors (80%) arise in the parotid gland;
cause obstructive sleep apnea, voice change, and dysphagia however, 80%of these are benign, most commonly,
in addition to cranial neuropathies, Horner’s syndrome, or pleomorphic adenomas (benign mixed tumors).
vascular compression  As the salivary gland gets smaller, the proportion of tumors
that are malignant increases; 50% of
R. BENIGNN NECK MASSES
submandibular/sublingual tumors and 80% of minor salivary
 Many benign neck masses require surgical intervention for
gland tumors are malignant.
diagnostic, cosmetic, and symptomatic relief. This is
 Slow growing & well circumscribed
particularly true for lesions that are prone to recurrent
infections, especially in the pediatric population.  Signs of malignancy:
 Thyroglossal duct cyst o Pain
o vestigial remainder of the tract of the descending thyroid o rapid growth
gland from the foramen cecum at the tongue base into the o Paresthesias
lower anterior neck during fetal development. o facial weakness
o midline or paramedian cystic masses adjacent to the hyoid o skin invasion
bone o fixation to mastoid tip.
o Treatment: Sistrunk procedure – remove the cyst, tract,  MRI: most sensitive study to know extent of lesion to soft
central portion of the hyoid bone and portion of tongue tissues & adjacent structures
base up to the foramen cecum; done to prevent recurrence  Treatment: excision followed by RT for malignant tumors. For
 Branchial cleft cyst benign tumors, excision would be enough.
o 1st branchial cleft cyst – associated with the EAC & parotid U. NEOPLASM
gland.  Benign epithelial tumors
o 2nd branchial cleft cyst – the tract courses between the o pleomorphic adenoma (80%)
internal & external carotid arteries and proceeds to the o monomorphic adenoma
tonsillar fossa o warthin's tumor (papillary cystadenoma lymphomatosum)
o 3rd branchial cleft cyst – tract courses posterior to the o oncocytoma
common carotid artery and ends in the pyriform sinus. o sebaceous neoplasms
o both 2nd & 3rd cleft cyst are found along the anterior  Non-epithelial benign tumors
border of the SCM & can produce drainage via a sinus tract o Hemangioma
to the neck skin. o neural sheath tumors
o Treatment: remove the cyst & fistulous tract to decrease o lipoma
recurrence  Treatment of benign neoplasms is surgical excision for
 Dermoid cyst diagnostic and therapeutic purposes.
o midline masses & presents trapped epithelium from the  The parotid superficial lobe is usually dissected off of the
embryonic closure of the midline facial nerve, which is preserved. For pleomorphic adenoma,
 Lymphatic malformations (lymphangiomas & cystic hygromas) an extracapsular dissection is favored over enucleation due to
o mobile fluid filled masses tumor pseudopods, incomplete excision, and a higher risk of
 General management: sclerotherapy or surgical excision. The tumor spillage, all of which are associated with higher
neck area has many critical structures and if sclerotherapy recurrence rates.
(1st line of management) fails, surgery is done.  Malignant epithelial tumors
S. DEEP CERVICAL FASCIA o mucoepidermoid carcinoma – most common malignancy of
 Cervical fascial planes- often predict the salivary glands in both adults and pediatrics
pathway and extent of infectious spread in the neck and are o Adenoid cystic carcinoma
nd
therefore clinically important.  2 most common malignancy in adults.
 high incidence of skip lesions & distant metastasis
 Investing Fascia (Superficial deep) – covers the SCM, &
 has propensity for neural invasion
triangles of the neck, it spans from the mandible to the nd
clavicle and manubrium o Acinic cell carcinoma – 2 most common malignancy in
 Pretracheal fascia (visceral layer) – covers the thyroid, pediatric age group
trachea & esophagus, blends laterally with the carotid sheath V. MAJOR SALIVARY GLAND
extending inferiorly to the upper mediastinum
 Retropharyngeal Space - Between visceral layer and the
a. Parotid gland
prevertebral fascia  85% of all neoplasms

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Disorders of the Head and Neck
 Majority are benign & comprised of pleomorphic adenoma X. TRACHEOSTOMY
(benign mixed tumor)  Indicated:
 Facial nerve separates superficial from deep lobe of the o most common cause for tracheotomy is prolonged
parotid intubationtypically (longer than 20 days or longer than 2
 parotid malignancies, particularly carcinomas, have a weeks) in critically ill intensive care unit patients
propensity for regional lymphatic spread, first to the intra- and o it has been hypothesized that early tracheotomy may
periglandular nodes followed by the upper cervical chain improve inpatient survival and decreased intensive care
(levels I–III) unit length of stay while increasing patient comfort
 Treatment :  pulmonary toilette
o Facial nerve preservation is always done regardless on  neurologic deficits w/out protective airway reflexes.
whether the tumor is malignant or benign, and especially if  Beyond prolonged intubation, tracheotomy is also indicated in
the nerve is not involved preoperatively/intraoperatively. patients who require frequent pulmonary toilet, in patients with
o In cases of facial nerve involvement, removal might as well neurologic deficits that impair protective airway reflexes, and
be done. in head and neck upper aerodigestive tract surgery as a
o Lateral lobe tumors - superficial parotidectomy with nerve temporary airway in the perioperative period to bypass airway
preservation obstruction.
o Deep lobes - total parotidectomy with nerve preservation  Complications:
o Malignant o Pneumothorax tracheal stenosis, wound infection/stomatitis
 (-) nodes – remove levels II & III with large-vessel erosion, and failure to close after
 (+) nodes – MRND decannulation
 Carcinoma Ex Pleomorphic Adenoma – aggressive tumor w/c o RLN injury
arises from a pre existing benign mixed tumor o Stenosias
b. Submandibular gland o Infection
 50% of tumors are malignant  The use of cricothyroidotomy, typically in the emergency
 Metastasis to prevascular facial lymph nodes followed by setting, is inferior to a tracheotomy due to higher incidence
submental & upper & mid jugular nodes (Levels I, II, III) of vocal cord dysfunction and subglottic stenosis.
 Treatment:  Most tracheostomies are not permanent and can be reversed
o En bloc resection simply by removing the tube and applying a pressure
o (-) nodes: supraomohyoid dissection dressing.
o (+) nodes: MRND  The stoma usually spontaneously heals within 2 to 3 weeks.
c. Sublingual gland
 50% malignant VI. REFERENCES AND CITATIONS
 May invade the lingual or hypoglossal nerves which may  Etalin, W.J. (2021). Diisorders of the Head & Neck. Powerpoint
preclude resection. RT can be done for patient management. Presentation and Discussion. October 27, 2021.
 Brunicardi , F. C. (Ed.). (2019). Schwartz's Principles of Surgery
W. MINOR SALIVARY GLAND (Eleventh Ed, Vol. 1). McGraw-Hill Education. Chapter 18, Pages
 75% of tumors are malignant 613-654.
 Presents as painless submucosal masses and usually seen at
the junction of the hard & soft palate
 Malignancies:
o adenoid cystic
o mucoepidermoid ca
o low grade polymorphous adenocarcinoma

13 | 13 Trans No. 14 Associate Editors ARIAS, BALBALOSA, CATALON, COLOMA, CE-ING, DORIANO | Chief Editor DE LA CRUZ