Behind the Knife ABSITE 2025 - Head and Neck

neck triangles. These, believe it or not, are pretty frequently asked, so let's go over some boundaries. So Kevin what are the boundaries of the anterior neck triangle? Yep. So the anterior boundary is the midline of the neck. The posterior boundary is the sternocleidomastoid the inferior boundary is the sternal notch and the superior boundary or the base is the. lower body of the mandible. Okay, what travels, what are the contents of the anterior neck triangle? They like to ask that sometimes too. Yeah, so this contains the carotid sheath. Yeah, carotid sheath lives in the anterior neck triangle. Okay, John, how about the posterior neck triangle? Yeah, so the anterior boundary is the posterior border of the sternocleidomastoid. The posterior boundary is the trapezius muscle. The base or the inferior portion is the middle third of the, middle third of the clavicle. The apex is the intersection, the sternocleidomastoid, and the trapezius. Okay, and how about the contents of it? What lives in the posterior neck? Yeah, so this is where you're going to find your

spinal accessory nerve. Great, so spinal accessory nerve, posterior neck triangle. It's a little bit difficult to, you know, visualize, but just make sure you look at our image that's in the companion book and become familiar with those different triangles. Just to have that image in your head and be able to walk through those different triangles will be very useful for you. How about the recurrent laryngeal nerve gets a lot of, a lot of attention. So what muscles does the recurrent laryngeal nerve innervate? And it's different from the left side to the right side. So Kevin, can you expound on that? What is recurrent laryngeal nerve innervate and how's it different from left to right? Yeah, boy, some people really love the recurrent laryngeal nerve. And so. So, it branches off the vagus nerve and innervates the muscles of the larynx, except for the cricothyroid muscle, which is innervated by the superior laryngeal nerve. And so on the right side, the vagus passes anterior artery and the recurrent laryngeal nerve loops behind the subclavian artery and travels superiorly in the tracheal esophageal

groove. Whereas on the left side, the vagus passes anterior to the aortic arch, between the left common carotid artery and the subclavian artery, And the recurrent laryngeal nerve loops behind the aortic arch and travels superiorly in the tracheal esophageal groove. Great, yeah. So be aware of that distinction between the left and right side. It is clinically relevant and it has to go back with everybody's favorite topic of embryology is how it ended up that way. Remember again, the superior laryngeal nerve innervates the cracothyroid. All other laryngeal muscles are innervated by the recurrent laryngeal nerve. So it's a very important nerve and it's prone to injury. Okay, so let's get into some head and neck cancers. This topic always was a struggle for me and always confused me. There can be a lot of distinctions between the different kinds of cancers, the different stages and the treatments are a little bit different than other parts of the body. So it's something that we don't see a lot of as general surgeons. So it's very important to review this, especially before any board type test. So Kevin, let's just start. I mean, what's the most common head and neck cancer? So that's

squamous cell cancer. Yeah, squamous cell cancer, most common head and neck cancer. It's the fifth most common cancer overall. And men are affected more than women at a ratio of five to one. John, what are some risk factors for squamous cell cancer to the head and neck? Yep, so the most common risk factors, or most significant risk factors, are alcohol and tobacco. And they also have a, for head and neck cancer, specifically in squamous cell, they have a synergistic effect. And don't, additionally, squamous cell cancer. Has bimicorm become more prominent due to HPV? Okay, yep, so HPV, alcohol, tobacco are the big risk factors. Now this is where things start to get a little confusing. So each sub site, so whether we're talking about the oral cavity, oral pharynx, the nasopharynx, The larynx, the nose, the sinuses, the salivary glands have their own staging system. Of course they do. And the treatment is different amongst those all. So it can be very complex, but in general, we'll talk broad strokes, high yield stuff or test taking stage one and two, when we talk

about stage one and two squamous cell cancer, head and neck, we're referring to local disease. So, in general, Stage 1 and 2, no regional or distant METs, whereas Stage 3 and 4 is either locally aggressive or has distant METs. So, Kevin, what about, let's talk about treatment for Stage 1 or 2 squamous cell cancer of the head and neck. Yeah, so for the treatment, it's a little confusing, but surgery or radiation is acceptable for Stage 1 and 2. And then it's surgery versus radiation will depend on the location and the morbidity of the resection. For example, if the wide vocal excision for enteral lesion versus radiation for vocal cord lesion. Great. So yeah, so it is radio sensitive. So you either have the option of surgery or radiation for stage one or two, depending on what structures are involved. Obviously, it'd be very morbid to go and cut out somebody's vocal cords. So you may opt for radiation therapy in that setting. Now, John, what about stage three and four? Again, squamous

cell cancer to head and neck stage three and four treatment. So like most cancers, you have a multimodal approach to stage three and four cancer. You will have surgery which includes a Y local excision and a modified radical neck dissection followed by radiation plus or minus chemotherapy. Yeah. Okay. So stage three and four multimodal. Again, we're talking about locally aggressive or distant meds, squamous cell cancer of the head and neck. You have a wide local excision, modified radical neck dissection, followed by radiation, plus or minus chemotherapy. Now, John, this is one of the ones, these oral squamous cell cancers, that has an actual cutoff of 4 centimeters. Why is that 4 centimeters important? What do you do for an oral squamous cell cancer that's over 4 centimeters? Yeah, these patients will need a resection. With a modified radical neck dissection followed by post operative radiation. Okay, so John, with regard to the salivary gland tumors, which are more likely to be malignant? Big ones or the little

ones? Yeah, the tiny ones. And I've seen this question on our website before. The small salivary glands are more likely to be malignant than large tumor glands. Right. So your sublingual glands have a higher chance of malignancy than your subventricular, which have a higher chance of malignancy than your parotid. So parotid tumors have a lower likelihood of malignancy. So small to large when it comes to salivary glands and a lot of times the question will give you a tumor and these different things and I'll simply ask you which of these is most likely to be malignant. So when we, let's break that down a little bit though. So what's the most common malignant salivary gland tumor? So that's your mucoepidermoid cancer. Okay, mucoepidermoid, most common salivary gland tumor. What's your treatment? So you're going to have to resect this. With a modified radical neck dissection, plus or minus radiation therapy. Okay, and when you say resect, what do you mean? So, for this, it'll be a total parotidectomy with facial nerve preservation, if it involves the parotid gland. Okay, yeah, so resection, if it's a parotid, that's a total, not just a superficial, total

parotidectomy. Facial nerve preservation, modified radical neck dissection, and then plus or minus post operative XRT. Okay, but what's, what is adenoid, John, adenoid cystic cancer of the salivary gland? What is that? This is a slow growing tumor with tendency to locally invade specifically nerves. Yeah, so slow growing, tends to locally invade. What's the treatment? Here, the treatment is resection with modified radical neck dissection. And plus or minus post operative radiation. Okay, let's say it's in the parotid gland. Again, be specific when you say resection. Yeah, so total parotidectomy with facial and nerve preservation. Once again, if it's in the parotid. With the caveat that you don't tend to be as surgically aggressive with adenoid cystic cancer if it would result in high morbidity because it does tend to be very sensitive to XRT. Okay, Kevin, back to, let's, let's talk about some benign tumors. What's the most common benign tumor of a salivary gland? So that's the

pleomorphic adenoma. Okay, so most common benign, pleomorphic adenoma. John, remind me, what was the most common malignant? That's your mucoepidermoid cancer. Okay, so mucoepidermoid, most common malignant, pleomorphic adenoma, most common benign. Kevin, treatment for a pleomorphic adenoma? So this is the superficial parotidectomy. Okay. So yeah, you don't do it. Need to do a total if it's in the parotid gland. Superficial parotidectomy. How about let's say you treat it and it is recurrent or let's say it's either recurrent or it was multifocal. Then you want to consider radiotherapy. Yeah. So again, also sensitive to radiotherapy. So you consider radiotherapy a key in this is just because it's benign, you do need to do that superficial parotidectomy and you don't want to, a lot of times they'll give you the option of a nucleating. But you don't want to enucleate because of the recurrence rate. John, what's a Wurthlin tumor? Yeah, the full name of this is papillary cystadenoma lymphomatosum. It's most commonly seen in male smokers that are greater

than 60 years old. It can be bilateral. And the treatment for this one, if you see it pop up, is this watchful waiting. Okay. Yeah. So that's important. So, you probably won't see warfarin tumor. You'll probably see papillary cystadenoma lithomatosum. Hard to say, but if you see that on the test, again, they can be bilateral and those are watchful waiting. Okay. Kevin, something that comes up frequently on tests, both written and oral boards. Is management of an unknown primary head and neck cancer tumor that is a regional metastasis to a node without a known primary. What do you do in that situation? Yeah, this is a tough situation and frequently tested. So you really have to start with a thorough head and neck exam. And so you want to include a fiber optic exam of the nasopharynx and larynx, and then you're gonna get an FNA or regional node, a biopsy or an excisional biopsy of that node. Then, of course, you're going to have your CT scan of the head, neck, chest, and then also with a PET scan involved with that. And then, generally, these patients are going to go to the

operating room for a direct laryngoscopy, with biopsies directed by the previous workup. Okay. Yeah. Again, so if you have a head and neck cancer, you don't know where it is there's a couple of ways that this will show up on the test. It'll ask you what to do next. Or actually what the most like, most common site is. So what you do next is you do a thorough head and neck exam, including fiber optic, FNA or excisional biopsy of the regional node, CT the head and chest and neck, plus or minus a PET, and then to the OR, as Kevin said, direct laryngoscopy, esophagoscopy, ipsilateral tonsillectomy, and targeted biopsy. So what is the most common site of an unknown primary? And the most common is the tonsils followed by the base of the tongue. Yeah, tonsil followed by the base of the tongue. So tonsils, that's why you do that ipsilateral tonsillectomy as part of your workup. So John, what if you still have no primary identified? What do you do? Yeah, you'll still need an ipsilateral modified

radical neck dissection, but you then do bilateral radiation. Okay. Key point. I've seen this show up several times. So you go through all that. You do your tonsillectomy. You still don't have a primary site. So in that case. You do an ipsilateral modified radical neck dissection and bilateral XRT. Kevin, let's move on to melanoma of the head and neck. How do you diagnose a melanoma of the head and neck? So, ideally, you want to diagnose this with a full thickness biopsy, either excisional or incisional or punch. You don't want to avoid shave biopsies. Yeah, again, so, as with most melanomas, you want to avoid shave biopsy. Of course, there are people that are doing that. But the principles are you need a full thickness biopsy. It's staged, like, we're not going to go into the staging of melanoma because we'll cover that in another section, but it's melanoma head and neck is staged just like melanoma of any other part of the body. John, how about treatment? So for the treatment of these, you want to resect with the same margins as other sites throughout the body.

So for example, a melanoma that's been biopsied and has less than one millimeter in depth, you do want to do a one centimeter cut. a resection with margins. For a tumor that is greater than 2 millimeters in depth, you'd want 2 centimeter margins. Okay, and how about, what do you do if you are, let's say, up against some critical structures? Yeah, that's where the head and neck gets a little harder because, and you have people specialized in this type of surgery, they can be adjusted if abutting critical structures, especially vascular structures or nervous structures. Okay, like, let's say the facial mirror, do you want to preserve that or do you sacrifice that? It should be preserved in melanoma. Okay. Melanoma is, I will say melanoma is one of those things that's changing on a day by day to month by month basis or a number of clinical trials or some very exciting things with immunotherapies that are going on. So it's doubtful that all that stuff is going to make it on the test, but just be aware that melanoma is one of those rapidly changing things that's very difficult to keep up on. Kevin, how about the role of lymphadenectomy

with head and neck melanoma? Yeah, so if you have clinically positive nodes, you need to do a lymphadenectomy. Okay, how about, what's the role of the sentinel lymph node biopsy in head and neck melanomas? Yeah, similar to breasts, if you have clinically node negative, you need to do a sentinel lymph. Okay, is there any caveats to that? For what size, do all of them get sentinel nodes? Yeah, so sentinel lymph node for melanomas smaller than 0. 8 millimeters with ulceration. Or melanoma is 0. 8 millimeters and greater in depth. Yeah, so similar to other parts of the body. So if it's under 0. 8 millimeters and without worrisome features, you don't necessarily need a sentinel lymph node, but certainly anything over 0. 8 millimeters in depth or anything with ulceration or worrisome features should get a sentinel lymph node, a biopsy. So what you'll see frequently is melanomas of the head and neck and distinctions in the treatment based on an imaginary line that goes from one tragus to the other. And this has to do with the drainage.

So let's say John, we have a head and neck melanoma that's anterior to this imaginary line. Well, what do we do in that situation? Yeah. So this would drain anterior to the parotid basin. So for treatment of this, you would do a superficial parotidectomy. Okay. A selective anterior neck dissection. Okay, great. Kevin, how about head and neck melanomas that are posterior to this imaginary line? In this situation, you do a selective posterior neck dissection. Okay. So that's head and neck malignancies and head and neck is pretty down and dirty. That should get you most of what you need to know for the outside. And as always, we're going to move into some quick hits. So you guys ready for some quick hits? Do it. Okay. John, painless mass on the roof of the mouth. What is it? This is torus palatinus. It's an overgrowth of cortical bone. Okay. And so what's the treatment? Yeah, I usually do nothing for these, but you kind of resect them if it's interfering with life such as denture fitting. Okay, this is one of the ones that will actually show up as a picture on the exam.

So, what I do is I Google image a Taurus Palatinus and know what it looks like because they're gonna show you the picture and they're gonna ask you what to do and the answer is generally do nothing. So, Kevin, what's the most common site for an oral cavity cancer? So, this is the lower lip related to sun exposure. Okay, and what do you do? So, if you need to resect more than half the lip, you'll have to do a flap reconstruction. Yep, if you have to resect over half the lip, you'll need flap reconstruction. John Epstein Barr virus related head and neck cancer. Yeah, this is a classic nasopharyngeal squamous cell cancer and the treatment for this is XRT irradiation great Yep, they're very sensitive to XRT. Kevin most common malignant salivary gland tumor. So that's your mucoepidermoid carcinoma Repetition is the key to adult learning mucoepidermoid carcinoma most common salivary gland malignant tumor John, most common benign. That's your pleomorphic adenoma. Okay, Kevin. What is so gustatory sweating following a protodactomy? What happened? What's the cause of it? What's it called?

So it's Fray's syndrome. It's an injury to the auriculotemporal nerve that can cross innervate with sympathetic fibers. Okay, John, you have an elderly patient that has a post operative fever, pain, and swelling at the angle of the jaw. What is the organism involved and what's the treatment? Yeah. You also see this in the ICU. It's super supportive parotiditis. It's most on the most commonly caused by staph aureus. The treatment for this is this hydration, antibiotics, and an IND if it's a, you know, larger abscess. Okay. Kevin, you have a patient who has vocal cord dysfunction following an emergent surgical airway. What happened? So this, they probably had a fracture of the thyroid cartilage. John, breast tracheostomy bleeding. How do you manage it? Yeah. So I delineate these into two different things. So if it's a small amount and it's easily controlled and it stops, you can do a brachioscopy to rule out tracheotomy fistula. If it's a large amount, you want to place your finger into the tracheostomy, hold manual pressure against the sternum.

So hooking your finger up against the sternum and go to the OR emergently for immediate sternotomy and resection of the abdominal artery. You want to close the tracheal side primarily and cover. This was some type of buttress, such as a strap muscle. Yeah, the way I see that one, Asa, they'll give you an option of going to the OR and resecting the inominate artery versus, you know, some type of graft or reconstruction. And that's the key point is do not put a synthetic interposition graft. You just resect it because your graft will get infected and blow out. So that's a key point there. How do you prevent a tracheo inominate fissure? Yeah, this is where you can prevent this by placing the tracheostomy between the second and third ring of the trachea. If you get too low down to three through five tracheal rings, that puts you at higher risk of a fistula. Great, well I think that does it for our head and neck ab site review. Great job and thanks for listening.