HEAD AND NECK

1
HEAD AND NECK
2
A 50 YO M has a 1 cm mass anterior to the ear.
The mass causes pain and a facial droop. CT of
the head shows the tumor is involved in the deep
and superficial portions of the gland. This most
likely represents

• A. Mucoepidermoid carcinoma
• B. Adenoid cystic carcinoma
• C. Pleomorphic adenoma
• D. Warthin's Tumor

3
A 50 YO M has a 1 cm mass anterior to the ear.
The mass causes pain and a facial droop. CT of
the head shows the tumor is involved in the deep
and superficial portions of the gland. This most
likely represents

• A. Mucoepidermoid carcinoma
• B. Adenoid cystic carcinoma
• C. Pleomorphic adenoma
• D. Warthin's Tumor
• There are two features that make the parotid
  tumor almost certainly malignant. The first is
  that it invades both the superficial and deep
  glands (unusual for benign tumors) and the second
  is that the facial nerve is affected (facial
  droop)
• Given that this tumor is almost certainly
  malignant, you have to go with the most common
  malignant tumor of the parotid, which is
  mucoepidermoid carcinoma

4
Treatment of mucoepidermoid carcinoma will most
likely involve

• A. Superficial parotidectomy
• B. Total parotidectomy
• C. Chemo-XRT only
• D. Chemotherapy only

5
Treatment of mucoepidermoid carcinoma will most
likely involve

• A. Superficial parotidectomy
• B. Total parotidectomy
• C. Chemo-XRT only
• D. Chemotherapy only
• Initial treatment is total parotidectomy
  including the facial nerve (b/c it's already
  out). Also need to figure out whether or not it
  is low grade
• If it is low grade you are done
• If it is high grade or any other cell type you
  should perform a prophylactic modified radical
  neck dissection and give post op XRT

6
The tumor most likely to involve B/L parotid
glands at the time of presentation is

• A. Mucoepidermoid carcinoma
• B. Adenoid cystic carcinoma
• C. Pleomorphic adenoma
• D. Warthin's tumor

7
The tumor most likely to involve B/L parotid
glands at the time of presentation is

• A. Mucoepidermoid carcinoma
• B. Adenoid cystic carcinoma
• C. Pleomorphic adenoma
• D. Warthin's tumor
• The tumor most likely to involve B/L parotid
  glands at the same time is Warthin's tumor

8
Treatment of most benign parotid tumors involves

• A. Superficial parotidectomy
• B. Total parotidectomy
• C. Chemo-XRT
• D. Chemotherapy

9
Treatment of most benign parotid tumors involves

• A. Superficial parotidectomy
• B. Total parotidectomy
• C. Chemo-XRT
• D. Chemotherapy
• Treatment of most benign parotid tumors involves
  superficial parotidectomy

10
The most common benign tumor is

• A. Mucoepidermoid carcinoma
• B. Adenoid cystic carcinoma
• C. Pleomorphic adenoma
• D. Warthin's tumor

11
The most common benign tumor is

• A. Mucoepidermoid carcinoma
• B. Adenoid cystic carcinoma
• C. Pleomorphic adenoma
• D. Warthin's tumor
• The most common benign tumor is pleomorphic
  adenoma

12
Following a parotidectomy, a pt. has gustatory
sweating. This is most likely caused by

• A. Recurrent tumor
• B. Cross-innervation of the vagus and sympathetic
  nerves to the skin
• C. Cross-innervation of the auriculotemporal
  nerve and sympathetic nerves to the skin
• D. Cross-innervation to the glossopharyngeal
  nerve and sympathetic nerves to the skin

13
Following a parotidectomy, a pt. has gustatory
sweating. This is most likely caused by

• A. Recurrent tumor
• B. Cross-innervation of the vagus and sympathetic
  nerves to the skin
• C. Cross-innervation of the auriculotemporal
  nerve and sympathetic nerves to the skin
• D. Cross-innervation to the glossopharyngeal
  nerve and sympathetic nerves to the skin
• Post op gustatory sweating is caused by cross
  innervation of the auriculotemporal nerve and the
  sympathetic nerves of the skin
• Usually goes away but if refractory and alloderm
  graft can be placed b/t the auriculotemporal and
  skin nerves

14
What is this syndrome called?

• A. Stewart-Treves Syndrome
• B. Ratatouille Syndrome
• C. Foster-Kennedy syndrome
• D. Sheehan's syndrome
• E. Frey's syndrome

15
What is this syndrome called?

• A. Stewart-Treves Syndrome
• B. Ratatouille Syndrome
• C. Foster-Kennedy syndrome
• D. Sheehan's syndrome
• E. Frey's syndrome

16
Match the cervical lymph node level with the
corresponding anatomic description

• Level I
• Level II
• Level III
• Level IV
• Level V
• Level VI
• Level VII

• Prelaryngeal, pretracheal, and paratracheal
• Upper jugulodigastric
• Posterior triangle
• Submental/submandibular
• Middle jugulodigastric
• Upper mediastinal
• Lower jugulodigastric

17

• Level I is bounded by the anterior and posterior
  bellies of the digastric muscle, mandible
  superiorly and hyoid inferiorly
• Level II extends from base of skull superiorly,
  hyoid inferiorly, posterior belly of digastric
  medially, and posterior border of SCM laterally
• Level III extends from hyoid superiorly to
  cricoid inferiorly
• Level IV extends from cricoid superiorly to
  clavicle inferiorly levels III and IV share same
  lateral border (posterior margin of SCM)
• Level V is posterior and lateral to II,III, and
  IV, and consists of the posterior triangle
• Level VI is the anterior compartment nodes from
  hyoid superiorly, sternal notch inferiorly, and
  laterally to medial borders of carotid sheaths
• Level VII contains upper mediastinal lymph nodes
  inferior to suprasternal notch

18
The nerve most likely injured with submandibular
resection is

• A. Vagus
• B. Hypoglossal
• C. Auriculotemporal
• D. Marginal mandibular

19
The nerve most likely injured with submandibular
resection is

• A. Vagus
• B. Hypoglossal
• C. Auriculotemporal
• D. Marginal mandibular
• The nerve most commonly injured w/ resection of
  the mandibular gland is the marginal mandibular
  nerve
• This nerve supplies the lower lip and chin

20
Massive bleeding 7 days after tracheostomy is
most likely from

• A. Tracheo-carotid fistula
• B. Erosion of tracheostomy into external jugular
  vein
• C. Tracheo-jugular fistula
• D. Tracheo-innominate fistula

21
Massive bleeding 7 days after tracheostomy is
most likely from

• A. Tracheo-carotid fistula
• B. Erosion of tracheostomy into external jugular
  vein
• C. Tracheo-jugular fistula
• D. Tracheo-innominate fistula
• The most common case of massive bleeding
  following tracheostomy is a tracheo-innominate
  fistula
• Place finger through tracheostomy site and try to
  compress the innominate artery against sternum
• Then go to OR for median sternotomy
• Ligate and divide innominate artery (can place
  graft but at high risk of infection)
• Ligation of innominate artery proximal to takeoff
  of right subclavian usually does not result in
  neurologic dysfunction due to collaterals

22
A 35 YO F comes in w/ CC of tinnitus and hearing
loss. You order a head MRI and there is a tumor
at the cerebello-pontine angle. The most likely
diagnosis is

• A. Glioma
• B. Glioma multiforme
• C. Neuroma
• D. Meduloblastoma

23
A 35 YO F comes in w/ CC of tinnitus and hearing
loss. You order a head MRI and there is a tumor
at the cerebello-pontine angle. The most likely
diagnosis is

• A. Glioma
• B. Glioma multiforme
• C. Neuroma
• D. Meduloblastoma
• An acoustic neuroma has the classic symptoms of
  unsteadiness, tinnitus, and hearing loss. A
  tumor at the cerebellopontine angle almost
  ensures the diagnosis

24
A 10 YO boy presents w/ a cyst and a cyst tract
near the angle of his mandible. This cyst has
had recurrent infections in it. This cyst most
likely connects to the

• A. External auditory canal
• B. The tonsilar pillar
• C. The nasal septum
• D. Thoracic duct

25
A 10 YO boy presents w/ a cyst and a cyst tract
near the angle of his mandible. This cyst has
had recurrent infections in it. This cyst most
likely connects to the

• A. External auditory canal
• B. The tonsilar pillar
• C. The nasal septum
• D. Thoracic duct
• Type I branchial cleft cysts extend from the
  angle of the mandible to the external auditory
  canal

26
A 10 YO boy presents with a cyst in his lateral
neck medial to the anterior border of the
sternocleidomastoid muscle. This cyst most
likely connects to the

• A. External auditory canal
• B. The tonsillar pillar
• C. The nasal septum
• D. Thoracic duct

27
A 10 YO boy presents with a cyst in his lateral
neck medial to the anterior border of the
sternocleidomastoid muscle. This cyst most
likely connects to the

• A. External auditory canal
• B. The tonsillar pillar
• C. The nasal septum
• D. Thoracic duct
• Type II branchial cleft cysts extend from the
  anterior border of the SCM, through the carotid
  bifurcation, to the tonsillar pillar

28
The most common branchial cleft cyst is

• A. Type I
• B. Type II
• C. Type III
• D. Type IV

29
The most common branchial cleft cyst is

• A. Type I
• B. Type II
• C. Type III
• D. Type IV
• The most common branchial cleft cyst is type II

30
Treatment of branchial cleft cysts involves

• A. Antibiotics
• B. Resection
• C. XRT
• D. Chemotherapy

31
Treatment of branchial cleft cysts involves

• A. Antibiotics
• B. Resection
• C. XRT
• D. Chemotherapy
• Treatment of branchial cleft cysts involves
  resection

32

• All branchial remnants are present at the time of
  birth
• In children, fistulas gt external sinuses gt cysts
  In adults, cysts predominate
• Clinical presentation may range from continuous
  mucoid drainage from a fistula/sinus to a cystic
  mass that may become infected. Dermal pits or
  skin tags may also be evident.
• 1st branchial remnants are typically located in
  front/back of the ear, or in upper neck in the
  region of the mandible. Fistulas typically course
  through the parotid gland, deep, or through
  branches of the facial nerve, and end in the
  external auditory canal
• Remnants from the 2nd branchial cleft are the
  most common. The external ostium of these
  remnants is located along the anterior border of
  the SCM, usually in the vicinity of the upper
  half to lower third of the muscle. The course of
  the fistula must be anticipated preoperatively
  because stepladder counterincisions are often
  necessary to excise the fistula completely.
  Typically, the fistula penetrates the platysma,
  ascends along the carotid sheath to the level of
  the hyoid bone, and then turns medially to extend
  between the carotid artery bifurcation. The
  fistula then courses behind the posterior belly
  of the digastric and stylohyoid muscles to end in
  the tonsillar fossa.
• 3rd branchial remnants usually do not have
  associated sinuses/fistulas and are located in
  the suprasternal notch or clavicular region.
  These most often contain cartilage and present
  clinically as a firm mass or as a subcutaneous
  abscess.

33
A 5 YO F presents w/ a midline anterior neck mass
that moves w/ tongue protrusion and swallowing.
This most likely represents

• A. Thyroid cancer
• B. Branchial cleft cyst Type I
• C. Branchial cleft cyst Type II
• D. Thyroglossal duct cyst

34
A 5 YO F presents w/ a midline anterior neck mass
that moves w/ tongue protrusion and swallowing.
This most likely represents

• A. Thyroid cancer
• B. Branchial cleft cyst Type I
• C. Branchial cleft cyst Type II
• D. Thyroglossal duct cyst
• A midline anterior neck mass in a child that
  moves w/ tongue protrusion and swallowing is
  classic for a thyroglossal duct cyst. Thyroid CA
  would appear more lateral as would branchial
  cleft cysts

35
Resection of this cyst involves

• A. Removal of the cyst only
• B. Removal of the cyst and total thyroidectomy
• C. Removal of the cyst along with the hyoid bone
• D. Post-op XRT

36
Resection of this cyst involves

• A. Removal of the cyst only
• B. Removal of the cyst and total thyroidectomy
• C. Removal of the cyst along with the hyoid bone
• D. Post-op XRT
• You need to resect the hyoid bone (or atleast a
  central portion of it) when resecting these cysts
  so that they do not recur. This is called the
  Sistrunk procedure

37

• Thyroglossal duct cysts most commonly present in
  preschool-aged children.
• Thyroglossal remnants produce midline masses
  extending from the base of the tongue (foramen
  cecum) to the pyramidal lobe of the thyroid gland
• Complete failure of thyroid migration results in
  a lingual thyroid (US or radionuclide imaging may
  be useful to identify the presence of a normal
  thyroid gland w/in the neck)
• May be located in the midline of the neck
  anywhere from the base of the tongue to the
  thyroid gland but most are found at or just below
  the hyoid bone
• Indications for surgery include increasing size,
  the risk for cyst infection, or the presence
  (1-2) of carcinoma
• The classic treatment involves complete excision
  of the cyst in continuity with its tract, the
  central portion of the hyoid bone, and the tissue
  above the hyoid bone extending to the base of the
  tongue Failure to remove these tissues will
  result in a high risk for recurrence because
  multiple sinuses have been histologically
  identified in these locations

38
Regarding oropharyngeal abscesses, which one of
the following statements is true?

• A. Peritonsillar, parapharyngeal, and
  retropharyngeal abscesses occur with
  approximately equal frequency among children lt10
  yrs. of age
• B. Parapharyngeal and retropharyngeal abscesses
  can progress rapidly to cause airway obstruction
• C. Drainage of peritonsillar, parapharyngeal, and
  retropharyngeal abscesses is best accomplished
  through the pharyngeal wall
• D. As with abscesses in other locations in the
  body, small drains should be placed into
  transpharyngeally drained abscesses to promote
  continued evacuation of the abscess cavity

39
Regarding oropharyngeal abscesses, which one of
the following statements is true?

• A. Peritonsillar, parapharyngeal, and
  retropharyngeal abscesses occur with
  approximately equal frequency among children lt10
  yrs. of age
• B. Parapharyngeal and retropharyngeal abscesses
  can progress rapidly to cause airway obstruction
• C. Drainage of peritonsillar, parapharyngeal, and
  retropharyngeal abscesses is best accomplished
  through the pharyngeal wall
• D. As with abscesses in other locations in the
  body, small drains should be placed into
  transpharyngeally drained abscesses to promote
  continued evacuation of the abscess cavity

40

• Peritonsillar abscess are rare in children lt10
  yrs. of age treated w/ abx and needle aspiration
  of abscess (if no response in 24 hrs. repeat
  aspiration or I and D) rarely causes airway
  obstruction
• Retropharyngeal abscesses occur in infants, young
  children, and the elderly (although rare after
  age 10) Loss of airway is a potential hazard
  Abx and drainage through posterior pharyngeal
  wall or neck are treatments of choice drains not
  necessary (drains w/ swallowing)
• Parapharyngeal abscesses occur in all age groups
  and may be due to dental infection, pharyngitis,
  or tonsillitis B/C these abscesses occur more
  laterally drainage through oropharynx is
  hazardous (close to ICA and jugular veins)
  Should be drained through lateral neck with a
  drain left in place
• Greatest morbidity is from IJ thrombosis,
  vascular erosion, or spread into
  mediastinum/abdomen via prevertebral or
  retropharyngeal spaces.

41
Regarding epistaxis, which one of the following
statements is false?

• A. In most cases, epistaxis occurs from the
  anteroinferior part of the nasal septum
• B. Properly applied anteroposterior packing
  controls bleeding in 95 of cases
• C. Hypoxemia is a potential complication of nasal
  packing
• D. Ligation of the internal maxillary artery is
  ineffective for controlling epistaxis and should
  be avoided

42
Regarding epistaxis, which one of the following
statements is false?

• A. In most cases, epistaxis occurs from the
  anteroinferior part of the nasal septum
• B. Properly applied anteroposterior packing
  controls bleeding in 95 of cases
• C. Hypoxemia is a potential complication of nasal
  packing
• D. Ligation of the internal maxillary artery is
  ineffective for controlling epistaxis and should
  be avoided

43

• Approximately 90 of cases of epistaxis arise
  from Kiesselbach's plexus (anteroinferior part of
  the nasal septum) in most cases it is easily
  controlled w/ digital pressure (can be cauterized
  chemically/electrically occasionally anterior
  nasal packing required)
• In 10 of cases the source is posterior
  (Woodruff's plexus) frequently occurs in pts. w/
  arteriosclerosis and HTN initial attempt should
  be anterior or ant/post packs which is successful
  in 95 of cases (give abx to prevent sinusitis
  and otitis media)
• Air exchange is frequently hindered by packing
  (supplemental O2)
• Posterior epistaxis that can not be controlled w/
  packing can be treated with transantral or
  transnasal endoscopic ligation of internal
  maxillary artery (If bleeding high on lateral
  nasal walls anterior ethmoid artery should be
  ligated)

44
Regarding acute suppurative parotitis, which one
of the following statements is false?

• A. It usually occurs in elderly or debilitated
  pts.
• B. Dehydration is a major contributing factor
• C. Immediate surgical drainage is mandatory
• D. The numerous vertically oriented fascial septa
  of the parotid space lead to multiloculated
  abscesses when infection progresses
• E. S. aureus is the most frequent causative
  organism

45
Regarding acute suppurative parotitis, which one
of the following statements is false?

• A. It usually occurs in elderly or debilitated
  pts.
• B. Dehydration is a major contributing factor
• C. Immediate surgical drainage is mandatory
• D. The numerous vertically oriented fascial septa
  of the parotid space lead to multiloculated
  abscesses when infection progresses
• E. S. aureus is the most frequent causative
  organism

46

• Acute suppurative parotitis is a severe, life
  threatening infection most often seen in
  dehydrated elderly or debilitated pts. W/ poor
  oral hygiene
• Its pathogenesis is thought to be related to
  stasis w/in the salivary ducts as a result of
  increased viscosity
• S. aureus is the usual causative organism
• Initial treatment includes IV hydration, warm
  packs, sialagogues, and abx If no improvement in
  12 hrs surgical treatment is warranted
• Drainage is performed through a preauricular
  incision, w/ elevation of the skin to expose the
  parotid capsule and vertical incisions through
  the gland in a direction parallel to the branches
  of the facial nerve

47
Regarding neck dissections, which one of the
following statements is true

• A. In a classical radical neck dissection, the
  internal jugular vein, spinal accessory nerve,
  phrenic nerve, and SCM are routinely resected en
  bloc w/ the specimen
• B. B/L simultaneous radical neck dissections are
  well tolerated and should be performed in cases
  of midline lesions that have or may have
  metastasized to both sides of the neck
• C. The term modified radical neck dissection
  refers to the dissection of all but the posterior
  triangle portion of the classic radical neck
  dissection
• D. Sentinel lymph node biopsy w/ selective neck
  dissection is now the standard of care for
  clinically N0 squamous cell carcinomas of the
  oral cavity
• E. Preservation of the spinal accessory nerve
  significantly reduces the morbidity of neck
  dissection

48
Regarding neck dissections, which one of the
following statements is true

• A. In a classical radical neck dissection, the
  internal jugular vein, spinal accessory nerve,
  phrenic nerve, and SCM are routinely resected en
  bloc w/ the specimen
• B. B/L simultaneous radical neck dissections are
  well tolerated and should be performed in cases
  of midline lesions that have or may have
  metastasized to both sides of the neck
• C. The term modified radical neck dissection
  refers to the dissection of all but the posterior
  triangle portion of the classic radical neck
  dissection
• D. Sentinel lymph node biopsy w/ selective neck
  dissection is now the standard of care for
  clinically N0 squamous cell carcinomas of the
  oral cavity
• E. Preservation of the spinal accessory nerve
  significantly reduces the morbidity of neck
  dissection

49

• Classical radical neck dissection is designed to
  remove lymph nodes that accompany the great
  vessels w/in the carotid sheath as well as the
  submandibular and posterior cervical triangles
• It involves removal of SCM, IJ, spinal accessory
  nerve, submandibular gland, and associated lymph
  nodes branches of external carotid, sensory
  branches of anterior roots C2-C4, and cervical
  branch of facial nerve can sacrificed (phrenic,
  lingual, hypoglossal nerves preserved)
• B/L radical neck dissection significantly
  increases surgical morbidity (facial, pharyngeal,
  orbital edema, changes in MS from increased CNS
  venous pressure) prophylactic or elective B/L
  simultaneous neck dissections should be avoided
• Modified radical neck dissection involves removal
  of a nodal tissue w/ preservation of 1 or more of
  the following SCM, IJ, and/or spinal accessory
  nerve
• Sentinel lymph node Bx is accepted for selected
  melanomas of the head and neck, but still
  investigational for for squamous cell CA
• Syndrome of shoulder droop, scapular
  displacement, discomfort, and weakness from loss
  of spinal accessory nerve is major source of
  morbidity from radical neck dissection.