Anterior neck triangle – sternocleidomastoid muscle (SCM), sternal notch, inferior border of the digastric muscle; contains the carotid sheath

  Posterior neck triangle – posterior border of the SCM, trapezius muscle, and the clavicle; contains the accessory nerve (innervates SCM, trapezius, and platysma) and the brachial plexus

  Parotid glands – secrete mostly serous fluid

  Sublingual glands – secrete mostly mucin

  Submandibular glands – 50/50 serous/mucin

  In larynx, the false vocal cords are superior to the true vocal cords

  Trachea has U-shaped cartilage and a posterior portion that is membranous

  Vagus nerve – runs between internal jugular (IJ) vein and carotid artery

  Phrenic nerve – runs on top of the anterior scalene muscle

  Long thoracic nerve – runs posterior to the middle scalene muscle

  Trigeminal nerve – ophthalmic, maxillary, and mandibular branches

•  Gives sensation to most of face

•  Mandibular branch – taste to anterior ⅔ of tongue, floor of mouth, and gingiva

  Facial nerve – temporal, zygomatic, buccal, marginal mandibular, and cervical branches

•  Motor function to face

  Glossopharyngeal nerve – taste to posterior ⅓ tongue

•  Motor to stylopharyngeus

•  Injury affects swallowing

  Hypoglossal nerve – motor to all of tongue except palatoglossus

•  Tongue deviates to the same side of a hypoglossal nerve injury

  Recurrent laryngeal nerve – innervates all of larynx except cricothyroid muscle

  Superior laryngeal nerve – innervates the cricothyroid muscle

  Frey’s syndrome – occurs after parotidectomy; injury of auriculotemporal nerve that then cross-innervates with sympathetic fibers to sweat glands of skin

•  Symptom: gustatory sweating

  Thyrocervical trunk – “STAT”: suprascapular artery, transverse cervical artery, ascending cervical artery, inferior thyroid artery

  External carotid artery – 1st branch is superior thyroid artery

  Trapezius flap – based on transverse cervical artery

  Pectoralis major flap – based on either the thoracoacromial artery or the internal mammary artery

  Torus palatini – congenital bony mass on upper palate of mouth. Tx: nothing

  Torus mandibular – similar to above but on lingual surface of mandible. Tx: nothing

  Modified radical neck dissection (MRND) – takes omohyoid, submandibular gland, sensory nerves C2–C5, cervical branch of facial nerve, and ipsilateral thyroid

•  No mortality difference compared with RND

  Radical neck dissection (RND) – same as MRND plus accessory nerve (CN XII), sternocleidomastoid, and internal jugular resection (rarely done anymore)

•  Most morbidity occurs from accessory nerve resection

ORAL CAVITY CANCER

  Most common cancer of the oral cavity, pharynx, and larynx – squamous cell CA

•  Biggest risk factors – tobacco and ETOH

•  Erythroplakia – considered more premalignant than leukoplakia

  Oral cavity includes mouth floor, anterior ⅓ tongue, gingiva, hard palate, anterior tonsillar pillars, and lips

  Lower lip – most common site for oral cavity CA (more common than upper lip due to sun exposure)

  Survival rate lowest for hard palate tumors – hard to resect

  Oral cavity CA increased in patients with Plummer–Vinson syndrome (glossitis, cervical dysphagia from esophageal web, spoon fingers, iron-deficiency anemia)

  Treatment

•  Wide resection (1 cm margins)

•  MRND for tumors > 4 cm, clinically positive nodes, or bone invasion

•  Postop XRT for advanced lesions (> 4 cm, positive margins, or nodal/bone involvement)

  Lip CA – may need flaps if more than ½ of the lip is removed

•  Lesions along the commissure are most aggressive

  Tongue CA – can still operate with jaw invasion (commando procedure)

  Verrucous ulcer – a well-differentiated SCCA; often found on the cheek; oral tobacco

•  Not aggressive, rare metastasis

•  Tx: full cheek resection ± flap; no MRND

  Cancer of maxillary sinus – Tx: maxillectomy

  Tonsillar CA – ETOH, tobacco, males; SCCA most common; asymptomatic until large; 80% have lymph node metastases at time of diagnosis

•  Tx: tonsillectomy best way to biopsy; wide resection with margins after that

PHARYNGEAL CANCER

  Nasopharyngeal SCCA – EBV; Chinese; presents with nose bleeding or obstruction

•  Goes to posterior cervical neck nodes

•  Tx: XRT primary therapy (very sensitive; give chemo-XRT for advanced disease – no surgery)

•  Children – lymphoma #1 tumor of nasopharynx. Tx: chemotherapy

•  Papilloma – most common benign neoplasm of nose/paranasal sinuses

  Oropharyngeal SCCA – neck mass, sore throat

•  Goes to posterior cervical neck nodes

•  Tx: XRT for tumors < 4 cm and no nodal or bone invasion

•  Combined surgery, MRND, and XRT for advanced tumors (> 4 cm, bone invasion or nodal invasion)

  Hypopharyngeal SCCA – hoarseness; early metastases

•  Goes to anterior cervical nodes

•  Tx: XRT for tumors < 4 cm and no nodal or bone invasion

•  Combined surgery, MRND, and XRT for advanced tumors (> 4 cm, bone invasion or nodal invasion)

  Nasopharyngeal angiofibroma – benign tumor

•  Presents in males < 20 years (obstruction or epistaxis)

•  Extremely vascular

•  Tx: angiography and embolization (usually internal maxillary artery), followed by resection

LARYNGEAL CANCER

  Hoarseness, aspiration, dyspnea, dysphagia

  Try to preserve larynx

  Tx: XRT (if vocal cord only) or chemo-XRT (if beyond vocal cord)

•  Surgery is not the primary Tx; try to preserve larynx

•  MRND needed if nodes clinically positive

•  Take ipsilateral thyroid lobe with MRND

  Papilloma – most common benign lesion of larynx

SALIVARY GLAND CANCERS

  Parotid, submandibular, sublingual, and minor salivary glands

  Submandibular or sublingual tumors – can present as a neck mass or swelling in the floor of the mouth

  Mass in large salivary gland → more likely mass is benign

  Mass in small salivary gland → more likely mass is malignant, although the parotid gland is the most frequent site for malignant tumor

  Malignant tumors

•  Often present as a painful mass but can also present with facial nerve paralysis or lymphadenopathy

•  Lymphatic drainage is to the intra-parotid and anterior cervical chain nodes

•  Mucoepidermoid CA – #1 malignant tumor of the salivary glands

•  Wide range of aggressiveness

•  Adenoid cystic CA – #2 malignant tumor of the salivary glands

•  Long, indolent course; propensity to invade nerve roots

•  Very sensitive to XRT

•  Tx for both: resection of salivary gland (eg total parotidectomy), prophylactic MRND, and postop XRT if high grade or advanced disease

•  If in parotid, need to take whole lobe; try to preserve facial nerve

  Benign tumors

•  Often present as a painless mass

•  Pleomorphic adenoma (mixed tumor) – #1 benign tumor of the salivary glands

•  Malignant degeneration in 5%

•  Tx: superficial parotidectomy

•  If malignant degeneration, need total parotidectomy

•  Warthin’s tumor – #2 benign tumor of the salivary glands

•  Males, bilateral in 10%

•  Tx: superficial parotidectomy

  Most common injured nerve with parotid surgery – greater auricular nerve (numbness over lower portion of ear)

  For submandibular gland resection – need to find mandibular branch of facial nerve, lingual nerve, and hypoglossal nerve

  Most common salivary gland tumor in children – hemangiomas

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