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
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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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