General Surgical Lists and Reminders

Discipline

1. HEAD AND NECK

Edited by Prof Bill Coman

■ POINTS IN HEAD & NECK ANATOMY

The Palate

All muscles of palate, except one, supplied by Vagus Nerve.

The exception: Tensor Palati Muscle, which opens the Eustachian Tube, supplied by Mandibular branch of Trigeminal Nerve.

The Larynx

All muscles of larynx, except one, supplied by Recurrent Laryngeal Nerve.

The exception: CricoThyroid Muscle, a tensor of the vocal cords, supplied by External Laryngeal Nerve.

Abduction of the Cords

Posterior Cricoarytenoid Muscle.

The Tongue

All muscles of tongue, except one, supplied by Hypoglossal Nerve.

The exception: Palatoglossus Muscle, supplied by Vagus.

The Facial Nerve

Three important branches in temporal bone:–

1. Greater Superficial Petrosal Nerve

2. Nerve to Stapedius Muscle

3. Chorda Tympani Nerve

Localisation of a facial nerve lesion:–

1. Testing lacrimation

2. Testing the Stapedius reflex

3. Testing taste

■ SIGNS OF R.I.C.P.

Diminished level of consciousness

Hypertension

Slow pulse

Slow resp. rate (stertorous resps.)

Papilloedema after 24 hours

+/– Lateralizing signs

■ C.S.F. RHINORRHOEA

1. Confirm with glucose test.

2. Check for fractures of ethmoidal, frontal, sphenoidal sinuses and temporal bone.

3. NG tube insertion contraindicated.

■ INAPPROPRIATE ADH SECRETION

Inability to excrete dilute urine

■ NECK SWELLINGS

Swelling Superficial to the Deep Fascia

1. Epidermoid (sebaceous) or pilar cysts

2. Lipomas

3. Neurofibromas and neurilemmomas

4. Some lymph nodes.

Swelling Beneath the Deep Fascia

1. Midline swellings

2. Lateral swellings

Midline Swellings

From unpaired midline structures:

1. Thyroglossal cyst

2. Pharyngeal pouch

3. Median sublingual dermoid cyst

4. Subhyoid bursa

5. Dissecting or plunging ranula

6. Laryngocele

Lateral Swellings

From paired lateral structures:

1. Lymph nodes

2. Thyroid swellings

3. Salivary glands

4. Branchial cysts

5. Cervical ribs

6. Carotid body tumour — (chemodectoma)

7. Cystic hygroma (cavernous lymphangioma)

8. Sternomastoid tumour

9. Arteriovenous fistula and cirsoid aneurysms

10. Soft tissue (muscle, neural or fatty) tumours.

11. Spinal and cervical abscesses e.g. actinomycosis.

12. Clavicular tumours, primary or secondary.

■ FINE NEEDLE ASPIRATION OF A NECK LUMP

1. May follow panendoscopy to identify malignant neck mass with unknown primary.

2. Contra-indicated where carotid body tumour suspected.

3. May not be helpful in lymphoma.

4. May aspirate cholesterol crystals from branchial cyst.

■ ASPECTS OF TONSILLITIS

Acute Tonsillitis

1. Generalised

2. Follicular

3. Membranous

Membranous Tonsillitis

1. Infectious mononucleosis

2. Coalescence of follicular tonsillitis

3. Diphtheria

Quinsy (Peritonsillar Abscess)

Sleepless night

Trismus

Drooling

Aspirate through large-bore needle, under L.A., with suction

■ INDICATIONS FOR TONSILLECTOMY

A. Absolute:

Obstructive symptoms and signs

B. Relative:

1. Recurrent tonsillitis

2. Attack of quinsy

3. Suspicion of malignancy

4. One larger tonsil (lymphoma)

5. Chronic suppurative otitis media

■ DEEP SPACE INFECTION OF THE NECK

1. Very sick patient.

2. Dysphagia, stridor and generalised neck swelling.

3. Mostly dental in origin.

4. Gas in tissues (anaerobic organisms).

5. Treatment: Surgical drainage.

■ BRANCHIOGENIC FISTULAE

1st cleft: Above hyoid to ext. auditory canal.

2nd cleft: Ant. border of sternomastoid to tonsillar fossa.

3rd cleft: Neck to piriform fossa.

4th cleft: None described.

■ NON-NEOPLASTIC SWELLING OF THE PAROTID

Acute inflammatory:

Viral (mumps etc.)

Bacterial (staph aureus)

Kussmaul’s

Chronic inflammatory:

Recurrent obstructive

Recurrent nonobstructive

(initial viral — Sjogren’s)

Benign lymphoepithelial lesion

T.B.

Actinomycosis

Sarcoidosis

Metabolic and Endocrine:

Diabetes

Alcoholism

Kwashiorkor

Vit. A deficiency

Others:

Trauma

Irradiation sialadenitis

Congenital lesions of 1st branchial cleft

■ MALIGNANT NECK MASS

The likely primary sites are:–

Pyriform Fossa

Base of Tongue

Tonsil

Larynx

Nasopharynx

Skin

■ Image Based Nodal Classification in Head and Neck Malignancy

Lymph node classification

• Allows selection of most appropriate neck dissection

Lymph node staging (N-Status)

• Prognostic significance

• Treatment philosophy

A short history of lymph node classification

1938 — Rouviere’s anatomical and clinical classification

1981 — Shah’s level based classification

1997 — AJCC nodal classification

1998 — AAO — HNS / Robins

1999 — Imaging based level classification

Level based classification

• Tumours in different parts of the head and neck spread to different groups of nodes

• The morbidity of a radical neck dissection

Imaging based nodal classification

• Most patients will have cross sectional imaging

• Imaging can identify clinically silent nodes

• Imaging defines precise anatomic landmarks leading to consistent definition of nodal groups

Level 1

• Below bottom of myelohyoid

• Above bottom of hyoid

Level 1 Nodes

• Lie anterior to a line joining the posterior margins of the submandibular glands

• Anterior belly of the digastric separates Level 1A (Medial) from Level 1B (Lateral).

• 1A = Submandibular nodes

• 1B = Submental nodes

Level 2

• Level 2 lies between the jugular foramen and the bottom of the hyoid (craniocaudally).

• Level 2 lies anterior to back of SCM, posterior to back of SMG.

IIA Nodes

Lie anterior, medial, or lateral to IJV. May also lie posterior but touch vein (= upper internal jug nodes).

IIB Nodes

Lie posterior to IJV but do not touch vein (= upper spinal accessory nodes).

The Node of Rouviere — the lateral retropharyngeal node

A node 2cm below the skull base medial to the IJV is not a IIA node — it is in a select group of named lymph nodes.

The Jugulodigastric Node — Level IIA

The JD node or sentinel node is the largest node in the neck — drains tonsils, mouth, pharynx and face.

Level III Nodes

• Lie between the lower body of the hyoid and the lower margin of the cricoid = midjugular nodes.

• Plane through medial margin of carotid artery

• Plane through posterior margin of SCM.

Level IV Nodes

• Lie below the inferior margin of the cricoid and above the clavicle = low jugular nodes.

• Plane through post margin of SCM and posterolateral margin of ant scalene.

• Plane through medial margin of carotid.

Level V Nodes (spinal accessory nodes)

• Lie anterior to transverse line through trapezius on each axial slice.

• Lie posterior to transverse line through posterior edge of SCM on each axial slice.

Level VA

• Lies between skull base and bottom of cricoid arch.

• Lies posterior to transverse line through post margin SCM.

• Lies anterior to transverse line through front of trapezius.

Level VB

• Lies between bottom of cricoid ring and clavicle.

• Lies behind oblique line running through posterior margin of SCM and PL edge of scalenus ant muscle.

Level VI Nodes

• Lie between inferior margin of body of hyoid and top of manubrium.

• Lie medial to line through CCA and ICA.

Level VII Nodes

• Between top of manubrium and brachiocephalic vein.

• Between medial margins of carotid arteries.

• Thyroid cancer.

Named Nodes in the imaging based level classification — ie. not in a level

• Supraclavicular — once you see clavicle on axial scans these are S/C nodes

• Retropharyngeal

• Parotid

• Facial

• Superficial

■ LYMPHADENOPATHY APPARENTLY LOCALISED TO NECK

A. Is it part of a local inflammatory process?

a. Tonsillitis

b. Pharyngitis

c. Infected skin lesion.

B. Is it part of a generalized lymphoid disease process?

Examine other nodal sites, particularly the axillae and groins. Palpate for hepatosplenomegaly.

Consider:

a. infectious mononucleosis,

b. ‘cat-scratch’ disease,

c. lymphoma.

C. Is it part of a carcinomatous process?

Depending on the site of lymphadenopathy: S.C.C of scalp, face, lips, tongue, floor of mouth. Tumours of the jaw, lung, stomach and breast. Do not forget malignant melanoma. All patients require detailed intra-oral, general and rectal examination.

■ GENERALIZED LYMPHADENOPATHY

Lymphoma — Hodgkin or Non-Hodgkin

Lymphoid leukaemia

Rubella (German measles)

Infectious mononucleosis (glandular fever)

Sarcoidosis

Chronic skin disease and sepsis (dermatopathic lymphadenopathy)

Cat scratch disease (a generalized form of this infection can occur)

Tuberculosis

Childhood rheumatoid arthritis (Still’s disease)

Adult rheumatoid arthritis (with splenomegaly and leucopoenia — Felty’s syndrome)

Secondary syphilis

HIV infection.

■ SPECIAL INVESTIGATIONS FOR NECK SWELLING

1. Endoscopy of the oropharynx, nasopharynx and larynx.

2. Fibreoptic bronchoscopy and biopsy, sometimes with carinal biopsy.

3. Fibreoptic oesophagoscopy.

4. Chest X-ray and views of thoracic inlet.

5. Full blood examination.

6. Mammography.

7. Fine needle aspiration cytology of a cervical swelling (90-95% accurate).

To classify lymphoma type, excision biopsy is required.

8. Excision biopsy of lymph nodes should be confined to cases of doubt and lymphoma.

Send fresh for:– Lymph node imprints, monoclonal antibodies, routine histopathology.

■ PAROTID GLAND TUMORS