H&N note by S.

Wichien (SNG KKU)

Congenital disease 1.Cystic hygroma -congen lymphangiomatous -post triangle -c/p=2nd infect, hmg -Tx-excision 2.Branchial cleft cyst Ext opening Int opening 1st preauri/subman 2nd ant SCM tonsillar fossa 3rd suprasternal piriform sinus Ludwig angina -rapid severe soft tissue infect -dental carried -DM,cirrhosis,poor dental hygiene -cellulitis above hyoid -UAWO Ix -film neck -contrast CT--ix of choice Tx -maintain aw--tracheostomy > ett -PGS -sx drainage :transverse incision :below mandible 1cm Neck mass 80% of non thyroid = tumor 80% of tumor = ca 80% of ca = SCC 80% of SCC = above clavicle HIV neck node 1st = inflame/ reactive hyperplasia 2nd = tumor (B cell lymphoma/kaposi) Salivary gland Parotid -stensen duct -serous content -auriculotemporal n Submandibular -wharton duct -hi mucin -easily stone Sublingual -rivinus dsublingual dwharton d 1.Acute suppurative parotitis -critical ill pt, elderly -poor oral hygiene -dehydration -staph aureus -bi-manaul palpation Tx -ATB--gr+ & anaerobe -mouth care, warm compression -sx-drain along cn7 2.Sialolithiasis -submand 90% -post pandrial pain -colicky pain -Ix-plain film,sialography Tx location of stone -duct opening--remove -in duct--open at FOM -recur--resect gland

H&N note by S.Wichien (SNG KKU)

Salivary gland tumor -<2% of HN tumor -usually slow growing -rapid growth,pain,FN palsy=ca Dx -MRI--most sen -FNA--all case -don't open Bx--metas -don't sialography Parotid gland 80%=tumor of salivary gland 80%=benign tumor 80%=benign mixed tumor 80%=superficial lobe Benign -Pleomorphic adenoma -Warthin tumor Malignant -Mucoepidermoid ca -Adenoid cystic ca -Mucoepidermoid & acinic cell ca -carcinoma expleomorphic adenoma Subman/sublingual gland 50%=malignancy Benign -benign mixed tumor -Tx-submandi resection Malignant -adenoid cystic (most com) -malignant mixed T -Tx-N0=SOHND, N1=MRND Minor salivary gland -submu of upper AD tract,palate -most aggressive salivary tumor -painless submu mass -may displace lat oropharynx/tonsil -ca=most at jxn soft&had palate -most com=SCC -Tx--WLE+LND Salivary Benign Tumor 1.Epithelial tumor Pleomorphic adenoma Warthin tumor Monomorphic adenoma Oncocytoma Sebaceous neoplasm 2.non epithelial tumor -hemangioma -neural sheath tumor -lipoma Pleomorphic adenoma (mix T.) -30-40 yr -single,well defined Tx -superficial parotidectomy -not recommend enucleation (incomplete+T.spillage) Warthin tumor -papilla cystadenoma lymphomatosum -40-60 yr -only parotid -rare cn7 involvement -10% benign parotid tumor 10%=bilat 10%=multicentric 10%=ca Tx -superficial parotidectomy -radioresistant

H&N note by S.Wichien (SNG KKU)

Salivary Malignant Tumor 1.mucoepidermoid ca -most common low grade -mucin secreting cell -acinic cell -Tx-superficial parotidectomy hi grade -epidermoid cell -resemble non-keratinize SCC -Tx-total parotidectomy 2.adenoid cystic ca -2nd most com -neural invasion--cn7 -skip lesion along n--cause of recur -distant metas--lung 3.mucoepidermoid ca & acinic cell ca -most com in ped 4.carcinoma expleomorphic adenoma -malignant mixed tumor -pre existed benign mix tumor Tx -sx excision -en bloc removal w prserve n, unless directed involve by tumor Salivary Tx Parotid gland superficial lobe -superficial parotidectomy -preservation cn 12 Deep lobe -total paraotidctomy -n preserve if wo leaving gross tumor radical parotidectomy -total parotidectomy + cn7 Submandibular gland -en bloc resection -submen and subman LN dissection LN removal -in LN palpate -hi gr mucoepidermoid :risk regional metas>20% Gross n invasion -lingual/hypoglosssl n -sacrifice of n+frozen secretion -if invade at level of skull base :left sx clip for p/o XRT XRT -extraglandular -perineural invade -vascular invade -regional metas -hi grade tumor -recurrent tumor -R1 resection -node+ve -unresectable CMT -unresectable -distant metas -adenoca

H&N note by S.Wichien (SNG KKU)

H&N cancer Risk factor -smoking/alc -poor oral hygiene -chronic irritation -plummer vinson synd -HPV-ca oropharynx -EBV-ca nasopharynx Precancerous erythroplakia > leukoplakia Staging T1<2cm T2 2-4cm T3 4-6cm T4>6cm/invade N1 single<3cm N2 single 3-6cm,multi,bilat N3 >6cm 1=T1N0 2=T2N0 3=T3N0, T1-2N1 4=T4N1-3M0 or anyTanyN M1 LN station 1=submen/subman 2=upper jugular 3=middle jugular (below hyoid) 4=lower jugular (below cricoid) 5=post triangle 6=central 7=upper medias Lymphatic drainage Lip=1,2,3 Oroharynx/hypopharynx=2,3,4 Nasopharynx=2,3,4,5 Thyroid/subglostic=6,7 Ant auricular=parotid,1,2,3,4,5 Post auricular=suboccipital,2,3,4,5 LND SOHND--1,2,3 Extend SOHND--1,2,3,4 Lat ND--2,3,4 Posterolat ND--2,3,4,5 CND--6 Bilat LN metastasis -floor of mouth -soft palate -tongue base -piriformis H&N cancer Sx Lip ca T1,2=WLE T3,4,N1=WLE+SOHND+PORT Hard palate T1,2=WLE+bone resect T3,4,N1= WLE+bone resect+SOHND+PORT FOM T2=WLE+bilat SOHND Tongue T2=WLE+SOHND Buccal T2=WLE+SOHND Alveolar ridge T2=WLE+bone resection Prophylaxtic ND (N0)Depend on T stage T2 -oral tongue/FOM/buccal/alveolar ridge piriform sinus/retromolar trigone T3 -lips/hard palate Neoadjuvant CRT -advance stage -carotid a involve RTx is 1Tx in -nasopharynx -oropharynx -hypopharyx -larynx Adjuvant RT -T3/4 -+ve margin -poorly diff -vascular/lymp/n invade -N2,3 -N1 + extacapsule extension not open bx--should FNA MRND Type1-preserve CN11 Type2-preserve CN11+IJV Type3-preserve CN11+IJV+SCM

H&N note by S.Wichien (SNG KKU)

Metastatic ca of unknown primary 1.SCC -most common type -most=tonsil Ix -Bx nasopharynx, piriform -resect tonsil 2.adenoca -lung, prostate, pancreas 3.undiff Sx complication Frey syndrome -late sx c/p--6m -auriculotemporal n (parasymp)) -parasym--join--sym fiber -symp when chewing -triad=sweating+flushing+warm Tx -topical anticholinergic -atropine iv -botox -sx=neurectomy Procedure Submandi gland Sx Branchial cleft cyst(2) Carotid body tumor Btw carotid bifurcate CN injury CN 5 (3) CN 7 (mandibu br) CN12 CN12 CN12 Chemodectoma -benign unifocal -non heredi paraganglioma -carotid bifurcate wall -lateral neck mass -hypervascular tumor -bruit/pulsatile mass Tx -excision -if>3cm--pre-op embolization -c/p--sup laryngeal n inj

Carotid artery rupture -common carotid A -previous XRT -s/p neck node dissection + remove SCM Tx -ligation