Surgery: Head/Neck

What makes up the anterior triangle of the neck?

medial: trachea, thyroid, cricoid cartilage

lateral: SCM

inferior: sternal notch and clavicle

superior: mandible

What makes up the posterior triangle of the neck?

anterior: SCM

posterior: trapezius

inferior: clavicle

What supplies blood to the head/neck?

R/L common carotids

*branch into internal/external carotids above the thyroid cartilage

What drains the head/necks blood supply?

internal jugular vein → drains to the subclavian vein

What drains most of the body’s lymph fluid?

Virchow’s node (left suprascapular node)

What connects the Thyroid to the trachea?

Ligament of Berry

What is the job of the thyroid?

responsible for the regulation of metabolism, growth, and electrolyte concentrations

What supplies blood to the thyroid?

superior and inferior thyroid arteries

What drains the thyroids blood supply?

superior, middle, and inferior veins

How many Parathyroid glands are there?

4

What is the main function of the parathyroid glands?

secretes PTH to maintain serum Ca homeostasis

What nerves are in the neck?

Recurrent laryngeal nerves: paired, branch from vagus

Superior laryngeal nerve: branches of vagus below base of skull

What is globus hystericus?

painful lump/sensation of lump in the throat

What is pyrosis?

sensation of painful burning in the upper chest (heart burn)

What is singultus?

sudden, involuntary spasm of the diaphragm that leads to the vocal cord snapping shut (hiccups)

What is a Type 1 (sliding) hiatal hernia?

95% of cases; GEJ slides into the mediastinum; only significant when gastric acid is refluxed into the lower esophagus

What is a Type 2 (paraesophageal) hiatal hernia?

part of the stomach migrates into the mediastinum parallel to the esophagus; reflux is uncommon; fundus can become incarcerated

What is a type 3 (sliding & paraesophageal) hiatal hernia?

both GEJ and portion of the stomach have migrated into the mediastinum

What is a Type 4 hiatal hernia?

stomach and additional organs (bowel, spleen) herniate into the chest

What are RF for hiatal hernias?

elderly, elevated intra abdominal pressure, COPD, previous surgeries

How do hiatal hernias present?

typically present for GERD workup; heartburn is most common complaint; dysphagia, regurgitation

When is surgery indicated for hiatal hernias?

pts w/ severe esophageal injury, Barrett’s, persistent sx despite medical management, gastric volvus

What is Nissen fundoplication?

*for hiatal hernias

360 degree wrap of the fundus of the stomach to restore the LES/GEJ

What is Partial fundoplication (Dor and Toupet)?

*for hiatal hernias

anterior vs posterior wrap respectively

What is Hill repair?

*for hiatal hernias

restores GEJ w/ posterior anchoring to the median arcuate ligament

What is Belsey surgical method?

*for hiatal hernias

uses a thoracic approach

What test can detect moderate/severe esophagitis, strictures, hiatal hernias, and tumors?

Barium swallow

What is the gold standard for dx GERD?

24hr pH monitoring

What are complications of GERD?

Barrett’s esophagus (precursor to esophageal cancer → adenocarcinoma)

What is the tx for Barrett’s esophagus?

radiofrequency ablation for low or high grade dysplasia; cryotherapy

When is surgery indicated for GERD?

failed medical management or wish to discontinue, underlying hiatal hernia

What are surgical options for GERD?

Laparoscopic Nissen fundoplication vs anterior approach; bariatric surgery

What are benefits of laparoscopic Nissen fundoplication?

85% of pts will have sx relief & healing of esophagitis, medical costs > costs w/in 10 yrs, pts may need to continue H2 blockers or PPI post op

What are complications of laparoscopic Nissen fundoplication?

secondary dysphagia, slipped wrap, recurrent heartburn, gastric distension, nausea → inability to tolerate PO

What are RF for squamous cell carcinoma?

smoking, alcohol consumption, diet low in fruits and vegetables, HPV

What are RF for adenocarcinoma?

Barrett’s esophagus, GERD, obesity, smoking

What are sx of esophageal CA?

dysphagia, anorexia, wt loss, odynophagia, constant mid-back or mic-chest pain, retrosternal discomfort, hoarseness

What workup needs to be done for esophageal CA?

barium swallow, CT/PET, endoscopic US (FNA suspicious lymph nodes)

What staging is used for esophageal CA?

TNM

What is the tx for esophageal CA?

chemo ± surgery (en bloc esophagectomy)

*< 20% 5 yr survival rate

What are sx of achalasia?

dysphagia and regurgitation of undigested food, CP, nocturnal cough, heartburn, wt loss

What workup is needed for achalasia?

Barium esophagogram: initial test → “bird-beak” deformity

EGD → r/o malignancy

esophageal manometry → gold standard

What is the surgical tx for achalasia?

pneumatic dilation of esophagus via endoscopy

Laparoscopic Heller myotomy w/ partial fundoplication

What is a laparaoscopic heller myotomy?

*for achalasia

incise the muscle layer of the lower esophagus to relieve the pressure at the LES ± partial fundoplication d/t risk of GERD post op

What are sx of Zenker’s diverticulum?

regurgitation, halitosis, dysphagia, choking, present for months-yrs

What is the tx for Zenker’s diverticulum?

sugery if sx or large (open vs endoscopic)

What is Boerhaave’s syndrome?

perforation after an episode of forceful vomiting or retching

What is a Mallory Weiss tear?

longitudinal mucosal tear secondary to forceful vomiting or retching

What are sx of esophageal perforations/tears?

neck pain and crepitus, dsyphagia, odynophagia, retrosternal CP, chest wall crepitus, mediastinal crackling, epigastric pain

red flag sx: fever, tachycardia, hypotension, cyanosis (late signs and shock)

What are the surgical options for esophageal perforations or tears?

endoscopic stent placement (if stable)

surgical drainage & debridement of devitalized tissue w/ wound repair

primary closure if < 24 hr and not infection/FB

What causes esophageal varices?

portal HTN (MCC cirrhosis)

What is the MC fatal complication of cirrhosis?

variceal rupture

What are sx of esophageal varices?

GI bleed → hematemesis, hematochezia, melena; hx alcoholism, jaundice, wt loss, pruritis

What is the gold standard test for esophageal varices?

hepatic vein pressure gradient

What is the surgical tx for exophageal varices?

endoscopic band ligation

Transjugular intrahepatic portosystemic shunt (TIPS) -used to stabilize pts awaiting liver transplants

Portosystemic shunt surgery

What is the TIPS procedure?

*for esophageal varices

performed via fluoroscopy; creates shunt w/in liver itself: links portal vein w/ a vein draining away from liver together w/ a stent → acts as a scaffold to support the connection btwn these two veins are the liver

T/F: more than 90% of thyroid nodules are benign

True

What are RF for thyroid nodules?

inc age, female, iron deficiency, hx thyroid radiation, Hashimoto’s

What are sx of thyroid nodules?

most asx, found incidentally; if they have concerning characteristics or are associated w/ cervical LAD think malignancy

What workup is needed for thyroid nodules?

TSH, T3/T4, thyroid US

FNA = definitive dx

What grading system is used to classify thyroid nodules?

Bethesda classification

What f/u test is used for thyroid nodules w/ indeterminate cytology?

Radioactive iodine scan -aids in differentiation btwn hyperthyroidism and subacute thyroiditis; classifies as “hot” or “cold”

What is the difference between hot and cold thyroid nodules?

hot: benign adenomas, toxic goiter

cold: cyst, carcinoma, lymphoma

Which Bethesda score is indeterminate?

III and IV

At what Bethesda score do pts require surgery?

V and VI

What are the surgical options for thyroid nodules?

thyroid lobectomy vs total thyroidectomy → open cervical approach

What are complications of removing thyroid nodules?

goal is to preserve parathyroid (transplant to SCM)

recurrent laryngeal nerve injury → paralysis of I/L vocal cord or B/L loss of phonation and airway control

What are surgical tx options for hyperthyroidism?

total thyroidectomy (pretx w/ Lugol’s)

*post op will need to be on Levothyroxine for life

What is a toxic adenoma?

solitary benign nodules w/ autonomous thyroid hormone production (low TSH, high T3/T4)

What is the tx for a toxic adenoma?

pre-tx w/ Lugol’s → thyroid lobectomy

What is the tx for papillary and follicular thyroid cancer?

*papillary is MC type

total thyroidectomy ± RAI ablation OR thyroid lobectomy if < 4 cm

What are sx of hyperparathyroidism?

bone/muscle pain, nephrolithiasis, abd pain, psychosis, fatigue

What workup is needed for hyperparathyroidism?

hypercalcemia, elevated PTH → definitive

nuclear medicine scan → standard imaging

4D CT parathyroid is more definitive

What is the tx for hyperparathryoidism?

parathyroidecotmy (use thyroidectomy approach)

What are complications of a hyperparathyroidectomy?

hypocalcemia “hungry bone syndrome” → perioral numbness, paresthesias, seizures, Chvostek’s sign

Rx: calcium, rocaltrol

What visual defect to pituitary adenomas cause?

bilateral hemianopsia

What is the 1st line tx for prolactinomas?

Cabergolin or Bromocriptine

What is the surgical tx for pituitary adenomas?

transphenoidal resection → H&N surgery (skull base surgeon) and neurosurgeon

What is a macroadenoma?

> 1 cm

What is considered a giant pituitary adenoma?

> 40 mm

Where are a majority of salivary gland tumors located?

parotid gland

What is the MC benign salivary gland tumor?

pleomorphic adenoma

What is the MC malignant salivary gland tumor?

mucoepidermoid carcinoma and adenoid cystic carcinoma

What is the tx for a salivary gland tumor?

parotidetomy using modified Blair incision

*watch out for facial nerve

Who are neck lesions MC seen in?

alcoholics and diabetics

What is the tx for superficial inflammatory lesions?

hot packs, abx, I&D

What is the “danger space” where you do NOT want to get an infection?

posterior to the retrovertebral space and anterior to the prevertebral space

What are sx of a deep inflammatory neck lesion?

painful soft tissue swelling, nuchal rigidity, fever, chills, odynophagia, trismus, dyspnea, muffled voice

What is the tx for a deep inflammatory lesion?

IV abx and urgent I&D intraoperatively

What are sx of Ludwig’s angina?

tongue displacement posteriorly, muffled voice and trismus, submental, swelling, firmness, floor of mouth is indurated

What is the tx for Ludwig’s angina?

aggressive airway management, bedside or OR drainage

abx: unasyn IV, or Vanc and Zosyn w/ Augmentin on d/c

Where the MC location of a branchial cleft cyst?

2nd branchial cleft

How do branchial cleft cysts present?

may see sinus opening at birth, usually along the anterior border of SCM, does not move w/ swallowing

What is the tx for branchial cleft cyst?

abx for acute infection, acute drainage, surgical resection of the mass including the sinus tract

How do thyroglossal cysts present?

90% midline, non-tender, move w/ swallowing and tongue protrusion

What is the tx for a thyroglossal cyst?

Surgical excision of the cyst and fistulous tract

*painful operation, removing part of hyoid bone and connection to tongue base

In adults, what masses are usually (80%) metastatic in origin?

firm, persistent, enlarging neck masses

Where do most malignant neck masses originate from?

head/neck SCC (lateral neck is more associated w/ metastatic lesions)

Which level of the neck is made up of the anterior or lateral tongue or floor of the mouth?

Level 1

Which level of the neck is made up of the oral cavity, base of tongue, pharynx, and nasal cavity?

Level II and III