Part VI

Special Subjects
Chapter Cuts and Caveats

CHAP TER 18
He a d a nd Ne c k Surg e ry:
T e most common neck lesion is a reactive lymph node. All adults with a persistent neck mass have
a malignancy until proven otherwise.
Most head and neck cancers are squamous cell and are treated with surgery, radiation, or
chemotherapy. Cosmetic and unctional def cits may be requent.
Congenital lesions are abnormal variants o normal structures. T yroglossal duct cysts are midline
structures that rise and all with swallowing. T ey should be resected i symptomatic, a er making
sure there is adequate residual thyroid tissue.
onsillectomy was once an extremely common operation and is now reserved or those with
repeated in ections, as the risk o surgery outweighs the benef ts or most patients.

CHAP TER 19
Ba ria tric Surg e ry:
Obesity a ects more than one third o Americans and an increasing percentage o children and
adolescents. Obesity creates metabolic comorbidities and decreases li e span.
BMI is the most use ul marker or obesity; people quali y or bariatric surgery with BMI greater
than 40 kg/m 2 or 35 kg/m 2 with medical comorbidities.
Bariatric procedures are classif ed as primarily restrictive or malabsorptive. Roux-en-Y gastric
bypass is the most common operation and is a blend o the two. Gastric banding and sleeve
gastrectomy are restrictive, and the duodenal switch operation is malabsorptive.
Postoperative bariatric patients are susceptible to a variety o unique complications, including
internal hernia, marginal ulceration, and nutritional def ciencies.
achycardia in a postoperative patient is a surgical complication until proven otherwise. T e patient
must be assessed or anastomotic leak and DV /PE.

CHAP TER 20
Minim a l Ac c e s s Surg e ry:
Minimally invasive surgery relies on technology to decrease the size o the access incisions; visual
cues largely replace tactile ones.
T e f rst steps in minimally invasive procedures are establishment o pneumoperitoneum and
diagnostic laparoscopy.
Pneumoperitoneum is an artif cial state that has a mechanical (pressure) component that can
mimic abdominal compartment syndrome. T e use o carbon dioxide gas also creates an acidosis.
T is does not have a signif cant clinical impact or brie procedures in patients who have minimal
physiologic compromise.


Most general surgical procedures have minimally invasive options, including surgery on the
gallbladder, appendix, intestines, and hernias. Robotic procedures are especially use ul in
anatomically conf ned cases, such as low pelvic surgery or prostatectomy.

CHAP TER 21
Surg ic a l Onc o lo g y:
Oncology is increasingly multidisciplinary. Benign and malignant re er to behavior, not
outcomes—benign lesions may be atal, and malignant processes may be indolent.
Oncogenes drive the cell cycle; tumor suppressor genes provide a natural checkpoint.
Dysregulation o either may lead to cancer.
Imaging, serum markers, and genomics can all provide diagnosis well in advance o clinical
symptoms. Screening can reduce mortality in breast, colon, cervical, and prostate cancer.
T e NM system provides a common language to group and stage tumors.

CHAP TER 22
Tra um a a nd Burns :
Primary survey: ABCs. Remember the ABCDE o trauma: airway, breathing, circulation, disability,
everything else.

Hemodynamically unstable patients should not go to the C scanner. Intubate all patients with a
low GCS or those with massive injury.
Fatal hemorrhage occurs in f ve major locations: chest, abdomen, retroperitoneum, thigh, and externally.
Hypovolemia is the most common cause o hypotension in trauma and is treated with uid
resuscitation. However, tension pneumothorax and cardiac tamponade cause hypotension, are
not associated with hypovolemia, and are not treated with uid resuscitation. T ey should be
considered early during resuscitation.
FAS exam reliably detects ree uid and can provide an early, sa e means o diagnosing the need
or operation.
Initial resuscitation o burn victims may be massive: use 4 mL/kg/% BSA over the f rst 24 hours.
Use the rule o 9’s to estimate BSA.
Hypothermia may cause coagulopathy and resultant bleeding a er trauma.
Simple pneumothorax usually presents with dyspnea and is not emergent, whereas a tension
pneumothorax presents with hypotension and requires emergent decompression.

CHAP TER 23
Org a n Tra ns p la nta tio n:
Calcineurin inhibitors have considerable nephrotoxicity.
Organ transplantation is considered or irretrievable end-organ dys unction.
T e main complications o immunosuppression are susceptibility to in ections and the
development o malignancy.
Kidney transplants are the most success ul solid organ transplants. Although dialysis is a
replacement option, patients live longer with kidney transplants than on dialysis; there ore, all endstage renal patients are considered transplant candidates. Although outcomes are superior with
living donors, deceased donors and extended criteria donors have produced acceptable results.
Because no alternative exists to replace a dys unctional liver, transplantation remains the only
option or severe liver ailure but is raught with complications due to the extent o disease in most
o these patients.
Most acute rejection occurs in the f rst year a er transplant and may be related to in ection or
inadequate immunosuppression. T e cornerstones o immunosuppression are corticosteroids, but
immune modulators have been developed that a ect all aspects o -cell unction and di erentiation.

Islet cell transplantation may provide the cure o diabetes without the heavy immunosuppression o
whole organ transplant. o date, results are promising.

297


CHAP TER 24
P e d ia tric Surg e ry:
Pediatric surgery represents a separate discipline, since the physiology o children di ers rom that
o adults.
Congenital hernias may be associated with other conditions and require care ul assessment be ore
repair. In general, umbilical hernias are not repaired, as they may close spontaneously. Inguinal
hernias are repaired with high ligation o the sac. Diaphragmatic hernias are repaired but with
caution, as pulmonary dys unction may also be present.
Many specif c problems can arise within the neonatal GI tract. Malrotation and necrotizing
enterocolitis may require urgent surgery and may result in long-term problems such as short gut
syndrome.
Failure to pass meconium in the f rst 24 hours suggests a diagnosis o Hirschsprung disease, which
is conf rmed on rectal biopsy.
Projectile vomiting in a 1-month old in ant may represent hypertrophic pyloric stenosis. reatment
is a surgical pyloromyotomy a er correction o any metabolic derangements.
Wilms tumor and neuroblastoma are the two most common childhood solid tumors.
Gastroschisis is an abdominal wall de ect with no sac and has rare associated congenital anomalies.
Omphalocele has a sac and has a high association with congenital anomalies.
Esophageal atresia is most commonly a proximal esophageal pouch and distal tracheoesophageal
( E) f stula and is associated with cardiac and VAC ERL anomalies.
Intestinal malrotation usually presents with bilious vomiting.
Duodenal atresia shows an abdominal double-bubble sign, is corrected by duodenoduodenostomy
and is commonly associated with other congenital anomalies.
Jejunal and more distal bowel atresia occur rom in-utero vascular accidents and have ew

associated congenital anomalies.

298


Chapter 18

Head and Neck Surgery
Andrea Hebert and Jef rey S. Wol

COMP ONENTS OF THE HEAD AND NECK EXAM
Ge ne ra l
I. Bre a thing : Note whether the patient is breathing com ortably and
the presence o stridor, stertor, or the use o accessory muscles.
II. Vo ic e : Note the quality o the patient’s voice (e.g., hoarseness or
mu ed or breathy qualities) and any dysarthria.
III. Swa llo w: Note i the patient is able to tolerate secretions or i he or
she is drooling.

Quic k Cut
Stridor is a highpitched s ound produced
by turbulent f ow through a
partially obs tructed upper
airway. Stertor is lower
pitched, s noring-type s ound.

He a d
I. Ge ne ra l
A. rauma: visible ecchymosis, edema, bony abnormalities, or lacerations
B. Masses/lesions: skin lesions, biopsy sites or surgical scars, edema, f rmness, induration, uctuance,

or erythema
II. Eye s
A. Examination: Be sure to note extraocular motion and pupillary response and to report nystagmus.
B. ests
1. Visual acuity: i the patient is complaining o any change in vision
2. Visual f eld test: i the patient is complaining o diplopia
III. Ea rs : Standard o ce assessment o hearing includes the Weber and Rinne tests.
A. Weber test: uning ork is struck and placed on the midline o the patient’s head to determine i the
sound lateralizes and identif es unilateral hearing loss.
B. Rinne test: involves placing the vibrating tuning ork on
Quic k Cut
the mastoid process and comparing the perception to
Per orm a Weber
that o the sound directly adjacent to the ear; also helps
and Rinne exam i the patient
discriminate between conductive and sensorineural
has any otologic complaints .
hearing loss
C. Auricle: Note any de ormity, tenderness to palpation o the
tragus or mastoid, or tenderness with tugging o the pinna.
D. External auditory canal: Note any canal stenosis, debris, erythema, or otorrhea.
E. ympanic membrane: Note whether intact, the presence and characteristics o uid
behind the tympanic membrane, presence o middle ear masses, and whether the
membrane retracts.
IV. No s e : Per orm anterior rhinoscopy on all patients.
A. Septum: Examine or deviations or lesions.
B. Nasal cavity: Note in erior turbinate hypertrophy, nasal masses or polyps, and the presence o
rhinorrhea.

299



300

Chapter 18

Neck Abscesses

V. Ora l c a vity/o ro p ha rynx: Note any masses or lesions and speci y the color, riability, and tenderness.
Note any ulceration and palpate with a gloved f nger to determine so ness or f rmness.
A. eeth: Note the quality o the dentition and the presence o any tenderness.
B. Assess: Look or any erythema, edema, palatal asymmetry, or tonsillar deviation. Note any uvular
deviation and trismus.
VI. La rynx: Per orm a laryngeal mirror exam i not per orming f beroptic laryngoscopy.
VII. Ne c k: Palpate or lymphadenopathy or thyroid masses. Note surgical scars, crepitus, or decreased
range o motion.
VII. Ne uro lo g ic : Per orm a complete cranial nerve (CN) exam.

BENIGN LESIONS OF THE HEAD AND NECK
Ove rvie w
I. Re a c tive lym p h no d e : most common neck mass and most o en
secondary to bacterial or viral in ections
II. Ma lig na nc y: Most neck masses in children are benign; in adults,
neck masses are more likely to be malignant.

Wo rkup o r Ac q uire d Le s io ns
I. De ta ile d his to ry: Obtain details about the ollowing.
A. Family history: malignancy and personal history o cancer
B. Risk actors: smoking; alcohol consumption; exposure to
radiation, sawdust, or other potential carcinogens; and exposure

to human papillomavirus (HPV) 16 or 18
C. Recent illnesses: upper respiratory in ection (URI), sinusitis, or
tonsillitis; otitis or conjunctivitis; and dental problems
II. P hys ic a l e xa m ina tio n: See earlier discussion.
III. La b o ra to ry te s ts : may include tuberculin test or tuberculosis,
heterophil titer (monospot test) or mononucleosis, thyroid
unction tests or thyroid scan, serologic tests or syphilis, and viral
titers (especially or Epstein-Barr virus, which is associated with
nasopharyngeal carcinoma and Burkitt lymphoma)
IV. Ra d io lo g ic s tud ie s : may include so tissue radiographs o the
neck, barium swallow, chest x-ray, or scanning procedures such as
computed tomography (C ) and magnetic resonance imaging (MRI)
V. End o s c o p y: indicated i a primary neoplasm is suspected
VI. Tre a tm e nt: depends on the f ndings (Fig. 18-1)
A. Antibiotics: i a bacterial in ection is suspected
B. Consultation: may be help ul
1. Dental consultation: i the teeth seem to be a source
2. Dermatology consultation: i skin lesions are present
C. Surgical biopsy: may be indicated i a mass does not shrink
signif cantly over 6 weeks and a source o in ection is not ound
1. Fine-needle aspiration (FNA): used with suspected malignancy
2. Excisional biopsy: indicated or persistent cervical adenopathy

NECK ABSCESSES
Typ e s

Quic k Cut
The mos t common
neck mas s is a reactive
lymph node.


Quic k Cut
The “rule o 7’s ”
provides a guide or etiology
o neck mas s es : A mas s
that has been pres ent or
7 days is inf ammatory;
7 months , malignant; 7 years ,
congenital.

Quic k Cut
Scrofula is
mycobacterial lymphadenitis
in the neck.

Quic k Cut
Endos copic biops y
and radiologic s tudies s hould
precede any open biops y o
the neck.

Quic k Cut
FNA can diagnos e
carcinoma but is us ually
inadequate to de ne
lymphoma.

Quic k Cut
A patient
pres enting with ever and

an erythematous , pain ul,
f uctuant neck mas s mos t
probably has an abs ces s .

I. P e rito ns illa r a b s c e s s e s (q uins y): most common abscesses in
the parapharyngeal space ( able 18-1)
A. Cause: arise as a complication o acute tonsillitis
B. Clinical presentation: Ipsilateral palatal edema, contralateral deviation o the uvula, “hot potato”
voice, trismus, and dysphagia. T e patient may have only a low-grade ever or be a ebrile.


Chapter 18

Head and Neck Surgery

Ma s s

Child

Adult

Infla mma tory

(+)

P hys ica l e xa mina tion

(−)

Antibiotics ;

la bora tory te s ts

(+)

Ra diology;
pos s ible biops y

Endos copy;
biops y of s us pe cte d
prima ry tumor

P os s ible
infla mma tory
ma s s

(−)
(+)

Re s olve s
Obs e rve

(−)

(+)

Ra diology;
pos s ible biops y;
e xcis ion

(−)


Antibiotics ;
la bora tory te s ts

(+)

FNA or biops y

(−)
Re s olve s

Obs e rve

FNA or biops y

Fig ure 18-1: Bas ic algorithm or treatment o head and neck cancer. FNA, ne-needle
as piration.

Ta b le 18-1: Ne c k Ab s c e s s e s
Sig ns a nd Sym p to m s
Pain
Swelling
Dysphagia
Dyspnea
Leukocytosis
Fever
Air in soft tissue radiograph
Tre a tm e nt
Airway protection
Incision and drainage

Antibiotics

301


302

Chapter 18

Congenital Masses

II. P a ra p ha ryng e a l s p a c e a b s c e s s e s : Arise rom the posterior
teeth or tonsils and can a ect the carotid sheath structures and
multiple CNs. T ey can cause mediastinitis and carotid “blowout”
(i.e., erosion o the artery wall leading to massive hemorrhage).
III. Re tro p ha ryng e a l a b s c e s s e s : arise rom in ected
retropharyngeal nodes or extension rom other spaces and can lead
to airway obstruction or mediastinitis
IV. Lud wig a ng ina : abscess that occupies the sublingual space that
generally arises rom a dental source. Can cause death rom airway
obstruction, commonly requires tracheostomy
V. Be zo ld a b s c e s s e s : arise rom in ection in the mastoid

CONGENITAL MASSES
Le s io ns o Thyro id Orig in

Quic k Cut
Neck in ections
mus t be drained but s hould
only be done by thos e amiliar

with neck anatomy owing
to the carotid artery, airway,
and the cranial nerves .

Quic k Cut
Abs ces s es in the
head and neck can caus e
airway compromis e, and
intubation or tracheos tomy
may be neces s ary.

I. Ove rvie w: T yroid gland originates at the oramen cecum and
descends centrally to the level o the thyroid and cricoid cartilages ( able 18-2).
A. T yroglossal duct: May pass in ront o , through, or behind the hyoid bone; it is generally
obliterated but may persist. Solid tumors o thyroglossal duct origin occur almost exclusively
within the tongue and above the hyoid bone.
B. T yroidal primordium: Some may remain at any site in the duct and give rise to cysts, f stulas,
accessory thyroid tissue, and neoplasms.
II. Thyro g lo s s a l f s tula s , c ys ts , a nd s inus e s : Occur in the midline; 20% are suprahyoid, 15%
occur at the hyoid, and 65% are in rahyoid.
A. Fistulas: almost always the result o in ection with spontaneous or surgical drainage
B. Cysts: Present by age 10 years in 50% o cases; no sexual predominance exists, but they are most
o en ound in caucasians.
1. Size: usually measure 2–4 cm in diameter and gradually
Quic k Cut
increase in size, although the size may uctuate
Imaging is important
2. Behavior: rise and all with the larynx during swallowing
to ens ure a normal thyroid
C. Sinus tract: may orm as direct connection to the skin and result

gland is pres ent els ewhere
in persistent drainage
be ore excis ion o a thyroid
D. reatment: total surgical excision
res t.
III. Thyro id re s ts : may be lingual or may occur in the neck
A. Endotracheal ectopias: may occur
B. Palpation: o the normal position o the thyroid o en reveals no evidence o thyroid tissue
C. reatment: dictated by the degree o obstruction and by the presence o other thyroid tissue
D. T yroid scan: Ensures that unctional thyroid tissue exists in the usual location; 75% o patients
have no other unctional thyroid.

Bra nc hia l Cle t Ano m a lie s
I. Em b ryo lo g y: In week 4, f ve ridges and grooves appear on the ventrolateral sur ace o the embryonic
head that orm the branchial arches and cle s, respectively, and the pharyngeal pouches develop
internally at the same level as the external grooves.

Ta b le 18-2: Co ng e nita l Ne c k Ma s s e s
Typ e

Lo c a tio n

Exa m ina tio n

Tre a tm e nt

Thyroglossal cysts

Midline


Firm, nontender

Surgical excision

Branchial cleft cyst

Preauricular anterior

Firm, nontender

Surgical excision

Teratoma

Anywhere

Firm

Surgical excision

Hemangioma

Anywhere

Diffuse

Observation; laser treatment

Cystic hygroma


Posterior triangle

Diffuse

Partial excision


Chapter 18

Head and Neck Surgery

303

II. Typ e s
A. Sinus (incomplete f stula): has either an internal or an external opening
B. Complete f stula: has both internal and external openings
C. Cyst: has neither internal nor external openings
D. Combinations (o any o the preceding types): can occur
III. Ana tom y: Anomalies are generally located along the anterior border
Quic k Cut
o the sternocleidomastoid (SCM) muscle or deep to it; they can occur
Second brachial
anywhere between the external auditory canal and the clavicle.
cle t anomalies are the mos t
A. First cle anomalies: always superior to the hyoid bone
common and pres ent with an
1. Fistula: i present, courses superiorly and end near the
external opening two thirds
external auditory canal
o the way down the anterior

border o the SCM mus cle.
2. Cyst and tract: may lie in the parotid gland, with a variable
relationship to the acial nerve
B. Second cle anomalies: most common type
1. External opening: approximately two thirds down the SCM muscle anteriorly i present
2. Fistula: i present, ascends with the carotid sheath and ends at the tonsillar ossa
C. T ird cle anomalies: rare
1. External opening: occurs in the same position as in a second cle f stula
2. ract: ascends along the carotid sheath and opens in the piri orm sinus
D. Fourth cle anomalies: have never been seen in their entirety
IV. Cha ra c te ris tic s : generally smooth, round, nontender masses
A. Size increase: common during URI
B. In ected cyst: may abscess or rupture spontaneously to orm a sinus
C. Symptoms: determined by size and location o the anomaly
1. Large cysts: may cause dysphagia, stridor, and dyspnea
2. Small cysts: o en undiscovered until adulthood because o
their slow rate o growth and minor symptoms

Quic k Cut
Cons ider a neck
mas s to be a branchial
cle t anomaly i it is located
laterally, increas es in s ize with
URIs , and has been pres ent
s ince birth.

V. Tre a tm e nt: Complete excision without damage to the surrounding
vital structures is the def nitive treatment.
A. iming: Excision is delayed until antibiotic treatment is completed.
B. Incision and drainage: avoided, i possible, because it makes subsequent excision more di cult


Te ra to m a s
I. De f nitio n a nd typ e s : growths that consist o multiple tissues
oreign to the part o the body in which they arise
A. Epidermoid cysts: most common type; lined by squamous
epithelium and have no adnexa
B. Dermoid cysts: epithelium-lined cavities containing skin
appendages (e.g., hair, glandular tissue, and ollicles)
C. eratoid cysts (rare in the head and neck): lined with simple
stratif ed squamous or respiratory epithelium and contain cheesy
keratinous material

Quic k Cut
Epidermoid
cys ts ectoderm; dermoid
cys ts ectoderm and
mes oderm; teratoid
cys ts ectoderm, mes oderm,
and endoderm

II. Ce rvic a l te ra to m a s : most commonly present at birth
A. Characteristics: usually 5–12 cm, semicystic, and unilateral
B. Symptoms: In ants usually have stridor, apnea, or cyanosis because o tracheal compression, and
dysphagia may also be present. Some in ants are asymptomatic at birth but become symptomatic
within weeks or months.
C. Associated anomalies: increased incidence o maternal hydramnios but no increase in associated
in ant anomalies
D. reatment: Early excision in in ants is mandatory.
III. Ma lig na nt te ra to m a s (o the ne c k): rare; occur exclusively in adults with a very poor prognosis
IV. Na s a l d e rm o id s : commonly apparent shortly a er birth

A. Location: Nasal dorsum is the most common site, but they may occur in the tip o the nose or
the columella (the external end o the nasal septum).


304

Chapter 18

Congenital Masses

Ta b le 18-3: Co ng e nita l Na s a l Ma s s e s
As s o c ia te d
Co ng e nita l
Ano m a lie s

Ca n Be
Mid line

As s o c ia te d
with
In e c tio ns
o Skin

De rm o id

No

Yes

Yes


Yes

Yes

No

Glio m a

No

Yes

No

Yes

No

No

Enc e p ha lo c e le

Yes

Yes

No

Yes


No

Yes

Me ning itis
Ris k

Sinus
Tra c t

Co m p re s s ib le

B. Characteristics ( able 18-3): male predominance o 2:1; must be di erentiated rom encephaloceles
and gliomas
C. reatment: Early removal is important; recurrences secondary to incomplete removal are common.

Va s c ula r Tum o rs
I. He m a ng io m a s : Most common tumors o the head and neck in children. Girls are more o en
a ected, and lesions are usually solitary.
A. Capillary hemangiomas: Include nevus ammeus (port-wine stain) and strawberry nevus and are
characteristically ound in the dermis. T ey have an early period o evolution, a er which they o en
regress. T ey may develop suddenly and grow quite large.
B. Cavernous hemangiomas: More permanent; spontaneous regression is more likely or
hemangiomas present at birth than in those appearing later.
C. Arteriovenous hemangiomas: occur almost exclusively in adults and have a predilection or the lips
and perioral skin
D. Invasive hemangiomas: occur in the deep subcutaneous tissues, deep ascial layers, and muscles
1. Presentation: Present as neck masses, predominantly in children; masseter and trapezius are
the muscles most commonly involved. Intramuscular hemangiomas most commonly present in

young adults as palpable, mobile, noncompressible masses.
2. Characteristics: end to recur a er excision but do not metastasize; they are generally
without thrills, pulsations, or bruits; and pain secondary to compression o other structures
is usually present.
E. Subglottic hemangiomas: Usually capillary in type. Owing to
Quic k Cut
their location, they o en present at birth with stridor and usually
When evaluating
with cutaneous involvement.
a newborn with s tridor,
F. reatment
conducting a thorough s kin
1. Congenital cutaneous hemangiomas: Many lesions regress
exam is important.
spontaneously, but several treatment options exist or those
that do not.
a. Medical: Glucocorticosteroids, inter eron al a, vincristine, and imiquimod have been used or
treatment. Propranolol has been shown to induce involution o in antile hemangiomas.
b. Excision: Laser excision is pre erred in areas with cosmetic or unctional concern
(pulsed dye laser is used). Surgical excision can also be per ormed.
2. Subglottic lesions: may require tracheotomy, steroids, propranolol, and, in some cases, laser
excision
3. Extensive lesions: Surgery may be needed.
4. Radiation therapy: Used to suppress tumor growth in areas that are inaccessible surgically;
however, the use o radiation alone is controversial and is known to increase risk o thyroid,
breast, and skin cancers.
II. Cys tic hyg ro m a s : ound predominantly in the neck and are usually noted at birth
A. Location: T ey are more common in the posterior triangle and may extend up into the cheek or
parotid region and down into the mediastinum or axilla.
1. Large masses: extend past the SCM muscle into the anterior compartment and may cross

the midline
2. Floor o the mouth and base o the tongue: may be involved


Chapter 18

Head and Neck Surgery

305

B. Signs and symptoms: di culty nursing, acial or neck distortion, respiratory distress, brachial
plexus compression with pain or hyperesthesia, and a sudden increase in size secondary to
spontaneous hemorrhage, which can be atal
C. Characteristics: Can be progressive, static, or regressive and generally transilluminate; no gender
predilection exists, or right or le side.
1. Small lesions: unilocular and f rm
2. Large tumors: loculated, shi able, and compressible
Quic k Cut
3. Cyst walls: Usually tense, and because the loculi tend to
The greater the
communicate, rupture o one locule can cause all o them
lymphangiomatous component
to partially collapse.
o a hygroma, the more likely it
D. reatment: Surgery is the mainstay o treatment, but recurrences
is to recur.
are common because resection is o en incomplete.
III. Ora l a nd p e rio ra l lym p ha ng io m a s : Relatively common lesions usually ound at birth or soon a er.
T ey behave very much like cystic hygromas.


ACQUIRED LESIONS
To ns illa r a nd Ad e no id a l Hyp e rtro p hy
I. Ob s truc tive hyp e rtro p hy: Patients benef ting rom tonsillectomy with adenoidectomy are those
with airway obstruction, sleep apnea, dysphagia, or ailure to thrive.
II. Ad e no id e c to m y: per ormed in children with chronic nasal obstruction, especially when they also
demonstrate chronic serous otitis media or orthodontic problems

Le uko p la kia , Erythro p la kia , a nd Ke ra to s is
I. De f nitio n: Leukoplakia presents as white lesions that occur on the mucosa o the mouth, pharynx, or
larynx. Erythroplakia is a similar red patch.
II. Etio lo g y: T ese lesions are associated with repeated trauma
Quic k Cut
(e.g., rom poorly f tting dentures and decayed teeth), smoking, or
Leukoplakia and
use o alcohol.
erythroplakia are cons idered
III. Tra ns o rm a tio n: Leukoplakia is precancerous, with a
precancerous les ions ; biops y
trans ormation rate ranging rom 11% to 36%. Erythroplakia has
and clos e obs ervation are
recommended.
a higher trans ormation rate. Little correlation exists between the
clinical appearance and their histology.
IV. Dia g no s is : Biopsy, to rule out squamous cell carcinoma, should be per ormed in high-risk patients
(smokers and drinkers) and i the lesion persists a er the removal o an irritative ocus.
V. Tre a tm e nt: Benign leukoplakic lesions require no treatment but do require continued observation.

P a p illo m a s
I. Sq ua m o us p a p illo m a s o the o ra l c a vity: usually occur as one lesion but may be multiple and are
common on the palate and aucial arches

A. Characteristics: usually pedunculated and cauli owerlike in appearance
B. Recurrence: rare a er excision
II. Na s a l (s c hne id e ria n) p a p illo m a s
A. Benign lesions o the sinonasal tract: rom the schneiderian mucosa and classif ed into three types:
ungi orm, oncocytic, and inverted
B. Inverted papillomas: ypically arise rom the lateral nasal wall
Quic k Cut
and can invade the sinuses and orbits. Grossly, the lesions appear
Inverted papillomas
bulky and deep red to gray in color and vary in consistency;
are unilateral, aris e rom the
unlike allergic polyps, they are unilateral.
lateral nas al wall, and can
1. Characteristics: Patients generally present with nasal
trans orm into s quamous cell
obstruction, a postnasal drip, and headaches. T ese lesions
carcinoma.
occur mainly in men age 50–70 years.
2. Malignant trans ormation: Incidence is 10%.
3. reatment: Complete excision that includes the lateral nasal wall and ethmoid sinus. Recurrence
is common; there ore, li elong ollow-up is usually recommended.


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Chapter 18

Acquired Lesions

III. La ryng e a l p a p illo m a s : most common laryngeal tumors o childhood and may be ound at any age

A. Juvenile type: occurs predominantly in childhood and tends to involute at puberty
1. Etiology: Viral; HPV 6 and 11 are the most common viral strains.
2. Characteristics: Multiple papillomas typically occur and
may involve the airway rom the epiglottis to the bronchi.
Quic k Cut
T e vocal olds are usually involved; hoarseness and
Laryngeal papilloma,
obstruction occur late.
or respiratory papillomatosis,
3. reatment: Laryngoscopic removal, o en by the use o
is as s ociated with HPV6 and
surgical microdebridement, is the mainstay o therapy.
11 and typically pres ents as
a. racheotomy: may be necessary but predisposes to
hoars enes s in a child.
papilloma seeding
b. Recurrence and spread: common
B. Adult type: In this orm, the papilloma is generally single.
1. Recurrence: As in the juvenile orm, the papilloma tends to recur ollowing excision.
2. Malignant trans ormation: in recurrent lesions, particularly in patients exposed to radiation

Na s a l P o lyp s
I. Inc id e nc e : rare be ore age 5 years and occur more commonly in men
II. Etio lo g y: believed to be an allergic response
A. Samter triad: T ey may be associated with asthma and an idiosyncratic reaction to aspirin.
B. In children: should prompt a sweat test to rule out cystic f brosis
III. Cha ra c te ris tic s : In ammatory polyps are almost always bilateral and may recur; paranasal sinus
involvement is common.
IV. Tre a tm e nt: Polyps are excised i they obstruct the nasal airways or the sinus drainage pathways;
patients are placed on a topical steroid medication to prevent recurrence, and management o their

allergies is vital.

P e rip he ra l Ne rve Tum o rs
I. Sc hwa nno m a s : solitary, encapsulated tumors surrounded by a nerve that are primarily located
centri ugally and are o en pain ul and tender
II. Ac o us tic ne uro m a s : constitute a type o slow-growing schwannoma
A. Etiology: arise rom CN VIII, usually within the internal
auditory canal (IAC)
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B. Signs and symptoms: may include hearing loss, tinnitus,
As ymmetric
imbalance, and vertigo
s ens orineural hearing los s
C. Evaluation: esting includes an audiogram and MRI with
is common and requires
gadolinium enhancement.
that acous tic neuroma be
D. reatment: Because these tumors grow slowly, they can
ruled out with MRI o the
internal auditory canal.
be observed in the right clinical context. Other treatment
options are surgical resection or radiation therapy.
III. Vo n Re c kling ha us e n ne uro f b ro m a to s is (NF I): Neurites (axons) pass through the tumor; lesions
are usually multiple, unencapsulated, located centripetally, and characteristically asymptomatic.
A. Etiology: Caused by a nerve growth actor gene on chromosome 17q11.2; inheritance is autosomal
dominant.
B. Malignant trans ormation: 8%
C. Signs and symptoms: Ca é au lait spots, vitiligo, gliomas (especially optic), osseous changes, Lisch
nodules (iris hamartomas), meningitis, spina bif da, syndactyly, hemangiomas, axillary or inguinal
reckles, NF I in a f rst-degree relative, or retinal and visceral mani estations may be present.

IV. Ce ntra l ne uro f b ro m a to s is (NF II): Classically, slow-growing, bilateral acoustic neuromas or
neurof bromas cause hearing loss or dizziness and lead to a diagnosis by age 20 years.
A. Etiology: Chromosomal abnormality involves encoding o a suppressor protein schwannomin.
Inheritance is autosomal dominant, but almost 50% o cases are new mutations.
B. Diagnosis: may also be established by a unilateral CN VIII mass and a relative with NF II or
any two o the ollowing: glioma, juvenile posterior subscapular lenticular opacity, meningioma,
neurof broma, or schwannoma.


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307

C. Signs and symptoms: Ca é au lait spots, hearing loss and balance issues. Lisch nodules, and
cutaneous neurof bromas are uncommon.
D. Wishart type: early-onset rapid growth and other f bromatous
Quic k Cut
tumors in addition to CN VIII masses
I an important
nerve mus t be cut at s urgery,
E. Gardner type: later onset, slow growth rate; usually bilateral
it s hould be generally
acoustic neuromas only
reanas tomos ed or a nerve
V. Tre a tm e nt: Most neurogenous tumors o the head and neck can be
gra t s hould be interpos ed.
excised sa ely without sacrif cing nerves.


No nd e nta l J a w Le s io ns
I. Fib ro us d ys p la s ia : Developmental anomaly o the bone that mani ests as a de ect in osteoblastic
di erentiation and maturation. Any bone(s) in the body can be a ected, including the cranio acial
skeleton.
A. Characteristics: active growth in childhood and stabilization in adulthood
B. Signs and symptoms: bone enlargement; the maxilla is more commonly involved than the mandible.
C. Radiographs: reveal sclerosis, lytic lesions, or unilocular lesions
D. reatment: Obvious de ormity, pain, or inter erence with unction suggests the need or surgery;
conservative resection appears to be the best treatment.
E. Malignant trans ormation: possible but uncommon
II. To rus : Benign bony growth, occurring at the midline o the palate
(maxillary torus) or bilaterally lingual to the bicuspid (mandibular
Quic k Cut
torus). T ey grow slowly and generally have no signif cance except
Tori are common
that they may inter ere with the f tting o dentures.
benign bony growths that
III. Os te o m a s : Slow-growing, benign tumors in the sinuses, jaws,
occur on the palate or the
or external ear canals. T ey may require excision i they produce
mandible.
symptoms.

La ryng e a l Le s io ns
I. La ryng o c e le : Dilatation o the laryngeal saccule, producing an air sac that communicates with the
laryngeal ventricle. Pressure increases the size o a laryngocele (e.g., coughing, straining, playing a wind
instrument).
A. Laryngopyocele: in ected laryngocele that can be atal i it results in asphyxia or i the purulent
contents are aspirated
B. Location: Laryngoceles may be unilateral or bilateral. T ey may also be internal (within the larynx),

external (presenting in the neck), or both (combined).
1. Internal laryngocele: causes bulging o the alse cord and aryepiglottic old
2. External laryngocele: appears as a neck swelling at the level o the hyoid and anterior to the SCM
muscle
C. Characteristics
1. Internal laryngoceles: cause hoarseness, breathlessness, and stridor on enlargement
2. External laryngoceles: increase in size with coughing or the Valsalva maneuver; are tympanic to
percussion and may produce hissing as the laryngocele empties air into the larynx when the air
pressure is reduced
D. Diagnosis: C and MRI scans
E. reatment
1. Symptomatic laryngoceles: excised
2. Laryngopyoceles: Incision, drainage, and subsequent excision. Antibiotics are also appropriate.
II. La ryng e a l we b s
A. Characteristics: May be congenital or ollow vocal old trauma. When extensive, they present with
stridor, weak phonation, and eeding problems in in ants.
B. reatment: Excision or division is generally the pre erred treatment, and placement o a stent
or keel is o en required.
III. Vo c a l no d ule s : bilateral benign masses that usually occur at the junction o the true vocal olds
A. Etiology: associated with vocal abuse
B. reatment: Best treated by modi ying the patient’s speaking or singing technique through voice
therapy. Surgery is rarely necessary


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Malignant Lesions o the Head and Neck


IV. Vo c a l p o lyp s
Quic k Cut
A. Characteristics: usually unilateral and o en do not regress with
Vocal polyps are
speech therapy
unilateral and do not improve
B. reatment: Recommended therapy is care ul excision with
with s peech therapy; vocal
microscopic visualization and avoidance o injury to the underlying
nodules are bilateral and are
lamina propria; in selected cases, the laser may be help ul.
treated with s peech therapy.
V. La ryng e a l g ra nulo m a s (intub a tio n g ra nulo m a s ): occur over
the vocal processes o the arytenoid cartilages
A. Etiology: Generally the result o trauma, usually rom an endotracheal tube, and are usually
associated with re ux laryngitis. Voice abuse may be a actor.
B. reatment: Antire ux and speech therapies o en help them regress.
1. Persistent granulomas: best treated by excision a er a period o voice and medical therapy
2. Botulinum toxin: used or selected, recurrent cases
VI. Aryte no id d is lo c a tio n: generally is the result o endotracheal tube or external trauma
A. Characteristics: So , breathy voice a er extubation. Flexible f beroptic exam will reveal an
immobile vocal cord.
B. reatment: Prompt reduction is advisable; otherwise, the arytenoid usually becomes f xed in the
dislocated position. However, late reduction (a er months or years) can be success ul.
VII. Co nta c t ulc e rs : mucosal disruptions usually located posteriorly on the vocal olds
A. Etiology: sometimes result rom trauma (e.g., rom intubation), occasionally rom vocal abuse, and
o en rom gastric re ux laryngitis or heavy coughing
B. reatment: antire ux medication and behavioral changes such as elevation o the head o the bed;
avoidance o ca eine, chocolate, late-night snacks, and atty oods
1. Antacid therapy: usually results in prompt resolution

2. Antibiotics: may be help ul i in ection is present

HEAD AND NECK INFECTIONS
To ns illitis a nd Ad e no to ns illitis
I. To ns ille c to m y with a d e no id e c to m y: Once the most common
operation per ormed in the United States. It remains quite prevalent
but is now per ormed only or specif c indications.
A. Obstructive hypertrophy: See earlier discussion.
B. Recurrent in ection: Patients with documented recurrent
adenotonsillitis are improved a er tonsillectomy with
adenoidectomy.
II. P e rito ns illa r a b s c e s s : onsillectomy is o en suggested a er
treatment or inpatients with a history o previous tonsillitis.

Atyp ic a l Myc o b a c te ria In e c tio n

Quic k Cut
Many common
in ections such as ear
in ections (otitis) can be treated
with antibiotics alone.

Quic k Cut
A his tory o three to
s ix epis odes o adenotons illitis
annually is a relative indication
or tons illectomy with
adenoidectomy.

I. Cha ra c te ris tic s : Presents as an in amed mass or draining

sinus in the head and neck, commonly associated with the parotid
or submandibular glands and is most common in children and
adolescents. Pulmonary involvement is rare.
A. Results: Fixation o overlying skin and sinus ormation are common.
B. Biopsy: can lead to a chronically draining sinus tract
II. Tre a tm e nt: Surgical excision or curettage and drainage. Antimycobacterial drug therapy is
not indicated because this is not systemic but a localized problem.

MALIGNANT LESIONS OF THE HEAD AND NECK
Ove rvie w
I. Cha ra c te ris tic s : able 18-4 shows the basic characteristics o head and neck cancer.
II. Ep id e m io lo g y: Primary malignant neoplasms o the head and neck, excluding skin cancer, account
or 5% o new cancers each year in the United States.
A. Incidence: Male to emale ratio is 3:1 to 4:1, and most lesions occur in patients older than age
40 years.


Chapter 18

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309

Ta b le 18-4: Ba s ic Cha ra c te ris tic s o He a d a nd Ne c k Ca nc e r
Mo s t P ro m ine nt
Lo c a tio n

Ris k o

Sym p to m


Ris k Fa c to r

Ce rvic a l Me ta s ta s e s

Nose and sinus

Mass

Nickel, wood

Moderate

Nasopharynx

Neck mass; serous otitis media

Epstein-Barr virus

High

Oral cavity

Pain

Tobacco, alcohol

Moderate

Oropharynx


Dysphagia

Tobacco, alcohol, HPV 16 and 18

High

Larynx

Hoarseness

Tobacco

Glottic, low; supraglottic, high

Hypopharynx

Dysphagia

Tobacco, alcohol

High

Salivary glands

Mass

Radiation

High-grade, high; other, low


B.

ypes: Approximately 80% o primary head and neck
Quic k Cut
malignancies are squamous cell carcinomas; the remainder
The number o
includes thyroid cancers, salivary neoplasms, lymphoma, and
patients with a s econd
other less common tumors.
primary malignancy o the
upper aerodiges tive tract at
III. Ris k a c to rs : obacco use, alcohol consumption, and exposure to
the time o initial pres entation
radiation are etiologic actors in most squamous cell carcinomas o
has been reported to be as
the head and neck.
high as 17% .
A. Smoking: Approximately 85% o patients with head or neck cancer
smoke or ormerly smoked cigarettes at the time o diagnosis.
B. HPV: associated with some head and neck squamous cell carcinomas, most commonly strains
16 and 18

Eva lua tio n
I. His to ry: Evaluation o the patient starts with a care ul history, especially head or neck malignancy.
A. Exposure to etiologic agents: such as tobacco, alcohol, sawdust, other toxins, and irradiation
B. Associated symptoms: hoarseness or sore throat o more than
3 weeks’ duration, dysphagia, otalgia, dyspnea, nonhealing
Quic k Cut
ulcers, hemoptysis, and neck mass

Otalgia is o ten a
re erred pain, s econdary to
C. Nutritional status
involvement o CNs IX and X.
1. Malnourishment: Either because o alcoholism or an
obstructive tumor; some patients may require nutritional
supplements.
2. Severe malnourishment: Consider re eeding syndrome.
Quic k Cut
Treatment needs to
D. Family history: critical with inherited actors (i.e., medullary
be individualized to the needs
thyroid cancer)
o the patient as well as their
II. P hys ic a l e xa m ina tio n: must include an inspection o all the skin
ability to comply with the
and mucosal sur aces o the head and neck
treatment plan.
A. Intranasal examination and indirect mirror examination:
o the nasopharynx and hypopharynx
B. Care ul palpation: o the oral cavity, base o the tongue, and oropharynx
C. Fiberoptic examination: o the nose, pharynx, and larynx is indicated in all patients who are being
evaluated or cancer

Tre a tm e nt
I. Surg e ry (Fig . 18-2): Indicated or many patients with head and
neck cancer. T e e ects o radiation are avoided, and radiation can
be saved or recurrent disease or other primary cancers. T e choice
o surgery can be in uenced by many actors.
A. Malnourishment: can increase the perioperative risk o

morbidity

Quic k Cut
Treatment is bas ed
on the s ite and pathology o
the primary cancer and the
extent o the local, regional,
and dis tant dis eas e.


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Chapter 18

Malignant Lesions o the Head and Neck

S te rnocle idoma s toid mus cle

Inte rna l jugula r ve in
Ca rotid a rte ry
Va gus
S pina l a cce s s ory
ne rve

A

B

Fig ure 18-2: Types o neck dis s ection, including traditional neck dis s ection and various levels o
modi cation. In a radical neck dis s ection (A), the s ternocleidomas toid mus cle, internal jugular vein,

and s pinal acces s ory nerve are removed. In the mos t cons ervative modi cation (B), only the as cial
compartment with the lymphatic tis s ue is removed, and all o the s tructures are s pared.

B. Coexistent systemic disease: Diabetes, chronic obstructive pulmonary disease, coronary artery
disease, etc. increase the surgical risk.
C. Results: Necessary procedures can be disf guring and can leave the patient with severe unctional
def cits and is best per ormed in institutions that can provide the ull range o rehabilitative services.
1. Resection o the larynx: alters communication
2. Surgery on the tongue, oropharynx, hypopharynx, or mandible: can alter or prevent swallowing
D. Contraindication: Surgery or a cure is generally contraindicated in patients with distant metastases.
II. Ra d ia tio n the ra p y: Radiation alone is adequate treatment or many early lesions.
A. Benef ts: It can provide a cure without the unctional or cosmetic def cits associated with surgery,
can treat multiple primary lesions simultaneously, and can prophylactically treat regional nodes that
are clinically negative.
B. Planned postoperative radiation: can signif cantly increase the
Quic k Cut
survival rate or patients with advanced lesions
A dental examination
C. Hyper ractionation (more than one daily treatment) and
and possibly extraction is
required be ore radiotherapy.
concomitant chemotherapy: Studies show that these techniques
Dental treatment during and up
can enhance the response to radiation therapy, but they increase
to 2 years a ter radiotherapy
the risk and severity o local side e ects.
can be hazardous because
D. Complications: mucositis, xerostomia, loss o taste, dermal
o decreased vascularity and
and so tissue f brosis, dental caries, and bone and so tissue

consequent delayed healing.
necrosis
III. Che m o the ra p y: not curative as a single treatment modality in head and neck squamous cell carcinoma
A. Neoadjuvant treatment: to reduce the tumor burden be ore radiation or surgery
B. Concomitant radiation therapy: to increase response rates in
advanced tumors
Quic k Cut
C. Palliation: in patients with unresectable tumors or distant metastases
The choice o a
IV. Re ha b ilita tio n: should be planned at the same time as treatment
surgical f ap depends on the
size o the de ect, history o
A. Surgical aps: Cosmetic and unctional de ects are reconstructed
peripheral vascular disease,
at the time o the cancer resection whenever possible.
prior s urgeries, or procedures
1. Local aps: nasolabial, orehead
in the desired donor region
2. Distant pedicled skin aps: deltopectoral, omocervical
and general health and
3. Pedicled myocutaneous aps: pectoralis major, latissimus
nutritional status o the patient.
dorsi, trapezius


Chapter 18

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311


B. Esophagectomy: Gastric “pull-up” (raising the stomach into the chest to replace the esophagus) or
colon interposition are options or reconstruction.
C. Free microvascular aps: have a high rate o complications but can be very e ective
D. Prosthetic rehabilitation: necessary when portions o the maxilla, orbit mandible, or palate are
resected
E. Voice restoration: When the larynx is removed, intensive rehabilitation is required to re-establish
the voice with an electrolarynx that is applied to the neck sur ace, regurgitated air (esophageal
speech), or with a prosthesis placed in a tracheoesophageal f stula.
F. Swallowing training: Many patients who undergo partial laryngectomy, pharyngectomy, or
glossectomy need this to avoid aspiration.

NECK CANCER
Ana to m y
I. Divis io ns : anterior and posterior triangles
A. Anterior triangle: Bounded by the midline o the neck, the in erior mandible border, and the
anterior SCM muscle. It can be subdivided urther into submandibular, submental, superior carotid,
and in erior carotid triangles.
B. Posterior triangle: Bounded by the posterior border o the SCM muscle, the anterior border o the
trapezius, and the clavicle. It is divided urther into supraclavicular and occipital triangles.
II. Lym p ha tic d ra ina g e : Fascial planes o the neck enclose the lymphatic system and are important
when discussing spread o in ections and malignancy in the head and neck.
A. Superf cial ascia: subcutaneous and envelops the platysma
B. Deep ascia: three parts:
1. Superf cial layer: invests the SCM and trapezius muscles and the parotid and submandibular glands
2. Middle layer: divided into muscular and visceral divisions
a. Muscular division: invests the strap muscles and pharyngeal constrictors and buccinators
b. Visceral division: also called the pretracheal ascia; envelopes the trachea, esophagus, and
thyroid
3. Deep layer: divided into the alar ascia anteriorly and the prevertebral ascia posteriorly

C. Retropharyngeal space: lies anterior to the alar ascia and is an important plane when discussing
spread o malignancy and in ection
D. Neck lymph nodes: Many drain specif c areas o the upper aerodigestive tract. T ese are divided
into six levels based on location and drainage patterns.
1. Deep jugular and spinal accessory chains: where most lymph nodes lie
2. Jugular chain divisions: superior, middle, and in erior groups

Ne c k Ma s s Eva lua tio n in Ad ults with
No P rim a ry Ca nc e r Se e n o n Exa m

I. His to ry a nd p hys ic a l e xa m ina tio n: Care ul history is taken,
Quic k Cut
A workup or
and the head and neck are examined or evidence o a possible
malignancy s hould be
primary cancer.
undertaken in all adults with
II. Dia g no s is : I the primary cancer is not identif ed on the initial
a pers is tent neck mas s .
examination, the subsequent workup should include the ollowing.
A. Imaging: Chest x-ray, barium swallow, and C scan o the neck
are indicated in most patients. MRI or ultrasound o the neck is
guided by f ndings on the history and physical examination.
1. MRI: particularly use ul in def ning deeply invasive tongue, pharynx, and larynx tumors
2. C o the sinuses: can be used to search or primary tumors
3. Staging: C or MRI o the chest and abdomen are o en used.
B. FNA: should be per ormed to provide a tissue diagnosis
C. Panendoscopy: direct laryngoscopy, esophagoscopy, bronchoscopy, and nasopharyngoscopy to
identi y any obvious lesions or biopsy
1. Random biopsies: I the result o the endoscopic survey is negative, biopsy o the nasopharynx

(right, middle, and le ), piri orm sinuses, tongue base, and a tonsillectomy may also be considered.
2. Next step: I all biopsies have negative results, proceed with open neck biopsy and rozen section.


312

Chapter 18

Nasal Cavity And Paranasal Sinus Cancer

Tre a tm e nt
I. Typ e s o ne c k d is s e c tio n: Figure 18-3
Quic k Cut
A. Radical neck dissection: en bloc dissection o the cervical
FNA biops y o a
lymphatics that includes removal o the SCM muscle, internal
s olid neck mas s is o ten the
jugular vein, or spinal accessory nerve
rs t s tep in its workup. I
B. Modif ed ( unctional, conservative) neck dissection: removes
the les ion is a metas tas is , a
ull head and neck exam, in
the cervical lymphatics within their ascial compartments
conjunction with imaging,
that spares the SCM muscle, internal jugular vein, and spinal
may demons trate the primary
accessory nerve
tumor
C. Segmental neck dissection: re ers to removal o less than f ve
nodal groups on one side o the neck (e.g., submandibular

triangle dissection, supraomohyoid dissection)
II. Ele c tive ne c k d is s e c tio n: surgical treatment with no known cervical disease; controversial because
radiation therapy can provide prophylaxis or metastatic neck disease in many cases
A. Choice between surgery and radiation: usually depends on the treatment o the primary tumor
B. In general: per ormed or a primary cancer that has at least a 20% chance o occult metastasis

NASAL CAVITY AND PARANASAL SINUS CANCER
Ana to m y a nd Cla s s if c a tio n
I. Ba s ic s truc ture : Sinuses are contiguous with the nasal cavity through natural ostia, and the nose
and sinuses are lined with a respiratory mucosa, which is pseudostratif ed columnar with goblet cells
and cilia.
II. Lym p ha tic d ra ina g e : to the parapharyngeal or retropharyngeal nodes
III. Lo c a tio n: Most tumors (59%) are in the maxillary sinus, 24% are in the nasal cavity, 16% in the
ethmoid, and 1% in the rontal/sphenoid sinuses.

A

Fig ure 18-3: A: Level o res ection in an en bloc
compos ite res ection o the oral cavity, oropharynx,
or both (the clas s ic commando procedure). B: The
s pecimen includes the primary cancer, a s egmental
mandibulectomy, and the radical neck dis s ection.

B


Chapter 18

IV. Cla s s if c a tio n: Nasal and sinus cancers are locally invasive. Nodal
metastases are unusual and tend to occur late, even with extensive

local disease.
A. Squamous cell carcinoma: 80%
B. Adenocarcinomas: including adenoid cystic carcinoma, 10%–14%

Head and Neck Surgery

313

Quic k Cut
Squamous cell
carcinoma is the most common
malignancy o the nasal cavity
and paranasal sinuses.

Clinic a l Eva lua tio n
I. P re s e nting s ym p to m s : can include nasal obstruction; epistaxis;
localized pain; tooth pain; CN def cits; mass in the ace, palate, or
maxillary alveolus; proptosis; and trismus
II. Dia g no s is : Extent o the disease is determined by physical
examination and radiographic studies.
A. C scan: use ul or identi ying bony erosions and orbital or
intracranial extension
B. MRI: can be used or intraorbital and intracranial invasion

Quic k Cut
Be s us picious or
a malignancy in a patient
who pres ents with unilateral
nas al obs truction, epis taxis ,
localized acial pain, or CN

de cits (III, IV, VI, or VII).

Tre a tm e nt a nd P ro g no s is
I. Ma xilla ry s inus c a nc e r
A. Less advanced cancers: Subtotal or radical maxillectomy. Adjuvant radiation may be used.
B. Advanced cancers: Usually receive a combination o surgical resection ollowed by chemotherapy
and/or radiotherapy. Orbital exenteration and skin resection are per ormed when necessary.
II. Ethm o id s inus o r na s a l c a vity tum o rs : combination o surgical resection and chemotherapy and/
or radiation
III. Exte ns ive c a nc e rs : Combined cranio acial resection or selected patients. Chemotherapy is used or
treatment or palliation.
IV. Ce rvic a l lym p h no d e m e ta s ta s e s : treated with radiotherapy or surgery
V. P ro g no s is
A. Overall cure rate: 30%–35%
B. 5-year survival rate: less advanced lesions, 70%; decreases to 15%–20% with more advanced disease

NASOP HARYNX CANCER
Ove rvie w
I. Ana to m y: Nasopharynx is the most cephalad part o the pharynx; its roo is ormed by the
basioccipital and sphenoid bones, and its posterior wall is ormed by the atlas.
A. Walls: Roo and posterior wall are covered by mucosa, and the adenoid tissue is embedded; the lateral
wall contains the orif ce o the eustachian tube, and, just posterior to that, the ossa o Rosenmüller.
B. Limits: Choanae def ne the anterior limit, and the ree edge o the so palate provides the in erior
limit.
C. Lymphatic drainage: to the lateral retropharyngeal, jugulodigastric (tonsillar), and high spinal
accessory nodes
II. Ep id e m io lo g y: High incidence among people living in China. People o Chinese ancestry who
live in other countries do not have the same incidence, suggesting an environmental risk actor
(i.e., consumption o smoked f sh) contributing to the increased incidence.
A. Elevated Epstein-Barr virus titer: high incidence among persons with nasopharyngeal cancer

B. Age: occurs at younger ages than do most solid head and neck tumors
III. Cla s s if c a tio n: Eighty-f ve percent o nasopharyngeal tumors are epithelial; 7.5% are lymphomas.
Epithelial tumors commonly arise in the ossa o Rosenmüller.

Clinic a l Eva lua tio n
I. P re s e nting s ym p to m s : Epistaxis, cervical adenopathy, serous
otitis media, and nasal obstruction (headache, diplopia, acial
numbness, trismus, ptosis, and hoarseness may also be present);
70% o patients will have nodal disease, 40% will have CN
involvement.

Quic k Cut
An adult with
a unilateral middle ear
e us ion s hould have
nas opharyngos copy to rule
out a nas opharyngeal mas s .


314

Chapter 18

Oral Cavity Cancer

II. Dia g no s is : conf rmed by biopsy o a metastatic lymph node
A. Staging: C and MRI
B. Elevated Epstein-Barr virus titer: Monitoring o the titer should show a decrease with success ul
treatment and an increase with recurrences.


Tre a tm e nt a nd P ro g no s is
I. Ra d ia tio n: Primary treatment or all epithelial nasopharyngeal tumors. T e dose is delivered to
the nasopharynx and to both sides o the neck. Improved responses are possible with combined
chemotherapy and radiation in patients who can tolerate the increased toxicity.
II. Ra d ic a l ne c k d is s e c tio n: per ormed or residual nodes i the primary tumor is controlled
III. 5-ye a r s urviva l ra te : 40% in patients without positive nodes and 20% in patients with positive nodes

ORAL CAVITY CANCER
Ove rvie w
I. Ana to m y: Oral cavity extends rom the lip anteriorly to the aucial
arches posteriorly and includes the lips, buccal mucosa, gingivae,
retromolar trigones, hard palate, anterior two thirds o the tongue
(the oral tongue), and oor o the mouth.
II. Lym p ha tic d ra ina g e : to the submental, submandibular, and deep
jugular nodes
III Etio lo g y: Ninety percent o patients are heavy users o tobacco
(either smoking or chewing); 80% o patients are heavy drinkers.

Quic k Cut
The s even s ubs ites
o the oral cavity are the lips ,
buccal mucos a, gingivae,
retromolar trigone, hard
palate, oral tongue, and the
f oor o the mouth.

Clinic a l Eva lua tio n
I. P re s e nting s ym p to m s : Can include loose teeth, pain ul or nonhealing ulcers, odynophagia, otalgia
(with posterior lesions), and cervical adenopathy. T e lip is the most common site o carcinoma,
ollowed by the oral tongue and oor o the mouth.

II. Dia g no s is : Pain, which is a late symptom, occurs a er ulceration develops.
A. Mandibular radiographs: assess the bony involvement by adjacent tumors
B. Nodal metastases: Common, especially in the oor o mouth and oral tongue with more advanced
primary tumors; much are microscopic (occult) disease.
C. Metastases: uncommon; usually occur late in cancer o the lip or the buccal mucosa

Tre a tm e nt a nd P ro g no s is
I. Sm a ll tum o rs with no lym p h no d e invo lve m e nt: can be
treated with either local excision or radiotherapy

Quic k Cut
Mos t malignancies
o the oral cavity are treated
with s urgery, with or without
radiation.

II. La rg e r le s io ns : should be treated with combined surgery and
radiation
A. Surgery: involves an en bloc resection and neck dissection
B. echnique: Either a partial mandibulectomy is included or the
tumor is “pulled through” medially to the mandible into the neck
(i.e., the tumor is removed en bloc, leaving the mandible intact).
III. Tum o rs a tta c he d to the m a nd ib le : May be removed with a partial thickness o mandible (i.e., the
lingual plate or alveolar process). T e mandibular arch is kept intact when possible.
IV. Tum o rs d e m o ns tra ting b o ny e ro s io n in the m a nd ib le : removed with a ull-thickness portion
o bone
V. 5-ye a r s urviva l ra te : overall, or cancer o all oral cavity sites, is 65%
A. Lip cancer: Rates as high as 90% have been reported.
B. ongue lesions: Prognosis is worse i the lesion is posterior.
1. Anterior (mobile) tongue lesions: O en diagnosed when they are small; overall 5-year survival

rate is more than 65%.
2. Posterior lesions: less than 40%


Chapter 18

Head and Neck Surgery

315

OROP HARYNX CANCER
Ove rvie w
I. Ana to m y
A. Boundaries: ree edge o the so palate superiorly, the tip o the epiglottis in eriorly, and the anterior
tonsillar pillar anteriorly
B. Contents: so palate, tonsillar ossae and aucial tonsils, lateral and posterior pharyngeal walls, and
base o the tongue
C. Parapharyngeal space: directly lateral to the oropharynx; contains the glossopharyngeal, lingual, and
in erior alveolar nerves; pterygoid muscles; internal maxillary artery; and carotid sheath and is a site
o early extension o an oropharyngeal tumor that also provides a
pathway or the tumor to spread to the base o the skull
Quic k Cut
D. Lymphatic drainage: Primarily to the jugulodigastric (tonsillar)
Tobacco, alcohol
nodes; tumors o the so palate, lateral wall, and tongue base also
us e, and HPV 16 and 18
spread to the retropharyngeal and parapharyngeal nodes.
expos ures are ris k actors or
oropharyngeal s quamous cell
II. Etio lo g y: Alcohol and tobacco use are commonly ound together

carcinoma.
in patients with oropharyngeal cancer.
A. HPV strains 16 and 18: associated with squamous cell cancer o
the oropharynx with increasing incidence
Quic k Cut
B. Local mucosal irritation, malnutrition, and immune de ects:
A s ynergis tic e ect
also implicated

Clinic a l Eva lua tio n

s eems to exis t between
alcohol and tobacco in
oropharynx cancer, but it has
not been de ned.

I. Pre s e nting s ym ptom s : Most common is a persistent sore throat,
which is requently accompanied by ipsilateral otalgia (re erred
pain via the tympanic branch o the glossopharyngeal nerve), vague
sensation o throat irritation, restriction o tongue motion (“hot potato voice”), odynophagia, and bleeding.
A. Malnourishment: Most patients are signif cantly malnourished.
B. Cervical adenopathy: Nodal metastases are ound in 70% o patients with cancer o the base o
the tongue and in 60%–80% o patients with tonsillar cancer; most o these nodes are palpable.
II. Initia l e xa m ina tio n: Must include care ul palpation o the base o the tongue. Many small tumors are
di cult to see but may be palpated easily.
III. Dia g no s is : O en made late in the course; many patients are asymptomatic until tumors are large;
others are treated conservatively or incorrectly diagnosed lesions.
A. Endoscopy under general anesthesia: or all lesions be ore treatment is chosen
B. C and MRI: use ul in determining tumor extension


Tre a tm e nt a nd P ro g no s is
I. Sm a ll le s io ns : most commonly treated with radiotherapy
II. La rg e le s io ns : Combined therapy o ers improved survival rates and is indicated when nodal
metastasis is present.
III. Co m p o s ite re s e c tio n (the ja w-ne c k o r c o m m a nd o p ro c e d ure ): most commonly used to
resect large lesions o the oropharynx and involves a neck dissection and a partial mandibulectomy in
conjunction with excision o the tumor (Fig. 18-3) and reconstruction (Fig. 18-4).
A. racheotomy: routine treatment
B. otal glossectomy: Occasionally, the larynx is spared a er in young and otherwise healthy patients.
C. Laryngectomy: per ormed when either the tumor invades the pre-epiglottic space or the entire
tongue base and both hypoglossal nerves are removed
IV. Tra ns o ra l ro b o tic s urg e ry (TORS): now used at some centers or surgical resection o
oropharyngeal tumors
A. Reduced morbidity: due to ability to resect the tumor without splitting the mandible
B. Decreased need or eeding tubes ollowing resection: demonstrated by some studies
V. P ro g no s is : Related to the HPV status o the tumor; patients who have HPV tumors generally have a
better prognosis than those who have HPV– tumors.


316

Chapter 18

Hypopharynx and Cervical Esophagus Cancer

Fig ure 18-4: Recons truction o a circum erential pharyngeal de ect with a jejunal
ree gra t. The vas cular pedicle has been anas tomos ed to branches o the
external carotid artery and internal jugular vein.

HYP OP HARYNX AND CERVICAL ESOP HAGUS CANCER

Ove rvie w
I. Ana to m y
A. Boundaries: Hypopharynx extends rom the pharyngoepiglottic old to the in erior border o the
cricoid area, excluding the larynx.
B. Contents: includes the piri orm sinuses, the postcricoid area, and the posterior pharyngeal wall
C. Lymphatic drainage: Hypopharynx has a rich lymphatic network.
1. Piri orm sinuses: drain to jugulocarotid and midjugular nodes
2. Posterior pharyngeal wall: drains primarily to retropharyngeal nodes
3. Lower hypopharyngeal areas: drain to paratracheal and low jugular nodes
4. Cervical esophagus: drained by mediastinal nodes
II. Cla s s if c a tio n: Ninety-f ve percent o the tumors in this region are epithelial cancers; 60%–75%
arise in the piri orm sinuses and 20%–25% on the posterior pharyngeal wall; tumors rarely arise in the
postcricoid area.
III. Etio lo g y: as with other head and neck tumors, related to heavy use o alcohol and tobacco

Clinic a l Eva lua tio n
I. P re s e nting s ym p to m s : riad o throat pain, re erred otalgia, and dysphagia is present in more than
50% o patients.
II. Ho a rs e ne s s a nd a irwa y o b s truc tio n: indicate laryngeal involvement
III. Sm a ll p o s tc ric o id tum o rs : o en present with mild symptoms o sore throat, globus (a “lump in the
throat”), and throat clearing
IV. Ce rvic a l lym p h no d e m e ta s ta s e s : ound in 75% o patients with piri orm sinus cancers (41%
occult) and in 83% o patients with pharyngeal wall tumors (66% occult)
V. Dia g no s is : C scan o the neck with contrast and endoscopy with biopsy complete the workup.


Chapter 18

Head and Neck Surgery


317

Tre a tm e nt a nd P ro g no s is
I. Ad va nc e d le s io ns : Laryngopharyngectomy and radical neck dissection ollowed by radiotherapy are
necessary or most.
II. Sm a ll tum o rs tha t s p a re the a p e x o the p iri o rm s inus : Supraglottic laryngectomy can be
considered.
III. Sm a ll tum o rs : can be treated by radiation therapy alone or by surgical resection via a lateral
pharyngotomy
IV. Ce rvic a l e s o p ha g us c a nc e r: can require removal o the pharynx, esophagus, and larynx
V. P ro g no s is : poor because o extensive submucosal spread and the high incidence o cervical metastasis
A. Overall 5-year survival rate: 30%
B. I eligible or supraglottic laryngectomy: Five-year survival rate rises to 50%.
VI. Che m o the ra p y with ra d ia tio n the ra p y: in organ-sparing protocols

LARYNX CANCER
Ove rvie w
I. Ana to m y
A. Divisions: three regions
1. Supraglottis: extends rom the tip o the epiglottis to include the alse vocal olds and roo o the
ventricle
2. Glottis: extends rom the depth o the ventricle to 1 cm below the ree edge o the true vocal old
3. Subglottis: extends rom 1 cm below the ree edge o the true vocal old to the in erior border o
the cricoid cartilage
B. Lymphatic drainage
1. Supraglottis: rich network that crosses the midline and drains to the deep jugular nodes
2. Glottis: poorly developed sparse lymphatics
3. Subglottis: drains through the cricothyroid membrane to the prelaryngeal (delphian) and
pretracheal nodes
II. Etio lo g y: More than 90% o patients have a signif cant history o smoking, and heavy alcohol

consumption is a common but not def nite etiologic actor.
III. Cla s s if c a tio n
A. Squamous cell carcinomas: account or 95%–98% o the tumors
B. Verrucous carcinoma: variant o squamous cell carcinoma that is locally invasive but almost never
metastasizes

Clinic a l Eva lua tio n
I. P re s e nting s ym p to m s : Most common symptom is hoarseness.
A. Other: Stridor, cough, hemoptysis, odynophagia, otalgia,
dysphagia, and aspiration also occur.
B. Neck masses: uncommon at the time o presentation
II. Dia gnos is : All patients require direct laryngoscopy and biopsy; barium
swallow, stroboscopic laryngoscopy, and C scan may be help ul.

Quic k Cut
Glottic cancers are
us ually diagnos ed relatively
early compared to other
cancers o the head and
neck due to the pres enting
s ymptom o hoars enes s .

Tre a tm e nt a nd P ro g no s is
I. Ca rc ino m a in s itu: excision o the involved vocal old mucosa and close monitoring
II. Ea rly-s ta ge le s ions : Many are treated with radiation because the resultant voice is usually o better quality
than the one a er surgical excision (at least initially). However, surgery is still indicated or many patients.
A. Removal o the involved vocal old: by traditional techniques or by carbon dioxide laser yields
equivalent local control
B. Hemilaryngectomy (vertical laryngectomy): or some glottic lesions that involve the anterior
commissure because o the increased risk o cartilage involvement

C. Limited surgical resection: or some small lesions o the tip o the epiglottis
III. La rg e s up ra g lo ttic tum o rs : Supraglottic (horizontal) laryngectomy spares the true vocal olds but
removes the epiglottis, aryepiglottic olds, and alse vocal olds.


318

Chapter 18

Skin Cancer

A

B

Fig ure 18-5: A: Total laryngectomy s pecimen ready or removal, attached only to the
tongue bas e. B: Pharyngeal de ect ollowing total laryngectomy. Clos ure is us ually
accomplis hed in layers in a T as hion.

IV. Tra ns g lo ttic tum o rs : For supraglottic tumors that spread to a true vocal old, a
suprahemilaryngectomy may be considered. Neck dissection, radiation, or both are o en necessary.
V. Ad va nc e d tum o rs : Usually require a total laryngectomy, o en combined with neck dissection
(Fig. 18-5). Postoperative radiotherapy is usually indicated.
VI. Ve rruc o us c a rc ino m a : Conservation laryngectomy, when possible. T ere is no need or elective
neck dissection, and the use o radiotherapy is controversial.
VII. Co nc urre nt c he m o ra d io the ra p y p ro to c o ls : achieve cure rates comparable to those or
traditional combined surgical therapy and allow some patients to avoid total laryngectomy (Fig. 18-6)
VIII. P ro g no s is : better than with cancer o other head and neck sites

SKIN CANCER

Ba s a l a nd Sq ua m o us Ce ll Ca rc ino m a s
I. Etiology: sunlight, radiation, arsenic, burns, scars, and genetic disorders
(xeroderma pigmentosum, basal cell nevus syndrome, albinism)
II. Clinic a l e va lua tio n: Usually present as slowly enlarging
cutaneous or subcutaneous lesions; some lesions orm nonhealing
ulcers. Nodal metastasis is uncommon.

Quic k Cut
Skin cancer is the
mos t common cancer in the
United States , with more
than 1 million new cas es
diagnos ed each year and
more than 10,000 deaths .

S ta ge s III a nd IV ca nce r
(−)

(+) Comple te re s pons e
or >70%
pa rtia l re s pons e
Cis pla tin/5-fluoroura cil
che mothe ra py

S urge ry

Ra dia tion
(−)
S urge ry


(+)
Obs e rve

Fig ure 18-6: Example o organ-s paring
neoadjuvant chemotherapy protocol.


Chapter 18

Head and Neck Surgery

319

III. Tre a tm e nt: T erapy includes electrodesiccation, curettage,
Quic k Cut
cryosurgery, excision, Mohs surgery, radiation, and topical
Ba s a l c e ll
uorouracil.
c a rc inoma a c c ounts or
A. Squamous cell carcinoma: Surgical excision is pre erred because
80% o s kin c a nc e rs , a nd
it allows removal o a margin.
s qua mous c e ll c a rc inoma
B. Basal cell carcinomas: O the nasolabial olds, medial and lateral
a c c ounts or 16% .
canthi, or postauricular regions are especially aggressive. T ey
can invade multiple tissue planes and, there ore, require an
extensive surgical resection.
C. Mohs surgery: involves the precise mapping and rozen-section control o the entire resection bed
D. Radiation therapy: usually reserved or advanced lesions in areas where surgical excision leaves a

cosmetically unacceptable de ect (e.g., the nose, eyelid, and lip)
E. All positive nodes: should be treated with neck dissection or radiotherapy

Ma lig na nt Me la no m a
I. Ep id e m io lo g y: Accounts or 1% o all cancers; incidence is
Quic k Cut
increasing by 5%–7% each year.
Twenty- ve percent
II. Etio lo g y: Sun exposure and heredity play important roles.
o all melanomas aris e in the
III. P a tho lo g ic va ria nts : lentigo maligna melanoma, superf cial
head and neck.
spreading melanoma, and nodular melanoma
IV. Sta g ing : depth o primary lesion, see part VII Chapter Cuts and
Caveats
Quic k Cut
When des cribing
V. Tre a tm e nt: wide excision with treatment o nodal basins or
s kin les ions concerning or
deeper melanomas
melanoma, us e the ABCD
A. Sentinel node biopsy: or intermediate depth o invasion to
s ys tem: a s ymmetry, b order
assess or nodal disease
irregularity, c olor (uneven
color pattern), and d iameter
1. Lymphoscintigraphy: Radiotracer is injected intradermally
greater than 6 mm.
around the melanoma lesion. Lymphatic imaging is then
per ormed a er injection to conf rm appropriate uptake o the

radiotracer.
Quic k Cut
2. echnique: Blue dye and radiotracer are injected
A s entinel node
intradermally at the site o the lesion. T e dye is visible and
is the rs t node involved
a gamma probe is used to identi y radiotracer activity and an
in lymphatic s pread o a
incision is made in the area.
malignancy.
3. Neck dissection: per ormed or positive nodes
4. Parotidectomy: added or lesions o the anterior scalp,
eyelids, auricles, and cheeks because the f rst-level lymphatic drainage is to the periparotid nodes
B. Radiation therapy: usually reserved or palliative treatment o recurrent disease
C. Chemotherapy: used or disseminated melanoma
VI. P ro g no s is : Survival rate is related to the tumor staging; the prognosis in patients with mucosal
melanoma is extremely poor.

HEAD AND NECK LYMP HOMA
Ove rvie w
I. Ep id e m io lo g y: Eighty percent o all malignant lymphomas arise rom nodes, many o which are in
the head and neck.
A. Hodgkin lymphoma: Seventy percent o patients have cervical lymph node involvement.
B. Extranodal presentation: rare in Hodgkin disease but occurs in 20% o patients with non-Hodgkin
lymphoma
II. Cla s s if c a tio n
A. Non-Hodgkin lymphoma: really a group o diseases, which are classif ed into avorable and
un avorable types on the basis o therapeutic response
B. Hodgkin lymphoma: Histology in uences the prognosis.



320

Chapter 18

Parotid Gland

Clinic a l Eva lua tio n
I. P re s e nting s ym p to m s : Usually a single, enlarged cervical node; most lymphomatous nodes are f rm
and rubbery.
A. Non-Hodgkin lymphoma: typically presents in upper cervical nodes
B. Hodgkin disease: discovered in nodes throughout the cervical chain
C. Sites o extranodal involvement in non-Hodgkin lymphoma: Head and neck, particularly in
Waldeyer tonsillar ring. Other sites include the nasal cavity, paranasal sinuses, orbit, and salivary
glands.
D. Systemic symptoms: Approximately 40% o patients with Hodgkin lymphoma have ever, sweats,
weight loss, and malaise.
II. Dia g no s is : Usually made by excisional biopsy o a lymph node; one o the largest nodes should be
removed in its entirety.
A. FNA o the lymph node and endoscopy: should be per ormed to rule out squamous cell carcinoma
B. I a possible extranodal source has been discovered: Biopsy f rst.
C. Frozen-section diagnosis: o little value except to exclude squamous cell carcinoma
D. Additional workup aids in staging: Chest radiograph, C scan o the abdomen, and bone marrow
biopsy are recommended.

Tre a tm e nt a nd P ro g no s is
I. Tre a tm e nt: Combination o chemotherapy agents and radiation
therapy are used depending on the stage and pathology.

Quic k Cut

Treatment or
lymphoma is generally not
s urgical.

II. P ro g no s is
A. Hodgkin disease: Favorable prognostic actors include localized
disease, limited number o anatomic sites, absence o massive
disease, and a avorable histology.
B. Survival rates: Patients with limited disease have 5-year, relapse- ree rates o 80%–90%; the rate alls
to 60%–80% in patients with advanced disease treated with combined therapy; and rates as low as
30% occur in advanced disease.
C. Non-Hodgkin lymphoma survival: Radiation therapy or limited disease yields 50%–70% cure rates.
1. With more advanced lesions: Patients with a avorable histology can have a 60%–70% 5-year
survival rate and a 30% cure rate.
2. Patients with an un avorable histology: ace a 24%–40% 5-year survival rate with little chance
or a cure

UNUSUAL TUMORS
Ca ro tid Bo d y Tum o rs
I. Cha ra c te ris tic s : Usually present as slow-growing, painless neck masses; 3% are bilateral (increasing
to 26% in patients with a amilial tendency or paragangliomas). T e mass may be pulsatile and may
have a bruit.
II. La rg e tum o rs : can cause dysphagia, airway obstruction, and CN palsies
III. Dia g no s is : Angiography shows a tumor blush at the carotid bi urcation that splays the internal and
external carotids.
IV. Tre a tm e nt: Surgical excision; large tumors may require carotid bypass.

PAROTID GLAND
Ove rvie w
I. Em b ryo lo g y: Largest o the salivary glands; average gland weighs 25 g. It appears in the ourth week o

gestation and originates rom the epithelium o the oropharynx.
II. Ana to m y: Covers the masseter muscle, extends beyond the vertical ramus o the mandible, and abuts
the external auditory meatus.
A. Fascial sheath: Encloses the gland; the tightness o this ascia is responsible or the severe pain that
accompanies acute swelling o the gland (acute parotitis).
B. Lobes: Classically, the parotid gland was thought to have two lobes, superf cial and deep, which is
use ul when discussing the surgical treatment o parotid disease.