Schwartz's Principles of Surgery ABSITE and Board Review, 9th Ed.

CHAPTER 18. Disorders of the Head and Neck

BASIC SCIENCE QUESTIONS

1. The relative risk of developing a squamous cell carcinoma of the head and neck for a patient who abuses both cigarettes and alcohol is

A. 4-fold increased risk

B. 10-fold increased risk

C. 22-fold increased risk

D. 35-fold increased risk

Answer: D

It should come as no surprise that abuse of tobacco and alcohol are the most common preventable risk factors associated with the development of head and neck cancers. This relationship is synergistic rather than additive. Smoking confers a 1.9-fold increased risk to males and a threefold increased risk to females for developing a head and neck carcinoma, when compared to nonsmokers. The risk increases as the number of years smoking and number of cigarettes smoked per day increases. Alcohol alone confers a 1.7-fold increased risk to males drinking one to two drinks per day, when compared to nondrinkers. This increased risk rises to greater than threefold for heavy drinkers. Individuals who both smoke (two packs per day) and drink (four units of alcohol per day) had an odds ratio of 35 for the development of a carcinoma when compared to controls. Users of smokeless tobacco have a four times increased risk of oral cavity carcinoma when compared to nonusers. (See Schwartz 9th ed., p 489.)

2. The primary lymphatic drainage of the midline of the upper lip is

A. Submandibular nodes

B. Submental nodes

C. Intraparotid nodes

D. Preauricular nodes

Answer: D

The midline of the upper lip drains initially to the preauricular nodes (Fig. 18-1). (See Schwartz 9th ed., p 491.)

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FIG. 18-1. Lymphatics of the lip.

3. Lymphatic drainage from the supraglottic larynx is primarily to

A. The prelaryngeal (Delphian) node

B. Paratracheal nodes

C. Deep cervical nodes

D. Superior jugular nodes

Answer: D

Lymphatic drainage of the larynx is distinct for each subsite. Two major groups of laryngeal lymphatic pathways exist: those that drain areas superior to the ventricle, and those that drain areas inferior to it. Supraglottic drainage routes pierce the thyrohyoid membrane with the superior laryngeal artery, vein, and nerve, and drain mainly to the subdigastric and superior jugular nodes. Those from the glottic and subglottic areas exit via the cricothyroid ligament and end in the prelaryngeal node (the Delphian node), the paratracheal nodes, and the deep cervical nodes along the inferior thyroid artery. Limited glottic cancers typically do not spread to regional lymphatics (1 to 4%). However, there is a high incidence of lymphatic spread from supraglottic (30 to 50%) and subglottic cancers (40%). (See Schwartz 9th ed., p 498, and Fig. 18-2.)

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FIG. 18-2. Sagittal view of the larynx with the divisions of the supraglottis, glottis, and subglottis demonstrated.

4. Which of the following infections have been correlated with nasopharyngeal carcinoma?

A. Herpes simplex virus (HSV)

B. Epstein Barr virus (EBV)

C. Cytomegalovirus (CMV)

D. Human immunodeficiency virus (HIV)

Answer: B

Risk factors for nasopharyngeal carcinoma include area of habitation, ethnicity, and tobacco use. There is an increased incidence of nasopharyngeal cancer in southern China, Africa, Alaska, and in Greenland Eskimos. A strong correlation exists between nasopharyngeal cancer and the presence of EBV infection, such that EBV titers may be used as a means to follow a patient’s response to treatment. (See Schwartz 9th ed., p 502.)

5. Level V lymph nodes in the neck are located

A. In the submental area

B. In the anterior triangle

C. In the posterior triangle

D. In the inferior jugular chain

Answer: C

The regional lymphatic drainage of the neck is divided into seven levels. These levels allow for a standardized format for radiologists, surgeons, pathologists, and radiation oncologists to communicate concerning specific sites within the neck (Fig. 18-3). (See Schwartz 9th ed., p 503.) The levels are defined as the following:

Level I—the submental and submandibular nodes

Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and hyoid inferiorly

Level Ib—the submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the posterior belly of digastric, and inferior to the body of the mandible

Level II—upper jugular chain nodes

Level IIa—jugulodigastric nodes; deep to sternocleidomastoid (SCM) muscle, anterior to the posterior border of the muscle, posterior to the posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)

Level IIb—submuscular recess; superior to spinal accessory nerve to the level of the skull base

Level III—middle jugular chain nodes; inferior to the hyoid, superior to the level of the cricoid, deep to SCM muscle from posterior border of the muscle to the strap muscles medially

Level IV—lower jugular chain nodes; inferior to the level of the cricoid, superior to the clavicle, deep to SCM muscle from posterior border of the muscle to the strap muscles medially

Level V—posterior triangle nodes

Level Va—lateral to the posterior aspect of the SCM muscle, inferior and medial to splenius capitis and trapezius, superior to the spinal accessory nerve

Level Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle

Level VI—anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the lateral extent of the strap muscles bilaterally

Level VII—paratracheal nodes; inferior to the suprasternal notch in the upper mediastinum

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FIG. 18-3. Levels of the neck denoting lymph node bearing regions.

CLINICAL QUESTIONS

1. The most common causative organism in otitis externa is

A. Staphylococcus aureus

B. Pseudomonas aeruginosa

C. Streptococcus pneumonia

D. Herpes simplex type 1

Answer: B

Acute otitis externa is commonly known as swimmer’s ear, because moisture that persists within the canal after swimming often initiates the process and leads to skin maceration and itching. Typically, the patient subsequently traumatizes the canal skin by scratching (i.e., with a cotton swab or fingernail), thus eroding the normally protective skin/cerumen barrier. Because the environment within the external ear canal is already dark, warm, and humid, it then becomes susceptible to rapid microbial proliferation and tissue cellulitis. The most common organism responsible is Pseudomonas aeruginosa, although other bacteria and fungi may also be implicated. Table 18-1 summarizes the microbiology of common otolaryngologic conditions. (See Schwartz 9th ed., p 476.)

Diabetic, elderly, and immunodeficient patients are susceptible to a condition called malignant otitis externa, a fulminant necrotizing infection of the otologic soft tissues combined with osteomyelitis of the temporal bone. In addition to the above findings, cranial neuropathies may be observed. The classic physical finding is granulation tissue along the floor of the EAC. Symptoms include persistent otalgia for longer than 1 month and purulent otorrhea for several weeks. These patients require aggressive medical therapy, including IV antibiotics covering Pseudomonas. (See Schwartz 9th ed., p 476.)

TABLE 18-1 Microbiology of common otolaryngologic infections

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2. Bell’s palsy is most commonly associated with

A. Injury to the temporal bone

B. Acute sinusitis

C. Infection with Herpes simplex

D. Infection with Herpes zoster

Answer: C

Bell’s palsy, or idiopathic facial paralysis, may be considered within the spectrum of otologic disease given the facial nerve’s course through the temporal bone. This entity is the most common etiology of facial nerve paralysis and is clinically distinct from that occurring as a complication of otitis media in that the otologic exam is normal. Historically, Bell’s palsy was synonymous with ‘idiopathic’ facial paralysis. It is now accepted, however, that the majority of these cases represent a viral neuropathy caused by herpes simplex. Treatment includes oral steroids plus antiviral therapy (i.e., acyclovir). Complete recovery is the norm, but does not occur universally, and selected cases may benefit from surgical decompression of the nerve within its bony canal. Electrophysiologic testing has been used to identify those patients in whom surgery might be indicated. The procedure involves decompression of the nerve via exposure in the middle cranial fossa. Varicella zoster virus may also cause facial nerve paralysis when the virus reactivates from dormancy in the nerve. This condition, known as Ramsay Hunt syndrome, is characterized by severe otalgia followed by the eruption of vesicles of the external ear. Treatment is similar to Bell’s palsy, but full recovery is only seen in approximately two thirds of cases. (See Schwartz 9th ed., p 478.)

3. Which of the following meet the diagnostic criteria for acute sinusitis?

A. Symptoms of facial pressure, headache, cough

B. Symptoms of nasal discharge and ear pain

C. Opacification of sinus on plain radiograph

D. Opacification of sinus on CT scan

Answer: A

Sinusitis is a clinical diagnosis based on patient signs and symptoms. The Task Force on Rhinosinusitis (sponsored by the American Academy of Otolaryngology–Head and Neck Surgery) has established criteria to define ‘a history consistent with sinusitis’ (Table 18-2). To qualify for the diagnosis, the patient must exhibit at least two major factors or one major and two minor factors. The classification of sinusitis as acute vs. subacute or chronic is primarily based on the time course over which those criteria have been met. If signs and symptoms are present for at least 7 to 10 days, but for less than 4 weeks, the process is designated acute sinusitis. Subacute sinusitis is present for 4 to 12 weeks and chronic sinusitis is diagnosed when the patient has had signs and symptoms for at least 12 weeks. In addition, the diagnosis of chronic sinusitis requires some objective demonstration of mucosal inflammatory disease. This may be accomplished by endoscopic examination or radiologically (i.e., CT scan). (See Schwartz 9th ed., p 478.)

TABLE 18-2 Factors associated with a history of rhinosinusitisa

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4. Initial treatment of a patient with allergic rhinitis and chronic sinusitis includes

A. Oral antibiotics for 3-6 weeks alone

B. Oral antibiotics for 3-6 weeks + tapering oral steroids

C. Antihistamines and nasal steroid spray alone

D. Endoscopic debridement + oral antibiotics for 3-6 weeks

Answer: B

Medical management of chronic sinusitis includes a prolonged course of oral antibiotics for 3 to 6 weeks, nasal and/or oral steroids, and nasal irrigations with saline or antibiotic solutions. Underlying allergic disease may be managed with antihistamines and possible allergy immunotherapy. Although the role of these treatments in resolving chronic sinusitis remains questionable, they may be considered in patients with comorbid allergic rhinitis or as part of empiric management before consideration of surgery. (See Schwartz 9th ed., p 479, and Fig. 18-4.)

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FIG. 18-4. Algorithm of chronic sinusitis signs and symptoms for 12 weeks. CT = computed tomography; ENT = ear, nose, and throat; PCP = primary care physician.

5. Timely antibiotic therapy is most likely to prevent which of the following complications of Streptococcal pharyngitis?

A. Endocarditis

B. Glomerulonephritis

C. Scarlet fever

D. Rheumatic fever

Answer: D

It is particularly important to identify group A beta-hemolytic streptococci in pediatric patients to initiate timely antibiotic therapy, given the risk of rheumatic fever, which may occur in up to 3% of cases if antibiotics are not used.

Complications of S. pyogenes pharyngitis may be systemic, including rheumatic fever, poststreptococcal glomerulonephritis, and scarlet fever. The incidence of glomerulonephritis is not influenced by antibiotic therapy. Scarlet fever results from production of erythrogenic toxins by streptococci. This causes a punctate rash, first appearing on the trunk and then spreading distally, sparing the palms and soles. The so-called strawberry tongue also is seen. (See Schwartz 9th ed., p 481.)

6. Which of the following is an indication for tonsillectomy in children?

A. >5 infections

B. >3 infections with strong family history

C. >3 infections in one year

D. >1 week missed from school in a year due to tonsillar infections

Answer: C

Tonsillectomy and adenoidectomy are indicated for chronic or recurrent acute infection and for obstructive hypertrophy. The American Academy of Otolaryngology–Head and Neck Surgery Clinical Indicators Compendium suggests tonsillectomy after three or more infections per year despite adequate medical therapy. Some feel that tonsillectomy is indicated in children who miss 2 or more weeks of school annually secondary to tonsil infections. (See Schwartz 9th ed., p 482.)

7. Which of the following is the most common therapy used in the treatment of recurrent respiratory papillomatosis?

A. Laryngoscopy with excision and/or ablation of lesions

B. Oral acyclovir

C. Intralesional cidofovir injection

D. Intralesional steroid injection

Answer: A

Recurrent respiratory papillomatosis (RRP) reflects involvement of human papillomavirus (HPV) within the mucosal epithelium of the upper aerodigestive tract. The larynx is the most frequently involved site, and subtypes 6 and 11 are the most often implicated. The disorder typically presents in early childhood, secondary to viral acquisition during vaginal delivery. Many cases resolve after puberty, but the disorder may progress into adulthood. Adult-onset RRP typically occurs in the third or fourth decade of life, is usually less severe, and is more likely to involve extralaryngeal sites of the upper aerodigestive tract. With laryngeal involvement, RRP is most likely to present with hoarseness, although airway compromise may be observed. The diagnosis can be established with office endoscopy. Currently, there is no “cure” for RRP. Treatment involves operative microlaryngoscopy with excision or laser ablation, and the natural history is eventual recurrence. Therefore, surgery has an ongoing role for palliation of the disease. Multiple procedures are typically required over the patient’s lifetime. Several medical therapies, including intralesional cidofovir injection and oral indole-3-carbinol, are being investigated to determine their abilities to retard recurrence. Additionally, the advent of HPV vaccines has suggested a role for this therapy in prevention of RRP. (See Schwartz 9th ed., p 482.)

8. What is the most likely diagnosis for the lesion seen in the photo below? (See Fig. 18-5.):

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FIG. 18-5.

A. Laryngeal granuloma

B. Polypoid laryngitis

C. Vocal cord cyst

D. Leukoplakia of the vocal cord

Answer: A

Laryngeal granulomas typically occur in the posterior larynx on the arytenoid mucosa.

Edema in the superficial lamina propria of the vocal cord is known as polypoid corditispolypoid laryngitispolypoid degeneration of the vocal cord, or Reinke’s edema.

Vocal cord cysts may occur under the laryngeal mucosa, particularly in regions containing mucous-secreting glands, such as the supraglottic larynx.

Leukoplakia of the vocal fold represents a white patch (which cannot be wiped off) on the mucosal surface, usually on the superior surface of the true vocal cord. (See Schwartz 9th ed., p 484.)

9. A classic Le Fort Type I fracture involves the

A. Forehead

B. Nose

C. Maxilla

D. Mandible

Answer: C

Le Fort I fractures occur transversely across the alveolus, above the level of the teeth apices. In a pure Le Fort I fracture, the palatal vault is mobile while the nasal pyramid and orbital rims are stable. The Le Fort II fracture extends through the nasofrontal buttress, medial wall of the orbit, across the infraorbital rim, and through the gomaticomaxillary articulation. The nasal dorsum, palate, and medial part of the infraorbital rim are mobile. The Le Fort III fracture is also known as craniofacial disjunction. The frontozygomaticomaxillary, frontomaxillary, and frontonasal suture lines are disrupted. The entire face is mobile from the cranium. It is convenient to conceptualize complex midface fractures according to these patterns (Fig. 18-6); however, in reality, fractures reflect a combination of these three types. Also, the fracture pattern may vary between the left and right sides of the midface. (See Schwartz 9thed., p 487.)

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FIG. 18-6. Classic Le Fort fracture patterns.

10. Which of the following temporal bone fractures is most likely to have an associated facial nerve injury?

A. Transverse

B. Longitudinal

C. Oblique

D. Open

Answer: A

Temporal bone fractures are divided into two patterns (Fig. 18-7), longitudinal and transverse, based on the clinical picture and CT imaging. In practice, most fractures are oblique. By classical descriptions, longitudinal fractures constitute 80% and are associated with lateral skull trauma. Signs and symptoms include conductive hearing loss, ossicular injury, bloody otorrhea, and labyrinthine concussion. The facial nerve is injured in approximately 20% of cases. In contrast, the transverse pattern constitutes only 20% of temporal bone fractures and occurs secondary to fronto-occipital trauma. The facial nerve is injured in 50% of cases. These injuries frequently involve the otic capsule to cause sensorineural hearing loss and loss of vestibular function. Hemotympanum may be observed. A cerebrospinal fluid (CSF) leak must be suspected in temporal bone trauma. This resolves with conservative measures in most cases. The most significant consideration in the management of temporal bone injuries is the status of the facial nerve. Delayed or partial paralysis will almost always resolve with conservative management. However, immediate paralysis that does not recover within 1 week should be considered for nerve decompression. (See Schwartz 9th ed., p 488.)

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FIG. 18-7. View of cranial surface of skull base. Longitudinal (left) and transverse (right) temporal bone fractures.

11. The treatment of choice for a small squamous carcinoma of the lip is

A. Surgical excision alone

B. Radiotherapy alone

C. Surgical excision + adjuvant chemotherapy

D. Radiotherapy + adjuvant chemotherapy

Answer: A

The treatment for lip cancer is determined by the overall health of the patient, size of the primary lesion, and the presence of regional metastases. Small primary lesions may be treated with surgery or radiation with equal success and acceptable cosmetic results. However, surgical excision with histologic confirmation of tumor-free margins is the preferred treatment modality. Lymph node metastasis occurs in fewer than 10% of patients with lip cancer. The primary echelon of nodes at risk is in the submandibular and submental regions. In the presence of clinically evident neck metastasis, neck dissection is indicated. The overall 5-year cure rate of lip cancer approximates 90% and drops to 50% in the presence of neck metastases. Postoperative radiation is administered to the primary site and neck for patients with close or positive margins, lymph node metastases, or perineural invasion. (See Schwartz 9th ed., p 491.)

12. Primary repair is possible after excision of what percentage of the lip?

A. 10%

B. 25%

C. 33%

D. 50%

Answer: C

Resection with primary closure is possible with a defect of up to one third of the lip. When the resection includes one third to one half of the lip, rectangular excisions can be closed using Burow’s triangles in combination with advancement flaps and releasing incisions in the mental crease. Borrowing tissue from the upper lip can repair other medium-size defects. For larger defects of up to 75%, the Karapandzic flap uses a sensate, neuromuscular flap that includes the remaining orbicularis oris muscle, conserving its blood supply from branches of the labial artery (Fig. 18-8). The lip-switch (Abbe-Estlander) flap or a stairstep advancement technique can be used to repair defects of either the upper or lower lip. (See Schwartz 9th ed., p 492.)

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FIG. 18-8. A Through C. Karapandzic labioplasty for lower lip carcinoma.

13. The most common location for Kaposi’s sarcoma of the oropharynx is

A. Tongue

B. Palate

C. Floor of the mouth

D. Tonsil

Answer: B

Squamous cell carcinoma and minor salivary gland tumors are the most common malignancies of the palate. The latter include adenoid cystic carcinoma, mucoepidermoid carcinoma, adenocarcinoma, and polymorphous low-grade adenocarcinoma. Mucosal melanoma may occur on the palate and presents as a nonulcerated, pigmented plaque. Kaposi’s sarcoma of the palate is the most common intraoral site for this tumor. (See Schwartz 9th ed., p 495.)

14. What is the probability that a neck mass measuring 2.5 cm in an adult is malignant?

A. 20%

B. 40%

C. 60%

D. 80%

Answer: D

In the adult population, a neck mass greater than 2 cm in diameter has a greater than 80% probability of being malignant. (See Schwartz 9th ed., p 503.)

15. Which of the following is removed in a modified radical neck dissection?

A. Level I-V lymph nodes

B. Internal jugular vein

C. Sternocleidomastoid muscle

D. All of the above

Answer: A

Traditionally, the gold standard for control of cervical metastasis has been the radical neck dissection (RND) first described by Crile. The classic RND removes levels I to V of the cervical lymphatics in addition to the SCM, internal jugular vein, and the spinal accessory nerve (CN XI). Any modification of the RND that preserves nonlymphatic structures (i.e., CN XI, SCM muscle, or internal jugular vein) is defined as a modified radical neck dissection(MRND). A neck dissection that preserves lymphatic compartments normally removed as part of a classic RND is termed a selective neck dissection (SND). (See Schwartz 9th ed., p 504.)

16. Which of the following is also removed when resecting a thyroglossal duct cyst?

A. Anterior jugular vein

B. External jugular vein

C. Hyoid bone

D. Superior laryngeal cartilage

Answer: C

Thyroglossal duct cysts represent the vestigial remainder of the tract of the descending thyroid gland from the foramen cecum, at the tongue base, into the lower anterior neck during fetal development. They present as a midline or paramedian cystic mass adjacent to the hyoid bone. After an upper respiratory infection, the cyst may enlarge or become infected. Surgical management of a thyroglossal duct cyst requires removal of the cyst, the tract, and the central portion of the hyoid bone (Sistrunk procedure), as well as a portion of the tongue base up to the foramen cecum. Before excision of a thyroglossal duct cyst, an imaging study such as ultrasound is performed to identify if normal thyroid tissue exists in the lower neck, and lab assay is performed to assess if the patient is euthyroid. (See Schwartz 9th ed., p 506.)

17. Branchial cleft anomalies involving the pyriform sinus arise from the

A. 1st branchial cleft

B. 2nd branchial cleft

C. 3rd branchial cleft

D. 4th branchial cleft

Answer: C

First branchial cleft cysts and sinuses are associated intimately with the EAC and the parotid gland. Second and third branchial cleft cysts are found along the anterior border of the SCM muscle and can produce drainage via a sinus tract to the neck skin. Secondary infections can occur, producing enlargement, cellulitis, and neck abscess that requires operative drainage. The removal of branchial cleft cysts and fistula requires removal of the fistula tract to the point of origin to decrease the risk of recurrence. The second branchial cleft remnant tract courses between the internal and external carotid arteries and proceeds into the tonsillar fossa. The third branchial cleft remnant courses posterior to the common carotid artery, ending in the pyriform sinus region. (See Schwartz 9th ed., p 506.)

18. The most common parotid tumor is

A. Warthin’s tumor

B. Pleomorphic adenoma

C. Mucoepidermoid carcinoma

D. Adenoid cystic carcinoma

Answer: B

Eighty-five percent of salivary gland neoplasms arise within the parotid gland. The majority of these neoplasms are benign, with the most common histology being pleomorphic adenoma (benign mixed tumor). In contrast, approximately 50% of tumors arising in the submandibular and sublingual glands are malignant. Tumors arising from minor salivary gland tissue carry an even higher risk for malignancy (75%).

Benign and malignant tumors of the salivary glands are divided into epithelial, nonepithelial, and metastatic neoplasms. Benign epithelial tumors include pleomorphic adenoma (80%), monomorphic adenoma, Warthin’s tumor, oncocytoma, or sebaceous neoplasm. Nonepithelial benign lesions include hemangioma, neural sheath tumor, and lipoma.

The most common malignant epithelial neoplasm of the salivary glands is mucoepidermoid carcinoma. The low-grade mucoepidermoid carcinoma is composed of largely mucinsecreting cells, whereas in high-grade tumors, the epidermoid cells predominate. High-grade mucoepidermoid carcinomas resemble nonkeratinizing squamous cell carcinoma in their histologic features and clinical behavior. Adenoid cystic carcinoma, which has a propensity for neural invasion, is the second most common malignancy in adults. Skip lesions along nerves are common and can lead to treatment failures because of the difficulty in treating the full extent of invasion. Adenoid cystic carcinomas have a high incidence of distant metastasis but display indolent growth. It is not uncommon for patients to experience lengthy survival despite the presence of disseminated disease. The most common malignancies in the pediatric population are mucoepidermoid carcinoma and acinic cell carcinoma. For minor salivary glands, the most common malignancies are adenoid cystic carcinoma, mucoepidermoid carcinoma, and low-grade polymorphous adenocarcinoma. Carcinoma expleomorphic adenoma is an aggressive malignancy that arises from a pre-existing benign mixed tumor. (See Schwartz 9th ed., p 507.)