354 HIGH-YIELD FACTS IN EAR, NOSE, AND THROAT SURGERY
mAl i g n An t t u mo r s
M c epi e m i C cin m
■ Most common malignant tumor o the salivary glands; derived rom epi-
thelial cells in the interlobar and intralobar epithelial cells o the gland.
■ Can vary rom low grade to highly malignant.
■ Symptoms: Range rom asymptomatic swelling (75%) to pain and acial
nerve paralysis.
■ Mostly a ects the parotid.
■ Most commonly induced by prior irradiation.
■ Lymph node metastases are common in ~40% o patients.
C cin m Ex Ple m p ic
■ Usually presents in patients who have undergone resection o a pleomor-
phic adenoma.
■ Pathology shows remnants o benign mixed tumor.
a en c cin m
■ Twenty percent o salivary tumors and only 4% o parotid tumors are
adenocarcinomas.
■ Eighty percent o patients are asymptomatic, although 20% have acial
nerve paralysis and 15% acial pain due to f xation o the tumor to underly-
ing/overlying structures.
■ Arises rom the terminal tubules and intercalated or strained duct cells in
the gland.
■ Many varieties have been described, and are graded as low, intermediate,
or high.
a en i C tic C cin m
■ Origin is the myoepithelial cell.
■ Most common malignant tumor o the submandibular and minor salivary
glands.
■ Malignant but slow growing; most patients are asymptomatic on presentation
even though a large percentage o those tumors are f xed to adjacent structures.
■ Neurotropic tumor with early distant metastasis.
a cinic Cell C cin m
■ Occurs exclusively in the parotid gland.
■ Women > men.
■ Pathologically def ned by the presence o amyloid.
■ Cell o origin in the serous acinar components and the intercalated duct cells.
Neck
An At o my
■ The neck is traditionally divided into anterior and posterior triangles
(Figure 22-4).
■ There are two main ascial planes (Figure 22-5):
■ Superf cial cervical ascia: Encloses the platysma and muscles o acial
expression. It begins at the zygoma o the ace and extends in eriorly to
the clavicle.
EAR, NOSE, AND THROAT SURGERY HIGH-YIELD FACTS IN 355
Digastric Muscle
Mandible
Anterior Triangle:
Submandibular
Triangle
Suprahyoid
Hyoid
Triangle
Trapezius Muscle
Carotid Triangle
Inferior
Carotid Triangle
Omohyoid Muscle
Sternocleidomastoid Muscle
Posterior Triangle:
Occipital
Triangle
Subclavian
Triangle
Clavicle
FIg u r E 2 2 - 4 . T i n le t e neck. (Reproduced, with permission, rom Lee KJ. Essential Otolaryngology:
Head &Neck Surgery. 8th ed. New York: McGraw-Hill; 2003: 423.)
■ Deep cervical ascia: Composed o our layers:
1. Superf cial layer/investing ascia: Encloses the trapezius, sterno-
cleidomastoid (SCM), and strap muscles; submandibular and pa-
rotid glands; and the muscles o mastication. Stretches rom the
mandible to the clavicle.
2. Middle layer/visceral/pretracheal ascia: Encloses the pharynx, lar-
ynx, trachea, and esophagus, thyroid/parathyroid glands, buccinator
and constrictors, and the strap muscles. It goes rom the skull base
to the mediastinum. Posteriorly, this ascia orms a midline raphe
that connects to the alar layer o the prevertebral ascia.
3. Deep layer/prevertebral ascia: Encloses the paraspinous and cervi-
cal muscles; goes rom skull base to the chest. Anteriorly, there are
two layers to this ascia—the prevertebral layer lies anterior to the cer-
vical vertebrae rom the skull to the coccyx; anterior to that is the alar
Trachea
Thyroid Gland
Esophagus
Superficial Fascia
Sternohyoid Muscle
Sternocleidomastoid Muscle
Internal Jugular Vein Sternothyroid Muscle
Common Carotid Artery
Carotid Sheath
Platysma
Vagus Nerve
Trapezius Muscle
FIg u r E 2 2 - 5 . F ci l pl ne t e neck.
356 HIGH-YIELD FACTS IN EAR, NOSE, AND THROAT SURGERY
Buccopharyngeal
(visceral) Fascia
Retropharyngeal
(retrovisceral) Space
Prevertebral
fascia:
Alar Layer
Danger Space
Prevertebral
fascia:
Prevertebral Layer
Prevertebral Space
FIg u r E 2 2 - 6 . F ci l l e t e et vi ce l p ce.
layer, which extends rom the base o skull to the mediastinum. The
danger space lies between the alar and prevertebral layers. Anterior to
that is the visceral/buccopharyngeal ascial layer o the middle ascia.
4. Carotid sheath ascia: Envelopes the carotid artery, internal jugu-
lar vein, CN X. Runs rom base o skull to the thorax.
■ The spaces ormed by the neck ascial layers are potential spaces or an
in ection to extend to, seed, and spread (Figure 22-6).
■ Above the hyoid bone:
■ Parapharyngeal: In ections spread rom tonsils, pharynx, teeth, parotid
gland, and extension rom other spaces. Parotid involvement, trismus,
ever, and sepsis common with an in ection here. Extraoral approach or
drainage.
■ Submandibular.
■ Masticator: In ected when molar teeth in ection spreads.
■ Parotid.
■ Peritonsillar: Loose connective tissue that lies between the tonsillar
capsule medially and the superior constrictor laterally. (See section on
peritonsillar abscess earlier in this chapter.)
■ Below the hyoid bone: Visceral space encloses the pharynx, esophagus,
larynx, trachea, and thyroid. The prevertebral and retropharyngeal spaces
lie posterior to it.
■ Entire length o the neck:
■ Retropharyngeal: Anterior to the alar layer and posterior to the bucco-
pharyngeal ascia/esophagus and pharynx, an in ection rom here can
spread to the danger space. Contains lymph nodes and connective tis-
sue. The greatest number o LN here are ound in children < 4 years
old, and accounts or a large number o retropharyngeal abscesses.
■ Danger/alar space: Between alar layer and the prevertebral layer o
deep cervical ascia. In ection spreads to superior mediastinum.
■ Prevertebral: In ection can spread to the coccyx.
■ Vascular: In ection o the carotid sheath.
V c l s ppl
Carotid and subclavian systems.
Ne ve s ppl
To the skin: C2–C4.
EAR, NOSE, AND THROAT SURGERY HIGH-YIELD FACTS IN 357
L mp tic d in e
■ The neck has a rich lymphatic network, and lymphogenous drainage rom
di erent sites in the head and neck is highly predictable.
■ Lymph node areas are divided into di erent levels, which become rele-
vant when per orming a neck dissection and staging nodal disease.
co n g en i t Al Di s eAs es i n t h e n eck
B nc i l a pp t a n m lie
■ The head, neck, and related structures orm embryologically rom f ve
branchial arches, grooves, and pouches (Table 22-1).
Ta B L E 2 2 - 1 . T e Five B nc i l a c e
Ar c h Ner v e Bo Nes /c Ar t il Ag e Mu s c l es /v es s el s o t h er
First arch Mandibular CN V3 Mandible, malleus, incus Muscles o mastication, The pouch orms the
tensor tympani, anterior middle ear cavity, and part
belly o digastric, tensor o the tonsillar ossa and
palatine palatine ossa. The groove
orms the EAC. A f stula
would extend rom the skin
o the neck to the regions
o the eustachian tube.
Second arch Facial CN VII Stapes, part o hyoid Stapedius muscle, acial The pouch orms the
muscles, buccinators tonsillar ossa, palatine
tonsil. A f stula would
extend rom the skin on
the lower one third o
the neck, anterior to the
SCM, to the supratonsillar
ossa.These are the m t
c mm n f stulas.
Third arch Glossopharyngeal CN IX Part o hyoid bone Stylopharyngeus, The pouch orms the
superior and middle thymus and in erior
constrictors, common parathyroid gland
and internal carotid
artery
Fourth arch Vagus CN X/superior Thyroid and cunei orm In erior pharyngeal The pouch orms the
laryngeal nerve cartilage constrictor, superior parathyroid
cricopharyngeus, glands, ultimobranchial
cricothyroid muscle, body
L aorta, and proximal R
subclavian artery
Sixth arch Vagus/CN X—recurrent Cricoid, arytenoids, Intrinsic laryngeal muscles, There is no associated
laryngeal branch corniculate, and in erior constrictor muscle, pouch
tracheal cartilage and ductus arteriosus
358 HIGH-YIELD FACTS IN EAR, NOSE, AND THROAT SURGERY
■ Anomalies occur when pouches persist as a branchial sinus or a branchial
f stula develops between the pouch and groove. A cyst can also develop i
part o a groove or pouch becomes separated rom the sur ace and does
not resorb and become prone to repeated in ections; need to be excised
completely.
T l l d ct C t
e mbr yo l o g y /Def in it io n
■ The thyroid develops rom the oramen cecum at the base o the tongue
and migrates down to the root o the neck along the thyroglossal duct.
■ A remnant o the embryological migration becomes a thyroglossal duct
cyst.
Sig n S a n D Sympt o mS
■ Presents as a midline in rahyoid structure.
■ The cyst can be at any level along the route o the duct, and usually moves
with swallowing and protruding the tongue because o its attachment to
the base o tongue.
■ These cysts can become in ected and drain cutaneously.
t r ea t men t
■ Surgical excision o the gland remnant (Sistrunk procedure), provided that
ultrasound investigation reveals normal thyroid gland.
■ The procedure involves removing the ectopic gland, duct, and central por-
tion o the hyoid bone to minimize the chances o recurrence.
L mp tic M l m ti n
e mbr yo l o g y /Def in it io n
A mal ormation o the lymphatic system results in a multilocular neck mass
f lled with straw-colored uid ( ormerly known as a cystic hygroma).
Sig n S a n D Sympt o mS
WARD TIP Usually presents at birth with extensive neck and acial swelling; may compli-
cate the airway.
Although a neck abscess is usually
suppuration o a reactive lymph node, t r ea t men t
investigation must be taken as to
whether the node is in ected with ■ Resection is indicated, both unctionally and cosmetically.
mononucleosis, tuberculosis (TB), or ■ Instillation o a sclerosing agent has shown some promise as well.
lymphoma. FNA o a TB abscess without
excision can lead to a persistent
i n Fect i o u s / i n Fl AmmAt o r y l es i o n s o F t h e n eck
draining sinus tract, and a lymphoma
must be excised or diagnosis, not just
needle biopsied. L wi ’ a n in
Def in it io n
■ Acute cellulitis o the submandibular triangle deep to the mylohyoid mus-
cle. An emergency! Risk o sepsis and airway compromise.
■ Usually arises rom an oral cavity in ection.
Sig n S a n D Sympt o mS
■ Triangle is bound by attachment o the deep cervical ascia to the man-
dible and hyoid; suppuration that builds up creates a lot o pressure and
pain.
■ In ection can track posteriorly and potentially cause laryngeal edema.
EAR, NOSE, AND THROAT SURGERY HIGH-YIELD FACTS IN 359
t r ea t men t
WARD TIP
■ Aggressive treatment with IV antibiotics is necessary.
■ Intubation or tracheostomy may be needed to protect the airway. Intubate (consider nasotracheal
■ I nonresolving, may need I&D. intubation) be ore excision o Ludwig’s
angina abscess i evidence o airway
r et p n e l a b ce compromise.
Def in it io n
■ Usually results rom a suppurating lymph node in the retropharyngeal space.
■ Can be secondary to a penetrating pharyngeal injury.
■ They can traverse to the danger space and track down to the mediastinum.
Sig n S a n D Sympt o mS
Patients are ill and ebrile, dehydrated, complain o dysphagia and pain, and
may be stridulous.
Dia g n o SiS
Lateral so t tissue radiography is help ul in diagnosis when there is marked
swelling o the prevertebral tissues, and CT can be used to f nd the exact loca-
tion o the abscess.
t r ea t men t
Drain abscess; maintain airway with an endotracheal tube or a tracheostomy.
mAl i g n An cy
T i /P t i T m
See Endocrine System chapter.
L mp m
Sig n S a n D Sympt o mS
■ A disease o young and middle-aged adults.
■ Usually presents with multiple, slow-growing, rubbery lymph nodes in the
neck, which may be the only presenting symptom o the disease.
■ Systemic symptoms, including ever and night sweats, imply a worse prognosis.
Dia g n o SiS
Open biopsy o the node. Cellular architecture is important in both diagnos-
ing Hodgkin’s vs. non-Hodgkin’s lymphoma and determining subtype o each.
t r ea t men t
Depends on type and stage, and can include chemotherapy or RT. WARD TIP
Met t tic L mp en p t Neck d i ecti n
r ic l: Removal o all levels o lymph
Sig n S a n D Sympt o mS
nodes, the SCM, internal jugular vein,
■ Neck mass is the presenting sign o SCC in the head and neck or other and CN XI.
anatomic location. M if e ic l: A more selective
■ Usually presents in older patients with a f rm neck mass. procedure—removal o all levels o
lymph nodes, but preservation o either
Dia g n o SiS SCM, internal jugular vein, or CN XI.
■ FNA helps di erentiate between metastatic disease and other causes o s elective: All levels o lymph nodes are
chronic cervical lymphadenopathy (e.g., TB). not removed.
■ Panendoscopy o the upper aerodigestive tract is use ul or diagnosis.
360 HIGH-YIELD FACTS IN EAR, NOSE, AND THROAT SURGERY
t r ea t men t
WARD TIP
Dictated by the location o the primary tumor. A surgical dissection and
The unknown primary head and neck removal o the neck nodes and associated structures is necessary to pathologi-
cancer: Identi y based on lymph node cally identi y and treat the disease.
presentation pattern and characteristic
locations draining to lymphatic groups.
Re erences
Lee KJ. Essential Otolaryngology: Head and Neck Surgery. 8th ed. New York:
McGraw-Hill; 2003.
Burton M. Hall and Colman’s Diseases o the Ear Nose and Throat. 15th ed. New
York: Churchill Livingstone; 2000.
