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Junior Surgery Lecture
Head and Neck

Christopher H. Rassekh, M.D.

I. INTRODUCTION

In general, key concepts for students:

• Evaluation and differential diagnosis of neck masses
• Basic understanding of major types of pathology
• Understanding of anatomic regions in upper aerodigestive tract
• Understanding of some risk factors for head and neck cancer
• Basic understanding of TNM staging system for head and neck cancer and classification of the 6 major levels in the neck at risk for cervical metastases
• Know that early stage cancer may be treated with surgery or radiation alone and that later stage cancer usually requires combined therapy: chemotherapy should be viewed as experimental at this time

II. NECK MASS

A. Diagnostic Work-up

• History (hoarseness, dysphagia, odynophagia, referred otalgia, neck pain, weight loss, hemoptysis, dyspnea or airway difficulty)
• Physical exam (entire head and neck, including indirect laryngoscopy and palpation of tongue, bimanual examination, and also general physical exam; lung and abdominal exam especially important for low neck masses)
• CT scan
• Fine needle aspiration (may precede CT in some cases)
• Other X-rays if indicated (MR, CXR, barium swallow)
• Panendoscopy (nasopharynx, base of tongue, tonsil fossa, supraglottic larynx and pyriform sinus are most likely sites of occult primary in any case where malignancy is proven by FNA or neck biopsy)
• Open biopsy is the last resort when cancer is suspected (exception: lymphoma)
• Remember that 95% of all head and neck cancer is squamous cell carcinoma and that up to 20% of patients will have a second primary now or later

B. When to Suspect Cancer

• History of smoking – an important etiologic factor in squamous cell carcinoma of the upper aerodigestive tract
• Alcohol is a factor also
• Poor oral hygiene
• Wood and nickel exposure (sinus cancers) Characteristics of the mass (firmness, immobility)
• Age of the patient (older = higher risk)

C. Non-neoplastic Neck Masses

• Congenital
  • Branchial cleft remnants
    • Located lateral neck
    • Usually anterior border of sternocleidomastoid
    • Type II are the most common and are in the upper neck. The tract may go into the tonsil fossa or pyriform sinus and may pass between internal and external carotid or behind both
    • Vary in size with upper respiratory infection

    • Treatment is excision

  • Thyroglossal duct remnants
    • Cysts or sinuses are midline and move on swallowing or tongue protrusion
    • May become infected; if so, antibiotics
    • Removal when infection resolves
    • Sistrunk operation - removes hyoid bone (and "tract")
  • Cystic Hygroma (Lymphangioma)
    • Ill-defined borders
    • Soft and doughy, compressible
    • Transilluminate
    • Rx is surgical excision

    • Differs from hemangioma, which usually resolves and rarely should be removed

• Inflammatory
  • Cervical lymphadenitis
    • -Variety of pathogens
    • -Suspect in immunocompromised patient
    • -Try medical Rx first (antimicrobials)

Neck Dissection Classification and TNM Staging

LYMPH NODE GROUPS:

• Level I: Submental and Submandibular nodes
• Level II: Upper Jugular nodes
• Level III: Middle Jugular nodes
• Level IV: Lower Jugular nodes
• Level V: Posterior triangle nodes
• Level VI: Anterior (visceral) compartment nodes; prelaryngeal (delphian) nodes, pretracheal and paratracheal nodes
• Level VII: Upper mediastinal nodes

Other node groups:

• Buccinator (facial)
• Intraparotid
• Preauricular
• Postauricular
• Suboccipital

Classification of Neck Dissection

• Comprehensive neck dissections:
• Radical neck dissection: Removal of all lymph node groups on one side (levels I-V) and removal of three important nonlymphatic structures (the internal jugular vein, the sternocleidomastoid muscle and the spinal accessory nerve).
• Modified radical neck dissection: Removal of all nodes in levels I-V preserving one or more of the three nonlymphatic structures mentioned above.
• Extended radical neck dissection: Removal of all nodes in levels I-V plus removal of additional lymph node groups (such as the upper mediastinal nodes or suboccipital nodes) or additional nonlymphatic structures (such as the carotid artery, hypoglossal or vagus nerve, or digastric muscles).

• Selective neck dissections:
• Removal of lymph nodes with preservation of one or more lymph node groups in
  levels I - V.
• Examples:
  • Levels I, II and III for oral cancer (also called supraomohyoid neck dissection)
  • Levels II, III, IV for laryngeal cancer (also called lateral neck dissection)
  • Levels II, III, IV and V for skin cancers of the posterior scalp and neck (also called posterolateral neck dissection)

Staging of Oral Cancer (American Joint Committee on Cancer)

• Oral Cavity Sites:
• Lips
• Buccal mucosa
• Alveolar ridges
• Retromolar trigone
• Floor of mouth
• Anterior tongue
• Hard palate
• Primary Tumor (T):
• Tx: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ
• T1: Tumor 2 cm or less in greatest dimension
• T2: Tumor >2 but < 4 cm in greatest dimension
• T3: Tumor > 4 cm in greatest dimension
• T4: Tumor invades adjacent structures (through cortical bone, into deep (extrinsic) muscles of tongue, maxillary sinus and skin)
• Regional Lymph Nodes (N):
• Nx: Regional nodes cannot be assessed
• N0: No regional nodes
• N1: Metastasis in a single ipsilateral node < 3cm in greatest dimension
• N2a: Metastasis in a single ipsilateral node > 3cm but < 6cm
• N2b: Multiple ipsilateral nodes, none > 6cm.
• N2c: Bilateral or contralateral nodes, none > 6cm
• N3: Metastasis in a lymph node greater than 6cm in greatest dimension
• Distant Metastasis (M):
• Mx: Distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

STAGE GROUPING (TNM)

Note:

• The AJCC has staging criteria for all head and neck sites published in their manual (5^th edition, 1997 is available for review by students on request).
• Oropharynx is staged using the "rule of 2’s" just like oral cavity.
• T staging varies for other cancers, but N and M and stage grouping are consistent.
• For the test, we focus on oral cavity as a "prototype" head and neck cancer.

Last Updated: 11/18/98
head-and-neck.htm