Head and Neck

Neck Mass

  • Dx:
    • Do not do an open biopsy of a lateral neck mass.
    • Location is key to diagnosis.
    • FNA for tissue diagnosis.
    • Differential includes infection, adenocarcinoma, squamous cell cancer, melanoma, breast cancer, lymphoma, thyroid cancer.
    • Bronchoscopy, laryngoscopy, and esophagoscopy identify primary lesion.
  • Tx:
    • Treat the primary.
    • Melanoma of scalp / ear can drain to lateral neck, so must do superficial parotidectomy with neck dissection for metastatic nodes.

Parotid Mass

  • Pleomorphic adenoma= #1 benign
    • Tx: superficial parotidectomy
  • Mucoepidermoid= #1 malignant
  • Acinic cell
  • Adenoid cystic= poor long term prognosis
    • Tx: complete parotidectomy, preserve facial n.
      • low grade malignancy can spare facial n & XRT
      • high grade gets nerve rsxn and graft if nerve worked preop
      • Modified radical neck dissection (MRND) for clinical supspicious nodes
      • XRT for +margin, high grade, nerve dysfunction preop, >T2 stage, perineural invasion, adjacent tissue invasion, >4cm.

Oral Cancer

  • Squamous cell cancer

    • MRND for clinical + neck nodes, consider selective neck for clinically - neck.

    • want 5mm margin

    • OR or XRT for < 4cm

    • OR and XRT for > 4cm 

Thyroid

  • Thyroid storm --> Lugol's solution
  • MEN syndromes
  • Complications of thyroidectomy:
    • Hypocalcemia
    • Hematoma with stridor
    • Recurrant laryngeal n. injury
    • Hypoparathyroidism
    • Superior laryngeal n. injury
  • Indications for FNA:
    • solitary/dominant nodule > 1cm
    • nodule > 0.5cm if
      • hypoechoic/microcalcifications
      • history with high risk for cancer
      • + PET scan
  • Hyperthyroid
    • postpartum thyroiditis
    • amiodarone 
    • Goiter without nodules --> Dx: check thyrotropin receptor antibody levels (LATS level) for possible Graves ; thyroid scan
    • Nodules --> Dx: Thyroid scan (128I)
    • Graves Disease
      • Dx: diffuse uptake; LATS levels
      • Tx:
        • 131I (need to FNA nodues to exclude cancer)
        • OR if Iodine allergy, pregnant, compression, exopthalmos, contraception adverse. (Use preop lugol's and B-blocker).
        • PTU for limited life expectancy
    • Solitary hyperfunction nodule
      • Dx: US
      • Tx:
        • >4cm --> OR lobectomy
        • <4cm --> OR or 131I
        • PTU for limited life expectancy
    • Toxic Multinodular Goiter
      • Dx: nodules with heterogeneous uptake
      • Tx:
        • OR for total thyroidectomy
        • 131I for patient preferance (Need FNA dominant nodule to R/O cancer)
        • PTU for limited life expectancy
  • Euthyroid
    • Dx: all with ultrasound
    • Cystic (simple)
      • Tx: Aspirate and re-eval in 6weeks
        • can repeat twice
        • OR for +cytology, >4cm, or recurrance x3
    • Multinodular Goiter
      • Tx:
        • OR for compression or dominant nodule > 4cm
        • FNA for dominant nodule 1-4cm
    • Solitary or heterogeneous nodule
      • Dx: FNA
      • Tx: based on FNA results:
        • insufficient
        • indeterminant --> repeat FNA x1, OR if indeterminant again
        • benign --> follow with US and FNA for changes
        • lymphoma --> Stage, OR if localized or compressive. Chemo/XRT for primary lympoma
        • Papillary thyroid cancer (PTC)
          • wu: staging cxr, US thyroid/central/lateral neck, FNA positive nodes, CT for bulky LAN or substernal disease, evaluate vocal cords
          • Total thoyridectomy with central/lateral neck if clinically positive nodes
        • Suspicious for follicular neoplasm (FTC) (20% are cancer)
          • Lobectomy for diagnosis
          • total thyroidectomy if final is cancer
        • Medullary thyroid cancer (MTC)
          • wu: staging same as PTC; screen MEN II
          • total thyroidectomy with MRLND (level I-VI)
          • Follow with CEA and calcitonin
  • PTC or FTC (not minimally invasive) adjuvent tx:
    • Radioactive iodine (RAI) for > 4cm, node +, residual disease
    • levothyroxine to suppress TSH
    • Follow Tg and AntiTg Antibodies
    • 2wk postop get RAI uptake scan (off levothyroxine and no iodinated contrast) to look for residual disease

Parathyroid

  • Hyperparathyroidism= PTH increases serum calcium and decreases Phos
    • Dx: Vit D, urinary Ca 24hr, serum Ca, PTH, US, sestimebe scan
    • OR for symptoms, include renal stones, osteitis fibrosis cystica, neuromuscular symptoms
    • NIH Criteria for asymptomatic primary hyperparathyroidism (any of the following)
      • Ca > 1mg/dl above normal
      • 30% reduced Cr clearance (GFR<60)
      • Age < 50
      • More than 2.5SD bone mass loss (Tscore < 2.5)
  • If can't localize all 4 glands:
    • look in mediastinum (Thymus)
    • tracheoesophageal groove
    • May do lobectomy if 3 other glands normal
  • Postoperative hypercalcemia with EKG changes (bradycardia, shortened QT intervul)
  • Postop stridor
  • MEN syndrome