Potpurri
What are consitutional/"B" symptoms?
Malaise, night sweats, fatigue
A trauma patient presents with somnolence and no response to pain. There are facial ecchymoses, with blood in the nose and mouth. What is the next step in management of this patient?
A. Perform a chin-lift maneuver.
B. Prepare for intubation with a video laryngoscope.
C. Perform a cricothyrotomy.
D. Prepare for nasal intubation.
E. Bag-mask the patient with a positive end-expiratory pressure (PEEP) valve.
B
An urgent, definitive airway must be provided in an injured patient with an altered mental status. The mouth should be suctioned out and orotracheal intubation performed if possible. Cervical spine precautions must be maintained and a chin-lift maneuver avoided. Nasal intubation is contraindicated with the concern for midface fractures. Trauma patients are at risk for aspiration and a rapid-sequence intubation should be performed; bag-mask ventilation can increase the risk of aspiration in an obtunded trauma patient. A surgical airway is needed only if orotracheal intubation is not successful.
A 35-year-old man presents with a solitary left cervical lymph node that is mobile on examination. It has been present for 4 months, slowly increasing in size. What is the best initial imaging modality?
A. Computed tomography
B. Ultrasound
C. Magnetic resonance imaging
D. Arteriography
E. Plain radiography
B
Ultrasound is a cost-effective test that does not expose the man to unnecessary radiation. It also allows for image-guided fine needle aspiration. Computed tomography exposes him to unnecessary radiation and is not cost-effective as an initial test. Magnetic resonance imaging is not cost-effective as an initial imaging modality. Arteriography is useful if there is concern for a vascular malformation. Radiographs are rarely useful to evaluate soft tissues of the neck.
What is Puneet's alma mater and the arch-enemy of Dr. Webber?
A 58-year-old woman is diagnosed with a well-differentiated thyroid cancer and evaluated in the office. On examination, she has one palpable lymph node that is concerning on ultrasound. Biopsy demonstrates cancer within the lymph node. Which of the following should be performed at the time of surgery to address her lymph node?
A
This woman has a biopsy-proven metastatic cervical lymph node. She should undergo lateral neck dissection. Radical neck dissection includes resection of the sternocleidomastoid, internal jugular vein, and spinal accessory nerve; this is not necessary. Prophylactic neck dissection is not indicated for thyroid cancer. Thus, only the side with biopsy-proven disease would require a neck dissection. There is no role for contralateral prophylactic dissection. Removing the pathologic node alone is not adequate; this patient should have a lateral neck dissection.
After a physical exam, how is a parotid mass diagnosis obtained?
FNA
Fine needle aspiration biopsy should be performed in virtually all parotid masses. Masses such as lipomas, benign lymph nodes, cysts, or Warthin tumors can potentially be observed if diagnosis is confirmed with fine needle aspiration.
What is Frey syndrome?
Auriculotemporal syndrome or gustatory sweating (also known as Frey syndrome), affects up to 10% of patients.
How should a LN specimen be sent to pathology
Fresh
Often, the lymph node specimen will undergo smears, stains, and cultures. This means the lymph node should ideally not be placed into a fixing agent
A 42-year-old woman, otherwise healthy, has been referred by her primary care physician regarding a neck mass. She is not taking any medications. She had a right parathyroid adenoma excision several years ago. Detailed physical examination is normal except for a thyroid mass. Ultrasound reveals a 3.5-cm left thyroid mass. The rest of thyroid gland appears normal with no retrosternal extension. Bulky central node metastasis from papillary thyroid cancer is confirmed on ultrasound-guided fine needle aspiration. Comprehensive metabolic profile is normal. Positron emission tomography–computed tomography is negative for distant metastasis. A total thyroidectomy with central node dissection is planned. Prior to surgery, which of the following is the next step of her preoperative workup?
D
Preoperative laryngeal examination is an important part of workup in this patient for two reasons: prior history of neck surgery and bulky central node metastasis. Other indications for laryngoscopy would be voice changes prior to surgery, prior upper chest surgery (such as patent ductus arteriosus ligation) or known thyroid cancer with posterior extrathyroidal extension. For a patient with prior cervical or upper chest surgery and a preoperative evaluation consistent with unilateral vocal cord paresis, a discussion should occur with the patient and the anesthesiologist about perioperative airway management and the need for tracheostomy if the contralateral nerve is injured.
A 35-year-old otherwise healthy man presents with several enlarged masses under his jaw that have been present for 1 week. He has also had occasional fevers, congestion, sore throat, and dry cough. On examination, you note multiple small submandibular cervical lymph nodes that are mildly tender and soft. What is the next best step in management of this man’s neck masses?
A
This man is presenting with symptoms of a viral upper respiratory infection (URI), and the etiology of the neck masses is most likely enlarged lymph nodes due to infection. Typically, infectious lymph nodes are soft and tender, and they typically resolve after 2 weeks and can occur with URI infection. Because this man is not describing any alarming or infectious symptoms that require further workup, observation to make sure resolution occurs is appropriate. If the masses are larger than 1 cm or do not resolve within 2 weeks, further evaluation with imaging is necessary. If the masses are firm, solitary, or fixed, this raises concern for a malignancy. In addition, if any constitutional B symptoms or immunosuppression history is present, this would be concerning for malignancy and would warrant further workup with imaging or biopsy. A lymph node biopsy is warranted if additional tissue is needed or if fine needle aspiration or core needle biopsy is nondiagnostic.
How long is head/neck cancer surveillance?
For most head and neck mucosal cancers, the patient requires careful examination for up to 5 years. It is not until 5 years have passed that the patient is considered to be "cured" of the cancer.
A 51-year-old man has a total thyroidectomy and left lateral neck dissection, and 1 week later he wants to know when the surgical drain that was placed at the time of surgery will be removed. He reports that the fluid was initially clear, but it has been cloudier for the past 3 days after he ate fried chicken. He empties about 200 mL/d. How do you approach the management of this situation?
A. Do not change anything. Have the patient continue to observe the drain output.
B. The fluid is concerning for a chyle leak. Try a low-fat diet or a medium-chain fatty acid diet or parenteral nutrition. If that does not decrease output, operative intervention to ligate the thoracic duct may be necessary.
C. The fluid is concerning for a chyle leak. Consider performing a right thoracotomy to ligate the thoracic duct at the origin.
D. Have the man return to clinic in 2 weeks for drain removal.
E. The fluid is concerning for a chyle leak. Perform an immediate operation to ligate the thoracic duct in the left neck.
B
The reported incidence of chyle leak after thyroid surgery and cervical node dissection is 0.5% to 8.3%. Park and colleagues conducted a retrospective review of all patients who underwent thyroidectomy and/or lymph node dissection for thyroid cancer over a 11-year period. The incidence of chyle leak was 0.9% (131/15,233) and was greater in lateral neck dissections (3.9%) compared to central neck dissection (0.6%). In the study, 105 patients were successfully treated with conservative management (nothing by mouth with total parenteral nutrition, low-fat diet, aspiration, negative pressure dressing, and octreotide) and 26 underwent surgical management (oversewing the thoracic duct via cervical incision) to stop the chyle leak. Most of chyle leaks from central and/or right lateral neck dissection were managed conservatively (92%). On average, they were detected within 1 to 2 days of surgery. Patients who needed surgical management had a significantly higher maximum daily drainage volume (763.5 mL vs 175.8 mL, P < .0001).
What is included in a modified radical neck dissection?
Removal of lymph nodes I to V with preservation of the sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein (unlike in radical neck dissection).
A 75-year-old man with a 35 pack-year history of smoking and end-stage liver disease presents for evaluation of dysphagia. A physical examination is notable for a 1-cm firm mass in the submental region, with palpable lymphadenopathy along the jugular-digastric chain. In addition to fine needle aspiration, which of the following is the most appropriate next step in evaluation?
A
In a patient with multiple risk factors for head and neck cancer, the initial diagnostic tests of choice are computed tomography with contrast (or magnetic resonance imaging of the neck) and fine needle aspiration. Open biopsy of the mass may yield a tissue diagnosis but risks tumor seeding and locoregional recurrence. Patients with head and neck cancer treated with inappropriate open biopsy often require more aggressive surgery and adjuvant therapy. Chest imaging is helpful for staging but would be secondary to imaging of the neck. Serologic testing for cytomegalovirus is not indicated for diagnosis. Direct laryngoscopy under general anesthesia is helpful for staging.
You are assisting with a thyroidectomy. During a lateral neck dissection, you retract the internal jugular vein medially, and a nerve is seen along the anterior scalene muscle. What is the expected impact of accidental injury to this nerve?
B
The description outlined in the question is classic for identifying the course of the phrenic nerve. Injury to this nerve results in shortness of breath. Shoulder syndrome is associated with spinal accessory nerve injury. Voice changes are associated with recurrent laryngeal nerve or superior laryngeal nerve injury. Sensory loss would not occur because no sensory nerves would be encountered on the anterior border of the scalene.
A 58-year-old Caucasian man presents with left axillary lymphadenopathy. You are consulted for evaluation. The man has a history of hypertension and end-stage renal disease, and he underwent deceased donor kidney transplantation 9 years ago. He had had several skin cancers, which have been excised by his dermatologist. Physical examination demonstrates a pale, slightly overweight male, with a right flank incision and an umbilical hernia. He has an enlarged, fixed lymph node in the left axilla and a suspicious-appearing lesion on the left upper back. Core needle biopsy demonstrates a round, blue tumor with neuroendocrine differentiation. What is the most appropriate initial therapy?
A. Pathologic assessment with an immunopanel consisting of cytokeratin 7 to confirm diagnosis
B. Complete lymph node dissection followed by radiation to the primary site
C. Complete history and physical examination with whole-body imaging as well as magnetic resonance imaging of the brain and computed tomography of the chest, abdomen, and pelvis with contrast or FDG-positron emission tomography to exclude distant disease.
D. Multidisciplinary tumor board consultation for clinical trial enrollment
E. Port placement followed by initiation of systemic chemotherapy using doxorubicin and ifosfamide
C
Merkel cell carcinoma (MCC) is a rare cutaneous malignancy that often arises in elderly males and in those with a history of immunosuppression. In the setting of regional metastasis, it is important to exclude distant disease. In the absence of distant disease, the recommendation would be for excision of the primary tumor and axillary lymph node dissection.
Diagnosis is confirmed by immunohistochemistry (IHC), which includes cytokeratin (CK) 20 and thyroid transcription factor-1 (TTF-1). IHC for CK and low-molecular-weight CK markers is typically positive with a paranuclear dot-like pattern. CK7 and TTF-1 are typically negative (in contradistinction, more than 80% of small cell lung cancers are positive for TTF-1). IHC markers for melanoma such as S100, Melan A, and mart1 would also generally be included in the immunopanel to evaluate for melanoma. Radiation to the primary site and/or regional nodal basin is determined based on the number of involved lymph nodes and presence/absence of extranodal extension. Given the rare but aggressive nature of these tumors, evaluation in a multidisciplinary tumor board is recommended, but after completion of the work up. Systemic chemotherapy, generally consisting of etoposide, carboplatin, or cisplatin, is given for distant disease. Doxorubicin and ifosfamide are more commonly used for soft tissue sarcoma metastases. Topotecan and pembrolizumab have also been used for MCC. Avelumab was recently approved for metastatic MCC.
Name four nerve structures that can be injured during lateral neck dissection
A 47-year-old man presents for evaluation of a neck mass. He is being referred to you for an open excisional biopsy; he already had a nondiagnostic fine needle aspiration and there is clinical concern for lymphoma. He undergoes an open lymph node biopsy. Postoperatively, he is noted to have an asymmetric drooped shoulder. In which region of the neck was the lymph node biopsy most likely performed?
D
The man has developed a winged scapula. This is likely the result of a spinal accessory nerve injury, which innervates the trapezius and the sternocleidomastoid muscle. This nerve is found in the posterior cervical region of the neck. In preauricular lymph node biopsies, one must be careful of the facial nerve and its branches. The inferior, submental, and submandibular regions are all anterior to the sternocleidomastoid and do not contain the spinal accessory nerve.
A 54-year-old man presents for evaluation of a neck mass. It is biopsied and comes back as squamous cell cancer. A lesion is noted within the tonsils consistent with the primary tumor. Which of the following is a known risk factor for this type of oropharyngeal cancer?
A
Human papillomavirus virus (HPV) has been demonstrated to have a causative effect on oropharyngeal cancers. It is important to ask about sexual history when seeing patients with neck masses and whether they have been vaccinated against HPV. In addition, alcohol and smoking are risk factors in the development of oropharyngeal cancers. Epstein-Barr virus has been linked to nasopharyngeal cancer, which is not described here. Diabetes mellitus and hypertension are not risk factors for the development of squamous cell cancer of the oropharynx. Hepatitis C has been linked to hepatocellular carcinoma.
What is the preferred imaging modality for parotid tumors?
MRI with gadolinium contrast remains the preferred imaging modality to investigate parotid tumors.
CT and ultrasound may also be helpful. PET may be useful in patients with proven malignancy.
When should a preop laryngeal exam (ie laryngoscope) be performed?
All patients should have preoperative voice assessment as part of their physical examination prior to thyroidectomy. This should include the patient's own assessment of vocal changes as well as the physician's.
What is a central neck dissection?
This involves removal of all level VI lymph nodes.
A 60-year-old man presents to your office for evaluation of left parotid mass. This mass has been present for 3 years and has grown marginally. He has no complaints associated with the mass. On examination, the mass is present in the mid-portion of the gland. However, the patient is concerned about cancer. Fine needle aspiration shows epithelial cells, myoepithelial cells, and a dense lymphoid infiltrate suggestive of a Warthin tumor. What is the diagnosis and appropriate surgical management for this patient?
B
Adequate resection of tumor with preservation of the facial nerve is the prime objective in management of salivary gland tumors. Unless the facial nerve is directly involved by malignant tumor, every effort is made to protect and preserve its function. This result of the fine needle aspiration is consistent with Warthin tumor. A conservative parotidectomy has been advocated to remove selected tumors, particularly Warthin tumors.
Superficial parotidectomy is recommended for most benign tumors confined to the superficial lobe, including pleomorphic adenomas (the most common benign salivary gland tumor.
A 42-year-old man presents with a malignant left parotid gland tumor. He undergoes resection, which goes well. He is seen in the office and says that he is doing fine, but he does complain that when he eats he starts to sweat from right over his left cheek. What is the cause of this?
B
The man is experiencing Frey syndrome or gustatory sweating. This complication affects approximately 10% of patients who undergo parotid surgery. They complain of sweating and flushing of the skin over the area of surgery during eating or mastication. This is believed to occur as a result of aberrant regeneration of parasympathetic fibers. The cut parenchyma heal into the subcutaneous tissue, and the nerves can grow into the sweat gland and innervate them, which is why sweat is then released with eating. Damage to the facial and auricular nerve is another complication that can occur with this procedure but would result in facial paralysis and numbness in the distribution of the great auricular nerve, respectively. Salivary fistula is also a complication, but rare after this procedure and would not cause gustatory sweating.