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