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