Head and Neck

J. Kenneth Byrd and Robert L. Ferris

Key Points

1 Squamous cell carcinoma (SCC) is the most common malignancy of the head and neck region.

Tobacco, alcohol, and human papillomavirus are the major risk factors.

2 A cystic neck mass in an adult represents a neck metastasis until proven otherwise, and should not be

incised and drained.

3 A multidisciplinary team should evaluate patients with a suspected head and neck tumor for

treatment options.

4 Functional reconstruction is equally important as oncologic resection in head and neck surgery.

5 Patients with new hoarseness for more than 2 weeks should be evaluated by a physician capable of

performing flexible fiberoptic laryngoscopy.

INTRODUCTION

The head and neck is a complex anatomical subsite, containing the major structures responsible for

sight, hearing, smell, speech, and swallowing. Disorders of the head and neck can therefore cause

detriment to quality of life by interfering with these functions. Knowledge of the anatomy of the region

is crucial to treat patients who present with complaints involving the head and neck, whether benign or

malignant. The following chapter will provide an overview of common presentations of head and neck

disorders, including head and neck cancer, which accounts for over 50,000 cases per year.

PATIENT EVALUATION

1 As in any clinical evaluation, a careful patient history should be taken, paying particular attention to

the timing of onset, severity, progression, and associated symptoms. Table 41-1 lists some of the more

common presenting signs and symptoms of head and neck cancer. Social history is of particular

importance in head and neck patients, as tobacco and alcohol use synergistically increase the risk of

head and neck squamous cell carcinoma (SCC).1 The clinician should document type, frequency, and

duration of use on any patient suspected to have a head and neck disorder. Sexual history may also be

of some interest, as the number of oral sexual partners has been associated with an increased risk of

HPV-related oropharyngeal cancer.2

On physical examination, the physician should proceed systematically through each area of the head

and neck. Gross deformity, skin lesions, previous incisions or scars, and radiation sequelae should be

noted. The physician should pay attention to any breathing difficulty, including stridor, stertor, and

nasal obstruction.

Each mucosal subsite of the head and neck region should be thoroughly inspected (Table 41-2). A

headlight or headlamp should be used to inspect the oral cavity, oropharynx, and larynx/hypopharynx

(if indirect mirror laryngoscopy is performed). Dentures should be removed prior to bimanual

examination of the oral cavity and oropharynx using tongue blades to check all mucosal surfaces.

Although some otolaryngologists prefer indirect laryngoscopy to visualize the larynx and

hypopharynx, patients with large tongues and/or hyperactive gag reflexes may be difficult to examine.

In the setting of possible malignancy, we recommend that all patients undergo flexible fiberoptic

laryngoscopy, which provides excellent dynamic visualization and the ability to record images and

video when coupled with appropriate equipment. Additionally, flexible or rigid endoscopy provides a

more detailed view of the nasal cavity than anterior rhinoscopy. Figure 41-1 demonstrates the view of

the larynx provided by in-office stroboscopy.

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The cervical lymph nodes should be palpated carefully, taking note of the location in levels I to V of

the neck, as described by Robbins et al. (Fig. 41-2),3 as well as lateral and superior–inferior mobility.

Pulsatility of the mass may suggest a vascular pathology, and should not be biopsied prior to imaging.

The laryngeal and tracheal framework should be examined to determine any disruption to the normal

architecture, as well as the position relative to the sternum. The thyroid gland should also be palpated

as part of every head and neck examination, although this is addressed in a separate chapter.

In the neurologic examination, particular attention should be paid to the cranial nerves. In sinonasal

pathology, hyposmia may be due to nasal obstruction, or alternatively due to direct involvement of the

olfactory nerve. Extraocular movement abnormalities can result from orbital or skull base pathology.

Temporal wasting or facial numbness may be a sign of perineural spread in the trigeminal nerve, and

facial weakness or twitching in the setting of a parotid mass suggests malignancy. Ipsilateral vocal

paralysis or impaired palatal elevation may suggest involvement of the vagus nerve, important to note

in skull base paragangliomas. Preoperative shoulder weakness in the setting of lymphadenopathy may

prompt the surgeon to counsel the patient about the need for radical neck dissection, as the spinal

accessory nerve may be involved by tumor.

WORKUP

In the setting of an accessible tumor (e.g., oral tongue, tonsil) biopsy may be performed in the office

under local anesthesia. In more distal subsites, operative direct laryngoscopy is required. For palpable

salivary or cervical masses, fine-needle aspiration is easily performed without image guidance. In most

patients with head and neck pathology, CT with contrast is the preferred imaging modality. MRI can be

of value in some cases, such as when perineural spread is a concern, to evaluate for invasion of intrinsic

tongue musculature in oral or oropharyngeal cancer, and for orbital and dural assessment. When

malignancy is diagnosed, metastatic workup with PET/CT or chest CT should be performed in stage

III/IV pathology.

Table 41-1 Differential Diagnosis of the Neck Mass

Table 41-2 Subsites of Head and Neck

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AIRWAY MANAGEMENT

Although the anesthesia team is primarily responsible for evaluating the airway, the surgeon should

share some responsibility in patients with head and neck disorders. A number of patient factors have

been described in the anesthesia literature as predictors of difficult laryngoscopy, including

sternomental distance, Mallampati score, thyromental distance, and mouth opening.4 However, the head

and neck surgeon will be more aware of the endoscopic airway anatomy as a result of preoperative

imaging and laryngoscopy. Bulky supraglottic and oropharyngeal masses may lead to failure of mask

ventilation and difficulty passing an orotracheal tube; lesions prone to bleeding may cause similar

problems. Patients with fibrosis from prior radiation or chemoradiation may have impaired laryngeal

excursion, in addition to trismus. In a prospective study of intubation in patients with head and neck

pathology, one group found that prior radiotherapy, a diagnosis of cancer, and supraglottic or glottic

subsite were predictive of airway difficulty.5 Indeed, it is imperative that the surgeon and

anesthesiologist communicate about the airway plan prior to induction.

Figure 41-1. In-office stroboscopy demonstrates a normal larynx with glottis open. Stroboscopy allows for dynamic visualization of

the mucosal wave and arytenoid movement.

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Figure 41-2. The cervical lymph nodes are divided into six groups, or levels.

Figure 41-3. Tracheostomy. A: The incision for an elective tracheostomy is typically placed on a horizontal axis, approximately

two finger breadths above the sternal notch. A vertical incision allows for less bleeding when the procedure must be performed

emergently. B: The strap muscles are separated in the midline. The thyroid isthmus may bulge into the wound (C), necessitating

inferior retraction or division (D). E: After the second tracheal ring is cleaned off, an inferiorly based flap (i.e., Bjork flap) is

developed in the tracheal wall and sutured to the skin. This allows for easy access to the trachea while the tract is maturing.

In patients for whom difficulty is predicted, fiberoptic nasotracheal or orotracheal intubation may be

safely performed with the patient spontaneously breathing with topical anesthesia and sedation.

Alternatively, planned awake tracheotomy is an option in patients with severe obstruction and abnormal

anatomy. Additionally, a tracheotomy kit should always be nearby for emergent cricothyrotomy or

tracheotomy, should it be necessary. Figure 41-3 demonstrates the typical sequence of steps in a

tracheotomy.

INFECTIOUS

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Pharyngitis and Abscesses

Acute pharyngitis is a common presentation in outpatient offices and the emergency department.

Although group A streptococcus is a concern due to its potential complications, it accounts for only 10%

to 15% of pharyngeal infections in adults; the majority are viral. Patients with fever, tonsillar exudates,

absence of cough, and cervical lymphadenopathy are more likely to have bacterial pharyngitis, and

should be tested for streptococcus and subsequently treated with amoxicillin, clindamycin, or a

macrolide.6 Those without streptococcal pharyngitis may generally be treated with hydration and

analgesics, although antibiotics may be indicated if atypical bacteria are suspected or if symptoms fail to

improve.

The most common head and neck abscess is the peritonsillar abscess, which typically arises from

untreated bacterial pharyngitis that leads to bacterial invasion of the parapharyngeal space if not

drained. Patients typically present with throat pain, trismus, dysphagia and odynophagia, and a muffled

voice. Physical examination reveals palatal and tonsillar bulging and uvular deviation toward the

unaffected side. Imaging is often unnecessary but may be useful in equivocal cases. Drainage is

performed at bedside after topical anesthetic spray and injected lidocaine or bupivacaine are used to

anesthetize the area; trismus is often greatly improved after local is administered, facilitating drainage.

An 18-gauge needle can be of use to localize the pus collection and plan the incision. An 11 or 15 blade

is then used to make an incision, which is enlarged with a hemostat when the abscess is localized.

Palpation of the tonsil with the hemostat or a cotton swab will express the remaining fluid (Fig. 41-4).

Antibiotics with broad coverage (e.g., amoxicillin-clavulanate or clindamycin) should be prescribed for

10 to 14 days.7 Patients with a history of multiple peritonsillar abscesses should be considered for

tonsillectomy.

Figure 41-4. Schematic representation of a peritonsillar abscess. Purulence develops between the tonsillar capsule and the superior

pharyngeal constrictor muscle. As a result, the palate bulges and the tonsil is deviated medially. Inflammation in the region of the

pterygoid muscles results in pain and trismus which may be significant.

In evaluating the patient with pharyngitis or a peritonsillar abscess, it is important to differentiate

from epiglottitis. Patients may present similarly, with odynophagia, a muffled voice, and drooling.

However, patients with acute bacterial epiglottitis are more toxic in appearance and have impending

airway compromise. Plain film radiographs of the neck will display the “thumbprint” sign, or an

edematous epiglottis. If the patient is tolerant, transnasal flexible laryngoscopy can be used to confirm

the diagnosis, but early securing of the airway in the operating room with tracheotomy or fiberoptic

intubation is paramount.

Progression of odontogenic or pharyngeal infections can lead to deep neck space infections, as well.

Early evaluation of the patient’s airway is paramount in deep neck infections, as they may rapidly

progress, particularly in the immunocompromised (e.g., diabetics). Elective intubation is often required,

and tracheotomy may be necessary in the setting of prolonged airway edema. Of particular concern are

infections involving the floor of mouth, or Ludwig angina, which can quickly progress bilaterally, and

cause airway compromise via posterior displacement of the base of tongue and trismus. In this setting,

awake fiberoptic transnasal intubation may be attempted, but the surgeon should be prepared for awake

tracheotomy. Infections in other neck spaces, including the Danger Space and Prevertebral Space, may

spread quickly through the entire neck and cause rapid decompensation. Figure 41-5 lists the relevant

deep neck spaces and paths of spread.

Operative intervention is usually required for deep neck infections, involving incision and drainage of

the affected spaces. Copious irrigation with placement of suction drains is recommended to decrease the

likelihood of reaccumulation, and reexploration is occasionally needed. Additionally, the odontogenic

source of the infection should be addressed, ideally at the same time as the incision and drainage.

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