Head and Neck Tumors

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Glands and palate 

  • salivary glands 
  • parotid – innervated by parasympathetic auriculotemporal nerve (CNV) and glossopharyngeal nerve, but CNVII passes through 
  • submandibular glands produce the most saliva > parotid > sublingual 


Head & Neck Neoplasms 


  • Pharyngeal fistula – presents as a lateral neck draining sinus over the SCM, and tracks deep to stylohyoid & digastric, superficial to ICA & stylopharyngeus 
  • Myxoma – presents as a slow growing benign tumor. treat with WLE 
  • Bruxism – presents with hypertrophy of the masseters. treatment is botox -> muscle relaxants -> resection masseter 
  • Nasopharyngeal angiofibromas – presents with epistaxis. these are benign but are locally invasive. treat with resection & radiation if there is intracranial extension. 
  • Benign lymphatic malformations – CO2 laser vs resection if symptomatic 
  • Fibrous dysplasia – ground glass appearance on imaging à treat by shaving and recontouring bone 


Tumors of the mandible/teeth: 

  • Aneurysmal bone cyst – multinucleated giant cells –> resection and curettage 
  • Osteonecrosis 
  • ORN occurs after 6500 gray and increased risk with dental caries, peridontal disease 
  • Bisphosphonate related osteonecorsis: related to bisphosphonate therapy (alendronate) 
  • Can develop nonvital bone (remember suffix onate) 
  • Stage 1: exposed alveolar bone without pathologic fracture –> responds to local debridment, oral care, and HBO 
  • Stage 2: needing major bony debridement or non responsive to HBO 
  • Stage 3: failed treatment, pathologic fracture, orocutaneous fistula, evidence of lytic involvement in the mandibular border -> treatment of mandibular segmental resection and reconstruction (free fibular graft if >6cm) 
  • Bilateral pathologic fractures- debridement and free fibular graft  
  • Gingival cyst – keratin containing cysts found on alveolar ridges of infants. 
  • Dentigerous cyst follicular cyst) – develop around an unerupted tooth when it degenerates and becomes unilocular cyst of nonkeratinizing stratified squamous epithelium 
  • Most common around the mandibular third molar (tooth will be at bottom of cyst and cyst will surround unerputed tooth, at an acute angle of the tooth) 
  • Radicular/periapical cysts – inflammatory cysts which develop from the periodontal ligament at the apex of nonviable erupted tooth (often after infection) 
  • Fibrous shell with inflammation and non keratinizing epithelium 
  • Primordial cysts/odontogenic keratocysts – keratinizing squamous lined cysts that develop from basal cell hamartomas à treat with enucleation and chemoablation 
  • Gorlin syndrome – calcifying odontogenic cysts (along with BCC + medulloblastoma etc discussed later) – biopsy shows epithelium undergoing keratinization with rete ridges and ameloblastic proliferations with some calcifications 
  • Ameloblastoma – presents as a mass/swelling on tooth bearing segments of the mandible. looks like a soap bubble on imaging with a radiolucent, multicystic, unilocular lesion.  
  • Benign but locally invasive àE&C (high recurrence)/complete segmental resection w/ reconstruction 
  • path shows odontogenic epithelial islands with palisading cells (odontogenic epithelium) 
  • Typically present in 4th and 5th decade of life   
  • Neurofibroma –  
  • Bilateral expansile lesions along inferior alveolar nerve is pathognomonic for neurofibromatosis 
  • mast cell in mixoid stroma, absence of sphenoid greater wing and macrocephaly 




  • Nasopharyngeal carcinoma – associated with EBV and burkitts lymphoma 
  • usually treated with chemo/radiation instead of resection 
  • Osteosarcoma –  
  • aggressive expanding mass in maxilla or mandible, needs radical excision with adjuvant chemo/rads (risk factors are fibrous dysplasia and retinoblastoma or previous radiation) 
  • looks like lamellar ossification and cortical destruction with poorly defined borders on XR 

Parotid: 80% of parotid tumors originate within the parotid gland  

  • Most common location for salivary gland malignancy: pain paresthesia and facial paralysis are signs of neural invasion (usually associated with malignancy) 
  • Also associated with malignancy is rapid growth, bony fixation, skin ulceration, palpable nodal enlargement  
  • Facial nerve divides superficial and deep portions –> superficial parotidectomy involves removal of parotid gland superficial to the plane of the facial nerve 
  • Indicated for benign parotid tumors (pleomorphic adenoma, mucocele, branchial cleft cysts, lymph nodes) 
  • Total parotidectomy is removal of superficial and deep parotidectomy 
  • Radical parotidectomy is indicated for malignant lesion of facial nerve –> total parotidectomy with facial nerve sacrifice 
  • If tumor invades parotid capsule, will need superficial parotidectomy 
  • Parotid: tympanomastoid suture as landmark to avoid facial nerve injury during parotidectomy, can use midpoint between fascial covering and tragus 
  • Pleomorphic adenoma (benign) and most common tumor of the parotid gland 
  •  biopsy will show stellate/spindle cells with mixoid background. à superficial parotidectomy to avoid local recurrence (preserve nerve) 
  • Warthin’s tumor (usually benign) and second most common parotid tumor 
  • Occur in men 50-70 years of age 
  • – commonly presents as bilateral tumors in older men who are smokers. biopsy will show papillary cysts, mucoid fluid, and lymphoid nodules. –> superficial parotidectomy vs monitoring 
  • Adenoid cystic carcinoma: second most common malignancy of salivary glands after mucoepidermoid carcinoma 
  •  propensity for neural invasion 
  •  presents with facial paralysis, pain, mets to lung. biopsy will show cribiform/swiss cheese cells with perineural invasion. –> radical surgical excision (high rate of recurrence/mets) 
  • MRI/CT first to determine neural invasion/plan for surgery 
  • 1-2cm margins +/- XRT 
  • Microcystic adnexal carcinomas: flesh colored nodules of upper lip, nose, perioorbital regions in middle aged patients, perineural invasion –> mohs resection 
  • Mucoepidermoid carcinoma – biopsy will show mucus producing and poorly differentiated epithelial cells. Locally invasive.  
  • high grade mucoepidermoid (total parotidectomy/ipsi neck dissection/post op radation) radiate if nodes clinically positive; superficial parotidectomy could be performed in low grade tumors 
  • Merkel cell tumors: aggressive, head and neck in elderly women, dark deep purple, dense oval sheets with indistinct borders that invade deep dermis, sq fat, muscle –> wide local excision of at least 3cm, ipsilateral neck dissection (parotid as well if in preauricular areas) 
  • Submandibular gland duct (wharton duct): can be blocked if cancer invades this area resulting in backup of salivary content, gland enlargement, becomes firm and painful, and can become infected 
  • Most common cause of hard mass in floor of mouth is salivary origin 
  • Minor salivary gland maligancy: less common, but more likely to be malignant 
  • Palate most common source of minor salivary tumors  
  • most adenoid cystic carcinomas –> requires surgical resection with adequate margins, radiation if high grade, mets, no good resection, etc 
  • Paresthesias are consistent with perineural invasion 
  • Remember to stage with CT/MRI prior to any operative intervention 


  • Complications include facial nerve paralysis, gustatory sweating, sialocele 
  • Chylous fistula: medium chain triglyceride diet, closed suction drain of neck after radical neck dissection; exploration and ligation may be considered in refractory cases, pec flap can help seal the fistula 
  • Parotid: 
  • Frey syndrome –gustatory sweating 
  • aberrent reinnervation of auriculotemporal nerve following superficial parotidectomy (postganglionic of parasympathetic to postg of dermal plexus) (place SMAS between parotid bed and overlying skin) –> can treat with skin excision or tympanic neurectomy, anticholinergics to abate the symptoms (can identify with idodine or tissue test) 
  • Can botox 
  • Bogorad syndrome (crocodile tears) – less common phenomenon gustatory hyperlacrimation after injury to facial nerve (another form of aberrant regeneration) –> lacrimal gland resection, botox, dilating lacrimal tract 
  • laceration of parotid duct – at risk from penetrating injury in line from the tragus to the mid upper lip 
  •  if identified early, try to explore and re-anastomose. if identified later, manage with drainage, pressure, and antisialogogues 
  • Last resort superficial parotidectomy for recalcitrant salivary collections
  • Salivary fistula is a risk after superficial parotidectomy for recalcitrant sialadenitis 


Neck Dissection and Staging 

  • SCC staging: T1<2cm, stage III>4cm T4 invades surrounding structures, N2 when contralateral nodes are involved or node >3cm 
  • SCC most common in maxillary region of paranasal area 
  • HPV- staging (p16+), better prognosis for chemoradiation therapy 
  • tumor size is T, N = nodes, M = mets 
  • P16 (HPV) downgrades it because lethality is less 
  • HPV 16, 18 common in oropharyngeal cancers 
  • recommendations 
  • n0 and N1 of oral cavity –> levels I-III 
  • clinically palpable mets –> modified neck dissection 
  • involvement of nerve, vein, or muscle –> radical resection/ neck dissection 
  • selective neck dissection in low grade oropharyngeal cancers (stage I/II) with negative palpable nodes- leads to decreased nodal recurrence, increased postop complications, and higher rates of survival compared to therapeutic surgery only 
  • Cortical invasion of SCC Is indication for segmental mandibulectomy; marginal mandibulectomy indicated for tumors that abut the mandible but do not invade 
  • SCC of lip –> excision, neck dissection (if nodes involved) and marginal mandibulectomy (if not invaded mandible), segmental if invasion present 
  • Radiation for T4 lesions 
  • Chronic exposure to nickel associated with development of SCC of nasal sinuses 


Node Drainage 

  • Level 1a and1b –> lie within the submental region with the mandibular body being the superior border and the hyoid bone being the inferior margin( submental and submandibular): drained teeth gums lips and anterior hard palate 
  • Level 2: upper jugular group (upper third internal jugular drain)drains naso/oro/hypopharynx and parotid 
  • Level 3 (middle third of the internal jugular) drains naso/oro/hypopharynx and larynx 
  • Level 4 (lower jugular with the cricoid cartilage as the superior border, clavicle of inferior border) drains hypo/larynx/ cervical esophagus 
  • Level 5 posterior triangle (naso and oro pharynx) 
  • Level 6 anterior central (between hyoid and sternum) and drains  thyroids/esophagus/larynx 



  • Mandible (need free vascularized transfer for defects >6cm) 
  • free fib-peroneal artery and vein (long pedicle, good skin island, able to accept dental implants to cortical bone) 
  • Free fibula dental implants initial depend on thickness of cortical bone (better initial stability) 
  • free iliac crest (better vertical height):Deep circumflex iliac  
  • free scapula: based on circumflex scapular artery (branch of subscapular artery) 
  • Can be harvested as a chimeric flap (latiss, seratus, scapular and parascapular skin  
  • free radius 
  • Maxilla 
  • small defect <5cm – bone grafting 
  • soft tissue only – temporalis muscle flaps 
  • posterior maxillary defects – ALT/rectus abdominis 
  • large bony defect – free fib, iliac crest, scapula  
  • Reconstruction of anterior mandible reconstructed with free fibula flap –> can perform multiple osteotomies 
  • Scalp 
  • In long standing scalp wounds with necrosis –> obtain biopsy first to rule out cancer recurrence, CT scan –> resection –. Reconstruction (in cases of presumed ORN) 
  • hx XRT – consider free vascularized tissue transfer particularly full thickness defects 
  • nonradiated, partial thickness – skin grafts 
  • defect <8cm and no radiation – scalp rotational flap 
  • Remember radial forearm has a long pedicle for cases with no local vessels 
  • tongue 
  • ideally thin, pliable, minimal morbidity (muscle flaps less desirable) 
  • Workhorse has been the RFFF, which requires STSG for closure of the donor site 
  • MSAP- medial artery sural perforator flap (medial sural artery) 
  • If patients fail swallow study, need to ensure enteral feeding via tube so patient may meet caloric needs 
  • Ideally radiation begins within 4-6 weeks of glossectomy for effectiveness 
  • Lower face/chin: can rely on submental flap based on facial vessels (myofascial or myocutaneous) -> is adjacent to defect and provides similar skin color and texture 
  • facial nerve: best outcomes are obtained by direct repair or cable nerve grafting  
  • <2cm –> direct repair 
  • 3-5cm –> conduit 
  • >5-7cm –> autologous cable graft 
  • If the nerve is resected very proximally to intracranial portion can perform cross facial nerve grafting 
  • Masseteric nerve transfer can provide facial reanimation as well as free innervated muscle graft 
  • Pharynx: 
  • Circumferential defects can be reconstructed with a tubularized ALT for single stage reconstruction to re-establish alimentary track 
  • Gastric pull up flap has high morbidity and poor perfusion 




candida (thrush) –> topical nystatin/clomitrazole 

  • The most ubiquitous and common flora –> can be seen in immunocompromised patients. Presents as white papules of oral mucosa 



Hypocalcemia- can cause perioral tingling and numbness (particularly after thyroidectomy if parathyroids are inadvertently removed) 





ACAPS inservice exams 2013-2020 

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