Surgery

Head and Neck Surgery

Natasha B. Emano-Elazegui, MD
September 21, 2020

OUTLINE ANATOMY OF THE NECK

Triangles of the Neck
NECK MASSES ................................................................................................ 1
Approach to Masses in the Neck .................................................................................... 1 - That small area of the neck is divided into two major triangles by the
sternocleidomastoid (SCM) muscle
ANATOMY OF THE NECK............................................................................... 1
Triangles of the Neck ...................................................................................................... 1
Lymph Nodes ................................................................................................................... 2 Anterior Triangle
HISTORY .......................................................................................................... 2 - Bounded by:
o Angle of the mandible
PHYSICAL EXAMINATION.............................................................................. 2
o Midline of the neck
ANCILLARY PROCEDURES ............................................................................ 3 o Anterior border of the SCM muscle
Ultrasound ....................................................................................................................... 3 - Subdivided into:
CT Scan/MRI .................................................................................................................... 3
Special Tests ................................................................................................................... 3 o Submandibular triangle
Biopsy .............................................................................................................................. 3 o Submental triangle
Biochemical Tests ........................................................................................................... 3
▪ Contains:
TREATMENT .................................................................................................... 3 • Sublingual gland
Benign tumor ................................................................................................................... 3
Malignancy ...................................................................................................................... 3 • Submandibular gland
o Carotid triangle
▪ Contains:
NECK MASSES • Carotid arteries
- Common presentation in the out-patient department • Internal jugular vein
- Rarely present as emergent cases o Muscular triangle
- Vast differential diagnosis
- Best to understand the anatomy of the neck by heart

Approach to Masses in the Neck

- History
- Physical examination
- Biochemical studies
- Radiologic procedures
- Pathology

Figure 1. Anatomy of the Neck.

Figure 1. Different Head and Neck Diagnoses.

Figure 3. Triangles of the Neck.

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 Surgery | Head and Neck Surgery
Posterior Triangle ▪ the cheek
- Bounded by: o Rarely involved early, except for the cancer of the lip
o Posterior border of the SCM muscle o similar with the submandibular triangle
o Clavicle - If you see enlargement of lymph nodes in the mid jugular chain, you
o Anterior border of the trapezius muscles will now start investigating:
- Subdivided into: o areas of the oral cavity;
o Occipital triangle o the pharynx;
o Supraclavicular triangle o the larynx; or
o in the Waldeyer’s ring
▪ nasopharynx, the tonsils, and the base of the tongue
- In the anterior cervical triangle, when you have an enlarged node,
probably the major source of this node is the thyroid gland.

So, when you see enlarged lymph nodes in these areas more or less you
will be able to predict the possible source on why these lymph nodes are
enlarged.

HISTORY
- Age
- Location
- Duration
- Change in size
o How fast the change was
- Past medical history
Figure 4. Contents of Each Triangle.
o Smoking
o Radiation
So more or less, when you see masses in these areas you might be able - Social history
to have a diagnosis of the source of those masses in that area. So, if you o Travel; might be infectious
have an enlarged mass or a mass in the submandibular triangle, - Family history
probably these are the lymph nodes in the submandibular gland or the o Malignancy
submandibular gland itself. Now if you have a mass in the area of the - Worrisome Information
carotid triangle, these can be lymph nodes in the area of the jugular o Hard, fixed mass
chain or there might also be a pathology in your carotid artery. o Rapid onset
o Hoarseness
Lymph Nodes o Difficulty in swallowing
- Structures that will drain fluids in the body or help drain fluids in the o Weight loss
body o Night sweats
- It is involved in our immune system o Nerve deficits
- Of the 800 lymph nodes in the body, 200 are in the head and neck
area PHYSICAL EXAMINATION
- It may be the only sign of a malignancy that once can see - Prerequisites
- Involved in the drainage of fluid in the body o Make sure you wear the proper level of protection
- Involved in the immune function o Introduce yourself
o Explain the process
o Secure consent
o Position properly
o Goal: get a very good description of the mass
- Components
o Inspection
o Palpation
o Auscultation
- Note for:
o 5S
▪ Site
▪ Size
▪ Shape
• Rounded, well delineated, irregular borders
▪ Skin changes
▪ Previous scars
o Consistency
Figure 5. Nodal Basins of the Neck Area ▪ Hard or soft
o Temperature
Nodal Basins of the Neck Area ▪ Warm (infectious cause)
- If you see an enlargement in the submental triangle o Transillumination
o There might be a tumor coming from: ▪ Can distinguish cystic or solid
▪ the areas of the anterior two-thirds of the tongue o Pulsatile
▪ the floor of the mouth o Bruit
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 Surgery | Head and Neck Surgery
ANCILLARY PROCEDURES
Ultrasound
- Cheap
- Available
- Reader and user dependent
- Can be used for guiding FNA/CNB

CT Scan/MRI
- Gives more detailed description
- More expensive
- Assess resectability

Special Tests
- Endoscopy
o Especially for patients who might end up with biopsy
- Thyroid Scan
o Mass in thyroid gland
o Determine activity of the mass
- Angiography
o Pulsatile mass with bruits
o Guide specific site of mass and plan on surgery

Biopsy
- Fine Needle Aspiration Biopsy
- Core Needle Biopsy
- Excision or Incision Biopsy
o Lymphoma

Biochemical Tests
- TSH
- T3
- T4

But for patients who present with anterior neck masses of which the
source is a thyroid gland wherein you do not have any other symptom
just a mass and there are no signs of hyperthyroidism, probably a TSH
will be enough.

TREATMENT
- Entirely dependent on the diagnosis

Benign tumor
- Observe
- Surgery – for cosmetic or obstructive symptoms

Malignancy
- Consult a multidisciplinary team
o might be composed of an endocrinologist, a plastic surgeon,
an anesthesiologist, a psychiatrist or psychologist, a
nutritionist
o Help decide the kind and extent of surgery needed to do
- Neo-adjuvant – Adjuvant procedure

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