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Ultrasound Imaging of the Neck

Key Points High-resolution ultrasound imaging is the “gold standard” modality for nodular thyroid disease and should include assessment of cervical lymph nodes. Thyroid nodules are very common and should be risk stratified by sonographic appearance according to the guidelines of the American Thyroid Association or American College of Radiology to avoid overtreatment. Sonographic features suggestive of thyroid malignancy include microcalcifications, irregular borders, extrathyroidal extension, hypoechogenicity, and…

Differential Diagnosis of Neck Masses

Key Points A thorough history and physical examination are still the cornerstones of the workup for neck mass. Pediatric neck masses are more often benign; in adults, neck masses should be assumed to be malignant until proven otherwise. Proximal aerodigestive tract evaluation is essential to neck mass workup. Computed tomography is still the most cost-effective imaging modality. Fine-needle aspiration should be attempted prior to obtaining incisional…

Diagnosis and Management of Tracheal Neoplasms

Key Points Ninety percent of primary tracheal tumors in adults are malignant. Tracheal squamous cell carcinoma (SCC) and adenoid cystic carcinoma (ACC) are the two most common primary tracheal malignancies, and together they account for 75% of all primary tracheal tumors. The 5-year survival for patients with resectable SCC is 39% and is influenced by completeness of resection, lymphatic invasion, and invasion of the thyroid gland.…

Vocal and Speech Rehabilitation After Laryngectomy

Key Points Surgical prosthetic voice restoration is the best option and gold standard for reestablishing oral communication in laryngectomized individuals. Surgical prosthetic voice restoration is feasible in all patients who are healthy enough to tolerate total laryngectomy and motivated to regain optimal oral communication. Surgical prosthetic voice restoration requires a multidisciplinary team approach including physician, speech therapist, and oncology nurse for achieving optimal results. In case…

Radiation Therapy for Cancer of the Larynx and Hypopharynx

Key Points LARYNGEAL CANCER THERAPY Early-Stage Glottic Cancer and Supraglottic Cancer (T1-T2 Lesions) Treatment options include either radiation therapy (RT) or surgery (e.g., “stripping,” laser excision for glottic cancers). Definitive RT offers several advantages over a primary surgical option, such as superior quality of voice outcome and obviating the need for a neck dissection. Radiotherapy dose/fractionation schemes are as follows for T1 and T2 lesions: For…

Total Laryngectomy and Laryngopharyngectomy

Key Points Total laryngectomy remains the standard by which other forms of treatment for advanced primary laryngeal carcinoma are evaluated. It should still be considered as a primary treatment modality for selected patients. Total laryngectomy is also occasionally indicated for advanced thyroid cancers or tumors of the oropharynx or neck that invade the larynx. The special subset of patients with laryngeal cancer who require a total…

Conservation Laryngeal Surgery

Key Points Four principles of organ-preservation surgery help provide consistent oncologic and functional outcomes: local control, accurate assessment of the three-dimensional extent of tumor, the cricoarytenoid unit as the basic functional unit of the larynx, and resection of normal tissue to achieve an expected functional outcome. Indirect laryngoscopy and staging operative endoscopy are critical to planning conservation laryngeal surgery. Vocal fold fixation must be distinguished from…

Transoral Laser Microresection of Advanced Laryngeal Tumors

Key Points Transoral laser microsurgery (TLM) permits both small and large laryngeal tumors to be resected. The limits of resectability are based on access and functional consequences and not on extent or T stage. Piecemeal resection of cancer permits precise tumor mapping and may improve local control over traditional en bloc resections. It further permits larger tumors to be removed through endoscopes that could otherwise not…

Management of Early Glottic Cancer

Key Points Early glottic cancer commonly presents as dysphonia associated with a white or red lesion of the vocal cord. Laryngeal leukoplakia is defined as a white lesion of mucosa that, based on its clinical features, cannot be assigned a definitive diagnosis. Biopsy is the standard management of leukoplakia and serves to assess for either malignancy or risk for subsequent development of malignancy based on degree…

Malignant Tumors of the Larynx

Key Points Squamous cell carcinoma (SCC) accounts for 85% to 95% of malignant laryngeal tumors. Tobacco and alcohol are the two most important risk factors for the development of laryngeal SCC. In the United States, laryngeal SCC occurs in the glottis more frequently than in the supraglottis. Subglottic SCC is rare. Laryngeal preservation may be achieved in properly selected cases by the use of conservation laryngeal…

Diagnostic Imaging of the Larynx

Key Points Computed tomography (CT) and magnetic resonance (MR) imaging have become the procedures of choice for defining mass lesions and traumatic abnormalities. They supplement the findings at laryngoscopy when additional diagnostic information is required to plan treatment. Appreciation of normal anatomy is essential when analyzing cross-sectional images. Diagnosis and extent of involvement of inflammatory conditions such as croup, epiglottitis, and retropharyngeal abscess can be confirmed…

Reconstruction of the Hypopharynx and Esophagus

Key Points To obtain the best outcome for the patient, perform pharyngoesophageal reconstruction as part of a knowledgeable multidisciplinary team. Hypopharyngeal defects are associated with the highest surgical complication rates in the head and neck. Careful monitoring of thyroid-stimulating hormone (TSH) and optimization of nutritional status improve wound healing outcomes. The pharyngoesophageal segment should be stented to help the flow of secretions through the reconstructed pharynx.…

Radiotherapy and Chemotherapy of Squamous Cell Carcinomas of the Hypopharynx and Esophagus

Key Points Advanced hypopharyngeal cancer is treated in a multimodality approach, either surgery followed by radiation with or without chemotherapy or with definitive chemoradiation. Induction larynx-preserving strategies should incorporate assessment of response to induction (bioselection). Postoperative chemoradiation with cisplatin is a standard for high-risk patients (extranodal spread and/or positive margins). In locally advanced esophageal cancer, preoperative chemoradiation improved resectability rates and locoregional control and ultimately increased…

Neoplasms of the Hypopharynx and Cervical Esophagus

Key Points Patients with hypopharyngeal carcinoma have the worst prognosis when compared with other subsites of head and neck cancer. Hypopharyngeal carcinoma tends to have significant submucosal extent that can be hard to appreciate clinically and radiographically. Organ-preservation therapy for hypopharyngeal lesions includes concurrent or induction chemotherapy and radiation or surgical options that include transoral laser microsurgery, transoral robotic surgery, and supracricoid hemilaryngopharyngectomy. Combined chemotherapy and…

Diagnostic Imaging of the Pharynx and Esophagus

Key Points An esophagogram, sometimes called a barium swallow, should be used to evaluate pharyngeal mucosa, whereas a modified barium swallow should be used to assess deglutition. Positron emission tomography–computed tomography (PET-CT) has become an essential modality for the staging, monitoring, and surveillance of skull base, pharyngeal, and esophageal cancers. The role of fluoroscopy in patients with dysphagia has undergone extensive changes in response to a…

Swallowing Function and Implications in Head and Neck Cancer

Key Points Understanding normal swallow physiology and pathophysiology is essential in the evaluation and management of dysphagia in patients with head and neck cancer. Evaluation of dysphagia in patients with head and neck cancer requires comprehensive assessment using clinical and instrumental modalities to determine the underlying pathophysiological and surgically altered structures. Dysphagia can be caused by the tumor itself or from interventions prescribed to treat the…

Reconstruction of the Oropharynx

Key Points Oropharyngeal reconstruction is complex, but an organized systematic approach using the reconstructive ladder aids the surgeon in the decision-making process. The simplest reconstruction that results in the highest level of function should be chosen. The size and location of the oropharyngeal defect combined with patient-related factors such as age and comorbid status determine the reconstructive technique that is appropriate for each patient. Limited oropharyngeal…

Transoral Approaches to Malignant Neoplasms of the Oropharynx

Key Points The four primary subsites of the oropharynx are the palatine tonsil, base of tongue, soft palate, and posterior pharyngeal wall. Transoral laser microsurgery uses a bivalved laryngoscope or mouth gag, operating microscope, and mounted or handheld carbon-dioxide laser to allow surgical resection of distal oropharyngeal (OP) and base-of-tongue tumors via multi-bloc resection with excellent oncologic and functional outcomes. Transoral robotic surgery offers surgeons improved…

Malignant Neoplasms of the Oropharynx

Key Points The oropharynx is a common site for the presentation of upper aerodigestive tract malignancies, more than 90% of which are histopathologically squamous cell carcinoma. A steadily progressive epidemic of human papillomavirus–associated oropharynx squamous cell carcinoma marks current head and neck epidemiology; these tumors exhibit a unique molecular biology characterized by p16 tumor suppressor protein overexpression and favorable oncologic outcomes compared with chemical carcinogen–associated tumors.…

Benign and Malignant Tumors of the Nasopharynx

Key Points A large number of different tumors can arise in the nasopharynx. Juvenile angiofibroma (JNA) is the most common benign tumor in the male adolescent, and tumor can extend into the paranasal sinuses, infratemporal fossa, and skull base as well as intracranially. Surgery, where appropriate, is the most effective treatment of JNA. The endoscopic route is efficacious in centers where expertise and resources are available.…