Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• Angiofibroma of the Nasopharynx:
  • Juvenile nasopharyngeal angiofibroma (JNA) occurs:
    • In male teenagers
    • Is a benign but locally aggressive tumor.
  • The tumor contains:
    • Both vascular and fibrous elements:
      • Intermingling together

• Epidemiology:
  • Juvenile nasopharyngeal angiofibromas occur:
    • Almost exclusively in males:
      • Usually in adolescence:
        • Approximately 15 years
  • They account for only 0.5% of all head and neck tumors:
    • But are the most common of the benign nasopharyngeal neoplasms

• The patient presents with:
  • Nasal obstruction and
  • Epistaxis:
    • One symptom usually predominates:
      • This depends on the proportion of either of the two elements present:
        • Recurrent epistaxis:
          • Which can be severe:
            • Is usually the presenting symptom
• The origin of JNA:
  • Is the posterolateral aspect of the roof of the nasal cavity:
    • In the region of the sphenopalatine foramen
  • When the tumor increases in size:
    • It may extend into:
      • The pterygopalatine fossa and then posteromedially into the nasopharynx or it may enlarge laterally into the infratemporal fossa
    • Other routes of expansion include:
      • Superiorly:
        • Eroding the sphenoid sinus
      • Anteriorly:
        • Into the maxillary sinus.
        • Growth into the orbit through the inferior orbital fissure:
          • Will lead to proptosis
          • In some cases extension superiorly into the middle cranial fossa
• On macroscopic examination:
  • The angiofibroma is:
    • Lobulated in appearance
  • Its consistency ranges from:
    • Spongy to a varying degree of firmness:
      • Depending on the proportion of:
        • Vascular tissue and fibrous component that forms the tumor
• Microscopically:
  • Tumor is uncapsulated
  • Formed by numerous blood vessels of varying calibre coursing through a fibrous tissue stroma
  • The thickness of the muscular coat of these vessels varies and:
    • In general elastic fibres in these vessels are lacking:
      • Thus the ability to retract is reduced:
        • This lack of contractile tissue is the pathological reason:
          • For frequent episodes of epistaxis once a minor vessel starts to bleed
• These clinical features of repeated epistaxis and nasal obstruction in a male adolescent:
  • Together with the finding of a vascular mass in the nasopharynx:
    • Clinches the diagnosis
• Imaging studies are required:
  • To confirm the diagnosis and to assess the extent of the tumor
  • Plain radiographs:
    • No longer play a role in the workup of a suspected juvenile nasopharyngeal angiofibroma:
      • However:
        • They may still be obtained in some instances during the assessment of nasal obstruction, or symptoms of sinus obstructions
    • Findings include:
      • Visualization of a nasopharyngeal mass
      • Opacification of the sphenoid sinus
      • Anterior bowing of the posterior wall of the maxillary antrum:
        • Holman-Miller sign:
          • Pathognomonic
      • Widening of the pterygomaxillary fissure and pterygopalatine fossa
      • Erosion of the base medial pterygoid plate
• Angiography reveals:
  • Typical vascular tumor blush with multiple sources of blood supply and for large tumors bilateral supply is not uncommon:
    • The internal maxillary artery and its branches are usually the principal feeder

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👉Primary hyperparathyroidism as first manifestation in MEN 2A: an international multicenter study. Larsen LV, Mirebeau-Prunier D, Imai T, Alvarez-Escola C, Hasse-Lazar K, Censi S, Castroneves LA, Sakurai A, Kihara M, Horiuchi K, Barbu VD, Borson-Chazot F, Gimenez-Roqueplo AP, Pigny P, Pinson S, Wohllk N, Eng C, Aydoğan Bİ, Saranath D, Dvorakova S, Castinetti F, Attila P, Bergant D, Links TP, Peczkowska M, Hoff AO, Mian C, Dwight T, Jarzab B, Neumann HPH, Robledo M, Uchino S, Barlier A, Godballe C, Mathiesen JS. Endocr Connect. 2020 May 1. PMID: 32375120 https://www.ncbi.nlm.nih.gov/pubmed/32375120

👉Increasing trend of bilateral neck exploration in primary hyperparathyroidism. Khokar AM, Kuchta KM, Moo-Young TA, Winchester DJ, Prinz RA. Am J Surg. 2020 Mar;219(3):466-470. PMID: 31630823 https://www.ncbi.nlm.nih.gov/pubmed/31630823
American Association of Clinical Endocrinologists Endocrine Society

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• Initiation phase:
  • Is the start of the mechanical breath:
    • Whether triggered by:
      • The patient or
      • The machine
    • With a patient initiated breath:
      • You will notice a:
        • Slight negative deflection:
          • Negative pressure, or sucking
• Inspiratory phase:
  • Is the portion of mechanical breathing during which there is:
    • A flow of air into the patient’s lungs:
      • To achieve a maximal pressure:
        • The peak airway pressure:
          • PIP or Ppeak and
        • A tidal volume:
          • TV or VT
• Plateau phase:
  • Does not routinely occur:
    • In mechanically ventilated breaths:
      • But may be checked:
        • As an important diagnostic maneuver:
          • To assess the plateau pressure:
            • Pplat
          • With cessation of air flow:
            • The plateau pressure and the tidal volume (TV or VT) are:
              • Briefly held constant
• Exhalation:
  • Is a passive process in mechanical breathing:
    • The start of the exhalation process can be either:
      • Volume cycled:
        • When a maximum tidal volume is achieved
      • Time cycled:
        • After a set number of seconds), or
      • Flow cycled:
        • After achieving a certain flow rate

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• Frequencies of metastases from NPC were as follows:
  • Bone:
    • 75% of the cases
  • Lung:
    • 46% of the cases
  • Liver:
    • 38% of the cases
  • Retroperitoneal lymph nodes:
    • 10% of the cases
  • Multiple organ involvement:
    • Is as high as:
      • 57% of the cases
• Most of the distant metastases (95%):
  • Occurred within three years:
    • After completion of radiotherapy:
      • The first year:
        • 52%
      • The second year:
        • 23%
      • The third year:
        • 20%
• The median survival time from the discovery of distant metastasis is :
  • 11.2 months:
    • For bone metastasis
  • 16.3 months:
    • For pulmonary metastasis
  • 3.2 months:
    • For hepatic metastasis

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• Control / target variables:
  • Are the targets that are set:
    • Based on the mode of mechanical ventilation chosen:
      • For example:
        • There are:
          • Pressure-controlled mode of ventilation and
          • Volume-controlled mode of ventilation
      • In pressure-control:
        • The clinician sets a designated pressure:
          • That is delivered with every breath
      • In volume-control:
        • They set a designated tidal volume:
          • That is delivered with every breath
• Conditional variables:
  • Are the dependent variables:
    • In mechanical ventilation:
      • For example:
        • In volume controlled modes of ventilation:
          • The tidal volume:
            • Is a set parameter
          • While the pressure:
            • Is a conditional variable:
              • And can vary from breath to breath
• Trigger:
  • The factor that:
    • Initiates inspiration:
      • A breath can be:
        • Pressure-triggered
        • Flow-triggered
        • Time-triggered
• Cycle:
  • The determination of the end of inspiration, and the beginning of exhalation:
    • For example:
      • The mechanical ventilator can be:
        • Volume cycled
        • Pressure cycled
        • Time cycled

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• The guideline first addresses the addition of chemotherapy to curative RT for oropharyngeal cancer:
  • Recommending concurrent chemoradiation for patients with:
    • Stage IV disease or
    • Stage III disease with large-volume tumors:
      • But not for patients with:
        • Stage I to II disease
  • Recommendations by disease stage are as follows:
    • Stage IV:
      • Patients with stage IVA to IVB tumors receiving definitive RT should receive:
        • Concurrent high-dose intermittent cisplatin:
          • Advanced-stage patients who are medically unfit for high-dose cisplatin:
            • Should receive:
              • Concurrent cetuximab or carboplatin-fluorouracil
            • Weekly cisplatin may be considered for these patients:
              • With the caveat that there is limited prospective evidence to support its use
            • Concurrent cetuximab:
              • Should not be co-delivered to patients receiving definitive chemoradiation (CRT), nor
              • Should intra-arterial chemotherapy be used in this population
    • Stage III:
      • Patients with stage III OPSCC receiving definitive RT should receive:
        • Concurrent systemic therapy for:
          • T3, N0 to N1 tumors
          • CRT may be considered:
            • For larger volume T1 to T2, N1 tumors:
              • That are at substantial risk for locoregional recurrence
        • Systemic therapy for other stage III patients:
          • May convey unnecessary toxicity
    • Stage I to II:
      • Concurrent systemic therapy:
        • Is not recommended for patients:
          • With stage I to II OPSCC receiving definitive RT:
            • Due to a lack of evidence supporting its use for early-stage disease
• The guideline also provides guidance for the use of radiation and chemoradiation following primary surgery for OPSCC:
  • Post-operative, or adjuvant, RT is recommended:
    • For patients who show pathologic risk factors for disease recurrence, such as:
      • Positive surgical margins
      • Positive lymph nodes following surgery:
        • Although concurrent chemoradiation is strongly recommended:
          • Only for high-risk patients
  • Recommendations by treatment type and risk level are as follows:
    • Concurrent systemic therapy:
      • For high-risk patients:
        • Systemic therapy, specifically high-dose intermittent cisplatin:
          • Should be delivered with post-surgical RT for patients with:
            • Positive surgical margins and/or
            • Extracapsular extension
        • Weekly cisplatin may be delivered to post-operative patients:
          • Who are unable to tolerate high-dose intermittent cisplatin:
        • Post-operative patients who are unable to tolerate cisplatin-based chemoradiotherapy:
          • Should not routinely receive concurrent chemotherapy:
            • Existing prospective data do not support the use of cetuximab, concurrent weekly carboplatin or routine concurrent weekly docetaxel with post-operative RT, although clinical trials are underway to examine these alternative agents
    • Adjuvant therapy for lower-risk patients:
      • Concurrent chemoradiation:
        • Should not be routinely used in intermediate-risk disease
      • Adjuvant RT is strongly recommended for post-operative OPSCC patients:
        • At significant risk of locoregional recurrence but only conditionally recommended in scenarios:
          • Pathologic N1 disease
          • Perineural invasion
          • Lymphovascular invasion
        • With a more uncertain risk of locoregional failure:
          • Adjuvant radiotherapy may be delivered to patients:
            • Without conventional adverse pathologic risk factors:
              • Only if the clinical and surgical findings imply a particularly significant risk of locoregional recurrence
• The guideline also outlines optimal dosing and fractionation schedules based on treatment approach, disease profile and risk of recurrence:
  • Recommendations by treatment setting are as follows:
    • Definitive RT:
      • Patients with stage III to IV OPSCC should receive:
        • A cumulative dose of 70 Gray (Gy):
          • Delivered to the primary tumor site and positive nodes:
            • Over seven weeks
        • As well as an equivalent dose of 50 Gy delivered in 2-Gy daily fractions:
          • To the regions at risk for tumor spread
      • For stage IVA to IVB patients not receiving concurrent systemic therapy:
        • Altered fractionation schedules (either accelerated or hyperfractionated):
          • Are recommended
      • For Stage IVA – IVB patients undergoing concurrent CRT:
        • Either standard or accelerated fractionation may be implemented
      • Altered fractionation also should be used for patients:
        • With T3 N0 to N1 disease not receiving concurrent chemoradiation, and
        • It may be used for patients with T1 to T2, N1 or T2 N0 disease:
          • At high risk for recurrence
    • Post-surgical / Adjuvant RT:
      • Post-operative OPSCC patients at high risk for recurrence:
      • Those with positive surgical margins should receive:
        • A total dose of 60 to 66 Gy delivered to the positive margins and region of extranodal extension in 2-Gy daily fractions:
      • High-risk patients:
        • Not undergoing concurrent systemic therapy:
          • Should receive the upper limit of this range
      • While the 60-Gy total dose is recommended for:
        • Patients with negative margins following surgery
      • Early T-stage tonsillar carcinoma:
        • Ipsilateral RT:
          • Which involves treating only one side of the oropharyngeal area:
            • Is strongly recommended for the subset of OPSCC patients with early-stage tonsillar cancer:
              • Specifically well-lateralized T1 to T2 N0 to N1 tumors
          • It is conditionally recommended for patients with:
            • Lateralized T1 to T2 N0 to N2a disease without evidence of extra-capsular extension

References:

• Smith BD, Haffty BG, Wilson LD et al. Smith BD, Haffty BG, Wilson LD et al. The future of radiation oncology in the United States from 2010 to 2020: will supply keep pace with demand? J Clin Oncol.2010 Dec 10; 28(35): 5160-5.
• Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. Nov 10 2011;29(32):4294-4301.
• Gillison ML, D’Souza G, Westra W, et al. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst.Mar 19 2008;100(6):407-420.

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• Lymph node metastases:
  • At presentation are common in OPSCC:
    • With over half of patients:
      • Having clinical or radiological evidence of cervical metastasis, and
    • Around a third of patients diagnosed as cN0:
      • Having pathologic evidence of lymph node metastasis
  • The lymphatic drainage from the oropharynx:
    • Is mainly to:
      • Levels II, III and IV
    • It also drains into:
      • The retropharyngeal (RP) nodes:
        • Which need to be considered in the assessment of disease in this area
        • The risk of metastasis to RP lymph nodes depends on subsite:
          • A meta-analysis of papers suggests risk of RP lymphadenopathy being:
            • 19% for soft palate
            • 12% for tonsil
            • 6% for base of tongue and
            • 21% to 57% for posterior pharyngeal wall tumors:
              • Including hypopharynx
      • The prognostic impact of positive RP lymph node metastasis is disputed:
        • Some authors showing an adverse impact:
          • And others not
  • A particular feature of OPSCC:
    • Is the propensity to metastasis to the contralateral neck:
      • This occurring in up to 30% of patients overall in one series:
        • The subsites in which this is mostly likely to occur are the:
          • Soft palate
          • Base of tongue
          • Posterior pharyngeal wall:
            • However:
              • Even tonsil cancers have an approximate rate:
                • Of contralateral nodal spread of 10%

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– The thyroid gland is located in front of the neck below the thyroid cartilage.
– The average weight of the thyroid gland, in healthy adults, is 15–30 g.
– It consists of two lobes connected by an isthmus in the middle.
– The pyramidal lobe, which ascends from the isthmus or the adjacent part of either lobe up to the hyoid bone, can be seen in 20 % of the patients.

Arterial blood supply of the Thyroid gland

The main arterial blood supplies of the thyroid gland come from:

Superior Thyroid Artery
The first branch of the external carotid artery, it enters the upper pole of the thyroid on its anterosuperior surface. 

Inferior Thyroid Artery
Usually arises from the thyrocervical trunk upward in front of the vertebral artery and Longus Colli to the lower pole of the thyroid gland. Before entering the thyroid, the artery usually divides into 2–3 branches.

The inferior thyroid artery and its terminal branches are closely associated with the recurrent laryngeal nerve at the insertion of the thyroid gland, and innumerable variations have been described, so care must be taken in all cases to avoid injuring the nerve.

Thyroid IMA Artery
An unpaired artery in the anterior surface of the trachea, which can be seen in 3–10 % of patients. It usually arises from the brachiocephalic trunk (innominate artery), and occasionally it may arise from the aorta, the right common carotid, the subclavian, or the internal thoracic artery. It supplies the lower part of the thyroid gland. 

Venous drainage of the Thyroid gland

– A well-developed thyroid venous plexus usually drains through the inferior thyroid vein to the left brachiocephalic (innominate) vein. 

– The superior and middle thyroid veins drain to the internal jugular vein.

Nerves must be aware of during thyroidectomy
During thyroidectomy, Care must be taken to preserve the right and left recurrent laryngeal nerves in addition to the superior laryngeal nerves.

– The left recurrent laryngeal nerve branches from the vagus nerve, and loops under the arch of the aorta. It usually ascends along the tracheoesophageal groove with a straight course.

– The right recurrent laryngeal nerve loops around the right subclavian artery. It courses more obliquely and more lateral than left. 

– The superior laryngeal nerve, which is a branch of the vagus nerve, takes part in the pitch of the voice. It descends, by the side of the pharynx, behind the internal carotid artery and divides into two branches: external laryngeal nerve as a motor nerve and internal laryngeal nerve as a sensory nerve. 

There is a close relationship between the superior thyroid artery and the external branch of the superior laryngeal nerve; therefore, it is recommended to ligate the superior thyroid arteries as low as possible on the thyroid gland to avoid injuring the external branch of the superior laryngeal nerve.

Parathyroid Glands

Usually, there are four parathyroid glands, which are located on the rear surface of the thyroid gland. 

The regular size of the parathyroid gland is less than 1 cm and weighs 25–40 mg.

They are yellowish-brown and may be distinguishable from the thyroid gland. 

The superior parathyroid glands are normally located on the dorsal aspect of the upper pole of the thyroid gland. 

The inferior parathyroid glands are usually located posteriorly to the lower pole of the thyroid but are commonly found within the thymus in the neck or upper mediastinum.

The inferior parathyroid gland is anterior and medial to the recurrent laryngeal nerve, while the superior parathyroid gland is located posterior to this plane.

The principal arterial blood supply to both superior and inferior parathyroid glands is described as the inferior thyroid artery; there are also other blood supplies from the superior thyroid artery or anastomotic vessels of superior and inferior thyroid arteries.

Lymphatic drainage of the Thyroid gland

In the first place, immediate lymphatic drainage is to the periglandular nodes. And it courses to the prelaryngeal (Delphian), pretracheal, and paratracheal lymph nodes.
These lymph node groups are called central lymph nodes or central neck compartment; (levels IA, IB, and VI), and they are the most common site of metastasis from thyroid cancer.
The central neck compartment boundaries are: the hyoid bone superiorly, the suprasternal notch inferiorly, and the medial border of common carotid artery laterally. 

The second part of lymphatic drainage is the lateral neck region, levels IIA, IIB, III, IV, VA, VB. 

References

1. Youn Y-K, Lee KE, Choi JY. Surgical Anatomy of the Thyroid Gland. In: Color Atlas of Thyroid Surgery. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014:1-10. doi:10.1007/978-3-642-37262-9_1

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• Oropharyngeal tumor histological types:
  • Squamous cell carcinoma (SCC):
    • Is the most common malignancy of the oropharynx:
      • Making up 90% of the tumors in this region
  • Non-Hodgkin’s lymphomas:
    • Accounts for 8% of tumors in these region
  • Minor salivary gland tumors:
    • Account for 2% of tumors in these region
• With regard to squamous cell carcinoma:
  • The most frequent locations of affected sites is:
    • Tonsil / lateral wall:
      • 60% of the cases
    • Tongue base:
      • 25% of the cases
    • Soft palate:
      • 10% of the cases
    • Posterior pharyngeal wall:
      • 5% of the cases

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• The majority of patients when diagnosed with hypopharyngeal cancer have:
  • Advanced stage disease:
    • With evidence of:
      • Advanced local disease:
        • T3 / T4
        • Regional involvementof:
          • Level II, III, IV
          • Paratracheal and retropharyngeal lymph nodes:
            • In greater than 80% of the cases
          • Involvement of contralateral lymph nodes:
            • In greater than 20% of the cases
    • Distant metastases:
      • In approximately 3% of the cases
        • Thus restricting the options for curative treatment
• Those few patients who present with early primary site (T stage) disease:
  • Should be considered for treatment by:
    • Surgical excision (endoscopic (CO2) or open surgery) when possible:
      • So that organ function:
        • Voice and swallowing:
          • Can be preserved
• In the recent past:
  • Treatment for operable patients:
    • Was surgery with post-operative chemoradiotherapy:
      • However:
        • Because of the morbidity of the procedure and the likely risk of local recurrence and / or distant metastases:
          • Manifesting within two years:
            • The option of ‘organ preservation’ treatment has been explored
• Patients with advanced inoperable disease:
  • Should be treated by chemo ± biotherapy and radiotherapy regimens:
    • With possible surgery for persisting neck disease:
      • Aiming to maximize symptom relief:
        • With minimal treatment toxicity:
          • While maintaining good quality of life for the remainder of such patients’ life
  • There is a high risk of:
    • Synchronous and metachronous:
      • Second primary tumors
• Treat the neck in all cases:
  • Approximately 80% are cN positive at the time of presentation
• Submucosal spread is common:
  • Surgical margins should be:
    • 3 cm inferiorly and
    • 2 cm:
      • Both superiorly and laterally
• Prevent tracheal tears:
  • By deflating the cuff of the endotracheal tube:
    • When dissecting the trachea from the esophagus during gastric transposition
• Consider the addition of chemotherapy to organ-preservation treatment strategies and post-operative radiotherapy

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