37.1 Head and Neck, Thyroid, Parathyroid, Endocrine and Bariatric Surgery and Otorhinolaryngology: Neck Masses and Head and Neck Cancer, Salivary Glands, Thyroid Nodules and Cancer, Goiter and Hyperthyroidism Surgery, Hyperparathyroidism, Adrenal Surgery, Bariatric Surgery, Nasal Polyps, Epistaxis, Vertigo, Hearing Loss and ENT Infections

Why this area matters

Thyroid disease, neck masses, nasopharyngeal cancer and ENT infections are common in Philippine practice. Goiter remains frequent in iodine-deficient areas despite salt iodization. Nasopharyngeal carcinoma is more common in Southeast Asian populations. The TOS asks for diagnosis, operations of choice and their complications.

Neck masses and head and neck cancer

• Neck masses by age:
  • children: mostly inflammatory (reactive nodes) or congenital (thyroglossal cyst in the midline, moving with tongue protrusion; branchial cleft cyst at the anterior border of the sternocleidomastoid; cystic hygroma);
  • adults: a persistent mass is neoplastic until proven otherwise (metastatic squamous carcinoma, lymphoma, thyroid);
  • tuberculous lymphadenitis is common in the Philippines at any age.
• Evaluation:
  • full examination of the oral cavity, pharynx and larynx (endoscopy);
  • ultrasound or CT;
  • fine-needle aspiration.
  • Avoid open excisional biopsy of a suspected metastatic squamous node, which complicates later treatment.
• Head and neck squamous cell carcinoma:
  • risk factors are smoking, alcohol, betel quid chewing and HPV (oropharynx);
  • oral leukoplakia and erythroplakia are premalignant;
  • treated by surgery (with neck dissection) and/or radiotherapy and chemoradiation.
• Nasopharyngeal carcinoma:
  • linked to EBV and dietary nitrosamines, and common in southern China and Southeast Asia;
  • presents with a painless upper neck node, unilateral serous otitis media in an adult, nasal obstruction or epistaxis, and cranial nerve palsies;
  • diagnosed by nasopharyngoscopy and biopsy, with EBV DNA as a marker;
  • treated with radiotherapy and chemotherapy, not primary surgery.
• Laryngeal cancer: persistent hoarseness for more than 3 weeks in a smoker requires laryngoscopy.

Salivary glands

• Most tumors arise in the parotid gland, and most parotid tumors are benign. A tumor in a smaller gland is more likely to be malignant.
• Pleomorphic adenoma:
  • the most common salivary tumor;
  • slow-growing and painless;
  • has a risk of recurrence and malignant change;
  • treated by superficial parotidectomy with facial nerve preservation; enucleation leaves tumor and leads to recurrence.
• Warthin tumor: often bilateral, in older male smokers.
• Malignant tumors:
  • mucoepidermoid carcinoma is the most common malignancy;
  • adenoid cystic carcinoma shows perineural spread;
  • malignancy is suggested by facial nerve palsy, pain, rapid growth and fixation.
• Complications of parotidectomy: facial nerve injury and Frey syndrome (gustatory sweating).
• Sialolithiasis:
  • most common in the submandibular gland (thick, alkaline saliva and an upward-running duct);
  • painful swelling with meals;
  • treated by stone removal, or gland excision if recurrent.
• Acute suppurative parotitis occurs in dehydrated elderly or postoperative patients (S. aureus). Treat with hydration, sialogogues and antibiotics.

Head & Neck Endocrine Surgery: Thyroid Disorders & Complications

Algorithmic Evaluation of the Solitary Thyroid Nodule

1. Serum Thyroid-Stimulating Hormone (TSH): The initial laboratory test of choice.
   • Suppressed (Low) TSH: Indicates hyperfunctioning tissue. Perform a Radioactive Iodine Uptake (RAIU) Thyroid Scintigraphy. Hyperfunctioning ("hot") nodules concentrate tracer and are almost universally benign ($< 1\%$ malignancy risk); treat hyperthyroidism.
   • Normal or Elevated TSH: Malignancy risk is higher. Proceed to High-Resolution Neck Ultrasonography.
2. Thyroid Ultrasonography & Fine-Needle Aspiration (FNA):
   • Suspicious Sonographic Features: Microcalcifications (psammoma bodies), marked hypoechogenicity, irregular or lobulated margins, "taller-than-wide" shape (transverse axis smaller than anteroposterior), extrathyroidal extension, and abnormal cervical lymphadenopathy.
   • Fine-Needle Aspiration Biopsy (FNAB): Indicated (ATA 2015) for nodules of 1 cm or more with high- or intermediate-suspicion sonographic features, 1.5 cm or more with low-suspicion features, and 2 cm or more with very-low-suspicion features (or observation). Results are reported using the Bethesda System for Reporting Thyroid Cytopathology (Classes I to VI).

Pathologic Spectrum of Thyroid Malignancies

Post-Thyroidectomy Complications & Emergencies

1. Postoperative Neck Hematoma: Expanding hemorrhage beneath the deep cervical fascia compressing the trachea. Clinical signs: progressive neck swelling, pain, dyspnea, and inspiratory stridor. Emergency Action: Immediate bedside decompression by cutting sutures/clips and evacuating hematoma at the bedside before transfer to the operating room.
2. Hypocalcemia & Hypoparathyroidism: Secondary to accidental excision or devascularization of the parathyroid glands. Manifests 24 to 48 hours post-op: perioral paresthesias, fingertip tingling, muscle cramps, hyperreflexia, Chvostek's sign (ipsilateral facial twitching when tapping over the facial nerve anterior to the ear tragus), and Trousseau's sign (carpopedal spasm elicited by inflating a sphygmomanometer cuff $20\text{ mmHg}$ above systolic pressure for 3 minutes). Treatment: Intravenous calcium gluconate ($10\text{ mL}$ of $10\%$ solution over 10 minutes) for acute symptomatic hypocalcemia; oral calcium and calcitriol for maintenance.
3. Recurrent Laryngeal Nerve (RLN) Injury: Unilateral injury causes vocal cord paralysis in the paramedian position, presenting as a hoarse, breathy voice. Bilateral RLN injury causes acute bilateral vocal cord adduction, precipitating upper airway obstruction that requires immediate reintubation or emergent tracheostomy.
4. Superior Laryngeal Nerve (External Branch) Injury: Denervates the cricothyroid muscle; manifests as loss of high-pitch vocal register and vocal fatigue.

Goiter, hyperthyroidism and endocrine surgery

• Indications for thyroidectomy:
  • compressive symptoms (dysphagia, dyspnea, stridor) or retrosternal extension;
  • suspicion or proof of malignancy;
  • cosmetic concerns;
  • hyperthyroidism not controlled by drugs, or when radioiodine is unsuitable (pregnancy, large goiter, severe eye disease).
• Preparing a patient with Graves disease for surgery:
  • make the patient euthyroid with antithyroid drugs;
  • give beta-blockers;
  • give potassium iodide (Lugol solution) for 7 to 10 days before surgery, to reduce gland vascularity;
  • this prevents thyroid storm during surgery.
• Primary hyperparathyroidism:
  • usually a single parathyroid adenoma (about 85%), less often hyperplasia (MEN 1 and 2A) or carcinoma (rare, with very high calcium);
  • classic features are "stones, bones, groans and psychic moans": kidney stones, osteoporosis, abdominal pain and pancreatitis, depression and fatigue, though most cases are found on routine calcium tests;
  • labs show high calcium with high or inappropriately normal PTH;
  • localize with a sestamibi scan and ultrasound;
  • parathyroidectomy for symptomatic patients, and for asymptomatic patients with calcium more than 1 mg/dL above normal, age under 50, osteoporosis, kidney stones or reduced kidney function;
  • after surgery, watch for hungry bone syndrome (severe hypocalcemia).
• Secondary hyperparathyroidism (CKD) is managed medically (phosphate binders, vitamin D, cinacalcet), with surgery for refractory cases.
• Adrenal surgery:
  • an adrenal incidentaloma is tested for function (overnight dexamethasone suppression test for cortisol, plasma metanephrines, aldosterone-renin ratio if hypertensive) and for malignant features (size over 4 cm, high density, growth);
  • functioning or suspicious tumors are removed by laparoscopic adrenalectomy;
  • pheochromocytoma needs alpha-blockade first.
• Bariatric and metabolic surgery:
  • indicated for severe obesity (BMI of 40 or more, or 35 or more with comorbidities; lower thresholds of about 32.5 to 35 are used for Asians and for poorly controlled type 2 diabetes);
  • the main operations are sleeve gastrectomy and Roux-en-Y gastric bypass;
  • benefits are sustained weight loss and remission of diabetes, hypertension and sleep apnea;
  • complications are leaks, strictures, dumping syndrome, internal hernia and deficiencies of iron, B12, calcium, vitamin D and thiamine, so supplements are given for life.

Otorhinolaryngology

Epistaxis (Nasal Hemorrhage)

• Anterior Epistaxis ($90\%$ of cases): Arises from Kiesselbach's Plexus on the anterior-inferior nasal septum (Little's Area), formed by anastomoses of five arterial supplies: anterior ethmoidal, posterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries. Management: Direct continuous manual compression of the soft nasal alae against the septum for $10-15\text{ minutes}$ while sitting upright and leaning forward. If bleeding persists, apply topical vasoconstrictors (oxymetazoline), chemical cautery with silver nitrate, or anterior nasal packing.
• Posterior Epistaxis ($10\%$ of cases): Arises from the Sphenopalatine Artery branches at Woodruff's Plexus in the posterior nasopharynx. Common in elderly, hypertensive, or atherosclerotic patients. Manifests as profuse bleeding running down the posterior oropharynx. Management: Posterior nasal balloon packing or Foley catheter tamponade, mandatory hospital admission (monitoring for hypoxia and bradycardia), or endovascular transcatheter embolization / endoscopic surgical ligation.

Peritonsillar Abscess (Quinsy)

Suppurative infection tracking into the loose connective tissue space between the palatine tonsil capsule and the superior pharyngeal constrictor muscle, following acute exudative tonsillitis (Streptococcus pyogenes, oral anaerobes).

• Clinical Presentation: Severe unilateral sore throat, high fever, dysphagia, odynophagia, muffled "hot potato" voice, and marked trismus (inability to open the mouth due to spasm of the adjacent internal pterygoid muscle).

• Physical Examination: Markedly swollen, erythematous tonsil displaced medially and downward, with contralateral deviation of the uvula.

• Management: Urgent bedside needle aspiration or incision and drainage (I&D) of purulent material, coupled with intravenous antimicrobial therapy (Ampicillin-sulbactam or Clindamycin) and analgesia.

• Nasal polyps:

  • bilateral, pale, insensitive grape-like masses linked to allergic rhinitis, chronic rhinosinusitis and aspirin-exacerbated respiratory disease;
  • polyps in children suggest cystic fibrosis;
  • a unilateral polyp or mass (especially with bleeding) must be biopsied to exclude a tumor, such as juvenile nasopharyngeal angiofibroma in adolescent boys (profuse epistaxis; do not biopsy in the clinic) or carcinoma;
  • treated with intranasal steroids, a short course of oral steroids, and functional endoscopic sinus surgery for refractory polyps.

• Vertigo:

  • benign paroxysmal positional vertigo: brief positional vertigo, diagnosed with the Dix-Hallpike test and treated with the Epley maneuver;
  • vestibular neuritis: acute prolonged vertigo with normal hearing;
  • labyrinthitis: vertigo with hearing loss;
  • Meniere disease: episodic vertigo with fluctuating sensorineural hearing loss, tinnitus and aural fullness, treated with a low-salt diet, diuretics and betahistine;
  • vestibular schwannoma (acoustic neuroma): unilateral sensorineural hearing loss and tinnitus, diagnosed by MRI;
  • central red flags: vertical nystagmus, ataxia and other neurologic signs (posterior circulation stroke).

• Hearing loss:

• Conductive causes: cerumen, otitis media with effusion, perforation, otosclerosis and cholesteatoma.
• Sensorineural causes: presbycusis, noise, ototoxic drugs (aminoglycosides, loop diuretics, cisplatin), Meniere disease, acoustic neuroma, meningitis and congenital infection.
• Sudden sensorineural hearing loss needs urgent oral or intratympanic corticosteroids.
• ENT infections:
  • acute otitis media: amoxicillin when antibiotics are indicated;
  • otitis media with effusion persisting more than 3 months with hearing loss: tympanostomy tubes;
  • chronic suppurative otitis media and cholesteatoma (a destructive keratinizing mass): mastoidectomy;
  • acute mastoiditis: IV antibiotics with or without drainage;
  • otitis externa: topical drops. Malignant (necrotizing) otitis externa in elderly diabetics (Pseudomonas, granulation tissue in the canal, cranial nerve palsies) needs IV antipseudomonal antibiotics;
  • tonsillectomy for recurrent tonsillitis meeting frequency criteria, peritonsillar abscess recurrence or obstructive sleep apnea;
  • deep neck infections (Ludwig angina, retropharyngeal and parapharyngeal abscess) threaten the airway and need airway control, IV antibiotics and drainage;
  • orbital complications of sinusitis (periorbital and orbital cellulitis, abscess) need urgent imaging and treatment.