What is the approximate incidence of metachronous carcinoma in patients with squamous cell carcinoma of the head and neck who continue to smoke cigarettes?

(A) 5%
(B) 10%
(C) 20%
(D) 40%
(E) 60%

The correct response is Option D.

In patients who have been previously diagnosed with squamous cell carcinoma but who continue to smoke, the incidence of metachronous carcinoma is 30% to 40%. In contrast, patients diagnosed with squamous cell carcinoma who stop smoking have only a 6% risk for development of metachronous carcinoma. The prevalence of metachronous carcinoma in all patients who have squamous cell carcinomas affecting a second site, regardless of smoking history and/or continued exposure to tobacco, is reported as 14.2%. The incidence of synchronous carcinomas has been reported as 5% to 7%. Further studies of tumor biology will continue to delineate the effects of carcinogens such as tobacco on the mucosal surfaces of the upper aerodigestive tract.

References
1. Carlson GW. Oncologic and reconstructive principles. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;3:1067-1092.
2. Piccirillo JF, Pugliano FA. Evaluation, classification, and staging. In: Myers EN, Suen JY, eds. Cancer of the Head and Neck. Philadelphia, Pa: WB Saunders Co; 1996:33-49.

In a 58-year-old man undergoing total parotidectomy, which of the following is the most appropriate technique to safely identify the facial nerve trunk?

(A) Identifying the temporal branches of the nerve and performing a retrograde dissection
(B) Using the midpoint between the fascial covering of the parotid gland and the earlobe as a landmark
(C) Using the plane between the superficial and deep lobes of the parotid gland as a landmark
(D) Using the tympanomastoid suture as a landmark
(E) Using a nerve stimulator

The correct response is Option D.

The safest and most convenient way to identify the facial nerve trunk during a parotidectomy procedure involves the use of the tympanomastoid suture as a landmark. This structure is defined as the suture line located between the posterior bony auditory canal and the mastoid portion of the temporal bone. The facial nerve can be found at a point 6 mm to 8 mm below the inferior end of the tympanomastoid suture line. If the region of the suture line is carefully dissected (ie, with a fine hemostat) in the direction of the facial nerve, the soft tissues can then be separated to reveal the glistening, white facial nerve.
Identification and dissection of the temporal branches of the facial nerve is a difficult, dangerous procedure; tagging of the distal branches is instead more reliable. With this technique, the surgeon identifies the marginal mandibular nerve as it crosses the facial vein and then performs a retrograde dissection to the nerve trunk.

Because the earlobe is not a fixed point, it cannot be used as a landmark. A tragal pointer, which is defined as the cartilaginous portion of the external auditory canal at its bony junction with the skull, is used instead. The facial nerve can be found within 5 mm from this point as it exits the stylomastoid foramen.

The plane between the superficial and deep lobes of the parotid gland is obscure; a proximal approach is safer and more effective.

Nerve stimulators are used as aids and are not the primary means for identifying the nerve trunk.

References
1. McGregor IA. Major salivary glands. In: McGregor IA, Howard DJ, eds. Rob & Smith's Operative Surgery: Head and Neck. 4th ed. Oxford, England: Butterworth-Heinmann Ltd; 1992:326-340.
2. Wagner JD, Coleman JJ. Salivary gland disorders. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;3:1355-1395.

A 46-year-old man undergoes excision of a 1-cm cyst on the right cheek that is thought to be an epidermal inclusion cyst. Histologic examination of a biopsy specimen shows pleomorphic adenoma. Which of the following is the most appropriate management?

(A) Observation
(B) Reexcision of the lesion
(C) Superficial parotidectomy
(D) Superficial parotidectomy and selective lymph node dissection
(E) Total parotidectomy

The correct response is Option C.

Pleomorphic adenoma is most appropriately managed with superficial parotidectomy. A pleomorphic adenoma is an isolated, firm, round tumor surrounded by a delicate capsule. It is the most common benign tumor of the salivary glands and is rarely associated with malignant transformation. Approximately 90% of pleomorphic adenomas affecting the parotid gland lie superficial to the facial nerve.

Because pleomorphic adenomas are characterized by microscopic extension of tumor through the capsule, and thus associated with a multifocal pattern of recurrence, superficial parotidectomy with preservation of the facial nerve is indicated.

Observation and/or simple reexcision are inadequate management and are likely to result in recurrence. Lymph node dissection is an unnecessary, excessive procedure in a patient with a benign tumor. Total parotidectomy is also excessive and can lead to serious morbidity resulting from injury or sacrifice of the facial nerve.

References
1. Granick MS, Solomon MP. Salivary gland tumors. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:453-457.
2. Hanna EY, Suen JY. Neoplasms of the salivary glands. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology Head & Neck Surgery. 3rd ed. Saint Louis, Mo: Mosby Ð Year Book, Inc; 1998;3:1255-1302.

A 42-year-old woman develops gustatory sweating in the parotid region six months after undergoing parotidectomy for removal of a benign mixed tumor. The most likely cause of this complication is abnormal regeneration of which of the following nerves?

(A) Auriculotemporal
(B) Chorda tympani
(C) Facial
(D) Great auricular
(E) Lingual

The correct response is Option A.

Gustatory sweating that develops following parotidectomy is known as Frey's syndrome or auriculotemporal syndrome and results from abnormal regeneration of auriculotemporal nerve fibers to sweat glands within the skin. Placement of thin surgical flaps over the parotid gland has been shown to exacerbate this condition; interposition of a submuscular aponeurotic system (SMAS) flap between the parotid bed and overlying skin may lead to improvement. The diagnosis can be confirmed by placing a single-ply facial tissue on the skin overlying the parotid gland; damp patches will be seen in areas affected by gustatory sweating. The Minor starch-iodine test, which involves placement of a 1 ( 1-cm test tape (containing iodine and starch) on the affected area, can be used to determine the total number of damp patches and thus confirm the distribution of the diaphoresis.

Although skin excision alone can successfully treat Frey's syndrome, tympanic neurectomy may be required. Systemic administration of anticholinergic agents results in abatement of symptoms but is associated with adverse effects and thus not recommended by many physicians. Topical glycopyrrolate (Robinul) or diphemanil methyl sulfate (Prantal) can be applied to the affected area to control gustatory sweating. When the diaphoresis has subsided, topical 20% aluminum chloride in alcohol (Drysol) should be applied once daily.

References
1. Allison GR, Rappaport I. Prevention of Frey's syndrome with superficial musculoaponeurotic system interposition. Am J Surg. 1993;166:407.
2. Singleton GT, Cassisi NJ. Frey's syndrome: incidence related to skin flap thickness in parotidectomy. Laryngoscope. 1980;90:1636.

A 38-year-old woman has a 2.5-cm squamous cell carcinoma of the tongue. On examination, she has one mobile 2-cm homolateral palpable lymph node; there are no distant metastases. Which of the following is the most appropriate classification of this patient's tumor?

(A) T1 N0 M1
(B) T1 N1 M0
(C) T2 N1 M0
(D) T2 N2 M0
(E) T3 N2 M1

The correct response is Option C.

In this patient who has a 2.5-cm squamous cell carcinoma of the tongue with involvement of one lymph node only, the tumor is correctly classified as T2 N1 M0. The staging of squamous cell carcinomas of the lip involves three descriptors: T, N, and M. The T descriptor is based on the diameter or surface area of the tumor. The N descriptor describes nodal status. The M descriptor indicates distance of metastasis beyond the neck. This staging criteria allows physicians to predict patient outcomes and choose appropriate therapy based on comparisons with patients in large studies.

A TNM classification table is shown on page below.

Status of Tumor (T)
TX - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor 2 cm or less in greatest dimension
T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 - Tumor more than 4 cm in greatest dimension
T4 (lip) - Tumor invades adjacent structures (eg, through cortical bone, inferior alveolar nerve, floor of mouth, skin of face)
T4 (oral cavity) - Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue, maxillary sinus, skin. Superficial erosion alone of bone/tooth socket by gingival primary tumor is not sufficient to classify as T4).

Stages of Lymph Nodes (N)
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimensions; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a - Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension

Status of Metastasis (M)
MX - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis

In order to determine the correct clinical staging of this type of tumor, the surgeon must first examine the primary lesion and the lymph nodes in the neck. A CT scan should be obtained to rule out potential invasion of adjacent structures; histologic evaluation of a biopsy specimen of the lesion will best establish and/or confirm the diagnosis. Further evaluation to determine the extent of metastases will include a radiograph of the chest, complete blood cell count, and blood chemistry studies. If the patient's symptoms are applicable to specific organ systems, other diagnostic tests may be required.

References
1. Beahrs OH, Henson DE, Hutter RV, et al, eds. Manual for Staging of Cancer - American Joint Committee on Cancer. 3rd ed. Philadelphia, Pa: JB Lippincott; 1988:27-32.
2. Jackson T. Intraoral tumors and cervical lymphadenectomy. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:439-452.

A 62-year-old man is being evaluated for mandibular reconstruction after undergoing segmental mandibulectomy and resection of the anterior floor of the mouth for management of squamous cell carcinoma. On examination, the mandibular defect extends from the ipsilateral canine to the contralateral bicuspid; the tongue and remaining dentition have been preserved.

Which of the following is the most appropriate method for reconstruction of this patient's defect?

(A) Fibula osteocutaneous free flap
(B) Pectoralis major/rib osteomyocutaneous transposition flap
(C) Pectoralis major myocutaneous flap and reconstruction plate
(D) Radial forearm osteocutaneous free flap and iliac crest bone graft
(E) Radial forearm fasciocutaneous free flap and reconstruction plate

The correct response is Option A.

Reconstruction of the anterior mandible is best accomplished with the fibula osteocutaneous free flap. This flap provides excellent bone quality and a segmental blood supply, which allows for multiple osteotomies. This is crucial because successful reconstruction of the anterior mandible will require a minimum of two osteotomies in order to restore the contour of the mandibular arch.

Pectoralis major flaps with attached rib have been shown to be inadequate for mandibular reconstruction because of the poor quality of bone and difficulties with orientation. In addition, reconstruction plates are especially susceptible to fracture and exposure when used in the anterior mandible. Although the radial forearm flap provides excellent soft tissue for replacement of intraoral lining, only a limited amount of bone can be harvested, and osteotomies are poorly tolerated. Bone grafts are useful for reconstruction of defects less than 3 cm in patients who will not be undergoing radiation therapy.

References
1. Cordeiro PG, Disa JJ, Hidalgo DA, et al. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients. Plast Reconstr Surg. 1999;104:1314.
2. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol. 2000;19:226.

Which of the following is the most common site of squamous cell carcinoma affecting the paranasal regions?

(A) Anterior ethmoidal sinus
(B) Frontal sinus
(C) Maxillary sinus
(D) Posterior ethmoidal sinus
(E) Sphenoid sinus
The correct response is Option C.

Although squamous cell carcinoma rarely affects the paranasal regions, 80% of tumors that do appear in this region arise within the maxillary sinus. The ethmoid, frontal, and sphenoid sinuses are affected less frequently.

Approximately 3% of malignancies involving the upper aerodigestive tract are found within the nasal and paranasal regions. Furthermore, approximately 70% of malignant tumors seen in this region are squamous cell carcinomas; this frequency is thought to be related to exposure to nickel and other chemicals.

The nasal floor is typically not associated with the development of malignancy but can be affected as a result of direct tumor extension, as many tumors are asymptomatic and thus remain undiagnosed while enlarging and advancing locally.

References
1. Casson PR, Bonanno P, Fischer J. Tumors of the maxilla. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;5:3317-3335.
2. Jackson IT, Shaw K. Tumors of the craniofacial skeleton, including the jaws. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;5:3336-3411.

A 45-year-old man with a 50 pack/year history of smoking has a 4.5-cm lesion in the midline of the lower lip. Histologic examination of a biopsy specimen of the lesion shows findings consistent with squamous cell carcinoma. Intraoperative examination shows extension of the tumor to the mandible without erosion or invasion of the mandible. There are no palpable lymph nodes or evidence of sensory or motor nerve involvement.

Which of the following is the most appropriate management?

(A) Surgical excision alone
(B) Surgical excision with neck dissection
(C) Surgical excision with neck dissection and marginal mandibulectomy
(D) Surgical excision with neck dissection and segmental mandibulectomy
(E) Surgical excision with neck dissection and adjuvant chemotherapy and radiation therapy

The correct response is Option C.

This patient who has a squamous cell carcinoma of the lip should undergo surgical excision of the lesion with bilateral supraomohyoid neck dissection and marginal mandibulectomy. A 4.5-cm tumor of the lower lip with extension into the mandible but without palpable nodes in the neck is classified as T3 N0 M0. One study of patients with squamous cell carcinoma reported neck metastases in 63% of patients with T3 lesions; therefore, selective neck dissection is warranted. Marginal mandibulectomy is also appropriate in this patient who has tumor extension, but not invasion, into the mandible.

Segmental mandibulectomy is not required because the tumor has not invaded the mandible. Adjuvant chemotherapy is not recommended for patients with squamous cell carcinoma of the lip. Radiation therapy alone may be an option in patients with N0 tumors who are at increased risk for metastases or in patients who are poor surgical candidates, but radiation therapy is not used in combination with chemotherapy.

References
1. Boyd J, Coleman J, Houck J. Lip cancer. In: Medina JE, et al. Clinical Practice Guidelines for the Diagnosis and Management of Cancer of the Head and Neck. American Society for Head and Neck Surgeons; 1996:17-25.
2. Netscher DT, Anous M, Spira M. Premalignant skin tumors, basal cell carcinoma, and squamous cell carcinoma. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;1:309-325.

A 70-year-old woman has a firm, pink 1.2-cm nodule located anterior to the tragus. Histologic examination of an incisional biopsy specimen of the lesion shows Merkel cell carcinoma. Which of the following is the most appropriate management?

(A) Excision with 1-cm margins and ipsilateral neck dissection
(B) Excision with 1-cm margins, superficial parotidectomy, and ipsilateral neck dissection
(C) Excision with 3-cm margins
(D) Excision with 3-cm margins and ipsilateral neck dissection
(E) Excision with 3-cm margins, superficial parotidectomy, and ipsilateral neck dissection

The correct response is Option E.

The most appropriate management of this patient's Merkel cell carcinoma is excision with 3-cm margins followed by superficial parotidectomy and ipsilateral neck dissection. Merkel cell carcinoma is a rare cutaneous malignancy believed to arise from neuroendocrine cells within the skin. It typically occurs on the head, neck, and other sun-exposed areas in patients 50 to 70 years of age. Lymphatic and distant metastasis are common, and prognosis is poor; mortality rates as high as 67% have been reported. Excision of the tumor with margins of 2 to 5 cm is generally recommended; prophylactic neck dissection is advocated because approximately 50% of affected patients have positive regional nodes at the time of initial diagnosis. Because the parotid gland is a primary drainage basin for preauricular lesions, superficial parotidectomy should also be performed. Although radiation therapy can be performed adjuvantly, it is inadequate when used with excision alone.

References
1. Jackson GL, Ballantyne AJ. Role of parotidectomy for skin cancer of the head and neck. Am J Surg. 1981;142:464-469.
2. Roth JJ, Granick MS. Squamous cell and adnexal carcinomas of the skin. Clin Plast Surg. 1997;24:687-703.
3. Shack RB, Barton RM, DeLozier J, et al. Is aggressive surgical management justified in the treatment of Merkel cell carcinoma? Plast Reconstr Surg. 1994;94:970-975.