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ABSITE Review: Head and Neck (Podcast)
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ABSITE Review: Head and Neck (Podcast)
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>> Okay, and welcome back to another Behind the Knife. We got a special series of episodes coming up for you. It's our ABSITE series, and we're pretty excited about this. We have spent a lot of time preparing for this, and we have some great content that we're going to bring to you this month, but before we get to that, we have to welcome back one of the primary members of Behind the Knife. Jason Bingham just spent four and a half months in the Middle East and was very busy, and we're lucky to have him back safely, and he has some good stories that he's going to tell us and lessons learned in future podcasts.
Welcome back, Jason, and thanks for all your work you did on this ABSITE review while deployed. >> Thanks, Kevin. It's, of course, very, very, very good to be home, and it's good to be back, and I'm very excited to be back on the podcast, and no better way to start than with a little ABSITE review. >> So Jason, why Behind the Knife board review? >> So we really spent a lot of -- I spent a lot of time -- we all spent a lot of time putting together this ABSITE review and, you know, if I were listening to an ABSITE review, I'd want to know that the people who were teaching me know what they're talking about, so I think the first reason to listen to the Behind the Knife ABSITE review is that -- it should be no secret at this point, but we're all dominators.
We've all scored regularly in the 98th and 99th percentile on the ABSITE every year. I recently took the general surgery qualifying exam, and despite, as you said, I was preparing for deployment, I was told I'd get one day off on my pre-deployment training to go take my boards, and I went and take my boards, and I got in the 95th percentile on the boards. I have no reason. >> You could have done better. >> Yeah, I know. It was a stressful time for me.
You know, we're not -- and I don't say this -- I don't want everybody out there to think we're bragging, which we may be bragging a little bit, but that's not the point of this. I have no reason to brag to a bunch of, you know, faceless strangers, but I just think it's important to know. If I was to devote a lot of time listening to an ABSITE review, I want to know that the people that are teaching it know what they're talking about. So we know how to study. We know how to take this test.
I've taken this test, you know, six, seven times now, if you count the actual boards, and we're just going share with our listeners the notes that we've taken, the lessons we've learned taking this test throughout the years. So this review is very approachable. It's convenient. There's really no other audio review of the ABSITE out there of this caliber. You know, our discussion format is going to be fun and easy to listen to. You can listen to it while you run, while you drive, while you're walking your dog, when you just can't take, you know, reading that ABSITE review book one more time anymore, and it's good to learn in different formats.
So you need to read, do questions, listen to, you know, this review, and it -- we really strove to kind of round out what's already out there when it comes to ABSITE review. So just to get into it a little bit, let's talk about first what this podcast or this ABSITE review isn't. It's not surgical trivia. There's a lot of surgical just -- ABSITE study guides out there that are very heavy in basic science minutia, so we're not going to spend a lot of time on that. We're not going to go through the components of the -- every component of the coagulation cascade.
We're going to focus on key components of clinical management of surgical disease based on the current guidelines. We spent a lot of time going through all the different clinical guidelines out there -- SAGES, ASCRS, the EAST trauma guidelines. You name, we've been through the guidelines looking for the best clinical recommendations from the guidelines, because those are -- we know that those are safe board answers. If you're going off of the clinical practice guidelines, those are safe board answers. >> And one thing I'd say about that is that throughout my time -- I'm in my sixth year of residency now -- the board exam has really moved towards clinical basis and much further away from basic science, so that also makes this very pertinent.
>> Absolutely. Like I said, I just took the ABS qualifying exam. There was very little basic science on there. It was all clinical, and so that's definitely the way things are going. So that's what we decided to focus on. Our focus is clinical, not basic science. Other review books out there will tell you that, you know, the APC gene is on chromosome five, but will they tell you the current clinical management guidelines for managing the axilla with a node-positive breast cancer?
No, but we'll discuss that in this review. >> And like we said, there are lots of minutia in topics of managing, say, breast cancer or carotid stenting versus carotid endarterectomy, and we understand that there's lots of controversies and discussion ongoing, but our focus in is going to be what is the right answer on your board exams. >> Yeah, the safe answer based off current clinical practice guidelines. So that being said, you know, this -- we designed this so that you can listen to it multiple times, and it's not just for ABSITE season.
It will help you on the ABSITE, but it'll also help you on the qualifying exam. It'll help in daily practice. It'll help you on rounds. It'll help you, you know, just study to, you know, be a surgeon. Okay. So that being said, let's just get into a little bit of -- you know, how do you guys prepare for the boards? What's your -- you know, we're already into prime ABSITE studying season, and so what's you guys' tactics? You guys are both dominators.
>> So, first of all, we have to note that if you're starting to study now, you may be a little bit late to the game. This is a test that you don't study for even two, three, four weeks before the exam. It's something that you make a part of your regular routine, that you're always trying to get better, striving to make yourself excellent at your job and dominating each day, and so there's no real replacement for this, no real replacement for studying every day to do a good job as a surgeon. That said, there are things that you could do to supplement your teaching.
And so, first of all, we would recommend that having a review book that you go through every single day and memorizing this, taking notes in the margin, being very thorough about making your way through this review book is the first principle component of studying. Second, we'd then say that you have to have a question bank, and at a minimum, you should be going through a thousand questions. Take notes as you go through these questions, mark the ones that you're getting wrong, review it, and juxtapose against that review book you're taking notes on the margins of and make sure that you're going through again and again the things that you're getting wrong so that you can then capitalize on those and make those good teaching points for yourself.
>> And they're -- I know most residents out there have access to SCORE, and the SCORE question bank has been getting better every year. So that's a great resource to use, and there are other question banks out there, but yeah, unfortunately, practicing year-round is a good idea, but most of us start in November or December studying for the ABSITE, and we're going to do everything we can to help get you ready and give you the points that we remember from previous exams. >> Yeah, so all hope is not lost if you have not started studying yet. So in addition to that ABSITE review book and those question banks, of course, what fills in the gap there is the Behind the Knife audio board review, so listen actively.
Listen again and again. Try and anticipate the answers before we tell them to you, and enjoy. >> And before we dive into our ABSITE series, I just want to let you guys know Jason spent the majority of his deployment on his down time putting together these reviews, and we're currently putting together ten to 15 hours of brand-new audio content for you guys, and this is all for free, all in the free online medical education, and so the only thing we're asking from our listeners is if you guys can sign up for our mailing list.
Our mailing list -- we promise we will not solicit anything from you, and it'll just be updates about our most recent episodes and things like of that nature, and if you -- the way you can sign up for our mailing list is if you go to our show notes and click the link, it'll take you to MailChimp, and you just put your email address in, and that way you can know about our newest episodes. And I know I've been mentioning an app for a long time. We finally have an app, a web app, that is going to make our podcast searchable by topic, and with the search bar, you just type in whatever topic you want to hear about.
So you type ABSITE, it'll bring up all the ABSITE episodes. We will likely be releasing that this week, so look forward to that, and that'll also have a link to our mailing list on there. So we've been putting a lot of work into that. That's why it's been a little quiet recently, is we've been doing a lot of work behind the scenes. Okay. Thank you, guys, and I hope you enjoy this ABSITE episode. >> All right. We're going to jump right into it, getting started with the head and neck ABSITE review.
So first and foremost, let's go over to some of the high-yield anatomy that shows up pretty frequently on the test. So, Kevin, anterior -- this question is asked almost every year. So you have your subclavian vein, your subclavian artery, your, you know, phrenic nerve, your scalenes, and it always asks you to put these in order from either anterior to posterior or posterior to anterior. So, anterior to posterior, what order do these structures come in? >> Yes. I would recommend Googling this these structures, and just, you know, maybe get a mental picture of this, but you start with the subclavian vein.
I always remember that because that's when you're putting your central line in. That's the most anterior, and so you go right into the clavicle, you know, the subclavian vein. Behind the subclavian vein, you have the phrenic nerve, and then you run into your first muscle, the anterior scalene, and then after that, you have your subclavian artery, and then it is bordered by the -- bounded by the middle scalene after that. >> Yep. So, the vein first, then your nerve. Your nerve lies right on top of your anterior scalene. You have your subclavian artery and then your middle scalene behind that.
So Woo, talking more about anatomy in the head and neck. The neck is broken up into system some different triangles. What's that all about? >> Yeah, Jason. So there's the anterior triangle and the posterior triangle. So, starting with the anterior triangle, looking at the anterior boundary, you have the midline of the neck. That runs into the posterior boundary, which is the sternocleidomastoid, and the inferior or the apex is the sternal notch, and the superior or the base is the lower border of the body of the mandible.
This contains the carotid sheath. So again, the main reason or the key important point about the anterior neck triangle is that it is contains the carotid sheath. >> And this is important for surgical incision-making and accessing, and so the sternocleidomastoid for both the anterior and posterior part of the neck is really what the landmarks are based on. And so the anterior triangle is anterior to the sternocleidomastoid, and that's where you find your carotid sheath. >> So then for the posterior neck triangle, again, that sternocleidomastoid forms the anterior boundary.
The posterior boundary is formed by the trapezius muscle, the base is the middle third of the clavicle, and the apex is the intersection of the sternocleidomastoid and the trapezius. The key clinical point here is that it contains the spinal accessory nerve. >> Great. So another thing that's commonly, you know, tested for head/neck anatomy is that darn recurrent laryngeal nerve. So Kevin, you know, they ask a lot of questions about the recurrent laryngeal nerve. First off, what is it and what does it do? >> Yeah. So this is a -- it's a branch off the vagus, but it takes a different course than most nerves.
Doesn't come straight off the vagus like you would expect it to as it passes the vocal cords. It actually goes more caudad into the chest and then wraps around either the subclavian artery or the aortic arch and comes back up, innervates the larynx, and so the recurrent laryngeal enervates all the muscles of the larynx except for the cricothyroid muscle. >> So what then enervates the cricothyroid muscle? Because they'll ask you that, too. >> Yeah. That is the superior laryngeal nerve. >> Right. So superior laryngeal nerve enervates your cricothyroid muscle, and what happens if you bag that?
>> You have difficulties with tone and hitting high notes. >> So it depends on -- you said something about coming down into the chest and wrapping around either the aortic arch or the subclavian artery. It differs based on the left or right side, right? >> Right, yeah, based on the anatomy of the aortic arch. You have your brachiocephalic trunk and right subclavian. So on the right side, the vagus passes anterior to the subclavian artery, and then the recurrent laryngeal loops being the subclavian artery and travels up the tracheoesophageal groove, whereas on the left side, the vagus passes anterior to the aortic arch, between the left common carotid artery and subclavian artery, and the recurrent laryngeal loops behind the aortic arch and travels superiorly in the trachoesophogeal groove.
>> Okay. Well, that's about enough for head/neck anatomy. Let's move into some head and neck tumors, which -- I don't know. It was always very confusing for me as a general surgeon studying for these tests, because it's not something we really dealt with every day. So we tried to break it down. Just kind of, you know, the basics that you need to know for the ABSITE, for the boards. >> One thing as far as head and neck cancer goes is this is probably worth, I would estimate, about three questions out of the 250 questions, and I'd say the anatomy is another question or two, so this is pretty low-yield overall, but there's definitely questions on this every year.
>> Yeah. That's why -- it's that distinction, though, Kevin, as to why you got a 98th percentile and not a 99th percentile. >> Exactly. >> So let's start with squamous cell cancer of the head and neck, as it is the most common. So Woo, can you tell me just a little bit about squamous cell cancer of the neck. Who does it affect? What are some risk factors? >> Yeah. So a little bit of epidemiology here. Squamous cell cancer of the neck is the fifth most common cancer, with men affected more than women by a ratio of five to one.
So the risk factors are alcohol and tobacco, and these both have a synergistic effect. So using one in and of itself is a risk factor, but you use both together and that compounds your risk. Additionally, HPV has been shown to be a risk factor as well. So when we think of squamous cell cancer, you can break it up into local versus aggressive or distant. So local disease you could think of as stage one or two. Then you could think of stage three and four as either locally aggressive or having distant metastases.
>> Yeah. You know, I really tried to focus on -- you know, there are some cancers that you absolutely need to know the staging for. There's others where a general idea is good. So I tried to break it down here into kind of what you need to know. So for squamous cell cancer of the head and neck, it's very -- it's changing all the time. Each sub-site, whether it's the oral cavity, oral pharynx, nasopharynx, have their own staging system and treatment recommendations, but in general, if you think about head and neck squamous cell cancer, stage one and two as being local disease.
Again, no regional -- no positive nodes, no distal mets. Stage three and four, either locally aggressive or having distant mets. So Kevin, so just in general, when you think about breaking it down like that, what are some treatment options for squamous cell cancer of the head and neck? >> Yeah. So in general, surgery or radiation. Generally they have tumor boards where they discuss kind of the modality based on the patient's age and the extent of their cancer and based on the location and if it's resectable or not.
>> Yeah. So that's that for stage one and two, so either primary surgery or radiation, and again, there's going to be a tumor board. They're going to discuss where it is, you know, whether it's resectable, whether it's nonresectable, so, for example, wide local excision for intraoral lesion versus radiation for a vocal cord lesion. That would not be -- it would be very morbid to do a wide local excision on the vocal cords. So that's for stage one and two. What about for stage three or four?
>> So once you're getting into either locally aggressive or distant metastases, that's when you're thinking about multi-modality therapy. So for stage three and four, you really need generally both surgery followed by radiation and/or chemotherapy. >> Yep. So the more -- you know, more locally advanced or distant mets need multi-modalities. So that's going to be wide local excision with a modified radical neck dissection followed by either radiation or chemotherapy. So Woo, you know, a lot of times they'll give you an oral squamous cell cancer, and they'll tell you how -- the size of it, and they'll give you some options as far as surgery alone, surgery/radiation, radiation alone.
What's kind of a good general rule of thumb as far as size cut-off for oral squamous cell cancers? >> Yeah, absolutely, Jason. So for oral squamous cell cancer, look for a size cut-off of four centimeters, so greater than four centimeters, or look for or mention of other concerning features, like node involvement or bone invasion, and when you see these markers, then think you need resection with modified radical neck dissection followed by post-op radiation. >> Right. So four centimeters is a good general rule or, again, like you said, some of those worrisome things that would put you into a more locally advanced or, you know, a distant met type situation where you need to add the modified radical neck dissection in addition to the primary section, and then followed by post-op adjuvant therapy, most likely radiation.
Okay, so moving on to the next one, these would be your salivary gland tumors. So Kevin, you know, you have -- which of these are the more -- most malignant? Which of these are the most benign? >> Yep. I still stick to the strategy of the small salivary glands. If they have a tumor in them, it's more likely to be malignant. So if you have a submandibular gland with a tumor, more likely to be malignant versus a parotid, which is more likely to have benign tumors. >> So what's the most common tumor overall?
The malignant -- I'm sorry; the most common malignant tumor overall. >> Right. Important distinction, because benign tumors are more common overall, but the most common malignant tumor is the mucoepidermoid cancer. >> Yeah. Well, how about the most common benign tumor? >> Is it pleomorphic adenoma? >> Yep. >> Pleomorphic adenoma. So going back to malignant, so what -- for mucoepidermoid cancer of a salivary gland, what's your treatment?
>> So you want to clear the cancer, so whatever it takes. You resection -- total parotidectomy with facial nerve preservation if it is in the parotid, followed by modified radical neck dissection on that side, and then consideration of post-op chemo. I'm sorry -- post-op radiation. >> Yeah. So this is another one. I mean, like Kevin said before, this can be three or four questions, but this is generally the way they go. They'll give you a head and neck tumor, and they'll ask you what the treatment is.
You have to know whether or not you resect it. You have to know whether or not you add radiation. You have to know whether or not you do a modified radical neck dissection. So mucoepidermoid gets resection, modified radical neck dissection, and post-op XRT. >> And I think it's a pretty safe bet if it's a malignant tumor in a head and neck scenario, you're going to add the modified radical neck dissection onto it. >> Unless it's a small stage one or stage two oral, you know, squamous cell -- something like that, so not always, but I guess if you're shotgunning, that's a good approach.
How about adenoid cystic cancer? That's the number-two most cancer of a salivary gland next to mucoepidermoid. Tell me a little bit about that. >> Yeah. So these are a little more slow-growing, with a tendency for local invasion, particularly into nerves. So the treatment for this is again resection with, you know, all attempts to spare the facial nerve if it is the parotid, and this will also follow up with the modified radical and then consideration for radiation therapy. >> So what about if, you know, it's -- it would be -- you meet with your tumor board.
It's adenoid cystic cancer. It's invading some very important structures. It would be a highly morbid resection. Where's another option? >> Right. So if it, you know, is totally invading the facial nerve or something of that nature, you could just consider radiation, as it's pretty sensitive to radiation. >> Yep. So it's another one of those exceptions to the rule that, yeah, you resect it if you can, but this adenoid cystic -- and I've definitely seen this -- it can be very slow-growing but very responsive to XRT, so you can get away with the -- primary radiation therapy for these is an option.
Another very, you know, popular question is that somebody comes in with a lymph node, or a palpable lymph node in the neck. They biopsy it, and it's malignant, but you -- for the life of you, you just can't find a primary tumor anywhere. What's your approach to these patients? >> Yeah. So these can actually offer quite a diagnostic dilemma, but if you can work through them systematically, there is a good way to make sure you don't miss anything here. So first, you want to start with a thorough head and neck exam, and this includes a fiber optic exam of the nasopharynx and larynx.
Once you complete that, then you can move to F and eight of regional nodes or an excisional biopsy of any nodes that are available to you. Once you have that back, you can then move to a CT scan of the head, neck, and chest, and you can consider adding on a PET scan as well. After that, then you would take the patient to the operating room for a direct laryngoscopy, esophagoscopy, an ipsilateral tonsillectomy, plus biopsies directed by the previous work-up. So the thing to note here is that the most common site of the unknown primary is typically the tonsil followed by the second being the base of the tongue, and if no primary is identified, you'll still need to do an ipsilateral modified radical neck dissection and a bilateral XRT.
>> So this is -- a popular way of asking this is what the -- what's the next step question. So you'll have a patient that presents to you with a mass. You'll biopsy it. It'll come back as, you know, squamous cell cancer. They'll ask you what's the next step. So if you think about it in that stepwise approach, you know, you start with your thorough head and neck exam, you know, fiber optic exam. Then if you don't already have a biopsy of that, you're going to go for a biopsy for diagnostic confirmation, which may be an F and eight or excisional, and then this is usually the next step, is a CT scan to the head and neck plus or minus the PET exam, but it's important to know that if you still don't find anything, you're taking them to the OR regardless, and again, that ipsilateral tonsillectomy with directed biopsies is another very popular question, a very popular answer.
So, moving on, let's move on to head and neck melanoma. So what's -- with all melanoma, Kevin, what's a very important principle with diagnosis? >> Right, yeah. They could ask you how to biopsy this, and of course you never want to shave biopsy a melanoma. You need to get the T-stage, and that is determined by -- generally by a punch biopsy or excisional biopsy, one of the two, and so the head and neck melanoma, it's managed very similarly to truncal or extremity melanoma.
It's just that there's less room for wide local excisions and things of that nature on the head and face, so that does make it a little tricky, and also, identifying the lymph node basins for which to do the lymphadenectomy also makes head and neck melanoma a little more tricky. >> Yeah. So, like you said, you know, it's similar to other parts of the body. We're going to go over, you know, the specific staging and talk more in-depth about melanoma in a different podcast, but specific to head and neck, what are some principles as far as margins and some other surgical principles when approaching melanoma of the head and neck?
>> Right. So if possible, you want to keep your same margins as you would anywhere else, so one centimeter margin for lesions that are less than one millimeter in depth or two centimeters for any margins -- anything over one millimeter in depth. So the difference is, though, is that the margins can be adjusted if a budding critical structure such as the facial nerve, why they -- you should always preserve unless clinically involved, and then you always want to confirm negative margins prior to reconstruction, and then -- so this is a good scenario where Mohs surgery can be really helpful in obtaining negative margins on melanoma.
The other tricky part comes in with lymphadenectomy, you know. So if you have a melanoma on the side of a head or on the top of the scalp of which area you do the lymphadenectomy, and so what you can do is you can actually get a lymphoscintigraphy of these patients, where they put tracer dye around the melanoma, and then they can determine where the regional nodes are that -- then you can proceed with, you know, the modified radical neck on that side or wherever the nodal basin ends up being. >> What's the role -- what about the role of sentinel lymph nodes for melanoma in the neck?
>> If clinically node-negative, sentinel lymph nodes for greater than one millimeter in depth. >> Yeah. So again, that's similar as in other parts of the body. Now, Woo, I know there's something -- I remember there being something about melanoma of the head and neck, and sometimes you have to do something with the parotid glands. What's that all about? >> Yeah. So, generally, you want to imagine a line from one tragus to the other, and so if the primary lesion is anterior to this line, then it will drain anteriorly to the parotid basin.
So superficial parotidectomy and selective anterior neck dissection is indicated for anterior lesions -- again, anterior to this line -- and selective posterior neck dissection is indicated for lesions that are posterior to this line. >> Yep. So that's highly testable. So just know -- you know, know the role of superficial parotidectomy with melanoma of the head and neck. Okay. The role of adjuvant therapy for melanoma of the head and neck, Kevin? >> Unfortunately, there's not a great therapy for this, and that's why good primary surgery is the key component, but adjuvant interferon alpha has been shown some survival benefits, but it does have severe side effects, and many people aren't able to complete this therapy, and then sometimes salvage radiation therapy for regional control, but no survival benefit has been seen in these, and thankfully, there are some ongoing trials targeting monoclonal antibodies and oncogene inhibitors to help treat this.
>> Yeah, just one of those things where it's still -- you know, it's -- there are still a lot of clinical trials going on, so it'd be hard for them to ask a question. They may ask you something about, you know, metastatic disease or something, and interferon alpha would probably be the answer for that. They may, with somebody with, you know, grossly positive regional lymph nodes, ask you about radiation therapy to the nodal bed, and then there's some other experimental things monoclonal antibodies, oncogene inhibitors -- but it's unlikely that they'll, at that point, ask you anything about that.
Okay. So that covers our head and neck tumors. Now it's time for -- we'll do some quick hits. So this is, you know, real quick question and answer. Not a lot of extrapolation on these, but these are good, highly testable, quick points. So, Woo, a painless mass on the roof of the mouth -- what is it? >> So it's an overgrowth of cortical bone. It's called torus palatinus. >> Yeah. So this shows up pretty commonly. It looks scary.
It's a big, protuberant mass on the bony part of the roof of the mouth. What do you do for them? >> So, typically, nothing. If you find that the patient has -- is describing that this interferes with the dentures fitting, then you might consider resecting, but overall, you don't need to -- >> Yeah. >> -- do anything for it. >> The answer on the boards is going to be leave it alone; don't do anything.
Okay, Kevin, what's the most common site for an oral cavity cancer? >> The lower lip. >> Why is that? >> Sun exposure. >> Okay, and what do you -- what's kind of the general rule? If it involves this much of the lip, you need reconstruction. >> Right. So if it's over half of the lip is resected, you should consider flaps for reconstruction. >> Okay. Some -- great.
Some associations, Woo. So, Epstein-Barr virus -- how does that relate to head and neck tumors? >> So, you want to think nasopharyngeal squamous cell cancer. >> Exactly. Epstein-Barr virus, nasopharyngeal squamous cell cancer, and it's a squamous cell, but how do you treat that? >> With radiation. >> Right, primary radiation. They're very sensitive to external beam radiation.
Kevin, we covered this a minute ago, but repetition is the key to adult learning, so what's the most common malignant salivary gland tumor? >> Mucoepidermoid carcinoma. >> Okay, and the most common benign salivary gland tumor? >> Pleomorphic adenoma. >> What's the treatment for pleomorphic adenoma? >> A superficial parotidectomy. >> Yep, superficial parotidectomy. >> Don't choose enucleate.
>> Yeah, do not enucleate these. You do the full -- I mean, superficial -- the parotidectomy is a pretty low-risk, low-morbidity procedure. So you do not enucleate these, and always be sure -- whenever they ask you the most common something, be sure you check for that benign versus malignant, because it's different. Woo, what's gustatory sweating? >> That's called Frey syndrome. >> Okay, and when does this occur?
>> So, it occurs if you have an injury to the auriculotemporal nerve and that then cross-innervates with sympathetic fibers. >> Yeah, and so this is a -- this is -- can be seen after a parotidectomy, and those, you know, nerve fibers are regrowing. So, Kevin, so, clinical scenario. So there's an elderly patient who has a post-op fever, pain, and a large swelling at the angle of the jaw. What is it? >> Yeah, I've actually seen this once.
Suppurative parotiditis. >> Okay, and what's the most common organism of this? >> Staph aureus. >> Okay. How do you treat it? >> So, generally, these patients will get better. Just hydration and antibiotics. If there's a large, obvious abscess, you can drain that, also. >> Yeah. So, they'll give you this. You know, again, an elderly patient who's post-op, you know, from whatever.
A lack [inaudible], and they're on the floor, post-op from a colon resection, and they all the sudden get very sick, high fevers, and they'll give you probably, you know, benign. Otherwise, clinical exam at the surgical site, and you'll have a big swelling at the angle of the jaw. Something you got to think about is suppurative parotitis. Staph infection, the most common. Again, antibiotics, first-line treatment, but if there's an obvious abscess, they may need an incision and drainage, as with any abscess.
Oh, another favorite, so another head and neck favorite. So, patient's post-op, Woo, from a tracheostomy, and you get some bleeding at the tracheostomy site. >> So, this is an alarm finding, and you should be thinking tracheoinnominate fistula. In the board scenarios, you might want to distinguish whether they are describing a small amount, such as a herald bleed, or a large amount. The reason that's important is because if it's just a small amount, you might consider a role for bronchoscopy to rule out a tracheoinnominate fistula, but more than likely, it's going to be a massive hemoptysis, and in this case, the next step will be to place your finger into the tracheostomy, hold manual pressure against the sternum, and take the patient to the operating room emergently.
The patient will then need a median sternotomy and resection of the innominate artery, and when you close, you're going to close the tracheal side primarily and cover it with strap muscle. >> Most importantly, do not place a synthetic interposition graft. They will try and get you to choose this. This will get infected and blow out, and if you want to hear more about this, Doctor Do does a fantastic oral board scenario of this in our thoracic oral board. >> Yeah, they will. That's absolutely right.
They will try and trick you. They will put that in, you know. You think it's a major artery, you got to reconstruct it, but you don't. So don't put any synthetic material on there. It'll absolutely get infected, and it will blow out. So, yep, like Woo said, put your finger there. You can also over-inflate the cuff of the tracheostomy as a good initial move. That might be an option on there, but ultimately, OR, median sternotomy, and resect that innominate artery.
You know, close it, the hole in the trachea, place some healthy tissue over that, and get out. >> It's just that easy. >> [Laughter] All right. Well, that does it for our first review. That was head and neck. It's not everybody's -- it's not every general surgeon's favorite topic, but it is certainly necessarily and highly testable. So, we'll see you next time on the Behind the Knife ABSITE review.