Head and Neck Oncology and Reconstructive Surgery
Core concepts
Master nodal levels I-VI, the relationship of the facial nerve to the parotid, and the principles of neck dissection (radical, modified, selective). Understand margin assessment, sentinel node biopsy indications, and reconstructive ladder from local flaps to free tissue transfer (radial forearm, fibula, anterolateral thigh).
Traps in questions
- Confusing selective neck dissection levels with the radical neck dissection's removal of the spinal accessory nerve, sternocleidomastoid, and internal jugular vein.
- Forgetting that the marginal mandibular branch of the facial nerve runs near the mandibular angle and is at risk in level I dissection.
- Assuming all oral cavity cancers need postoperative radiation; indications hinge on margins, nodal disease, and perineural invasion.
- Missing the need for free flap monitoring and the signs of venous versus arterial compromise.
Rule of thumb
In free flap monitoring, a congested, dark flap suggests venous thrombosis; a pale, cool flap suggests arterial insufficiency.
Worked example
A patient has a floor-of-mouth squamous cell carcinoma with a clinically negative neck. The question asks about management. The rule: elective selective neck dissection (levels I-III) is appropriate for tumors with depth of invasion above the threshold, because occult nodal disease is common. Choosing observation alone in a deep tumor is the classic trap.