SURGERY OTHERNECKSURGERIESOTHER NECK SURGERIES

CST CFA Mary Sutton, , Severalof surgical the procedures Head are per- usually and smooth, nontender Neck masses locat- formed for specific benign process- ed between the preauricular area and the es in the neck, including branchial cleft supraclavicular area of the neck. How- and thyroglossal duct cysts, and Zenk- ever, these cysts may form a sinus tract er’s diverticulum. This article will also extending to the skin. review three surgeries of various sali- The maj ority of branchial cleft cysts vary glands and conclude with an over- arise from the second branchial arch. view of tracheotomy. Indications for surgery to remove a branchial cleft cyst include: recurrent BRANCHIAL CLEFT CYST infections, increase in size, and for cos- Between the fourth and sixth week of metic reasons. In removing the branchi- gestation, five paired swellings occur al cleft cyst, it is important to remove in the head of the embryo. These swell- the cyst, any sinus tract, and any tis- ings, or branchial arches, have a corre- sue surrounding the cyst that may have sponding internal pouch and are sepa- been involved in attempts to the Editor’s Note: This is rated by four grooves or clefts external- infected cyst. the fourth and final ly. Inside each branchial arch are devel- Instruments for a branchial cleft cyst insta ll ment i n th is oped specific anatomic features, such as excision are contained in the standard seri es. P l ease refer to cranial nerves, arteries, and cartilage. neck set. Any special instrumentation past i ssues f or an over- During natural development, the pouch- needed depends on the location of the view of norma l anat- omy for thi s reg i on. es should close and the grooves dissolve. cyst. Supplies are similar for any neck Anatomi ca l var i at i ons When these pouches and grooves do not dissection and include a bipolar specific to a procedure follow their natural course, an anoma- and cord. The surgeon will likely use a will be d i scussed with ly occurs. Branchial cleft remnants are headlight. its descri pt i on.

SEPTEMBER 2005 The Surgical Technologist 9 261 SEPTEMBER 2005 2 CE CREDITS

The patient can choose between general anesthe- sue descends anteriorly to the pharynx. The tis- sia or local injection with monitored anesthesia sue has two lobes with a stalk-like attachment to care depending on the size and location of the the base of tongue. The hyoid bone divides the cyst. Most patients undergo the procedure with tract into upper and lower segments. When the general anesthesia. The patient is placed on the thyroid settles into its final position, the tract operating table in the supine position with the should be resorbed. When it is not resorbed, a neck extended and the head turned away from thyroglossal duct cyst may form. the affected side. A patient with a thyroglossal duct cyst pres- The surgeon will make a horizontal inci- ents with a midline mass, which moves upon sion in the nearest skin crease of the neck. If a swallowing or with movement of the tongue. sinus tract is present, it is incorporated through Dysphagia and/or a choking sensation, and rare- an elliptical incision. The sinus tract is part of ly upper respiratory obstruction may also occur. the specimen. Skin and tissue flaps are dissect- Indications for thyroglossal duct cyst excision ed around the cyst to protect any major struc- are an undiagnosed midline mass, history of tures that may lie in the area. The cyst is identi- infection in the mass, the possibility of malig- fied and dissected from the surrounding tissue. nant degeneration into cancer, and cosmetic Care is taken not to rupture the cyst, as the con- appearance, as the mass may increase in size. Ttents could contaminate the wound. The cyst is A standard neck set is required for a thyro- carefully dissected from the carotid sheath and glossal duct cyst excision. A bone cutter should hypoglossal nerve. also be available, as most surgeons remove part Once the cyst is dissected fully, the tract is of the hyoid bone. Supplies are the same as for a followed superiorly, usually between the internal branchial cleft cyst. As with any similar proce- and external carotid arteries, to rule out a sec- dure, a headlight is needed. ond branchial cleft cyst. The tract then runs past Excision of a thyroglossal duct cyst is called the posterior digastric belly to the pharynx. If the Sistrunk procedure. Walter Sistrunk first no internal connection to the pharynx is estab- performed the surgery in 1920. He had excellent lished, the tract can be ligated and removed with results with a recurrence rate of about 1.5% to 4%. the cyst. If it is connected to the pharynx, the The Sistrunk procedure includes the excision of whole tract must be removed. The wound is irri- the mass with the midportion of the hyoid bone gated and a drain is placed. The wound is closed and the block of muscle that theoretically con- and dressed appropriately. tains the thyroglossal duct remnant. The drain is removed 24 to 48 hours post- The patient undergoes general anesthesia and operatively. If there is spillage in the wound or is placed in the supine position on the operating communication with the pharynx, the patient table with the neck extended. The incision is made is given prophylactic antibiotics for 48 hours. in a skin crease in the upper midline of the neck. If Complications are rare, but include hematoma, the skin is adhered to the cyst as a result of recur- seroma, and infection. rent infection, that skin is excised with the mass via an elliptical incision. A superior flap is dissect- Thyroglossal duct cyst ed to the hyoid bone. The strap muscles are iden- Thyroglossal duct cyst is an upper-midline cer- tified and retracted. The cyst is dissected free on vical mass, with a common presentation next to all sides. The hyoid bone is grasped, usually with a the hyoid bone and the thyrohyoid membrane. It Lahey or a Kocher, and the muscle and soft is the most common mass in the midline of the tissue are dissected from the body of the hyoid neck. bone. The body of the hyoid bone is transected The surgeon’s k nowledge of embr yolog- with bone cutters or a curved . ical and developmental anatomy of the thy- A large cur ved is placed in the roid is important. Embryologically, thyroid tis- mouth to push the base of the tongue into the

10 The Surgical Technologist SEPTEMBER 2005 Stensen’s duct

Buccinator muscle Parotid gland Mandible Masseter muscle Sublingual gland

Wharton’s duct

Submandibular gland

neck wound. The stalk of the cyst is followed mittent cervical dysphagia that becomes pro- FIGURE 1 upward and cut out of the muscle of the tongue gressively worse. The patient may hear a gurgling base. The wound is irrigated, a drain is placed, sound when swallowing and have excessive sali- Major salivary and the wound is closed. An appropriate dress- va, which can lead to aspiration. Halitosis, or bad ing is placed, if necessary. Complications of thy- breath, is a frequent symptom. glands and roglossal duct cyst excision are hematoma, sero- In patients with a Zenker’s diverticulum, ma, and wound infection. food gets caught in the diverticulum instead of surrounding going down to the stomach. The food caught in Zenker’s diverticulectomy the diverticulum can be expelled into the air- anatomy. Zenker’s diverticulum is a pharyngoesophageal way causing aspiration. Patients with advanced pouch that is formed by forces within the mus- cases of Zenker’s diverticulum may have recur- cles of the esophagus acting against an area of low rent pulmonary infections due to aspiration and resistance. The diverticulum was first described weight loss. Patients rarely feel a mass, as the by Frederick Albert Von Zenker in 1877. Patients diverticulum is located deep within the neck. with Zenker’s diverticulum present with inter- Indirect laryngoscopy in the doctor’s office often

SEPTEMBER 2005 The Surgical Technologist 11 shows pooling of secretions in the hypopharynx. ach for postoperative feeding until healing is A barium esophagram is used to determine the complete. This reduces the risk of pharyngocu- size and exact location of the diverticulum. taneous fistula. The cut muscle is not closed to Instrumentation for the excision of a Zenk- prevent stricture. A drain may be placed in the er’s diverticulum is a standard neck set and wound before the wound is closed. A pressure an esophagoscopy set, which includes a light dressing may be applied. source. There will be two fields, one clean and Complications of Zenker’s diverticulecto- one sterile. Supplies are the same for a branchi- my are recurrent laryngeal nerve injury, hypo- al cleft cyst, but should also include something pharyngeal stricture, or pharyngocutaneous fis- to pack the diverticulum: either plain gauze or tula. These complications are rare but must be Vaseline® gauze (surgeon’s preference). Some explained to the patient. surgeons may use a linear stapler (30 or 55 mm) to remove the diverticulum and close the esoph- Submandibular gland excision agus in one step. The surgeon will likely wear a The submandibular gland is one of three paired headlight. Separate sets are needed for salivary glands that drain into the oral cavity each field. (Figure 1). The gland lies under the mandible in The patient undergoes general anesthesia and what is called the submandibular triangle. The is placed in the supine position on the operat- marginal mandibular nerve passes right above ing table with the neck extended. A rigid esopha- the gland and care must be taken not to injure goscopy is performed before the prep, so that the the nerve when excising the gland. The subman- surgeon can visualize the diverticulum, clean dibular gland is removed for recurring infection it out, and pack it if necessary. The packing will due to presence of a stone in the duct or the pos- help to identify the diverticulum in the neck. sibility of a mass in the gland. The patient is prepped and draped. A trans- Instrumentation for a submandibular gland verse incision is made two finger breadths above excision is the standard neck set. Supplies are the the clavicle. The upper f lap is dissected to the same as a neck dissection but fewer are needed. thyroid cartilage of the larynx. The sternocleido- Make sure that a bipolar electrosurgical unit is mastoid muscle is retracted laterally. The carot- available, and a bipolar cord and forceps are on id sheath is identified and retracted laterally. The the field. Peanut dissectors are often used to dis- larynx is retracted medially. The dissection is sect the submandibular gland. The surgeon will carried out to the prevertebral fascia of the spi- use a headlight. nal cord. The patient is placed in the supine position on The Zenker’s diverticulum is identified the operating table with the neck extended, and through the cricopharyngeus muscle. The mus- the head turned away from the affected side. The cle is cut, and strips of the muscles are excised to incision is made in a skin crease below the level prevent stricture formation postoperatively. The of the submandibular gland. The skin flap is dis- diverticulum is exposed and grasped with Bab- sected upward to identify the gland. The gland is cock clamps. The linear stapler is placed along grasped by an , and downward trac- the esophagus and fired. The diverticulum is tion is applied. excised from the closed esophagus. If the stapler The vessels supplying the gland are divid- is not used, the diverticulum is removed from ed, and the gland is pulled upward to expose the the esophagus and the defect is closed, usually duct. Care is taken to identify the lingual and with an absorbable suture. hypoglossal nerves before dividing the duct. A nasogastric tube is placed into the esoph- The duct is divided, ligated, and the gland is agus and saline is injected to ensure that the removed. The wound is irrigated and hemosta- mucosa of the esophagus is properly closed. The sis is achieved. A nerve stimulator may be used nasogastric tube is then advanced into the stom- to check the marginal mandibular, lingual, and

12 The Surgical Technologist SEPTEMBER 2005 hypoglossal nerves for damage . A drain may be placed, and the wound closed. Postoperatively, the head of the patient’s bed is elevated for about 24 to 48 h ours. If present, the drain is removed on the sec ond or third post- operative day. Complications i nclude: injury to marginal mandibular nerve, w hich would cause the lower lip to droop; injuries to the lingual and hypoglossal nerves, which would disturb func- tion of the tongue; hematoma; and infection.

Parotid gland The parotid gland is the largest salivary gland, which lies directly in front of each ear. The gland functions to produce sa liva, which aids digestion of food and is a me chanical cleans- er of the mouth. In some ani mals, the parot- id gland serves as a defense me chanism by pro- ducing and storing venom, wh ichisusedtodis- able prey. Tumors of the parotid gla nds account for less than 5% of all head and ne ck cancers. Treat- ment of these cancers has b een controver- sial with many differing opin ions on the sub- ject. Currently, superficial p arotidectomy is the treatment of choice for be nign lesions, and total parotidectomy is preferred for malignant and deep lobe. The plane between the lobes is the lesions. The pathology of the malignancy deter- facial nerve and its branches. mines whether or not a neck dissection is per- The facial nerve exits the skull base at the formed with the parotidectomy. The most com- stylomastoid foramen and proceeds up to the mon parotid tumor is a pleomorphic adenoma, parotid gland where it branches. There are five which is a benign, mixed-cell tumor. Most often, branches of the facial nerve: the temporal, zygo- the patients with a parotid lesion present with a matic, buccal, marginal mandibular, and cervi- painless, slow-growing mass in their cheek or in cal. The place where the nerve starts to branch is front of their mandible. Patients are most com- called the pes anserinus or goose’s foot. monly in their forties or fifties. Knowledge of how the nerve branches and where it exits the skull base is very important Parotid anatomy to a successful parotidectomy. The pes anseri- The parotid glands are situated in front of and nus is often identified first and then the branch- slightly below the ears. The lateral surface of es are followed to complete the dissection. Some- the gland is covered with skin, and the medial times a branch of the nerve may be involved in or deep portion is bordered by the styloid pro- the tumor and has to be sacrificed. If the whole cess and the muscles, which attach to it and to nerve has to be sacrificed, it is only necessary to the carotid sheath. The superior border of the reinnervate the zygomatic and marginal man- gland is the zygomatic arch, and the inferior dibular branches for cosmetic reasons. The zygo- border is the sternocleidomastoid muscle. The matic branch is responsible for closing the upper parotid gland is described as having a superficial eyelid and, if injured, may require the placement

SEPTEMBER 2005 The Surgical Technologist 13 of a gold weight in the eyelid to facilitate clos- sion begins in front of the tragus of the ear and ing until it is healed. The marginal mandibular is continued inferiorly to the ear lobule, where it nerve turns the corner of the mouth up and out. gently curves back over the mastoid tip. The inci- If injured, the mouth would droop. Most sur- sion then follows the anterior border of the ster- geons verify that the facial nerve is intact postop- nocleidomastoid muscle to a point two finger- eratively by having the patient blink and smile. breadths below the mandible. The parotid duct, also called Stensen’s duct, The skin flap is elevated superiorly from the appears to originate from the superficial lobe but zygomatic arch to the midportion of the digas- also has been described as arising from a pattern tric muscle inferiorly. Care is taken to leave the of extra glandular ductules from both lobes. The parotid capsule intact. The skin f lap may be duct goes over the surface of the masseter mus- sutured out of the way with silk sutures. The sur- cle and crosses the mandible at a point approx- geon carefully dissects the gland from the exter- imately one finger breadth below the zygomatic nal auditory canal, taking care not to puncture arch. From there, the duct abruptly turns medi- the canal. ally to pierce the buccinator muscle and the buc- The surgeon tries to find the cartilaginous cal fat pad to enter the oral cavity at the level of tragal pointer, which is said to point to the facial the second maxillary molar. nerve. The surgeon identifies the facial nerve and follows it to its branches. Parotid tissue is dis- Superficial parotidectomy sected carefully from each nerve branch until A basic neck set is often used for superficial the gland is removed. The surgeon may use a parotidectomy. Make sure that fine tonsil clamps nerve stimulator/locator to ensure the nerve is in and fine mosquitoes are available. If not on the working order, as well as for identification. set, small needle holders may also be needed. Once the gland is removed, the skin f lap is Make sure that the tips come together correctly. closed carefully. Depending on the size of the Supplies needed for a superficial parotidectomy tumor, some skin may have to be removed for include X-ray detectable 4˝ x 4˝ sponges, suction proper closure. A 7 mm Jackson-Pratt may be apparatus, unipolar and bipolar electrosurgical used to drain the wound. The skin can be closed units. A nerve stimulator/locator is used to help with a 5-0 or 6-0 fast absorbing gut suture, which identify the facial nerve. A 7 mm Jackson-Pratt does not have to be removed. Most often, the drain set should be available. Most often, 3-0 silk only dressing is antibiotic ointment. ties and stick ties are utilized, as well as a small Several complications may arise in superfi- suture (eg 5-0 or 6-0 fast-absorbing gut). Nylon cial parotidectomy patients. They include facial may also be used. A 2-0 silk on a cutting needle nerve paralysis or weakness, salivary fistula, may be required to secure the drain, if placed. and Frey’s syndrome. Frey’s syndrome is also The patient is placed on the operating table in known as gustatory sweating and has to deal the supine position with some semi-Fowlers and with the thickness of the skin flap. If the skin flap undergoes general anesthesia. The table is turned is too thin, the nerves for the sebaceous glands so the affected side is away from the anesthesia may intermingle with the nerves of the salivary provider and equipment. The patient is prepped, gland, producing sweat while eating. The way to taking care to avoid prep solution entering the prevent this is through an adequate skin flap. ear canal. Often, a cotton ball is placed in the ear canal for prevention. The cotton ball is removed Tracheotomy when the prep is finished; a sterile cotton ball may Tracheotomy is most often performed to main- be placed to prevent any blood or irrigation fluid tain airway patency. Indications for tracheoto- from entering the canal. The patient is draped. my are relief of upper airway obstruction, pro- The most common incision for parotidecto- viding means for mechanical ventilation, and my is called the modified Blair incision. The inci- to enable more efficient tracheobronchial com-

14 The Surgical Technologist SEPTEMBER 2005 munication. Tracheotomy was first described around the patient’s neck after the procedure. A many centuries ago. It is rumored that Alexan- Velcro® strap designed for this purpose may be der the Great performed a tracheotomy in the substituted. fourth century BCE. The first successful modern An incision is made approximately 1 cm tracheotomy was performed in 1546 by Antonio above the sternal notch. The surgeon dissects Brasavola, a French physician. In 1909, Chevalier through the soft tissue, until the strap muscles Jackson modified and improved the safety of the are identified. The strap muscles are separated procedure, as well as devised the style of trache- at the midline and retracted bilaterally. The next otomy tube that remains in use today (see Histo- set of strap muscles is split the same way, and the ry of Surgery, page 24). Through the years, endo- retractors are repositioned. tracheal intubation has replaced tracheotomy If the thyroid isthmus is over the trachea in in many circumstances, especially in emergen- the field, the surgeon must decide whether it can cy situations where the glottis is not obstructed be pushed out of the way with a peanut dissector due to injury. or must be divided. If the isthmus is to be divid- A standard tracheotomy set is required for ed, right-angle clamps are used, and the clamped this procedure. This set should contain several isthmus is divided electrosurgically. Each side clamps, at least two right-angle clamps, curved of the isthmus is secured with a stick tie, then Kocher clamps, at least four Allis clamps, a cri- placed with the strap muscles in the retractor. coid hook, and a tracheal spreader. Supplies for The trachea is cleaned off with a peanut dis- a tracheostomy include: peanuts, X-ray detect- sector and prepared for tracheotomy. The sur- able 4˝ x 4˝ surgical sponges, a suction appara- geon’s preference should determine which rings tus, silk stick ties, silk ties, and suture to stabilize are cut to achieve the tracheotomy. Some sur- the tracheotomy tube. A 12 cc syringe is needed geons use a flap technique (ie a flap of a tracheal to inflate the balloon of the tracheotomy tube. ring is cut and sutured back) so that, if the tube is Typically, the tracheotomy tube is cuffed and taken out, it is easy to replace. Other techniques nonfenestrated. The type of tube is chosen based may be utilized according to the surgeon’s pref- on the surgeon’s preference. Use caution when erence based on the anatomy and the indications obtaining the tube as the sizes may differ accord- for tracheostomy. ing to the manufacturer. Often, a rule of thumb Before an incision is made into the trachea, a is a smaller trach tube for women (eg a 6 Shiley) cricoid hook is placed in the cricoid cartilage and and a larger one for men (eg an 8 Shiley). Head- the trachea is pulled up. The surgeon will make lights for adequate lighting are important in this an incision in the trachea between two tracheal case, especially if it is an emergency. rings, usually the first and second. The incision The patient is placed in the supine position on may be extended with a curved Mayo scissors. the operating table with the neck extended. The Some surgeons use 4% lidocaine (plain) to anes- patient is most often awake, and the procedure is thetize the trachea and to provide some comfort performed with local injection and a little seda- for the patient while the trachea becomes accus- tion to make sure the patient’s airway isn’t lost. tomed to the tube. The surgical technologist should learn prior A tracheal spreader may be used to enlarge to the start of the procedure what size trach tube the opening in the trachea as the tube is being the surgeon anticipates. It is the surgical technol- positioned. The obturator is pulled out of the ogist’s responsibility to assemble the tracheoto- tube, the inner cannula is placed in the tube, my tube with the obturator in place and verify and the balloon is inflated. Care is taken not to patency of the balloon. Patency of the balloon is apply too much pressure to the balloon, as exces- verified with air—never water. Time permitting, sive pressure may cause necrosis to the sides of the wide umbilical tape, included in the tube’s the trachea. The trach tube is sewn to the skin package, is prepared for use in securing the tube and secured around the neck. The obturator is

SEPTEMBER 2005 The Surgical Technologist 15 cleaned and given to the circulator to be placed 6. Lore JM, ed. An Atlas of Head and Neck Sur- on the patient’s chart in case of dislodgement of gery, 3rd ed. Philadelphia: WB Saunders; the tube. If there is an extra incision, the sur- 1988. geon may close the wound. If not, the patient is 7. Myers EN, ed. Operative Laryngology. Vol. 1- cleaned off and taken to the postanesthesia care 2. Philadelphia: WB Saunders; 1997. unit. 8. Robbins KT. Classification of neck dissection: Postoperative complications include: hem- current concepts and future considerations orrhage, displacement of the tracheotomy tube, in management of the neck in head and neck wound infection, and tube obstruction caused cancer. Management of the Neck in Head and by heavy mucous from the bronchi. The patient Neck Cancer, Part 1. Otolaryngology Clinics must be taught how to properly care for the tube of North America. Vol. 31. No. 4; 1998. prior to discharge from the hospital. 9. Bobby R Alford Department of Otolaryn- Tracheotomy is generally performed for gology and Communicative Sciences, Bay- short term use. Tracheostomy is preferred when lor College of Medicine. www.bcm.tmc.edu/oto a long-term need of a stoma is expected. Trache- (accessed 4/1998) ostomy involves suturing the mucosa of the tra- 10. www.vesalius.com (accessed 4/1998) chea to the skin to form a stoma. A tracheotomy tube may remain in place during healing, but is removed when the stoma has matured.

About the author Mary Sutton, CST, CFA, is currently an instruc- tor at Concorde Career Institute in Jacksonville, Florida, and was recently a speaker at AST’s 36th Annual National Conference in Orlando. She has been active in the Florida State Assembly, the AST national Board of Directors, and continues to serve the profession on the LCC-ST Board of Directors. Are you a specialist in: References Cardiovascular 1. Breau RL and Suen JY. Management of the N₀ General Neck. Management of the Neck in Head and Harvesting/Transplant Neck Cancer, Part 1. Otolaryngology Clinics OB/GYN of North America. Vol. 31. No. 4; 1998. Opthalmic 2. Chaffee EE and Lytle IM. Basic Physiology Plastic/Reconstructive and Anatomy, 4th ed. Philadelphia: Lippin- Pediatrics cott; 1980. Trauma/Emergency Medical Care 3. Cummings C, ed. Otolaryngology-Head Or any other specialty? and Neck Surgery. Vol. 1-3. 2nd ed. St Louis: Mosby;1993. If so, we need you. AST needs writers for journal CE 4. Gray H. Gray’s Anatomy, 15th ed. London: articles. Show your expertise and get the recognition Chancellor Press; 1994. you deserve. Come up with a topic, write an outline 5. Kennedy (Sutton) M. Superficial Parotidec- and e-mail it to [email protected]. Want more tomy for Parotid Gland Tumors. Englewood, information? Download the Guidelines for Authors CO: Association of Surgical Technologists; at www.ast.org and click on Publications. 1997.

16 The Surgical Technologist SEPTEMBER 2005 1. A majority of branchial cleft cysts arise 6. Which is the largest salivary gland?

CE261Exam SEPTEMBER 2005 2 CE CREDITS from the: a. parotid a. sinuses b. submandibular b. second branchial arch c. sublingual c. cranial nerves d. Ebner d. fourth branchial arch 7. During submandibular gland excision, Surgery of the 2. Which is the most common mass in the which nerves are checked for damage? midline of the neck? a. mandibular head and neck: a. branchial left cyst b. hypoglossal b. Zenker’s diverticulum c. lingual other neck surgeries c. parotid gland tumor d. all of the above d. thyroglossal duct cyst Earn CE credit at home 8. If the nerve must be sacrificed during You will be awarded continuing education (CE) credit(s) for 3. A Sistrunk procedure is performed to: parotidectomy, which branches must be recertification after reading the designated article and complet- a. remove a branchial left cyst reinnervated for cosmetic reasons? ing the exam with a score of 70% or better. b. excise Zenker’s diverticulum a. zygomatic and marginal mandibular If you are a current AST member and are certified, credit c. remove a thyroglossal duct mass b. temporal and zygomatic earned through completion of the CE exam will automatically d. excise a parotid gland tumor c. cervical and buccal be recorded in your file—you do not have to submit a CE report- d. marginal mandibular and temporal ing form. A printout of all the CE credits you have earned, includ- 4. What structures are removed during the ing Journal CE credits, will be mailed to you in the first quarter Sistrunk procedure? 9. The point at which the facial nerve starts following the end of the calendar year. You may check the status a. midsection of the hyoid bone to branch is: of your CE record with AST at any time. b. muscle of the tongue base a. stylomastoid foramen If you are not an AST member or not certified, you will be c. skin that has adhered to the cyst b. zygomatic arch notified by mail when Journal credits are submitted, but your d. all of the above c. pes anserinus credits will not be recorded in AST’s files. d. Stensen’s duct Detach or photocopy the answer block, include your check or 5. Zenker’s diverticulum is formed: money order made payable to AST and send it to the Accounting a. during development of the esophagus in utero 10. Tracheotomy was first performed by: Department, AST, 6 West Dry Creek Circle, Suite 200, Littleton, CO b. by pressure of the esophageal muscles against a. Alexander the Great 80120-8031. low resistance b. Chevalier Jackson c. after recurrent laryngeal nerve injury c. Antonio Brasavola Members: $6 per CE, nonmembers: $10 per CE d. by hypopharyngeal stricture d. None of the above

261 SEPTEMBER 2005 2 CE CREDITS Surgery of the head and neck: other neck surgeries a b c d a b c d

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