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Technical Variations and Refinements in Head and Neck Surgery
First Edition: 2014
ISBN 978-93-5152-317-8
Printed at:
Dedicated to
Jack and Kaia
and all the aspiring
Head and Neck Surgeons
around the globe
Preface
Unique among the specialties that make up the field of cancer care, surgical
oncology is both a science and an art. The outcome of patients with head
and neck cancer depends not only on the surgeons decision-making and
knowledge base, but also on his technical ability to accomplish a surgically
safe and complete cancer operation. No two operations are the same, no
surgery is ever routine, and even minor technical aspects of the procedure
can affect the patients quality, and length of life. This is a perennial aspect
of high-quality cancer care that is difficult to convey in a textbook or journal
article. Over the past 30 years, training programs for the increasingly complex
specialty of Head and Neck Surgical Oncology have evolved to train the next
generation in high quality surgical care for diseases of the head and neck.
This textbook will cover the advanced technical aspects, variations, and
refinements of head and neck surgical procedures, developed by the senior
author over the past 40 years. These variations in technique are currently
practiced by the surgeons on the Head and Neck Service at Memorial
Sloan-Kettering Cancer Center in New York, USA. For each procedure, the
refinements will be directly compared with conventional surgical techniques.
These refinements were developed, keeping function and esthetics in mind,
which clearly impact on the quality of life. This focused text is a companion
to Jatin P Shahs Head and Neck Surgery and Oncology, 4th edition, and
therefore does not seek to cover oncologic aspects of surgical decisionmaking, nor does it encompass the critical multi-disciplinary nature of head
and neck cancer treatment, or the rapidly evolving science of the field. It also
does not describe the step by step conduct of operations, for which the reader
is referred to the main textbook. On the other hand it highlights the important
components of operative procedures, concentrating on technical nuances.
Thus, this book is intended to take the reader on a focused tour through some
major refinements to the performance of the craft of head and neck surgery.
We hope that this work will be of value to residents and fellows in training,
as well as established surgeons who may not perform a high volume of head
and neck procedures.
Luc GT Morris
Jatin P Shah
Acknowledgments
We would like to thank the many courageous patients with head and neck
cancer who we have had the good fortune to meet, treat and glean inspiration
from. We would also like to thank Ms Raia Mohammed and Mr Benjamin
Hegel of the Head and Neck Service for their superb editorial assistance,
Ms Chetna Malhotra Vohra (Senior ManagerBusiness Development) and
Ms Sheetal Arora (Development Editor) of M/s Jaypee Brothers Medical
Publishers (P) Ltd., New Delhi, India.
Contents
1.
2.
3.
26
Facial Incision 26
Partial Maxillectomy 29
4.
35
5.
Oral Cavity
42
6.
59
xii
7.
The Neck
69
8.
78
9.
Salivary Glands
88
Superficial Parotidectomy 88
Parotidectomy and Excision of Deep Lobe Parotid Tumor 94
Excision of the Submandibular Gland for Sialolithiasis 97
99
103
Index 123
Chapter
from electrical wires, tubes and connections, all electrical connections, wires,
and ducts for the delivery of gases and suction channels should emanate
from ceiling-mounted cylinders. Ideally, mobile flat-screen TV monitors
for open procedures and endoscopic procedures should be mounted to the
ceiling. A modern-day OR that is equipped with these capabilities is shown
in Figure 1.1.
To most effectively maintain the routine for the day-to-day conduct of
common operative procedures, the position of equipment in the OR should
remain constant. Whenever possible, the position of the operating table and
equipment should be standardized so that they remain in the same location for various procedures. The head of the operating table should generally
remain in proximity to the anesthetic equipment. Turning the operating table
should be avoided unless specific circumstances absolutely require different
positioning.
Most head and neck surgical procedures are conducted with a single
surgical team consisting of the operating surgeon and two assistants.
A scrub nurse and a circulating nurse are essential members of the surgical
team. Similarly, an anesthesiologist with at least one assistant is required
for induction and smooth conduct of anesthesia throughout a long operative procedure. A nursing assistant must be available on demand at all times.
Several complex surgical procedures require the involvement of more than one
surgical team. These two-team procedures may be conducted sequentially, or
both teams may require simultaneous intervention. Therefore, when multiple
surgical teams are involved, the plan of the conduct of the surgical procedure
and the sequence of involvement of each surgical team should be discussed in
advance with the OR nurses and the anesthesiologist to ensure smooth conduct
Fig. 1.2: Position of the surgical team for standard open head and neck operations.
The primary surgeon (blue) customarily stands on the patients right, with the assistants
(orange) at the head of the bed and standing opposite. The anesthesia circuit is sterilely
isolated at the top of the bed and brought out toward the anesthesiology team (purple).
The scrub nurse (light blue) is positioned along the patients side.
Fig. 1.3: Sterile drape for head and neck surgery, comprised of two sterile drapes,
placed under the head. One drape is placed flat on the bed and tucked under the
shoulder blades; the other is wrapped around the head and used to secure the anesthesia tubing.
the operating surgeon stands on the right hand side of the patient, with the
first assistant situated at the head end of the operating table and the second
assistant directly across from the operating surgeon, on the left hand side of
the patient. The endotracheal tube and anesthetic connections are isolated by
sterile transparent drapes brought out at the top of the bed, between the first
and second assistants (Fig. 1.3). Intravenous access to the patient, through a
line in the upper extremity, is provided through the contralateral arm, which
may be kept abducted at 90 and isolated out of the sterile field, or it may
be tucked next to the patient with an extension of the intravenous tubing.
The anesthesiologist should have access to the endotracheal tube and oral
cavity, as well as to the intravenous line; therefore, an appropriate length of
anesthetic tubing and intravenous line should be made available. The scrub
nurse may stand on the right or left hand side of the patient, with the
Gerhardt instrument table brought over the patient on the operating table,
up to the level of the umbilicus. The electrosurgical unit is positioned behind
and between the operating surgeon and the scrub nurse. Suction tubing and
collection chambers are positioned farther out from the operating team and
are connected to the ceiling-mounted suction channels. Waste-disposal
buckets are necessary and should be positioned adjacent to the operating
surgeon and the first assistant. Further illustrative diagrams for a variety of
operative procedures are shown in Figures 1.4A to C.
B
Figs 1.4A to C: (A) Position of the surgical
Fig. 1.5: Standard tips for electrosurgical instruments. From left to right, insulated
needle tip and flat tip (generally used in the oral cavity); extended length insulated flat
tip (generally used in the oropharynx); Colorado tip (generally used for fine dissection in
the skin or mucosa); standard needle tip (for incision through dermis); standard flat tip.
Electrodissection Instruments
The standard needle tip is recommended for making the incision in mucosa
or skin. It minimizes charring and gives a clean and sharp cut without
bleeding. After incision of the epidermis with the scalpel, we recommend
using the needle tip to incise the dermis on a pure cutting current. This allows
exposure of the subcutaneous fat plane, with minimal bleeding and charring
of the cut edges of the skin. In contrast, cutting deeper with the scalpel blade
will invariably lead to dermal and subcutaneous bleeders, which obscure the
field and, if cauterized, lead to burning of the skin.
Once the dermis is incised, the paddle tip is used generally throughout
dissection of nearly all operative procedures; it is indeed the workhorse for
the surgeon. It is necessary to remember that dissection should be performed
in the direction of the tip, using it as a blade and not as a brush.
To avoid inadvertent burning of the lips during intraoral surgery, we
recommend the use of an insulated needle and paddle tips for the cautery
unit (Fig. 1.5).
The Colorado tip is an extra fine needle tip that is coated with Teflon to
prevent accumulation of charred tissue on the needle. The usual needle and
paddle tips are too large for working in delicate regions that include fine, thin
tissue, such as the skin of the eyelids.
Figs 1.7A and B: Relaxed skin tension lines guide the design of skin incisions.
Fig. 1.8: In open head and neck surgery, incision through the epidermis only is carried
out with a sharp scalpel blade.
10
Fig. 1.9: The needle tip Bovie is then used to incise the dermis only.
Fig. 1.10: The flat tip Bovie is then used to incise the platysma.
wet surgical field (caused by blood, tissue fluid or irrigation). Similarly, tissues
that are lax and not under sufficient tension or traction will not be amenable
to good dissection with electrocautery. Accordingly, the plane of dissection
must always be maintained in tension by retraction and countertraction,
Fig. 1.11: Skin flaps are raised with the flat tip Bovie using a light touch and emphasizing tissue traction and countertraction.
and dissection relies on a light touch, without digging the blade into tissue
(Fig. 1.11).
Pinpoint bleeding during dissection is most effectively controlled by
the use of hemostats or fine forceps, coagulation by monopolar cautery, and
diffuse surface bleeding by bipolar cautery; larger vessels need to be ligated.
To avoid collateral injury from spread of current from monopolar cautery,
bipolar cautery is strongly recommended to control bleeding in the vicinity
of nerves and major vessels.
11
12
Fig. 1.12: Fish hooks (inset), provide excellent retraction of skin flaps.
Stability of the surgeons arms is crucial during endoscopic laser resections, which can take from several minutes to several hours. A comfortable
chair with adjustable armrests is indispensable for supporting the operating
surgeons arms, providing stability and avoiding tremor (Fig. 1.13).
Fig. 1.13: An example of the surgical chair used for transoral laser microsurgery, with
adjustable armrests.
Fig. 1.14: Commonly used dissection clamps: a fine Adson hemostat (top) and a
micro-mosquito hemostat (bottom).
13
Chapter
Surgery of the
Scalp and the Skin of
the Face and Neck
GENERAL PRINCIPLES
To appreciate the complexities involved in surgical procedures on the scalp
and skin of the face and neck, four basic areas need to be understood:
1. Arterial blood supply of the skin and scalp
2. Venous drainage of the skin and scalp
3. Anatomy of the underlying muscles of facial expression
4. Relaxed skin tension lines (Figs 2.1 and 2.2).
Nearly all of the blood supply to the scalp and face is provided by the
branches of the external carotid arteries, through the facial, superficial
temporal and occipital arteries. The skin of the neck also derives blood
supply from the internal mammary, transverse cervical, and suprascapular
Fig. 2.1: Depiction of the major blood supply to subsites and angiosomes of the
face. (1) Infraorbital and inferior alveolar; (2) Labial branches of the facial artery;
(3) Supratrochlear and supraorbital arteries; (4) Superficial temporal artery distribution;
(5) Auricular branches; (6) Occipital artery; (7, 8) Transverse cervical and supraclavicular
arteries; (9) Inferior thyroid artery; (10) Superior thyroid and lingual artery branches.
Surgery of the Scalp and the Skin of the Face and Neck
Fig. 2.2: Relaxed skin tension lines guide the design of skin incisions.
15
16
Fig. 2.3: Depiction of a scalp excision with incisions oriented at 90 (not recommended).
Surgery of the Scalp and the Skin of the Face and Neck
Fig. 2.4: Incisions oriented at 90 create troughlike defects in the scalp, which predispose toward accumulation of crusting and dry sebaceous material.
17
18
Fig. 2.6: The shiny skin-on-bone appearance that results from using split-thickness
skin grafts on the scalp.
Fig. 2.7: Scalp excision, with preservation of pericranium, except for a central portion
where pericranium has been removed. This central portion of exposed bone will not
support a skin graft.
A skin graft will not be supported in cases in which some or all of the
pericranium has been resected as a deep margin (Fig. 2.7). In such cases,
bare cortical bone will not support a skin graft, which relies on imbibition
Surgery of the Scalp and the Skin of the Face and Neck
Fig. 2.8: Design of a double rotation scalp flap to reconstruct a wide scalp defect.
In this case, a rotation flap was preferred to a skin graft, as postoperative radiation
therapy was anticipated.
Fig. 2.9: Appearance of the scalp after wide excision and rotation of flaps.
and inosculation from underlying tissue. However, the cortical bone can be
drilled down to bleeding cancellous bone, which will form granulation tissue,
ultimately supporting a skin graft. We prefer to perform a scalp rotation flap
in these cases.
Scalp rotation flaps, elevated above the level of the pericranium, carry
a robust blood supply and provide immediate closure of the donor site
(Figs 2.8 and 2.9). In cases where postoperative radiation therapy is
19
20
Fig. 2.10: Appearance of the scalp rotation flap immediately after postoperative
radiotherapy.
Fig. 2.11: Galeal relaxing incisions are not recommended. They contribute minimal
stretch to the inelastic scalp but compromise blood supply to the rotation flap.
anticipated, a rotation flap will withstand irradiation better than a skin graft
(Fig. 2.10). Nevertheless, because the scalp lacks laxity, closure will generally
be under some tension. Therefore, scalp rotation flaps should be designed
with a broad front. In most cases, we do not recommend galeal relaxing
incisions (galeotomies); these provide minimal stretch but place the blood
supply of the flap at significant risk (Fig. 2.11). When a scalp flap closure is
under extreme tension, it is preferable to place a small skin graft at the donor
Surgery of the Scalp and the Skin of the Face and Neck
site (where periosteum has been preserved and will support a skin graft),
rather than risk loss of the tip of the rotated flap.
Once inset, the distal tip of the scalp rotation flap is generally placed
under some tension and may undergo epidermolysis, although the galeal
closure will generally remain viable. It is important to be aware of this potential sequela in the postoperative period and to implement wound care and
even conservative debridement as needed, to promote healing.
Fig. 2.12: Scalp edges lifted off the bone by tie-down sutures (not recommended). Skin
graft depicted in blue. Bolster depicted in yellow.
21
22
Fig. 2.13: The bolster is secured to staples at least 1 cm from the wound edge,
avoiding lifting of the edges of the scalp defect (recommended). Skin graft depicted in
blue. Bolster depicted in yellow.
Fig. 2.14: Long-term result of the described refinements, including beveled incisions,
thicker skin graft and tie-down sutures.
The silk ties are tied over the bolster, without lifting the edges of the scalp
defect (Fig. 2.13).
Sutures at the periphery of the defect help to ensure complete take of the
skin graft. Removal of the bolster is easy and painless for the patient, since the
staples need only be removed and no sutures are removed from the skin graft.
The potential for subgaleal hematoma is avoided. The long-term result of this
technique is very pleasing (Fig. 2.14).
Surgery of the Scalp and the Skin of the Face and Neck
23
24
B
Figs 2.15A and B: Closure after wedge excision of the auricle. Protruding cartilage is
excised to facilitate closure.
Smaller grafts with excellent color match can be harvested from the
preauricular region, closing the defect in line with a preauricular skin crease.
If the neck is not available as a donor site, large grafts from lax skin in the
deltopectoral groove or on the abdominal wall can also be primarily closed,
although they offer poorer color match for the face.
On all other parts of the face, local flaps should be used for small defects;
when local flaps are not large enough to fill the defect, regional or free flaps
should be used. Facial skin lines and facial expression are crucial factors in
designing a local flap to repair a surgical defect. The goal should be to leave
minimal esthetic or functional deficit.
Surgery of the Scalp and the Skin of the Face and Neck
The planning and design of local flaps for repair of facial defects require
knowledge of superficial vascular anatomy of the head and neck, as well as
an appreciation of the esthetic and functional units of the face. Owing to the
extensively rich blood supply of facial skin, any flap with a length to width
ratio of 3:1 can be safely used. In such a setting, esthetic planning of the donor
site closure will play a major role.
Axial flaps with a larger length-to-width ratio require an identifiable
feeding vessel. The reader is referred to larger publications on various types
of facial skin flaps, which are beyond the scope of this publication.
25
Chapter
Nose, Paranasal
Sinuses, and Orbit
INTRODUCTION
Several technical modifications, refinements and reconstructive efforts can
improve exposure for adequate resection of tumors while decreasing the
esthetic and functional morbidity of open surgical procedures.
FACIAL INCISION
One of the significant problems in surgical management of neoplasms of
the nasal cavity and paranasal sinuses that are not amenable to endoscopic
resection is surgical access. Although the Weber-Ferguson incision, with its
various extensions (Diffenbach, subciliary, transconjunctival and Lynch),
has provided excellent exposure for the last several decades, the esthetic and
functional sequelae of this approach leave much to be desired. The standard
Weber-Ferguson incision with standard extensions, as originally described,
has the following disadvantages:
Unacceptable scar
Does not respect nasal subunits
Causes flaring of the ala
Distorts the nasal aperture
Causes cicatricial ectropion of the lower eyelid
Widens the palpebral fissure
Causes loss of nasolabial symmetry.
To avoid these esthetic and functional sequelae, a significant modification of the incision has been developed and practiced by the authors for more
than 15 years. The short- and long-term outcomes of this modification have
stood the test of time.
The incision provides essentially the same exposure but is placed in skin
creases of the nasolabial-orbital region, respecting the nasal subunits, and
the periorbital skin crease. The incision is not a subciliary incision and is
placed away from the tarsal margin, thereby minimizing cicatricial ectropion.
The incision is shown in Figures 3.1 and 3.2.
Fig. 3.1: Modifications to the lateral rhinotomy incision include a notch in the nasal sill
following the columella in the floor of the nasal cavity and careful respect of the alar
border and the nasal subunits. Importantly, the incision is not placed in the nasolabial
fold.
Fig. 3.2: Modifications to the Weber-Ferguson incision include careful respect of nasal
subunits, and avoidance of a subciliary incision, which causes ectropion. Instead, the
skin incision is brought down lower, in an infraorbital skin crease.
27
28
The incision must be marked on the patient with a marking pen before
induction of anesthesia and oral or nasal intubation. Taping of the endotracheal tube pulls the upper lip to one side, causing distortion and displacement of the midline. This can make precise delineation of the midline lip
split quite difficult. Even subtle divergence from the midline is easily
recognized by the human eye, creating an abnormality that is quite visible
postoperatively.
The incision begins at the vermilion border of the upper lip, exactly in
the midline, splitting the philtrum of the upper lip. The upper lip is divided
through its full thickness. To facilitate precise alignment at closure, we find
it is helpful to make a small, perpendicular, crosshatch skin incision right at
the vermilion border of the lip. The skin incision then follows the mound of
the columella into the floor of the nasal cavity. From there, it takes a 45 turn
and exits the nasal cavity into the alar groove. It then follows the alar groove,
up to the lateral edge of the alar rim. At that point, it takes a nearly 90 turn
cephalad, on the side of the nose, medial to the nasolabial skin crease. Note
that the incision along the nasal sidewall is not placed in the nasolabial skin
creasedoing so invariably flattens the nasolabial fold.
The vertical component of the incision extends cephalad up to the medial
end of the eyebrow (Lynch extension) or stops at the level of the medial
canthus, still remaining on the nose. If a subciliary extension is required, the
incision again takes a 90 turn laterally, in the infraorbital region. Here, the
incision is kept away from the medial canthus and the tarsal margin. Rather
than taking a subciliary course, the incision now follows an infraorbital skin
crease. The distance between the skin crease and the tarsal margin varies
from patient to patient, but generally the highest infraorbital skin crease is
well positioned. The incision can be extended laterally as far as necessary
but should remain in the periorbital/orbitozygomatic skin crease. Note that
the lateral extension is not placed in the traditional subciliary location on the
eyelid, thereby minimizing scar contracture and resultant ectropion.
The depth of the skin incision on the upper lip and the nasolabial and
paranasal regions is through the full thickness of the soft tissues, down to the
bone. However, the skin incision in the infraorbital region is only through
the skin, remaining superficial to the underlying orbicularis oculi muscle. By
keeping the incision superficial to the muscle, the orbicularis is not disturbed
or divided, again minimizing scarring and the risk of subsequent eyelid eversion or ectropion. The skin incision on the upper lip is extended through the
mucosa of the upper lip and the upper gingivobuccal sulcus, leaving approximately 8 mm of mucosal cuff on the attached gingiva. The upper cheek flap is
then elevated in the usual fashion, directly over the underlying anterior wall
of the maxilla but superficial to the orbicularis oculi muscle. Extreme care
should be exercised in elevating the skin in this area. The skin is paper thin,
and inadvertent button holes can occur in the skin if delicate dissection
is not performed. The skin in this area should be elevated superficial to the
orbicularis muscle by use of an ultrafine needle tip (Colorado tip) electrocautery device.
After the upper cheek flap is elevated completely, as above, and retracted
laterally, dissection and elevation of the orbicularis oculi muscle take place.
By use of a periosteal elevator, the muscle is gently separated from the underlying maxillary bone up to the orbital rim. Care should be exercised to prevent
inadvertent tears in the muscle. The muscle is then retracted cephalad to the
lower eyelid, giving complete exposure of the anterior wall of the maxilla.
Surgical resection of the tumor is then completed as required by the extent of
the tumor. Repair of the surgical defect may require a dental obturator (with
or without the use of a skin graft) or a free flap.
To achieve an optimal esthetic outcome, closure of the incision requires
meticulous attention to detail. The orbicularis oculi muscle is draped back
in its normal place. In the infraorbital region, subcutaneous closure is
performed with fine 5-0 absorbable sutures (Vicryl). Subcutaneous closure
of the remaining incision is performed with 3-0 chromic catgut inverting
sutures, carefully matching each of the 90 and 45 angles of the incision.
Additional subcutaneous sutures are placed, as necessary, to accurately align
all of the nasal and labial subunits. Finally, skin closure is performed with 6-0
interrupted nylon sutures.
The typical postoperative appearance, as demonstrated in the same
patients before and after surgery, is shown in Figures 3.3 and 3.4. Note the
lack of cicatrical ectropion, which is attributable to the modification of the
subciliary limb of the incision.
PARTIAL MAXILLECTOMY
Extent of Resection
Resection of the lower part of the maxilla (infrastructure) involves removal
of the anteroinferior portion of the maxilla, below Ohngrens line. The operation can be easily performed through the open mouth and seldom requires a
lateral rhinotomy for exposure. Many textbooks describe this operation as a
hemimaxillectomy, whereby the entire ipsilateral alveolar process, from the
anterior midline up to the junction of the hard and soft palates, is removed.
This results in the loss of all of the teeth on that side, which is often not necessary. Depending on the location and extent of the tumor, several uninvolved
teeth can be safely preserved. Thus, for posteriorly located tumors of the
upper gum or hard palate, the incisor teeth can be safely preserved, retaining
the esthetic appearance of the patient and aiding in retention of the eventual
dental obturator. Similarly, for anteriorly located lesions, the molar teeth can
be preserved.
29
30
Fig. 3.4: Postoperative photo of the patient in Figure 3.2. There is no ectropion.
palate (retaining the palatal arch) that can be preserved. This is of tremendous help to the prosthodontist in the fabrication and retention of the dental
obturator.
31
32
If the orbital floor is resected, the free flap provides support to the globe
If orbital exenteration is performed, the free flap provides sufficient soft
tissue and skin for immediate reconstruction of the defect
There are, however, some disadvantages with free-flap reconstruction.
They are:
It requires two surgical teams and prolongs the operation by several hours
In the dentate patient, rehabilitation with a denture is difficult, since,
with passage of time, the flap sags and displaces the denture
Prosthetic rehabilitation of orbital defects may be difficult because of an
inability to retain the prosthesis in the orbital socket
Placement of dental implants in osteocutaneous flaps is sometimes difficult
All of the benefits and disadvantages of a free flap must be weighed,
taking into consideration tumor and patient factors.
Palatal Fenestration
Central palatal lesions can be removed completely, without the need to
sacrifice the uninvolved alveolar process. This is often the case for tumors
originating in the minor salivary glands. If the palatal bone is involved, then
a full-thickness resection requires creating an oronasal defect, which will
require a dental/palatal obturator for speech and swallowing without nasal
regurgitation. If, however, the palatal bone is not involved with the tumor and
the bone appears normal on imaging studies, then a full-thickness resection
can be avoided. Clearly, this is preferable, since it will avoid the need for an
obturator.
To accomplish the goal of avoiding full-thickness defects, the mucosa
of the floor of the nasal cavity must be preserved, without perforating it
during resection. At the beginning of the operation, saline with epinephrine
(1:100,000) is bilaterally infiltrated into the submucosal plane of the floor of
the nasal cavity. A long spinal needle is used, and the submucosal plane of
the floor of the nasal cavity is entered through the anterior nostril, advancing
along the upper surface of the palatal bone. This hydrodissection creates a
plane between the bone and the mucosa of the floor of the nasal cavity.
The resection then begins through the open mouth with a circumferential mucosal incision around the tumor. Then, with a power saw or a drill, the
bone is scored through nearly 90% of its thickness. Finally, with a small osteotome, the bone is fractured at one place, to allow entry into the previously
created plane between the bone and the nasal mucosa. By use of a perio
steal elevator, the palatal bone is dissected off the undersurface of the nasal
mucosa. Finally, by use of the osteotome, the bone is fractured circumferentially, and the specimen is removed. Hemostasis is secured, and a Xeroform
gauze packing is placed in the surgical defect. A temporary dental obturator
is required to hold the packing in place. The dental obturator is required for
several weeks, until the defect granulates in and is covered by palatal mucosa.
C
Figs 3.5A to C: Palatal island flap for reconstruction of a hard palate defect.
33
34
defect depends on the size and location of the palatal defect. Large and more
anteriorly located defects are difficult to repair in this manner and are most
effectively managed by use of a dental obturator.
Chapter
INTRODUCTION
During the last 40 years, the specialty of skull base surgery has matured into a
safe surgical undertaking, with operative mortality now in the low single digits
and postoperative complications having significantly declined in frequency.
These improvements are attributable to increasing experience; technological
advances in imaging, surgical navigation, and instrumentation; and moreinformed selection of cases.
Clearly, technical improvements have also developed over the years to
reduce morbidity, as well as the functional and esthetic impact of craniofacial
surgery. The following refinements are noteworthy.
36
combines bifrontal craniotomy from above with endoscopic-assisted mobilization of the tumor through the nostrils. The surgical specimen can then be
removed through the craniotomy exposure. Needless to say, one must have
sufficient experience and expertise in nasal endoscopic surgery to accomplish a safe and satisfactory operation.
37
38
Fig. 4.2: Maxillary swing approach. Mucoperiosteal incision, designed to not overlie
the palatal osteotomy.
Fig. 4.3: Maxillary swing approach. With the cheek flap not elevated off of the maxilla,
osteotomies are made through the hard palate, nasal process of maxilla, below the
orbital rim, and through the zygoma.
Fig. 4.4: Maxillary swing approach. After performing the osteotomy to separate the
posterior maxilla from the pterygoid plates, the maxilla can now be swung laterally.
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Fig. 4.5: Maxillary swing approach. Realignment of the transposed maxilla with
miniplates.
Fig. 4.6: Final appearance after maxillary swing approach. The modified facial incisions
are camouflaged well by respecting nasal subunits and minimize the risk of ectropion.
The maxillary swing, rather than maxillectomy, allows maintenance of facial contour
and preservation of the palate.
of the middle cranial fossa, and the region of the major foramina of the
middle fossa skull base. Thus, this procedure may be used for neurogenic
and neurovascular tumors of the infratemporal fossa, soft tissue and
bone tumors, minor salivary gland tumors arising from the posterior wall
of the maxilla and extending to this region, and other selected situations
in which such an exposure would be necessary.
Repair of the surgical defect requires simply repositioning the transposed
maxilla back into its natural position, followed by plating. Miniplates
and screws are used to fix the maxilla in position at the zygomatic arch,
at the nasal process of the maxilla, and in the midline at the prema
xilla. In addition, a prefabricated dental obturator is wired to the upper
alveolar process bilaterally. The obturator is retained in position for at least
68 weeks. The remaining incision is closed in the usual fashion (Fig. 4.5).
The final appearance is shown in Figure 4.6.
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Chapter
Oral Cavity
INTRODUCTION
There are several fine points to note in surgery for oral cavity lesions that
result in superior esthetic and functional outcomes. The details and technical
aspects of these refinements are discussed below.
PARTIAL GLOSSECTOMY
Traditionally, many textbooks of surgery recommend a longitudinally
oriented resection of lesions on the lateral border of the tongue. Unless the
lesion is a long linear lesion (Fig. 5.2), a longitudinally oriented resection will
result in too much loss of normal tissue and a long, thin, snakelike tongue,
which does not give the optimal functional outcome. Such a long, thin tongue
hampers accurate recovery of speech and delays resumption of swallowing.
Oral Cavity
Fig. 5.1: A fine suture is used to evert the mucocutaneous junction at the vermilion
border of the lip to create the vermilion mound.
Fig. 5.2: A long linear excision of the tongue is appropriate for a longitudinally oriented
tongue resection.
For superior functional outcomes, most lesions on the lateral border of the
tongue (Fig. 5.3) should be resected using a transverse wedge (Fig. 5.4).
A transverse wedge is marked out, with sufficient margins in all dimensions. The apex of the wedge may need to cross the midline. After threedimensional resection of the tumor, and after confirmation of clear margins
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Fig. 5.3: A lateral tongue lesion that is not long and linearly oriented is more common,
and better suited for a transverse wedge excision, rather than longitudinal excision.
Oral Cavity
should be tied snug, although not too tight, to avoid cutting through musculature. As the closure progresses laterally, one must take into account accurate alignment of the mucosal edges of the dorsum and the undersurface of
the tongue. The mucosa of the dorsum of the tongue is rough and furry,
while the mucosa of the undersurface of the tongue is smooth and glistening.
The junction of these two surfaces is exactly at the lateral edge of the tongue.
This junction must be accurately aligned. After the muscular closure has
approximated the anterior and posterior edges of the cut muscles, mucosal
closure is completed with interrupted absorbable sutures.
Initially, in the postoperative period, the suture line at the apex of the
transverse closure will show a moundlike prominence. This will flatten out
during the next several weeks, and a functionally superior outcome will be
achieved. By this method, the tongue is foreshortened but retains bulk, thus
resulting in superior recovery of speech and swallowing.
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to provide coverage of a larger area of the mucosal defect and soft tissue to
fill the three-dimensional defect. The radial forearm free flap works best in
these situations.
Oral Cavity
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Fig. 5.6: Fixation of a fibula graft to a segmental mandibulectomy defect, where the
angle of the mandible has been preserved. In most cases, miniplates can be used
rather than high-profile mandibular fracture reconstruction plates.
at the end of the bone, with an exposed root or socket, will eventually be lost
and will often cause sepsis at the site of bone union between the free flap
and the native mandible. Making the bone cut through the socket of a tooth
preserves an intact socket of the adjacent remaining tooth, improving the
likelihood of viability.
Fabrication of the neomandible (usually from fibula) to match the resected
mandible requires knowledge of esthetics, geometry and mechanics. We do
not recommend the use of a reconstruction plate to hold the free flap in position. The finer and esthetic aspects of the reconstruction are lost by using the
relatively crude means of bending the reconstruction plate to the contour of
the mandible. It is preferable that multiple osteotomies be performed in the
fibula to create the necessary angulation, curvature, and height of the osseous
free flap to exactly match the resected part of the mandible. The osteotomized
segments of the free flap are retained in position with several miniplates and
screws. Similarly, the reconstructed free flap is fixed to the native segments
of the mandible with several miniplates and screws (Fig. 5.6). Custom made
commercial planning devices are now available to give guides and molds
for the exact sites of osteotomies to create the neomandible for perfect
reconstruction. It also does away with guess work and minimizes operating
room time.
Oral Cavity
B
Figs 5.7A and B
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D
Figs 5.7A to D: Design of marginal mandibulectomy bone cuts to maximize preservation of blood supply and minimize risk of pathologic fracture.
However, with increased patient age, the alveolar process recedes and
the superior border of the alveolus comes closer to the alveolar canal. Accordingly, in the elderly, edentulous patient, the mandibular canal is nearly at the
alveolar ridge. In such patients, the likelihood of performing a safe marginal
mandibulectomy is not high. The alveolar canal and, thus, the inferior alveolar
artery are invariably included in the marginal mandibulectomy specimen,
thereby sacrificing the primary endosteal blood supply to the remaining
mandible. In addition, if a lower cheek flap is elevated for access, that aspect
of the periosteal blood supply to the mandible is also compromised, making
avascular necrosis of the remaining mandible more likely. This can eventually
lead to pathologic fracture during the postoperative period. The risk is higher
in previously irradiated patients. Therefore, marginal mandibulectomy in a
previously irradiated edentulous patient is contraindicated.
Oral Cavity
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MANDIBULOTOMY
In general, large tumors of the posterior third of the tongue (T2 or T3) and
other large tumors of the oropharynx that were not accessible for resection
through the oral cavity were approached in the past by use of composite
resection (Commando operation). The adjacent, uninvolved mandible was
resected to allow access to the oropharynx for resection of the primary tumor.
This approach created significant esthetic and functional morbidity. Therefore, a mandibulotomy approach (mandibular swing) was developed to avoid
the functional and esthetic sequelae of composite resection.
Mandibulotomy provides the necessary exposure for resection of the
tumor but preserves the mandibular arch. Mandibulotomy can be performed
in one of three locations: (1) lateral; (2) midline; or (3) paramedian.
Owing to the following reasons, lateral mandibulotomy is not preferred:
It gives limited exposure
It denervates distal teeth and skin of the chin, as the inferior alveolar
nerve is transected
It devascularizes the endosteal blood supply to the distal mandible
The muscular pull on the two segments of the mandible is unequal,
producing distraction at the site of mandibulotomy.
The mandibulotomy site is located within the lateral portal of radiation
therapy (if the patient needs postoperative radiation therapy)
A midline mandibulotomy avoids all of the above disadvantages of
lateral mandibulotomy. It avoids denervation of the teeth and chin and does
Oral Cavity
not devascularize the mandible. However, it has other sequelae that make the
midline a less than ideal site for mandibulotomy. These are:
The space between the two lower central incisor teeth is narrow and the
roots are often convergent, resulting in a high risk of exposing the roots
of both central incisors and causing potential loss of one or both central
incisor teeth.
Alternatively, to avoid exposure of the roots of both central incisor teeth,
an extraction of one is often performed, and the mandibulotomy is
performed through this socket. This alters the esthetic appearance of the
lower teeth.
To get to the oropharynx through the paralingual extension, the geniohyoid, genioglossus, myelohyoid and hyoglossus muscles have to be
divided and repaired. Repair is difficult and often incomplete. This causes
significant delay in recovery of mastication, swallowing and speech.
A paramedian mandibulotomy is performed between the lateral incisor
and the canine teeth on the side of the tumor. It may sometimes be performed
between the canine and the first premolar tooth, if these roots are more divergent on preoperative panoramic X-ray (Panorex). This approach avoids all
the disadvantages of lateral and midline mandibulotomy and offers excellent
exposure with minimal if any functional or esthetic sequelae. The advantages
of paramedian mandibulotomy are:
Excellent exposure
It does not require extraction of any teeth
It does not cause loss of any teeth, since the roots of the lateral incisor
and canine teeth diverge, offering a space to perform the mandibulotomy
It does not denervate or devascularize any part of mandible
The muscles inserting at the genial tubercle do not need to be divided
It does not cause any major disturbance in mastication, speech or swallowing, since only one muscle, the myelohyoid, needs to be divided and
repaired
The mandibulotomy site does not have unequal traction on the segments
of the mandible
The mandibulotomy site is not in the portals of radiation therapy.
A paramedian mandibulotomy is performed through a midline lowerlip-splitting skin incision, which is curved laterally to the side of the lesion in
the neck, at the level of the thyroid notch. Short cheek flaps are elevated on
both sides of the midline to expose approximately 3 cm of the anterior surface
of the mandible. To do this, an incision is placed in the gingivolabial sulcus,
leaving approximately 5 mm of mucosa attached to the gingiva. The midline
lip-splitting incision is connected to this incision, and all the soft tissues
lateral to the anterior cortex of the mandible are elevated in the cheek flap.
The cheek flap elevation extends laterally up to the mental foramen, which is
at the location of the first to second premolar teeth, carefully preserving the
mental nerve on the side of mandibulotomy (Fig. 5.10).
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middle, all the way up to the posterior border. This allows the mandibular
segment to be swung laterally, providing a wide exposure of the oropharynx.
Resection of the tumor and repair of the defect is performed in the usual
manner. Repair of the mandibulotomy defect begins with mucosal closure
in the posterior floor of the mouth, approximating the mucosa of the lateral
border of the tongue to the mucosal cuff along the gingiva. Lateral retraction of the mandible should be avoided, as this closure progresses anteriorly; otherwise, the suture line will tear and cause dehiscence. Fixation of
the two segments of the mandible is performed with the previously shaped
miniplates at the site of the predrilled holes in the mandible. Both plates
are screwed halfway through first, and then the screws are tightened, with
the surgeons assistant holding the two segments of the mandible in perfect
alignment. Once all eight screws are tightened, the two sides of the mandible
are tested to see whether there is any motion at the site of mandibulotomy.
If motion is detected, the screw holes are repositioned. If motion is detected
even after repositioning of the screw holes, the two segments of the mandible
are wired together by use of a prefabricated lingual/dental prosthesis. A postoperative panoramic X-ray of the mandible shows perfect alignment of the
two segments of the mandible (Fig. 5.12).
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Fig. 5.13: In certain patients without significant submental skin laxity, the lip-splitting
incision is designed with a geometric broken-line design, or a series of Z-plasties,
to avoid cicatricial contraction.
laxity of the submental skin, we advocate using either a geometric brokenline configuration or a series of Z-plasties, to avoid cicatricial contraction
(Figs 5.13 and 5.14). This incision is then transitioned to a lateral neck incision.
Oral Cavity
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of the operation, saline with epinephrine (1:100,000) is bilaterally infiltrated in the submucosal plane of the floor of the nasal cavity. A long lumbar
puncture needle is used, and the submucosal plane of the floor of the nasal
cavity is entered through the anterior nostril, hugging the upper surface of the
palatal bone. This hydrodissection creates a pseudoplane between the bone
and the mucosa of the floor of the nasal cavity.
The resection then begins perorally, with a circumferential mucosal incision around the tumor. With a power saw or drill, the bone is scored through
nearly 90% of its thickness. With a small osteotome, the bone is fractured at
one place to allow entry to the previously created plane between the bone
and the nasal mucosa. By use of a periosteal elevator, the palatal bone is
dissected off the undersurface of the nasal mucosa. Finally, using the osteotome, the bone is fractured circumferentially, and the specimen is removed.
Hemostasis is secured, and a Xeroform gauze packing is placed in the surgical
defect. A temporary dental obturator is required to hold the packing in place.
The dental obturator is required for several weeks, until the defect granulates
in and is covered by palatal mucosa.
Chapter
Larynx, Hypopharynx
and Trachea
LOW-STAGE TUMORS
A dramatic change in the surgical management of tumors of the larynx and
pharynx has taken place during the last 25 years. Selected early-stage tumors
(T1 and T2) of the supraglottic larynx and hypopharynx are increasingly
managed by endoscopic laser resection. Similarly, early-stage lesions of the
glottic larynx (T1 and T2) are managed either by external radiation therapy or
by endoscopic laser surgery (see Chapter 11).
Thus, open partial laryngectomy for both supraglottic and glottic tumors
is now used rarely and for very select patients. These are patients who are not
suitable for endoscopic surgery (because of trismus or cervical spine deformities, such that adequate exposure of the larynx is not feasible) and who
are also not candidates for radiation therapy (previous radiation to the neck)
or are undergoing salvage of persistent or recurrent cancer after radiation
therapy.
To ensure that successful outcomes are achieved in patients undergoing
conservation laryngeal surgery after failure of radiation therapy, extremely
rigid selection criteria must be met. These criteria are:
The index tumor (i.e. the tumor before radiation therapy) was suitable for
partial laryngectomy
The persistent or recurrent tumor is not larger or more extensive than the
tumor at initial presentation
There is no cartilage destruction
Soft tissue, skin and mucosa of the larynx and soft tissue in the central
compartment of the neck in the irradiated field are suitable for partial
laryngeal surgery, with the anticipation of satisfactory healing.
In the literature, the reported experience with all conservation surgical
procedures (supraglottic partial laryngectomy, vertical partial laryngectomy,
and supracricoid partial laryngectomy) for laryngeal cancers in which radiation therapy has failed is limited. However, with stringent selection criteria,
these operations can be performed successfully, and excellent local control
rates can be achieved.
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Incision
Several incisions have been described for performance of a total laryngectomy. These are described below.
Fig. 6.1: Incisions for laryngectomy, historical. Midline vertical incisionnot recommended.
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Apron Incision
An apron-shaped (U-shaped) incision is sometimes used for laryngectomy.
This incision begins at the level of the digastric tendon on one side and ends
at the digastric tendon on the other side, incorporating the upper half of the
tracheostome at the apex of the incision. Although this incision provides
adequate exposure for laryngectomy, it is also poorly designed, owing to a
number of reasons. The blood supply to the apex of the apron-shaped skin
flap of the neck, near the tracheostome, is the poorest, since it is derived
from the peripheral branches of the facial artery in the submental region, in a
retrograde fashion. This incision often leads to skin necrosis at the midpoint
of the incision, and problems with healing of the tracheostome. In addition, if
neck dissection is required, the incision does not provide adequate exposure
of the posterior triangle, and a lateral extension may be required. Insertion of
a regional flap, such as a pectoralis major myocutaneous flap, for reconstruction of the pharyngoesophageal defect is difficult. If the pharyngeal suture
line breaks down, resulting in a fistula, the salivary drainage accumulates
under the flap and, by gravity, drains at the lower end of the skin suture line
into the tracheostome. For all of these reasons, we do not recommend this
incision (Fig. 6.2).
H Incision
An H-shaped incision is sometimes used for laryngectomy and bilateral neck
dissections. Although this incision provides excellent exposure of the lateral
neck for neck dissections, the skin surrounding the tracheostome in the lower
flap has precarious blood supply, putting it at an increased risk of necrosis.
Therefore, we do not recommend this incision (Fig. 6.3).
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over the clavicle, on the side of the flap. For insertion of the flap, the addition
of a vertical trifurcation incision is generally not necessary to transpose the
pectoralis flap.
PHARYNGEAL CLOSURE
Attention to detail in the closure of the pharynx after laryngectomy is crucial
to (1) prevent wound breakdown and fistula formation; (2) prevent pharyngoesophageal stricture; and (3) create a wide pharyngoesophageal junction
(neogullet) to provide a large enough reservoir of air to facilitate speech
restoration. When sufficient mucosa of the base of the tongue and esophagus
is available, a primary closure can be easily performed. Ideally, the closure of
the pharyngoesophageal defect should be performed with a transverse linear
closure. This is accomplished with interrupted inverting absorbable sutures.
To complete this without tension, a suture is initially placed in the midline
of the mucosal edge of the base of the tongue and in the midline of the anterior wall of the esophagus. This permits the opening to be divided into two
halves. Each half of the opening is closed with another suture in the middle
of the defect on one side, further dividing the opening into two halves. This
is repeated on the opposite side. The opening is thus divided into four equal
segments, which distributes the tension and mucosal surfaces of the base of
the tongue and esophagus equitably throughout the suture line. A watertight
closure is completed.
A vertical closure or a T-shaped closure should be avoided. The vertical
closure increases the risk of stricture formation, and the T-shaped closure
increases the risk of suture line breakdown at the trifurcation of the T closure.
Similarly, if there is tension on the suture line, a primary closure should not
be attempted, as it will lead to wound breakdown and fistula formation. In
situations in which a tension-free primary closure in a transverse fashion is
not feasible, repair of the pharyngoesophageal defect should be performed
with a regional myocutaneous flap or a free flap as a patch.
Compromised vascularity of the mucosa and soft tissues of the pharyngoesophageal region caused by previous radiation therapy or chemoradiation therapy also increases the risk of poor healing and wound breakdown. In
these situations, the risk of fistula formation is higher, even if the transverse
primary closure is performed in a tension-free manner. To prevent wound
breakdown, the suture line should be buttressed with nonirradiated vascularized soft tissue. This is best provided by use of a pectoralis muscle flap or
a free flap. Using this tissue layer provides new blood supply and protection
to the suture line, as well as to the carotid artery. A pectoralis myocutaneous
flap or fasciocutaneous free flap may be used to patch or buttress the pharyngeal closure. If this approach is chosen and the pharynx is able to be closed
primarily in a transverse, linear fashion, the flap can be used to buttress the
pharyngeal suture line. If the pharyngeal closure is compromised by either
extensive tension or poor tissue quality, it is preferable to patch the pharyngeal defect with the regional or free flap.
TRACHEOESOPHAGEAL PUNCTURE
Restoration of speech by means of tracheoesophageal puncture (TEP) and
voice prosthesis has now become the standard of care for patients undergoing
total laryngectomy. The question remains, however, whether the TEP should
be performed primarily, at the time of total laryngectomy, or secondarily, at
a later date. There is not widespread agreement in the head and neck surgery
community on this issue, and practices vary significantly. In our practice, the
indications for primary TEP are the following:
The area of the tracheostome has not been subjected to radiation therapy
An adequate tracheostome can be created with a beveled shape (a longer
segment of the posterior wall of the trachea is available, compared with
the anterior wall)
The pharyngoesophageal suture line (either by primary closure or with
a flap) is at least 2 cm cephalad to the upper border of the tracheostome.
On the other hand, a primary TEP is not recommended if:
The area of the tracheostome has been previously irradiated or if postoperative radiation therapy is planned
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TRACHEAL RESECTION
The indications for resection of the trachea are:
Primary tracheal tumors
Secondary invasion of the trachea from cancers of the thyroid or esophagus
Tracheal stenosis
Resection of the trachea for stenosis usually requires a circumferential,
segmental or sleeve resection, since strictures occur as a result of concentric
narrowing of the lumen. Often these involve a short segment of the trachea
(34 cm), and primary end-to-end anastomosis can be easily performed.
However, circumferential involvement is rarely seen in primary tumors of
the trachea or in secondary invasion by thyroid or esophageal cancer. In
these situations, accurate assessment of the extent of invasion is crucial to
determine the extent, feasibility, and method of reconstruction to be used.
Radiographic imaging is usually performed with CT or MRI, which shows the
extent of tumor invasion in three dimensions.
In addition, suspension laryngoscopy and tracheoscopy, under general
anesthesia with jet ventilation, is necessary for adequate assessment of the
intraluminal surface extent of the tumor. This requires assessment of the
longitudinal (cephalocaudad) and circumferential extent of the tumor.
Careful delineation of a cervical tracheal stenosis often is most straightforward via suspension laryngoscopy. A rigid laryngoscope can be carefully
suspended, permitting passage of either a rigid Hopkins rod telescope or a
flexible bronchoscope. We often favor inserting a smaller, anterior commissure laryngoscope just beyond the vocal folds to provide excellent exposure
to the subglottis and proximal trachea. If performed judiciously, this can be
accomplished with no sequelae to the glottic larynx.
When examining the tracheal stenosis under jet ventilation, it is critical
that the Hunsaker catheter or method of delivery be maintained entirely
within the supraglottis. Jet ventilation must not be delivered beyond the area
of stenosis, as lack of egress of air carries a very high risk of pneumothorax.
Fig. 6.5: Location of hyoid bone cuts (solid black lines) when performing a suprahyoid
laryngeal release to facilitate tracheal resection and reanastomosis.
If the length of resection is less than 5 cm, a circumferential segmental
resection is recommended. Primary end-to-end anastomosis can be easily
performed for a defect of this length. If necessary, to avoid tension on the
suture line, additional length can be gained by use of a supraglottic laryngeal release. This entails detaching all the central suprahyoid muscles from
the hyoid bone. By the use of an electrocautery device, the muscular attachments at the central portion of the upper border of the hyoid bone, between
the lesser cornua, are detached. The hyoid bone can then be divided lateral
to the lesser cornua. The digastric muscle slings are left intact (Fig. 6.5). Care
should be exercised as one approaches the greater cornua of the hyoid
bone laterally, to avoid inadvertent injury to the lingual artery, hypoglossal
nerve, and internal laryngeal branch of the superior laryngeal nerve. Once all
these muscles are detached, the larynx will drop downward and give approximately 23 cm of length for primary anastomosis of the trachea.
To avoid devascularizing the distal segment of the trachea, mobilization
of the distal segment of the trachea should be minimal, as its blood supply
is derived from the branches of the bronchial arteries, which run parallel to
the trachea. Therefore, the distal tracheal stump is mobilized using gentle
finger dissection in the superior mediastinum only on the tracheas anterior surface; the temptation to dissect laterally along the trachea should be
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Chapter
The Neck
INTRODUCTION
Significant advances have been made during the last three decades in surgery
of the neck, particularly for metastatic carcinoma. These advances have been
possible largely due to improved understanding of the biology of epithelial
cancers of the head and neck, patterns of neck metastases, and sequential
progression of metastatic spread from each primary site. First-echelon lymph
nodes are identifiable for nearly all primary head and neck cancers.
In addition, the development of sentinel lymph node biopsy techniques
for cutaneous cancers such as melanoma and Merkel cell carcinoma has
largely avoided the need for elective comprehensive neck dissections for
patients at risk of metastatic lymph nodes. The accuracy of sentinel lymph
node biopsy for cutaneous melanoma approaches 98%. Therefore, the
finding of a sentinel lymph node with no evidence of metastasis on pathologic analysis identifies patients who are very unlikely to benefit from an
elective nodal dissection.
These developments have allowed the evolution of operative procedures
that are less morbid, equally oncologically effective, and functionally better
and that produce more esthetically pleasing results.
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Fig. 7.1: Poorly placed lymph node biopsy incisions which create challenges for subse
quent neck dissection. In this example, biopsy of a level II lymph node at the angle
of the mandible (hashmarked line) was done with an incision that could not be incor
porated into the subsequent neck dissection incision (solid line).
NECK DISSECTION
Incision
A variety of incisions for neck dissection have been described in the literature. Each of them claims superiority, either for better exposure; for extension
of the operation to the oral cavity, larynx, pharynx, thyroid, etc.; for improved
esthetic outcome; or for ease of surgery. None of these incisions fulfills all the
criteria for an ideal incision for neck dissection.
The Neck
Fig. 7.2: Incisions for neck dissection (preferred). From top left to bottom right, selec
tive neck dissection; parotidectomy and neck dissection; thyroidectomy and lateral
neck dissection; thyroidectomy and bilateral neck dissections; bilateral comprehensive
neck dissections (lateral and anterior views).
In our opinion, the ideal incision for neck dissection is a single transverse
incision along a midcervical skin crease (below the beard line in men). For
additional exposure to the submental region, the incision may be extended
across the midline. For bilateral dissections, it can be extended along the
same crease to the opposite side of the neck. The incision may be made as
long as is necessary to facilitate exposure of the lateral neck up to the mastoid
process or down to the supraclavicular fossa. Surgery for primary tumors of
the larynx, pharynx and thyroid can be performed through the same incision.
For oral cancer requiring mandibulotomy or mandibulectomy, a vertical
limb of the incision may be placed in the midline, splitting the lower lip (an
inverted T incision). The incision provides excellent exposure, is esthetically superior, and rarely causes skin flap loss, even in a postchemoradiation
setting. The selection of the skin crease for placement of the incision varies
from patient to patient, depending on the location of natural skin creases,
additional primary sites requiring surgery (lower incisions for concomitant
thyroid surgery), or the need for tracheotomy (in which case a higher incision
is used) (Fig. 7.2).
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where only a select group of lymph node levels are dissected. Several operations are described under these two broad categories.
The Neck
B
Figs 7.3A and B: (A) Identification of the marginal mandibular branch of the facial
nerve during elevation of the superior skin-platysma flap; (B) Alternatively, the facial
vein can be divided and elevated to protect the marginal mandibular nerve.
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PRESERVATION OF VASCULARITY OF
THE ACCESSORY NERVE
A significant number of patients undergoing comprehensive modified neck
dissections or selective lateral node dissections develop weakness of the
shoulder and some atrophy of the trapezius muscle, despite the anatomically
preserved accessory nerve. This occurs as a result of circumferential dissection of the nerve during comprehensive neck dissections, or dissection of
level IIB in selective node dissections.
We do not recommend routine dissection of level IIB in patients undergoing anterolateral (levels I to IV) or supraomohyoid (levels I to III) nodal
dissection in whom there are no grossly enlarged lymph nodes at level IIA. In
the absence of gross metastatic disease at level IIA, the incidence of metastasis at level IIB is very low, close to zero. By avoiding level IIB dissection, the
accessory nerve is not circumferentially dissected, preserving its vascularity
and minimizing ischemic nerve dysfunction.
Similarly, in patients undergoing comprehensive modified neck dissections, circumferential dissection of the nerve should be avoided, to preserve
its vascularity as much as possible. The apex of level V, superior and posterior
to the accessory nerve, can be safely left in situ, in most cases. There are essentially no lymph nodes of concern posterior to the accessory nerve at the apex
of the posterior triangle, and metastases to the apex of level V are exceedingly rare. Therefore, the nerve should be left undisturbed in its fascial bed,
keeping the nodal dissection anterior and inferior to the nerve in the posterior triangle. Preserving the vascularity of the nerve in this fashion minimizes
ischemic nerve injury and subsequent shoulder dysfunction. Certainly, in
the uncommon case of bulky metastatic disease along the accessory chain,
dissection of the apex of level V may be required.
The Neck
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excising lymph nodes between the carotid arteries, from the hyoid bone to the innomi
nate artery, preserving both recurrent laryngeal nerves.
The Neck
Such thorough dissection is necessary to prevent recurrence of disease
in the central compartment of the neck. This extent of node dissection will
often jeopardize the vascularity of the inferior parathyroid glands. If there
is any concern about the viability of the inferior parathyroid glands, they
should be implanted in the adjacent sternocleidomastoid muscle. The superior parathyroid glands generally retain an intact blood supply and can be
easily dissected off and preserved with their blood supply intact. When this is
performed, nerve monitoring may be useful for inexperienced surgeons or in
patients with extensive nodal disease.
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Chapter
Thyroid and
Parathyroid Glands
INTRODUCTION
The traditional large, low cervical incision has been mostly abandoned,
except for use in patients with large retrosternal goiters. Most patients with
tumors 23 cm in diameter can easily undergo lobectomy or total thyroidectomy through incisions of 34 cm in length without the need for endoscopes
or other advanced techniques. The placement of the incision is crucial to
achieve the best esthetic outcome. The standard post-thyroidectomy incision
and scar is demonstrated in Figures 8.1A and B.
In general, female patients with large breasts should have the incision
placed in a natural skin crease, as high as possible, to obtain the necessary
exposure. In these patients, the incisions will be displaced inferiorly when
they are upright. It is helpful to mark the incision on the patients neck in
the preoperative holding area, with the patient sitting upright. Conversely,
patients of average build should have the incision placed in a natural skin
crease over or near the region of the cricothyroid membrane. The incision
B
Figs 8.1A and B: (A) Incision outlined for thyroidectomy; (B) Long-term postoperative
appearance of carefully placed incision for thyroidectomy.
should be equal in length on both sides of the midline, regardless of the location of the nodule(s). The platysma is divided, and upper and lower skin flaps
are elevated.
The skin flaps are retracted using fish hook retractors (short blunt metal
hooks anchored on an elastic rubber band). Several steps of the operation
have been modified to facilitate a safe, complete, meticulous, and essentially
bloodless operation. Generous use of bipolar cautery is recommended. The
operative steps should be followed in the following sequence:
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1. The strap muscle fasciae are divided in the midline, and the sternohyoid
muscles are retracted laterally.
2. The sternothyroid muscle is divided as high as possible, which substantially enhances exposure of the superior pole, and then carefully dissected
off the anterior surface of the gland and either excised or left pedicled
inferiorly. Although this step is not universally necessary, it substantially
enhances exposure in nearly every case.
3. Terminal branches of the superior thyroid artery and tributaries of the
superior thyroid vein are each individually divided and ligated low on
the gland, below the superior pole of the gland. The superior pole vessels
should not be ligated en masse. This protects the external laryngeal
branch of the superior laryngeal nerve.
4. The upper pole is retracted medially, and the superior parathyroid gland
is identified, dissected off the thyroid, and carefully dissected laterally,
preserving its blood supply, which is lateral to the parathyroid gland.
5. Dissection continues caudally, along the posterior capsule of the thyroid,
in an extracapsular plane, to identify the inferior parathyroid gland,
which is separated from the thyroid and retracted laterally, with its blood
supply intact.
6. The lower pole vessels are dissected and divided, taking care to remain in
a pretracheal plane, thereby mobilizing the lower pole while remaining
well anterior to the location of the recurrent laryngeal nerve.
7. The thyroid lobe is retracted medially, and the recurrent laryngeal nerve
is identified. The course of the nerve must be carefully ascertained proximally and distally.
8. All thyroid tissue at Berrys ligament is meticulously dissected off
the trachea, protecting the recurrent laryngeal nerve and ligating the
terminal branches of the inferior thyroid artery.
9. The thyroid lobe and isthmus are peeled off the trachea, using either
judicious cautery or cold steel dissection.
10. The pyramidal lobe is traced up to the hyoid bone and dissected off
completely.
11. The contralateral lobe is dissected similarly, to complete the total thyroi
dectomy.
12. The thyroid gland is meticulously inspected for retained parathyroid
glands.
13. Absolute hemostasis is secured.
14. A drain is generally not required.
15. The wound is closed in layers.
16. The patient may be discharged the same day or stay overnight and go
home the next morning.
There is some variation among the practice of thyroidectomy. We believe
that it is safest to routinely identify the recurrent laryngeal nerve during
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access for lateral neck dissection(s). A U-shaped incision curving upwards toward the
mastoid tip is not recommended.
with gentle traction. Rough digital dissection can be hazardous and may
lead to uncontrollable bleeding: it should be avoided. Gentle and meticulous digital mobilization and sequential division and ligation of the blood
vessels result in safe delivery of the goiter. The entry of the recurrent laryngeal nerve should be identified at the cricothyroid joint, which is the most
consistent landmark and is helpful in cases of goiter, where the nerve may be
displaced in any direction. From this location, the nerve is followed caudally,
as dissection of the goiter proceeds into the mediastinum. In cases of large
goiters, it is difficult to preserve the blood supply to the inferior parathyroid
glands. Therefore, efforts should be made to identify these glands and to
reimplant them into the sternomastoid muscle.
Management of a differentiated thyroid cancer with recurrent laryngeal nerve invasion depends on a number of factors, most importantly the
preoperative function of the nerve. A patient presenting with vocal cord
paralysis is very unlikely to regain function of the nerve, even if it is preserved,
and therefore there is little benefit to preserving the nerve in these situations.
On the other hand, if the nerve is functioning preoperatively, we seek to
remove all gross tumor from the nerve, leaving behind microscopic disease,
which will be targeted with adjuvant therapy. This is performed with careful
dissection, using a fine clamp. In some cases, the extent of tumor involvement precludes dissecting out the nerve anatomically intact. If the nerve is
to be sacrificed, the integrity of the contralateral nerve should first be absolutely ensured.
NERVE MONITORING
Routine use of intraoperative nerve monitoring is not necessary. However,
this technique may be useful for a relatively inexperienced surgeon to
identify and confirm the recurrent laryngeal nerves location and function.
Additionally, even for experienced surgeons, nerve monitoring may be
useful for the management of select patients undergoing surgery for recurrent cancer in a scarred field, as well as for patients with massive tumors in
whom early identification of the nerve may be difficult or in whom extensive
dissection of the nerve may lead to a loss of nerve conduction. In these cases,
knowledge of loss of nerve conduction may influence the surgeons decision
to move to the other side and dissect the contralateral nerve or not.
In these respects, nerve monitoring is very much an adjunct to surgery,
and not a substitute for the above-delineated principles of routine nerve
identification and careful dissection.
If nerve monitoring is performed a number of practical aspects can be helpful.
The anesthesiologist should use only short-acting paralytics for
induction.
If working with anesthesiologists unfamiliar with the monitoring tube,
the surgeon should personally verify appropriate placement of the
electrodes at the level of the true vocal cords after positioning the patient
and extending the neck.
Respiratory variation in the baseline electromyography (EMG) tracing
will confirm correct tube placement. Tapping on the larynx can stimulate
the nerve monitor, regardless of appropriate placement, and is therefore
less reliable.
For the most part, the stimulator probe will be used at 1 mA.
Once the surgical field is open, test the nerve stimulator on strap muscles
to confirm muscle twitch.
When stimulating tissue, a lack of signal should never be accepted as
negative until a positive control is obtained by successfully stimulating
the recurrent laryngeal nerve.
In cases where the recurrent laryngeal nerve has not been identified
and a positive control is needed, it is straightforward to open the carotid
sheath lateral to the thyroid lobe, expose the vagus nerve, and stimulate
it, to confirm that the system is working properly.
At the completion of dissection on one side, the nerve should be stimulated as proximally as it has been dissected, to confirm intact stimulation.
A loss of proximal nerve conduction (with intact distal conduction near
the nerve insertion to the larynx) may indicate an unappreciated neuropraxia caused by stretching, clamp, or cautery injury and may influence
the surgeons decision to operate on the contralateral lobe.
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PARATHYROID SURGERY
Once a diagnosis of primary hyperparathyroidism is made by use of biochemical testing, the critical aspect of parathyroid surgery becomes preoperative localization. The modality or modalities used for preoperative
localization are highly dependent on local expertise and surgeon preference.
These include nuclear medicine sestamibi scan, ultrasound, thin-slice
contrast-enhanced CT scan, and dynamic 4D CT imaging. The goal of
pre-operative localization imaging is to identify the precise location of the
parathyroid adenoma and to facilitate minimally invasive surgery. Surgeons
who perform high-volume parathyroid surgery are well served by learning
skills for cervical ultrasound, which provides an unparalleled threedimensional sense of the location of the enlarged parathyroid gland.
Fig. 8.3: Locations of local anesthetic injection (black Xs) for local and regional anesthesia for minimally invasive parathyroidectomy.
Fig. 8.4: Short, lateral incision for minimally invasive parathyroidectomy. The entire
skin crease should be marked, in case of a need to extend the incision for bilateral
parathyroid exploration.
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Fig. 8.5: Cross sectional view of the lateral approach to parathyroid glands, used
need to be ligated. With the thyroid lobe retracted medially and the common
carotid artery retracted laterally, the adenoma is readily identified and
removed en bloc (Fig. 8.5). Embryologic development dictates that an inferior
parathyroid gland will be in the plane anterior to the recurrent laryngeal
nerve and that a superior parathyroid gland will be in the plane posterior
to the recurrent laryngeal nerve. Gentle, meticulous dissection is critical to
avoid spillage of parathyroid tissue and possible subsequent development
of recurrence. If slow, careful extracapsular dissection is performed, it is not
necessary to routinely identify the recurrent laryngeal nerve. The superior
parathyroid glands will invariably be located adjacent to the course of
the nerve.
Intraoperative PTH monitoring and frozen-section pathologic analysis are used to confirm removal of parathyroid tissue and completeness of
surgery. The intricacies of intraoperative PTH monitoring are beyond the
scope of this text, but, in general, the Miami criteriawhich specify a PTH
level decrease of greater than 50% into the normal rangeare followed. If
additional surgery is required, the ipsilateral gland can be explored through
this same incision, and the incision can be extended.
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Chapter
Salivary Glands
SUPERFICIAL PAROTIDECTOMY
Superficial parotidectomy with dissection and preservation of the facial
nerve is the most common operation used for neoplasms located in the
superficial lobe of the parotid gland. The operation is advocated for both
benign and malignant tumors confined to the superficial lobe of the parotid
gland, with normal facial nerve function. In general, this means tumors that
are staged T1 or T2. There are several technical points that are crucial and
important to follow for safe, smooth and expeditious conduct of this operation and to produce a pleasing esthetic and functional outcome.
Incision
In older patients, who have lax skin and natural skin creases, a preauricular
skin crease is selected for placement of the incision. The incision is made in
the preauricular skin crease and curves around the lobule of the ear, on to the
postauricular skin overlying the mastoid process, and then extends anteroinferiorly into an upper neck skin crease. This is the usual modified Blair incision. The lower end of the incision should not extend beyond the anterior
border of the lower part of the parotid gland.
On the other hand, in young patients and those lacking natural skin
creases in the preauricular region, such an incision should not be used. In
such cases, the incision should be modified to avoid a visible preauricular
scar. The incision used in this setting is called a tragal incision. The incision
begins at the upper end of the tragal cartilage, on the free edge of the tragus,
up to the lobule of the ear. It is not necessary to carry the incision over to the
posterior border of the tragus. The incision then continues on the junction
of the lobule and preauricular skin, curves around the lobule of the ear in
the skin overlying the mastoid process, and then follows an upper neck skin
crease anteroinferiorly (Fig. 9.1). When this incision is used, extreme care
should be exercised to not perforate the skin while elevating the skin flap over
the tragus. There is no soft tissue between the skin and the tragal cartilage.
Salivary Glands
Therefore, the pretragal skin is elevated with the scalpel by sharp horizontal
dissection, separating skin from cartilage up to a distance of 1 cm. To prevent
perforation of the skin, use of electrocautery during elevation of this part of
the skin flap should be avoided. The skin is quite thin and should be handled
very delicately. Subsequent elevation of the skin flap can be easily performed
using an electrocautery device. The esthetic impact of the tragal incision is
minimal, with superb postoperative appearance (Fig. 9.2).
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For deep lobe parotid tumors, the incision is slightly modified. The standard superficial parotidectomy incision is generally not adequate in these
cases. In these patients, exposure of the posterior belly of the digastric and
stylohyoid muscles is required to gain access to the parapharyngeal space.
Therefore, to expose the region of the stylohyoid window, the lower part of
the incision is extended anteroinferiorly along the upper neck skin crease.
Salivary Glands
Figs 9.3A and B: Surface landmarks (dotted black lines) helpful in identifying the
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Fig. 9.4: Preservation of the posterior branch of the great auricular nerve is often
feasible during parotidectomy.
into several branches over the surface of the parotid gland. Thus, it needs to
be sacrificed as the parotid gland is mobilized and dissected away from the
sternocleidomastoid muscle. However, in a significant minority of patients,
the nerve bifurcates early on the surface of the sternomastoid muscle, with
its posterior branch proceeding directly cephalad toward the mastoid tip.
In these patients, the anterior branch of the greater auricular nerve is sacrificed, but the posterior branch can be preserved, thus retaining sensations
for a significant portion of the auricle (Fig. 9.4). Therefore, during elevation of
the skin flap, meticulous attention should be given to identifying the greater
auricular nerve and determining whether it bifurcates early, thereby enabling
preservation of its posterior branch.
Salivary Glands
Similarly, the superficial lobe of the parotid gland is dissected away from
the cartilaginous portion of the external auditory canal by use of electrocautery, expeditiously and with excellent hemostasis. Care should be taken to
avoid cauterizing the cartilage itself. However, to prevent transmission of
electrical current or thermal injury to the facial nerve, the use of monopolar
electrocautery should cease once the cartilaginous external auditory canal
is separated but still slightly superficial to the plane of the posterior belly of
the digastric muscle. At this point, bipolar electrocautery should be used for
further division of tissue. A long Adson or fine tonsil clamp is used to dissect
the parotid tissue, which is first cauterized with the bipolar cautery device and
then sharply divided with a scalpel or fine scissors. This method of dissection
provides excellent hemostasis and maintains a dry field.
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Fig. 9.5: Landmarks helpful in identifying the main trunk of the facial nerve during
parotidectomy.
Salivary Glands
innervation to the gland, resulting in unopposed, simultaneous parasympathetic stimulation of myoepithelial cells. Patients undergoing superficial
parotidectomy have little or no remaining parotid tissue, and therefore
have a much lower incidence of first bite syndrome: approximately 510%,
compared with 3040%.
The operative procedure for a deep lobe parotid tumor begins with either
the usual parotid incision in a preauricular skin crease or a tragal incision. In
general, excision of a deep lobe parotid tumor requires minimal elevation of
the preauricular skin but does require extension of the skin incision further
anteroinferiorly along an upper neck skin crease to allow access to the retromandibular portion of the deep parotid space. After elevation of the skin flap,
dissection of the superficial lobe of the parotid gland, to identify the main
trunk of the facial nerve, proceeds in the usual fashion. The main trunk of
the facial nerve is identified as described above. Further dissection proceeds
in the usual fashion, to expose the lower division of the facial nerve and its
lowest branch, the cervical branch. The dissection of the cervical branch
continues peripherally until its exit from the anterior border of the superficial
lobe of the parotid gland. At this juncture, the lower division and its lowest
branch have been dissected and can be safely maintained in view. There is no
need for further dissection of the superficial lobe of the parotid gland at this
point. However, during the remainder of the surgical procedure, the main
trunk, the lower division, and the cervical branch are all constantly kept in
view to maintain anatomic and functional integrity.
Dissection now begins in the deep parotid space cephalad to the superior border of the posterior belly of the digastric muscle. The stylohyoid
muscle and the distal external carotid artery both traverse this area, running
superficial to the deep lobe parotid tumor, and, therefore, usually need to
be divided and ligated. In some patients, the styloid process is long and
may have to be amputated to facilitate digital dissection and mobilization
of the tumor to avoid rupture. The muscles attached to the styloid process
are detached with an electrocautery device, and the bony styloid process is
denuded. A rongeur is used to amputate the styloid process near its base.
The sharp edges at its divided stump are smoothed out. Dissection now
begins digitally around the deep lobe parotid tumor in the parapharyngeal
space, delicately and carefully, to avoid rupture of the tumor or unnecessary bleeding. Once the tumor is mobilized circumferentially with digital
maneuvers, it is delivered from the parapharyngeal space through the stylohyoid window. This is a tight anatomic space between the posterior border
of the ascending ramus of the mandible and the greater cornu of the hyoid
bone. The tumor should be delivered intact in a monobloc fashion (Figs 9.6A
and B). Rupture and spillage of certain tumors, such as pleomorphic
adenomas, may increase the risk of recurrence.
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B
Figs 9.6A and B: (A) Identification and dissection of lower division of facial nerve
branches for exposure of a deep lobe parotid tumor; (B) followed by monobloc delivery
with careful digital dissection.
Salivary Glands
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in toto for neoplasms of the submandibular salivary gland. On the other hand,
for patients with obstructive sialadenitis and calculous disease, the entire
submandibular salivary gland as well as its extensions and the collecting
ducts, including Whartons duct, up to its opening at its papilla in the floor
of the mouth, should be excised to best prevent development of recurrent
stones in the duct remnant. This procedure requires bimanual through-andthrough resection of the entire course of Whartons duct from the anterior
floor of the mouth, through the intermuscular plane in the floor of the mouth,
into the submandibular salivary gland.
The operative procedure is conducted using an upper neck skin crease,
in the usual fashion, elevating the upper skin-platysma flap and paying
careful attention to identifying and preserving the marginal mandibular
branch of the facial nerve, which is dissected off the capsule of the submandibular gland and reflected cephalad with the upper skin flap (see Chapter 7).
When there is no suspicion of malignancy, it is possible to incise the fascia
of the submandibular gland low on the gland and to elevate this superiorly,
to protect the nerve. The facial artery and vein are divided and ligated in the
usual fashion. The external/cervical component of the operation requires
complete mobilization of the submandibular salivary gland up to and deep
to the lateral border of the mylohyoid muscle.
At this point, a circumferential incision is made in the mucosa of the
floor of the mouth, around the opening of the papilla of Whartons duct on
the ipsilateral side, carefully avoiding any injury to the papilla of the contralateral Whartons duct. This incision is extended up to 1 cm posteriorly in the
lateral floor of the mouth. Circumferential mobilization of Whartons duct is
now performed, carefully separating it from the lingual nerve and the lingual
artery and vein, securing absolute hemostasis. Once the duct is mobilized, a
2-0 silk suture is used to tie the distal stump of the duct, and long ends of the
silk suture are left for identification of the distal end.
Once mobilization of Whartons duct through the floor of the mouth up
to the mylohyoid muscle is completed intraorally, attention is focused back to
the cervical wound, where further distal mobilization of Whartons duct deep
to the mylohyoid muscle is performed, until the entire duct is completely
mobilized, permitting removal of the duct in its entirety. This maneuver
ensures that the entire inflamed salivary gland and salivary collecting duct
system is resected, to avoid formation of recurrent stones in the salivary duct
system. The intraoral wound is closed, in the usual watertight fashion, with
interrupted chromic catgut sutures, and the neck wound is closed in layers.
A small Penrose drain is used for drainage of the dead space, and the drain is
brought out through the posterior end of the incision.
Chapter
Other Tumors
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Fig. 10.1: Postcontrast T1 weighted MRI, showing Shamblin type II (Right) and type III
(Left) carotid body tumors.
Fig. 10.2: Instruments used in dissection of carotid body tumors. From left to right,
a Penfield #4 dissector, Freer elevator, fine Adson hemostat, fine-tipped tenotomy
scissor, and micro-mosquito hemostat.
Other Tumors
Fig. 10.3: Detail of the dissecting tips of the Freer elevator (top) and the Penfield #4
dissector (bottom).
Fig. 10.4: Exposure of the carotid sheath first requires excision of level II and III
lymph nodes.
lymph node-bearing tissue from levels II and III (Fig. 10.4). It is quite common
to observe hypervascularity of the adventitia of the carotid artery proximal to
the tumor, over the common carotid artery, or of the involved vagus nerve
or sympathetic chain. This increased vascularity results from the dilated,
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Chapter
Transoral Surgery and
Endoscopic Techniques
11
Choosing an Approach
The decision of whether to use the robot or the operating microscope and laser
depends on the surgeons personal preference, with the exception of cases of
tumors of the glottic larynx, which cannot currently be approached via TORS.
There are other critical differences. TLM lends itself better to systematic,
piecemeal tumor resection, whereas TORS is generally better suited to monobloc resection of the tumor. TORS permits operating with a 30 endoscope,
whereas TLM is a line-of-sight procedure. TORS is performed with a bedside
assistant for retraction and suctioning, whereas TLM is performed with the
surgeon at the head of the bed. These factors may have implications for which
technique is better suited to a particular tumor.
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1.
2.
3.
4.
5.
6.
7.
8.
Teeth: The presence of upper incisors and the degree of overjet, which
affect the extension of the laryngoscope
Trismus: Significant trismus will limit exposure
Tongue: The volume of the base of the tongue will affect exposure of base
of tongue and laryngeal tumors
Tilt: Atlanto-occipital extension is necessary for adequate laryngeal
exposure
Transverse dimensions of the mandible: A narrow mandibular arch will
limit exposure and ability to displace the tongue
Torus: Mandibular tori will limit mobility of the laryngoscope
Treatment: Radiation therapy-induced fibrosis will limit exposure
Tumor: An exophytic tumor may require debulking in order to clearly
expose the complete base of the tumor and its extent of mucosal
involvement
The Gttingen suspension arm provides a mobile base attached to the bed
and keeps the scope suspension arm off the patients chest (Fig. 11.3).
Obtaining ideal exposure may require sequentially inserting a series
of different laryngoscopes or using a variety of different tongue-retracting
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B
Figs 11.5A and B: Participation of a bedside assistant during transoral robotic surgery.
depth at multiple sites along the tumor and reduces the chance of an unintentionally positive deep margin (Fig. 11.7B). To expose the base of the
tumor, it may be necessary to initially debulk tumors that are large and bulky
(Fig. 11.7C). Accordingly, in most cases, the initial laser cut is made directly
through the midportion of the tumor and carried down to the depth of the
tumor (Fig. 11.8). The interface between tumor and normal tissue is easily
Fig. 11.6: A surgical chair with adjustable armrests is critical for transoral laser
microsurgery.
C
Figs 11.7A to C: Tumor cuts in transoral laser microsurgery. (A) Very small tumors
can be removed en bloc with incisions made widely around the tumor; (B) Most tumors
should be removed in a multibloc fashion, with transtumoral incisions used to ascertain
depth; (C) Large tumors may need to be initially debulked, then removed in a multibloc
fashion.
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Fig. 11.8: Initial transtumoral laser cut through the midpoint of an oropharyngeal tumor.
tumor, the tumor should be immediately mounted in place (Fig. 11.9) and
the orientation of margins should immediately be marked with ink or pins as
soon as the tumor has been removed from the patient (Fig. 11.10).
Fig. 11.10: Immediate labeling of margin orientation with pins or ink in the operating
room.
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Fig. 11.11: Use of a latex glove finger to avoid tongue prolapsed between the blades
of the bivalve laryngoscope.
Fig. 11.12: The vocal cord spreader is a useful instrument to distract tissue laterally
when making a transtumoral cut through a large tumor.
confluence of the lateral edge of the epiglottis, the aryepiglottic fold, and
the pharyngoepiglottic fold. The artery will be encountered just beyond the
superior laryngeal nerve. Once the nerve is encountered, dissection should
be deliberately slow in this region; once the vessels are identified, they should
be repeatedly clipped with endoscopic clips and then divided.
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Fig. 11.13: The FK retractor provides excellent access to base of tongue tumors, for
either TLM or TORS resection.
ENDOSCOPIC MANAGEMENT OF
TRACHEAL AND SUBGLOTTIC STENOSIS
In adult patients, tracheal stenosis is most definitively treated with tracheal resection and reanastomosis, a safe and straightforward procedure
(see Chapter 6). However, in certain highly selected patients, endoscopic
management of tracheal stenosis may be effective. These include:
Patients with short-segment (< 1 cm), web-like stenosis
Patients with very recent (fresh) stenosis observed shortly after prolonged
intubation
Patients unable to undergo definitive tracheal surgery because of significant comorbidity
As with all transoral and airway operations, these procedures depend on
a high level of communication between the surgeon and the anesthesiologist. The importance of this is particularly escalated in patients with airway
stenosis. Therefore, it is critical to have a detailed discussion regarding the
airway management plan before induction of anesthesia. Along the same
lines, it is critical to assemble all airway equipment and instruments before
the patient is brought into the OR.
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For subglottic and tracheal stenosis, we have found suspension laryngoscopy with jet ventilation to provide ideal exposure and access to the trachea.
This procedure generally requires the following instrumentation:
A rigid (e.g. Dedo) laryngoscope
Lewy suspension system
Jet ventilation setup (such as a Hunsaker catheter)
0 and 30 Hopkins rod telescopes
Flexible bronchoscope
Balloon dilator (esophageal balloons are preferred to tracheal balloons)
The following equipment may not always be necessary but should be
immediately available:
A selection of small (size 4.5, 5.0, 5.5, 6.0) endotracheal tubes
Rigid bronchoscope with jet ventilation catheter attached
Tracheotomy set, opened and ready to use
CO2 laser (micromanipulator on a microscope or handheld fiber)
Chest tube tray (in the event of tension pneumothorax)
There are a multitude of approaches to the anesthetic and airway plan.
In the standard patient with subglottic or tracheal stenosis, we tend to follow
this sequence of events for establishment of the airway and initial exposure:
1. The patient is brought into the room; IV access is secured. The tracheotomy set is opened, a Bovie grounding pad is placed, and suction tubing
is set up in case there is a need to perform an urgent surgical airway at
any point.
2. The patient is preoxygenated, and general anesthesia is induced with a
short-acting paralytic.
3. The anesthesiologist verifies that the patient can be easily mask ventilated, with satisfactory chest rise.
4. The table is turned 90.
5. The patient is maximally paralyzed.
6. The Dedo laryngoscope is inserted and suspended, and jet ventilation is
connected.
7. The jet ventilation catheter must be kept above the stenosis at all times, to
avoid the risk of pneumothorax attributable to incomplete egress of air. If
a Hunsaker catheter is used, its tip is placed in the supraglottis.
8. Satisfactory chest rise and fall is confirmed with jet ventilation.
9. If there are concerns about egress of air, a large-gauge angiocath can be
placed percutaneously below the stenosis. However, in this scenario,
dilation should proceed expeditiously, and a high level of suspicion
should be maintained for pneumothorax.
If there are difficulties maintaining adequate ventilation, the options
are to:
Intubate through the stenosis with a small endotracheal tube. The dilation can still be performed by removing and replacing the tube.
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B
Figs 11.15A and B
PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY TUBE INSERTION
Percutaneous endoscopic gastrostomy (PEG) tube insertion is a useful
technique for the head and neck surgeon and is particularly applicable in
the management of patients undergoing extensive resection and reconstruction, in whom it is most straightforward to insert the PEG tube at the
time of surgery. This avoids the need for instrumentation of the upper
D
Figs 11.15C and D
aerodigestive tract for PEG insertion at a later date. In patients who are not
undergoing surgical resection but are undergoing examination and biopsy
under general anesthesia, it may be logistically desirable to insert a PEG
feeding tube in anticipation of chemoradiation therapy, obviating the need
for a second anesthetic.
A single dose of antibiotics (commonly, first-generation cephalosporin)
is administered. A standard, complete upper gastrointestinal endoscopy is
performed. Careful examination of the esophageal mucosa has particular
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E
Figs 11.15A to E: Technique for endoscopic management of tracheal stenosis.
(A) Preoperative photograph demonstrating high-grade stenosis; (B) Intraoperative
photo after radial incisions made in stenotic segment and (C) after balloon dilation;
(D) Endoscopic view 1 week and (E) 1 year after dilation
Source: Pavan Mallur, MD, Beth Israel Deaconess Medical Center, Boston, USA.
Fig. 11.16: Inflatable balloon dilator used for the dilation of tracheal stenosis.
importance for the patient with head and neck squamous cell cancer, who is
at elevated risk of second primary cancers of the esophagus. Since the PEG
will be used for feeding, gastric outlet and duodenal obstruction should be
quickly ruled out by advancing the scope into the duodenum.
The stomach is maximally insufflated with air, and the room lights are
dimmed. The anterior abdominal wall should be transilluminated with the
gastroscope; if needed, the light can be turned up to the transilluminate
setting. A single finger is then used to indent the anterior abdominal wall at
least 12 cm away from the costal margin. It is important that the endoscopic
view reveal focal indentation of the abdominal wall. In most cases, the PEG
tube should not be inserted if excellent transillumination and focal finger
indentation cannot both be achieved.
The abdominal wall is now sterilely prepared and draped. Before inserting
the needle, the endoscopic snare is passed through the gastroscope and positioned. This saves time; once the stomach is punctured, effective insufflation
is sometimes difficult to maintain.
At the point of PEG insertion, a 5 mL syringe with sterile water is carefully inserted, with suction in the syringe. The presence of air bubbles in the
syringe before entry into the stomach may indicate entry into the colon; if
this occurs, another site of insertion should be used. Once the angiocath is
in the stomach, the snare is maneuvered around the angiocath, to facilitate
grasping the guidewire. The feeding tube can then be inserted in the standard
pull fashion and secured to the abdominal wall with 12 cm of distance left
between the external bumper and skin.
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Index
Page numbers followed by f refer to figure.
A
Abdominal wall 121
Adenoma 84
single 86
Anesthetic injection for local, locations
of local 85f
Angiosomes of face 14
Anterior
abdominal wall 121
craniofacial surgery 35
Anterolateral neck dissection 72
Apron incision 62, 62f
Atlanto-occipital
extension 104
joint 106
Autologous bone 31
B
Balloon
dilator 116
of endotracheal tube 68
Bedside assistant transoral robotic
surgery 108f
Berrys ligament 80
Bifrontal craniotomy 35
Bilateral comprehensive neck
dissections 71f
Biopsy
excisional 70
incisional 70
Bipolar electrocautery device 99
Bivalve supraglottiscope 105f
Bleeding cancellous bone 19
Blood supply to
face 14
scalp 14
subsites, major 14
Bone segments during healing 54
Buccinator see Cheek
C
Cancellous bone 46
Canine fossa 34
D
Debulk tumors 108
Deep lobe parotid tumor 96f
excision of 94
Dental obturator 32, 58
124
Diffenbach 26
Digastric muscle 67, 90, 92, 95
Dissection technique, basic 12
Double adenoma 86
Double rotation scalp flap, design of 19f
Dry sebaceous material 17f
E
Electrocautery tip extensions 7
Electrodissection instruments 6
Electrosurgical instruments 6f
Endonasal skull base surgery 36
Endoscopic
intracranial surgery 36
management of tracheal 115
techniques 103
Endotracheal tube 28
Epiglottis, lateral edge of 112
Erbs point, muscle 90
Esophageal mucosa 119
Eye in facial paralysis, management of 97
Eyebrow 28
F
Facial
expression, muscle of 14
incision 26
nerve 95, 96
during parotidectomy, main trunk
of 94f
sacrifice of 96
skin
flaps, types of 25
lesions, excision and primary
closure of 23
Feyh-Kastenbauer laryngopharyngo scope see F-K laryngopharyngo scope
Fibula graft to segmental mandibulec tomy defect 48f
FIO2 see Inspired oxygen, fraction of
Fish hook
excellent retraction of skin flaps 12f
retractors 79
F-K laryngopharyngoscope 105f, 107
FK retractor excellent access to base of
tongue tumors 114f
Flat tip bovie 10f
Four-gland
exploration 86
hyperplasia see Double adenoma
Frontal craniotomy 35
G
Galeal relaxing incisions 20f
Gingivolabial sulcus 53
Gland, superior 87
Glottic tumor 59
Gttingen suspension arm 105
suspension 106f
Great auricular nerve, management
of 90
H
H incision 62
Handheld carbon dioxide laser scalpel 8
Harbor multigland disease 86
Hard palate, preservation of 34
Harmonic scalpel 8
Healing of tracheostome 62
Hemimaxillectomy 29
Hunsaker catheter 116
Hyoid bone 80
cuts, location of 67f
Hyperkeratosis see Leukoplakia
Hypopharynx 59
I
Incise platysma 10f
Inferior alveolar 14
Inferior thyroid artery 80
Infiltration before incision 15
Inflatable balloon dilator for dilation of
tracheal stenosis 120f
Infraorbital
alveolar 14
skin crease 27f, 38f
Infratemporal fossa 31, 37
Initial transtumoral laser 110f
Inspired oxygen, fraction of 104
Intralesional steroids 117
Intraoral lesions 47
J
Jugular node 72
Index
K
Keratinizing mucosa 42
L
Labial branches of facial artery 14
Langers lines 8
Large retrosternal goiters 78
Laryngeal
nerve 80
superior 112
squamous cell cancer 75
tumors, advanced 60
Laryngectomy, incisions for 61f64f
Larynx 59
Lateral neck dissection 71f
Lateral neck dissection See Jugular node
Leukoplakia 45
Ligasure cautery device 7
Lip, excision of 42
Lip-splitting incision 55
Lower division of facial nerve branches,
dissection of 96f
Lower part of maxilla, resection of 29
Low-stage tumors 59
Lymph node biopsy 69
Lynch 26
extension see Eyebrow
M
Mandible, management of 46, 48
Mandibulectomy 46
bone 50f, 51f
marginal 48
segmental 47f
Mandibulotomy 52
lateral 52
Marginal
mandibular branch of facial nerve
identification of 73f
preservation of 72
mandibulectomy 48
Maxillary
antrum 34
swing approach 3840f
Maxillectomy defect 31
management of 31
Merkel cell carcinoma 69
Midcervical skin crease 71
Middle cranial fossa 37, 41
Midline
mandibulotomy 52
vertical incision 61, 61f
Minimally invasive parathyroidec tomy 84
Monobloc delivery with careful digital
dissection 96f
Mouth 45
Mucocutaneous junction 43f
Mucoperiosteal incision 38f
Mucosal edges closer 44
Myelohyoid see Mouth
sling 54
muscle 98
Myoepithelial cells 95
N
Nasal
cavity 26
intubation 28
subunits 27f, 38f
Nasolabial
orbital region 26
skin crease 28
Neck 69
dissection 70, 71
extent of 71
in postchemoradiation salvage
setting 75
incision 70, 71f
lateral 81
selective 72
squamous cell cancer 121
Needle tip bovie 10f
Nerve monitoring 83
Nonthyroid diagnoses 78
Nose 26
Nuclear medicine 84
O
Oculi muscle, orbicularis 28
Ohngrens line 29
Open head and neck surgery 9f
Operating room setup 1
Oral cavity 42, 70
partial glossectomy 42
Oropharyngeal tumor 110f
Osteotomies preserving angle of
mandible 47f
125
126
P
Palatal
fenestration 32
for hard palate tumors 57
island flap for reconstruction of hard
palate defect 33f
osteotomy 37, 38f
Paragangliomas 99
Paramedian mandibulotomy 53
design of 54f
Paranasal sinuses 26
Parathyroid
gland 78, 84
superior 80
surgery 84
Parathyroidectomy, subtotal 86
Parotid gland 95
initial dissection of 92
Parotidectomy 94
neck 71f
Partial maxillectomy 29
Pectoralis major myocutaneous flap 62
Penfield dissector 99
Percutaneous endoscopic
gastrostomy 118
tube insertion 118
Pericranium
level of 19
preservation of 18f
Perivascular lymph nodes 73
Pharyngeal
closure 64
reservoir 61
squamous cell cancer see Laryngeal
squamous cell cancer
Pharyngolaryngectomy see Total laryn gectomy
Philtrum of upper lip 28
Phrenic nerve 75
Piecemeal resection with margin
mapping 107
Pinna, primary closure of 23
Platysma 79
Pleomorphic adenomas 95
Positron emission tomography 60
Postcontrast T1 weighted MRI 100f
Posterolateral neck dissection 72
Postmaxillectomy defect, management
of 31
Preauricular
region 88
skin 88, 95
Premature blood vessels 102
Pretragal skin 89
Primary closure of facial skin lesions 23
Proximal trachea 66
Pterygoid plates 31
Ptotic submandibular gland 72
R
Ramus, ascending 47
Rapid parathyroid hormone 81
Regional anesthesia for minimally
invasive parathyroidectomy 85f
Relaxed skin tension lines guide of skin
incisions 9f, 15f
Rhinotomy incision notch in nasal sill,
lateral 27f
Robotic arms FK retractor 114f
Rotation of flaps 19f
S
Salivary glands 88
Scalp
after wide excision 19f
excision 18f
with beveled incisions, depiction
of 17f
incisions, surgery of 15
primary closure versus skin graft
versus rotation flap,
surgery of 16
surgery of 15
Segmental mandibulectomy 46
Serum calcium level 81
Shah
angled bipolar cautery forceps 7f
bipolar forceps 7
Shiny skin-on-bone 18f
Skin
flaps, elevation of 8, 90
graft 23
in oral cavity 45
on scalp 18f
fixation of 21
method of 21
incision 8
of face, scalp 14
Index
platysmal flaps 8
sensation, preservation of 74
Skull base surgery 35
Small tumors of mucosa 57
Soft palate, preservation of 30
Specific surgical procedures 3
Sterile drape for head and neck
surgery 4f
Sternocleidomastoid muscle 84, 92
Sternohyoid muscles 80, 81
Sternomastoid muscles 8082, 92
Straight bipolar forceps 7
Styloglossus muscle 114
Stylohyoid muscle 90, 95
Stylopharyngeus muscle 114
Subciliary 26
incision 38f
Subgaleal hematoma, potential for 22
Subglottic stenosis 115, 116
Submandibular
gland
fascia 73
for sialolithiasis, excision of 97
salivary gland 98
Submental skin laxity 56f
Suborbicularis plane 97
Subplatysmal flaps 84
Suction drains, placement of 77
Superficial
parotidectomy 88, 94
incision 88
temporal artery distribution 14
Superior skin-platysma flap, elevation
of 73f
Superselective nodal dissection 75
Supraclavicular fossa 71
Supracricoid partial laryngectomy 59
Supraglottic
partial laryngectomy 59
tumor 59
Supraomohyoid neck dissection 72
Supraorbital arteries 14
Supratrochlear arteries 14
Surgical
instrumentation, basic 5
principles, basic 1
techniques, basic 8
Symphysis and parasymphyseal
region 46
T
Teeth 104
Tertiary hyperparathyroidism 87
Thyroid
cancer 82
gland 7, 78
lobectomy 78
tumors and retrosternal goiters,
surgery for large 81
vein, superior 80
Thyroidectomy 71f, 79f
and bilateral neck dissections 71f
and neck dissection 81
incision for 79f
TLM see Transoral laser microsurgery
TM joint 46
Tongue 104
prolapsed between blades of bivalve
laryngoscope 112f
resection, oriented 43f
TORS see Transoral robotic surgery
Torus 104
Total
laryngectomy 61
thyroidectomy 80
thyroidectomy see Thyroid lobectomy
Trachea 59
Tracheal
resection 66
stenosis see Subglottic stenosis
stenosis, endoscopic management
of 120f
Tracheoesophageal
plane 66
puncture 65
Tragal
cartilage 88
incision 88
for parotidectomy 89
pointer 93
Transconjunctival 26
Transoral
exposure, evaluating candidacy
for 103
laser microsurgery 5f, 103
critical for 109f
robotic surgery 103
127
128
U
Upper aerodigestive tract 115
Upper gingivobuccal sulcus 28
Upper neck skin crease 90, 99
V
Vagus nerve 83
Valsalva maneuver 75
Vascularity of accessory nerve, preserva tion of 74
Vermilion border of lip to create
vermilion MOUND 43f
Vertical partial laryngectomy 59
W
Waste-disposal buckets 4
Weber-Ferguson incision 26, 27f, 37, 38f
Whartons duct 97
X
Xeroform gauze 32
Z
Z-plasties, series of 56
Zygomatic arch 37