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Technical Variations and Refinements in

Head and Neck Surgery

Technical Variations and Refinements in

Head and Neck Surgery

Luc GT Morris MD MSc


Catherine and Frederick R Adler Chair for Junior Faculty
Assistant Attending Surgeon
Head and Neck Service
Memorial Sloan-Kettering Cancer Center
Assistant Professor of Otolaryngology
Weill Medical College of Cornell University
New York, NY, USA

Jatin P Shah MD PhD(Hon) FACS FRCS(Hon)


FDSRCS(Hon) FRACS(Hon)

Chief, Head and Neck Service


EW Strong Chair in Head and Neck Oncology
Memorial Sloan-Kettering Cancer Center
Professor of Surgery
Weill Medical College of Cornell University
New York, NY, USA

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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

A large part of abdominal work is recreation as compared with the work of


what might be called the heavy surgery of the neck.
Charles H Mayo, 1905

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.

Basic Surgical Principles

Operating Room Setup and Instrumentation 1


Basic Surgical Techniques 8

2.

Surgery of the Scalp and the Skin of


the Face and Neck
14
General Principles 14
Surgery of the Scalp 15

3.

Nose, Paranasal Sinuses, and Orbit

26

Facial Incision 26
Partial Maxillectomy 29

4.

Skull Base Surgery

35

Anterior Craniofacial Surgery 35


Endonasal Skull Base Surgery 36
Middle Cranial Fossa and Infratemporal Fossa 37

5.

Oral Cavity

42

V Excision of the Lip 42


Partial Glossectomy 42
Skin Grafts in the Oral Cavity 45
Management of the Mandible: Segmental Mandibulectomy 46
Management of the Mandible: Marginal Mandibulectomy 48
Mandibulotomy 52
Optimizing the Lip-splitting Incision 55
Palatal Fenestration for Hard Palate Tumors 57
Repair of the Central Palatal Defect 58

6.

Larynx, Hypopharynx and Trachea


Low-stage Tumors 59
Advanced Laryngeal Tumors 60
Total Laryngectomy or Pharyngolaryngectomy 61
Pharyngeal Closure 64
Tracheoesophageal Puncture 65
Tracheal Resection 66

59

xii

Technical Variations and Refinements in Head and Neck Surgery

7.

The Neck

69

Lymph Node Biopsy 69


Neck Dissection 70
Extent of Neck Dissection 71
Preservation of the Marginal Mandibular Branch of
the Facial Nerve 72
Preservation of Skin Sensation 74
Preservation of Vascularity of the Accessory Nerve 74
Selective Neck Dissection in the Postchemoradiation
Salvage Setting 75
Central-compartment Node Dissection 76
Placement of Suction Drains 77

8.

Thyroid and Parathyroid Glands

78

Thyroid Lobectomy or Total Thyroidectomy 78


Thyroidectomy and Neck Dissection 81
Surgery for Large Thyroid Tumors and Retrosternal Goiters 81
Nerve Monitoring 83
Parathyroid Surgery 84
Minimally Invasive Parathyroidectomy 84
Four-gland Exploration and Subtotal Parathyroidectomy 86

9.

Salivary Glands

88

Superficial Parotidectomy 88
Parotidectomy and Excision of Deep Lobe Parotid Tumor 94
Excision of the Submandibular Gland for Sialolithiasis 97

10. Other Tumors

99

Carotid Body Tumors and Paragangliomas 99

11. Transoral Surgery and Endoscopic Techniques

103

Transoral Laser Microsurgery and Transoral


Robotic Surgery 103
Endoscopic Management of Tracheal and Subglottic
Stenosis115
Percutaneous Endoscopic Gastrostomy Tube Insertion 118

Index 123

Chapter

Basic Surgical Principles

OPERATING ROOM SETUP AND INSTRUMENTATION


Operating Room Setup
Head and neck surgery developed during the first half of the 20th century as
a surgical discipline focused on the management of diseases and neoplasms
arising in the head and neck. This specialty initially encompassed the fields
of general surgery, otolaryngology, plastic and reconstructive surgery, and
other allied specialties, such as thoracic surgery and neurosurgery. The
primary focus of the specialty has always been the surgical management of
head and neck cancer. As the understanding of the biology of these tumors
has evolved during the last 60 years, traditional, established operations are
being revised or modified as we seek to maintain oncologic efficacy while
reducing the physical and functional impact on the patient.
At the same time, technological developments have greatly improved
the safety and the ease of conduct of operative procedures in the head and
neck, such that major efforts at resection and reconstruction are now safe
and routine. The physical characteristics of the operating room (OR) have
evolved during the last 50 years. Initially a simple room with an overhead
light and basic surgical instruments, the OR has become a highly advanced,
technologically state-of-the-art environment with equipment for electrosurgical, laser, endoscopic and robotic instrumentation, as well as instrumentation for real-time image guidance and intraoperative video monitoring
and recording. The modern-day OR is larger than its predecessor, to accommodate the increased needs for personnel and equipment during operative
procedures. Space becomes especially critical in head and neck operations
involving multiple surgical teams, for example, when microvascular reconstructive, intracranial, or intrathoracic approaches are used.
The OR is equipped with laminar airflow and is separated by a green core
and a gray core. The floor space available in the OR should allow easy flow
of OR personnel and convenient placement of electrosurgical equipment
and towers, video monitoring towers, and robotic equipment, as well as laser
surgical equipment including an operating microscope. To minimize clutter

Technical Variations and Refinements in Head and Neck Surgery

Fig. 1.1: Depiction of a contemporary operating room.

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

Basic Surgical Principles

of the procedure. Presence of visitors, students and others observing the


surgical procedure is generally a routine for ORs in most academic institutions.
However, to minimize overcrowding in the OR, a video camera mounted on
the operating light, with large monitors, should be available to allow observers
to watch the operative procedure without being too close to the surgical team.

Setup for Specific Surgical Procedures


Standardization of placement of instrument tables and trolleys is critically important for making complex head and neck procedures routine. To
avoid unnecessary delays and to eliminate confusion about the location of
equipment during the operative procedure, the positions of surgical team
members should be relatively constant. Since most operations on the upper
aerodigestive tract and paranasal sinuses are considered clean-contaminated
procedures, perioperative antibiotic coverage is frequently required before
the incision is made. The patient is brought into the OR with a satisfactory
intravenous line, and the first dose of antibiotics is given before induction
of general anesthesia. General anesthesia is then induced. The placement
of the anesthetic endotracheal tube and its connections and the positions
of the surgical team, for general open head and neck operations, are shown
in Figure 1.2. For a surgical procedure on the right hand side of the patient,

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.

Technical Variations and Refinements in Head and Neck Surgery

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.

Basic Surgical Principles

B
Figs 1.4A to C: (A) Position of the surgical

team for transoral laser microsurgery. The


primary surgeon (blue) sits at the patients
head with the microscope. Connections
to the laser and smoke evacuator are
brought down toward the patients feet.
The scrub nurse (light blue) and assistant
stand to the surgeons side. The anesthesiologist (purple) is positioned toward the
patients other side, or alternatively, at the
patients feet; (B) Position of the surgical
team for craniofacial surgery. The neurosurgeon and head and neck surgeon
(both in blue) stand at the top of the head,
and the patients side, respectively, with
their assistants (orange). Scrub nurses
for each team (light blue) are positioned
accordingly; (C) Position of the surgical
team for head and neck operations with
free flap reconstruction, depicting the
positions of each teams scrub nurse (light
blue).

Basic Surgical Instrumentation


In addition to the fundamental basic instrumentation for an open surgical
procedure, the modern-day operating suite is equipped with a variety of new
technical devices. This new equipment aids the surgeon in completing the
operative procedure safely, often expeditiously, and with better visualization
and reduced blood loss.

Technical Variations and Refinements in Head and Neck Surgery

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.

Basic Surgical Principles

Fig. 1.6: Shah Angled bipolar cautery forceps.

Straight bipolar forceps: In general use, bipolar forceps provide excellent


hemostasis without excessive charring of tissue. These also offer the advantage of safe use in patients with pacemakers. One disadvantage of the straight
bipolar forceps is that they provide pinpoint coagulation of an exposed
vessel but are less effective in controlling oozing or bleeding along a flat
surface.
Shah bipolar forceps: These bipolar forceps are devised with fine tips angled
at 3045, which allows linear coagulation along a flat surface. They are
effective in controlling surface oozing from muscle, thyroid gland and
vascular tumors, such as carotid body tumors and paragangliomas (Fig. 1.6).
Their use facilitates a larger area of surface coagulation, without deep tissue
charring.
Electrocautery tip extensions: Extensions of up to 10 cm are available for both
the needle tip and the paddle tip, to allow working in deep regions, such as
the oropharynx and the pharyngeal wall, through the open mouth.
Other more recently developed instruments offer additional salutary
advantages, although at somewhat increased cost.
Ligasure cautery device (manufactured by Covidien): This is a bipolar cautery
device with impedance measurement by a computer, which allows modulation of energy delivery until the tissue is coagulated. It combines electrocautery with physical pressure when the handpiece is clamped onto tissue,
flattening and coagulating vessels. This technology coagulates vessels up to
7 mm in size, although the handpiece is slightly larger than bipolar forceps
and can sometimes be cumbersome in small areas. Nevertheless, it can
be safely used, with minimal dissipation of heat, near nerves. Examples of
vessels appropriate for this device are the feeding vessels of the thyroid gland.

Technical Variations and Refinements in Head and Neck Surgery

Harmonic scalpel (manufactured by Ethicon): Rather than using electrical


current, the harmonic scalpel vibrates at 55,500 Hz, causing protein denaturation and coagulating vessels up to 5 mm in size. This allows the device
to simultaneously cut and coagulate tissue, with minimal spread of heat and
no electricity, making it safe near nerves. A disadvantage is that the device
cannot be used for coagulation alone, as it cuts all tissue placed between the
blades. In addition, the handpiece can be too large to use in narrow fields.
Handheld carbon dioxide laser scalpel (manufactured by Omniguide): This
device uses a flexible fiber to conduct CO2 laser energy to a straight or curved
handpiece, which offers the advantage of maneuverability; it can be used
for open surgery or transoral surgery or placed through a laryngoscope. The
mode of action of this device is easily modulated by distance from the tissue:
if held 23 mm away, the laser cuts finely; if held 23 cm away, the laser beam
becomes diffuse and instead coagulates tissue. However, bleeding vessels
that cannot be controlled with spot-welding will still require coagulation by
traditional means. This device is well-suited for transoral approaches to the
supraglottic larynx and oropharynx.

BASIC SURGICAL TECHNIQUES


Skin Incision and Elevation of Skin Flaps
It is generally recommended that the planned skin incision be marked out
on the patient before beginning the surgery. The fundamental principle of
surgery of the head and neck is to place incisions along natural skin lines. A
general understanding of Langers lines is required to appreciate the esthetic
outcome from a healed incision (Figs 1.7A and B).
If local skin flaps are to be used to reconstruct small surgical defects,
they should be planned in such a way that both the donor site defect and the
reconstructed site are esthetically pleasing, keeping in mind the relaxed skin
tension lines and the esthetic subunits of the face.
The skin incision is made with a sharp scalpel blade. The skin incision
should not be made deeper than through the epidermis layer (Fig. 1.8). If
the skin incision is carried through to subcutaneous fat, dermal vessels will
create nuisance bleeding, obscuring the field and tempting the surgeon to use
cautery on the skin. Instead, the dermis should be incised with the needle-tip
Bovie on a cutting current (not using coagulating current, which will create
thermal injury to the skin edges). This creates a fine incision to subcutaneous
fat, preserving the skin edges and maintaining hemostasis (Fig. 1.9).
The remainder of dissection in open head and neck surgery is largely
performed with electrocautery, using the flat paddle tip (Fig. 1.10). This allows
expeditious elevation of skin-platysmal flaps. Dissection with electrocautery
is a satisfying technique, producing a clean, sharp, bloodless operative field

Basic Surgical Principles

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.

and resulting in expeditious execution of the operative procedure. However,


there are several critical concerns necessary to achieve the maximum benefit
of electrocautery dissection. The tissues being dissected must be dry and
under constant tension. Electrocautery dissection will not be effective in a

10

Technical Variations and Refinements in Head and Neck Surgery

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,

Basic Surgical Principles

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.

Access, Exposure, Visualization and Stability


Access and exposure are crucial in any surgical procedure. Fortunately, for
performance of the required surgical procedure, most parts of the neck and
face are readily exposed after elevation of the skin flaps. While an assistant can
help retract the skin flaps and provide the requisite exposure, elastic rubber
blunt fish hook retractors are also an excellent addition to the surgeons
armamentarium. We recommend generous use of these relatively cheap and
simple tools, which retract skin flaps in the desired direction without injuring
tissue (Fig. 1.12).
The overhead OR light is often inadequate to provide sufficient lighting
for intraoral procedures, owing to a narrow field and the inevitability of
surgeons heads blocking the light. To provide sufficient lighting for intraoral
operations, we strongly recommend the use of headlights worn by both the
surgeon and the first assistant.

11

12

Technical Variations and Refinements in Head and Neck Surgery

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).

Basic Dissection Technique


Since most open head and neck surgery relies heavily on electrocautery,
special precautions and dissection techniques must be followed to maintain absolute hemostasis and to avoid burning or charring tissue or causing
thermal damage to adjacent structures. As mentioned above, dissection
with electrocautery works best with the tissues under tension, using traction and countertraction techniques. We recommend that the electrocautery
current setting be adjusted by each surgeon for his or her level of comfort,
with cutting current on pure or a low blend setting and coagulating
current on low or desiccate, avoiding the spray and fulgurate modes.
These settings should be calibrated to the surgeons individual preferences.
Judicious use of the bipolar forceps near nerves, at low settings ranging from
510 watts, can achieve excellent hemostasis of small vessels, without collateral damage to nearby tissues.
When the plane of dissection in the head and neck is contiguous with
underlying vital structures, such as nerves and vessels, the usual dissection technique of cut and see as you go is not advisable. Tissue dissection
in these regions can be performed with a fine-tip long hemostat, such as

Basic Surgical Principles

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).

an Adson hemostat clamp, or a fine tonsil clamp. In some regions, use of a


finer dissecting clamp, such as a fine mosquito clamp, can be advantageous
(Fig. 1.14). The tissues to be dissected are first entered with the fine tip of the
clamp, separated and elevated from the underlying tissues to be protected,
and then divided by the use of electrocautery. This sequence of actions results
in safe, bloodless, and expeditious dissection.

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.

arteries. Accordingly, planning incisions for resection and elevation of local


or regional skin flaps for reconstruction should include particular attention
to the vascular anatomy of the skin. For esthetic reasons, all incisions should
be planned along natural skin creases and relaxed skin tension lines, which
generally run perpendicular to the direction of underlying facial muscles.

Infiltration before Incision


To minimize bleeding, many surgeons use infiltration of local anesthetic with
epinephrine in the subcutaneous plane before incision. We do not feel that
this is an effective adjunct and do not routinely use it. Frequently, waterlogged tissues hamper the use of electrocautery, as do injection hematomas.
If scalpel incision is limited to the epidermis and electrocautery is used for
the dermis, the skin incision is bloodless and further vasoconstriction is not
needed.

SURGERY OF THE SCALP


Scalp Incisions
The scalp is a highly vascular region of the head and neck, and simple skin
incisions on the scalp, such as a coronal incision for a bifrontal craniotomy,
can result in significant blood loss.

15

16

Technical Variations and Refinements in Head and Neck Surgery

Fig. 2.3: Depiction of a scalp excision with incisions oriented at 90 (not recommended).

When feasible, surgical procedures on the scalp should be performed


with the patient in a sitting position. This will minimize bleeding from the
scalp, taking advantage of reduced arterial pressure and venous backflow.
In addition, we discourage the use of the scalpel for incising the scalp. We
recommend that an electrocautery device should be used, with a blend of
cutting and coagulating functions, to minimize bleeding from small vessels
and to allow the surgeon to identify the major feeding vessels and either ligate
them or coagulate them. This technique permits essentially bloodless surgery
on the scalp in an expeditious manner. Use of electrocautery rather than the
scalpel for incision through the galea will often obviate the need for the application of Raney clips.

Primary Closure versus Skin Graft versus Rotation Flap


The nature of the incision through the thickness of the scalp depends on the
planned method of closure of the surgical defect. If a primary closure or a
rotation scalp flap or other flap closure is planned, the incision through the
thickness of the scalp should be at 90 to the surface of the scalp (Fig. 2.3).
On the other hand, if a skin graft is planned for resurfacing of the scalp
defect, a 90 cut through the thickness of the scalp should be avoided. Such
an incision creates a troughlike effect, allowing crusting and dry sebaceous
material to collect at the periphery of the graft (Fig. 2.4). Therefore, when a
skin graft is planned, the incision on the scalp is beveled at an angle closer
to 45. This allows the skin graft to fuse with the raw surface of the cut edge
of the scalp smoothly, without leaving a troughlike defect and resulting in an
esthetically superior result (Fig. 2.5).

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.

Fig. 2.5: Depiction of scalp excision with beveled incisions (recommended).

If a split-thickness skin graft is used for coverage of the surgical defect


on the scalp, it should be as thick as possible, and not meshed. Thin splitthickness skin grafts will always be susceptible to being easily traumatized
and ulcerated. Esthetically, they are conspicuous, resulting in a shiny skinon-bone appearance (Fig. 2.6).

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Technical Variations and Refinements in Head and Neck Surgery

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

Technical Variations and Refinements in Head and Neck Surgery

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.

Method of Fixation of Skin Graft on the Scalp


Traditionally, the skin graft applied to a defect on the scalp is sutured with
silk sutures, several of which are left with long ends to be used for tying
over a bolster, to retain the graft in position. When these sutures are tied
down over the bolster, the cut edges of the scalp defect along the periphery
are lifted off the pericranium, which can cause a subgaleal hematoma
(Fig. 2.12). We therefore feel that this method of fixation of the skin graft on
the scalp is not satisfactory. We recommend the following:
Excision of the scalp lesion with a beveled scalp edge
Suturing the skin graft to the scalp edges with a running suture of 3-0
catgut. This offers complete hemostasis from the cut edge of the scalp,
and the sutures do not have to be removed.
A series of skin staples applied circumferentially around the periphery of
the scalp defect, approximately 1 cm from the edge of the defect
Silk ties passed through the stapled area and left long to be tied over the
bolster

Fig. 2.12: Scalp edges lifted off the bone by tie-down sutures (not recommended). Skin
graft depicted in blue. Bolster depicted in yellow.

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22

Technical Variations and Refinements in Head and Neck Surgery

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

Wedge Excision and Primary Closure of the Pinna


Small skin cancers on the helix of the ear often require a wedge excision, and
the defect is closed primarily. One of the complications of this technique is
that the suture line often separates, causing dehiscence. This occurs because
of retraction of the skin over the cartilage. To avoid this, the following steps
should be taken:
After adequate wedge excision, hemostasis is secured by pinpoint electrocoagulation of small subcutaneous bleeders
At this point, one notices that the skin edges of the defect have retracted
away from the cut ends of the cartilage, both anterior and posterior to the
cartilage, and cannot be pulled back together
Therefore, approximately 11.5 mm of the edge of the protruding cartilage needs to be trimmed (Figs 2.15A and B)
This procedure permits easy closure of the anterior and posterior skin in
two layers, without tension.
Large wedge excisions of the auricle will create the appearance of a
proptotic ear as it is distracted forward by the sutures. In these cases, a
conchal bowl setback suture should be used, exactly as in otoplasty for prominent ears. Through a postauricular incision, mattress sutures of fine permanent suture are placed through auricular cartilage and mastoid periosteum
and tied, bringing the auricle back.

Excision and Primary Closure of Facial Skin Lesions


Excision of small skin lesions on the face should be performed in an elliptical fashion along facial relaxed skin tension lines. If primary closure of the
surgical defect can be achieved without tension, then that is the best way
to repair such surgical defects. This technique is esthetically very pleasing.
If, however, the surgical defect is large and is unable to be closed primarily,
other means of repair of the defect will be required. These include:
Skin graft, either full thickness or split thickness
Local flaps
Regional flaps
Free flaps
Skin grafts are generally used on the parts of the face where there is no
movement or facial expression, such as the dorsum of the middle third of the
nose, the temple, the preauricular region, and the forehead. When feasible, a
full-thickness skin graft is preferred, keeping in mind the size limitations for
the harvest of a full-thickness skin graft. In general, a full-thickness skin graft
of up to 4 4 cm, harvested from the neck, is quite satisfactory from the point
of view of color match, as well as for the possibility of primary closure of the
donor site.

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24

Technical Variations and Refinements in Head and Neck Surgery

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.

Nose, Paranasal Sinuses, and Orbit

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.

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28

Technical Variations and Refinements in Head and Neck Surgery


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

Nose, Paranasal Sinuses, and Orbit

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.

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 3.3: Postoperative photo of the patient in Figure 3.1.

Fig. 3.4: Postoperative photo of the patient in Figure 3.2. There is no ectropion.

Preservation of the Soft Palate


If the soft palate is not involved and is not required to be resected for oncologic reasons, every effort should be made to preserve any part of the soft

Nose, Paranasal Sinuses, and Orbit

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.

Management of the Postmaxillectomy Defect


Traditionally, a split-thickness skin graft is used to line the maxillectomy
defect. The advantage is that the defect heals quickly and the immediate postoperative management period is shortened. In addition, the patient is able
to start postoperative radiation therapy sooner, if indicated. However, there
are several disadvantages to the use of the skin graft. They are that (1) the
defect is dry; (2) the epithelialized lining secrets sebaceous secretions, which
often produce odor; and (3) the defect requires regular irrigations and a high
degree of maintenance. Indeed, the routine use of a skin graft can be avoided
in many circumstances.
Management of the maxillectomy defect depends on the extent of the
surgical defect. The management options can be classified into three categories: (1) infrastructure maxillectomy with pterygoid plates preserved;
(2) maxillectomy with resection of the pterygoid plates and the defect
extending into the infratemporal fossa; and (3) total maxillectomy with resection of the floor of the orbit.
In the case of an infrastructure maxillectomy with intact pterygoid
plates, the use of a skin graft should be avoided. Simple packing of the defect
with Xeroform gauze intraoperatively and insertion of an immediate dental
obturator are sufficient. Oral irrigations during the next several weeks allow
the defect to remain clean and epithelialize spontaneously. The long-term
outcome with this approach is an excellent, moist, and comfortable defect
without any odor or requirement for regular maintenance.
If the surgical defect extends into the infratemporal fossa because of
resection of the pterygoid plates, there are two choices for repair of the defect:
(1) a skin graft and a dental obturator or (2) a skin-lined soft-tissue free flap.

If the surgical resection includes a total maxillectomy including the bony
support of the orbital floor, a free flap is required to support the rigid reconstruction of the floor of the orbit, whether performed with autologous bone
or a metallic plate.

The pros and cons of free-flap reconstruction must be weighed before
deciding on the management of the maxillectomy defect. The advantages of
free-flap reconstruction are:
The defect is immediately closed, requiring no postoperative maintenance
Postoperative radiation therapy can be started in 23 weeks
In elderly and edentulous patients with atrophy of the alveolar process,
the free flap provides an immediate and permanent solution to the defect
If an osteocutaneous free flap is used, dental rehabilitation with dental
implant is possible

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Technical Variations and Refinements in Head and Neck Surgery

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.

Nose, Paranasal Sinuses, and Orbit

Repair of the Central Palatal Defect


Small, full-thickness defects in the hard palate can be repaired with a mucoperiosteal or myomucosal palatal island flap from the soft palate; the flap
is based on the vascular pedicle from one or both greater palatine arteries
(Figs 3.5A to C). This can be performed at the time of resection or secondarily.
The ability of such a reconstruction to completely obliterate the oronasal

C
Figs 3.5A to C: Palatal island flap for reconstruction of a hard palate defect.

33

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Technical Variations and Refinements in Head and Neck Surgery

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.

Preservation of the Hard Palate


In rare cases, a carcinoma arising from the superior aspect of the maxillary
antrum may permit a subtotal maxillectomy, sparing the hard palate. This is
very helpful in avoiding the need for palatal reconstruction or the need for
an obturator. When contemplating this option, MRI imaging can be helpful
in distinguishing between tumor and retained secretions, helping to delineate whether the maxillary sinus floor appears to be free of tumor. In these
cases, after raising the cheek flap, a window can be judiciously made in the
anterior face of the maxillary sinus. The canine fossa is often the most direct
approach. This permits examination of the extent of tumor. If the hard palate
can be preserved, bone cuts are made with an osteotome along the medial
and posterior walls of the maxilla, and the remainder of the maxillectomy
performed in the standard fashion.

Chapter

Skull Base Surgery

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.

ANTERIOR CRANIOFACIAL SURGERY


Traditionally, a bifrontal craniotomy is performed to provide exposure of
the floor of the anterior cranial fossa. However, in many instances, such
wide exposure is not necessary. Thus, the size of the frontal craniotomy has
been steadily reduced over the years, from a wide bifrontal craniotomy, to a
smaller bifrontal craniotomy, to a subcranial approach, to a total endoscopic
resection without craniotomy. However, reducing the size of the craniotomy
or avoiding a craniotomy should not compromise the oncologic completeness of a safe resection.

For small central anterior skull base lesions involving only the region of
the cribriform plate, a small anterior craniotomy or subcranial approach can
be performed. The transfacial exposure may be limited to a lateral rhinotomy
or an external ethmoidectomy incision. In some instances with bilateral
ethmoid involvement, a nasal bone disassembly approach may be used. In
this case, both nasal bones are osteotomized and removed for exposure and
then plated back, after en bloc removal of the surgical specimen.
There are many approaches to craniofacial resection that obviate the
need for facial incisions. For example, small to moderate-sized tumors of the
ethmoid sinuses can be extirpated using a cranioendoscopic approach that

36

Technical Variations and Refinements in Head and Neck Surgery

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.

ENDONASAL SKULL BASE SURGERY


With the increasing experience in endonasal surgery for benign inflammatory diseases, there is increasing interest in extending these techniques to
resection of malignant tumors. The development of advanced endoscopic
instrumentation and real-time imaging/navigation has advanced the ability
to use these techniques safely. However, there are several prerequisites that
must be met to accomplish a safe endonasal resection of a malignant tumor.
These are as follows:
Two surgeons are required: the operating surgeon and an assistant, who
handles the camera and other required instruments, such as a suction.
In cases of endoscopic intracranial surgery, one of the surgeons is a head
and neck surgeon, and one is a neurosurgeon. This is a four-handed technique.
Both surgeons must have sufficient expertise and experience performing
endonasal surgery.
Both surgeons should have adequate experience and comfort performing
an open craniofacial resection, should an open approach become necessary.
Intraoperative navigation must be available.
Lesions should be small to medium-sized tumors confined to the anterior skull base.
The anatomy of the paranasal sinuses and central skull base must be
favorable.

The contraindications to the endonasal approach are:
Advanced tumors with extensive bone destruction of the frontal sinus or
clivus
Significant tumor extension into the orbit
Significant tumor extension into the middle cranial fossa
Tumor involvement of the lateral wall of the sphenoid sinus
Involvement of the skin
High-grade histology
Insufficient surgeon experience and expertise in endoscopic transnasal
surgery

Importantly, these approaches use different techniques of tumor dissection. When endoscopic techniques are used, tumors are rarely removed
en bloc. Rather, they are first debulked in a piecemeal fashion. If the area of

Skull Base Surgery

skull base invasion is resected en bloc and an appropriate dural resection is


performed, if indicated, these techniques can remain oncologically sound.

Endoscopic transnasal skull base surgery and reconstruction of the skull
base defect has legitimately become a specialty in its own right, the technical
aspects of which are beyond the scope of this text.

MIDDLE CRANIAL FOSSA AND INFRATEMPORAL FOSSA


Traditionally, lesions of the infratemporal fossa, with or without extension
to the middle cranial fossa, have been treated via a maxillectomy approach,
with or without middle fossa craniotomy. However, if the anterior wall of the
maxilla and the alveolar process of the maxilla are not involved by the tumor,
they can be safely preserved, retaining facial contour and the integrity of the
palate, by use of the maxillary swing approach. This approach was originally
developed for nasopharyngectomy but is quite suitable for lesions of the
infratemporal fossa.
We find the maxillary swing approach to generally provide superior
exposure to the infratemporal fossa, compared with the lateral preauricular
approach, which provides entry into the area through a narrow corridor.

Providing full technical details of the maxillary swing approach, in a stepby-step fashion, is beyond the scope of this book. However, the broad and
important features of the operation are:
The incision is a modified Weber-Ferguson incision, with an infraorbital
extension, along a natural skin crease (Fig. 4.1).
The cheek flap is not elevated over the maxilla. In fact, the entire cheek
flap must remain attached to the anterior surface of the maxilla to
preserve the blood supply to the maxilla.
The skin incision is deepened up to the bone, and only approximately
56 mm of soft tissue is elevated from the bone to perform the required
osteotomies.
A mucoperiosteal incision is placed on the hard palate, in a paramedian
or lateralized position, on the side of the operation, extending from the
lateral incisor tooth back to the soft palate, then extended laterally to the
maxillary tubercle. To avoid a postoperative palatal fistula, it is critical
that the mucoperiosteal incision not directly overlie the palatal osteotomy (Fig. 4.2).
Four osteotomies are performed: (1) in the midline of the hard palate,
between the two central incisor teeth, up to the posterior edge of the hard
palate; (2) at the nasal process of the maxilla; (3) in the infraorbital region,
approximately 3 mm below the anterior orbital rim; and (4) through the
zygomatic process of the maxilla, up to the lower border of the zygomatic
arch. These osteotomies free up the maxilla for it to swing laterally, except
at the posterior margin at the pterygoid plates (Fig. 4.3).

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 4.1: Maxillary swing approach. Modified Weber-Ferguson incision, respecting


nasal subunits and using an infraorbital skin crease, rather than a subciliary incision.

Fig. 4.2: Maxillary swing approach. Mucoperiosteal incision, designed to not overlie
the palatal osteotomy.

A curved osteotome is then used to fracture the posterior border of the


maxilla from the pterygoid plates at the hamulus of the pterygoid. Once
this is fractured, the assembly of the maxilla and the attached cheek flap

Skull Base Surgery

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.

is rotated (swung) laterally by gentle traction, with concomitant sharp


division of the attached soft tissues (Fig. 4.4).
This maneuver provides wide exposure of the masticator space, infratemporal fossa, undersurface of the greater wing of sphenoid bone, floor

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Technical Variations and Refinements in Head and Neck Surgery

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.

Skull Base Surgery

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.

41

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.

V EXCISION OF THE LIP


Traditionally, repair of defects of the lip after wedge resection requires accurate alignment of the vermilion border (at the junction of the vermilion or
red lip and the external skin of the lip). However, this alone is not sufficient.
To optimize the esthetic outcome, there are several other anatomic landmarks that must be aligned accurately.
If the lip is viewed in cross section, one can see the protuberance (mound)
of the vermilion junction. A fine, everting subcutaneous suture with catgut,
exactly at the mucocutaneous junction, restores this prominence (Fig. 5.1).
In addition, a subvermilion skin crease is present in the lower lip of nearly
all individuals. This must be similarly aligned by use of an everting subcutaneous suture. Similarly, the junction between the dry vermilion (keratinizing
mucosa) and the wet vermilion (mucosa containing minor salivary glands)
is a line of separation that should also be accurately aligned to achieve
the perfect esthetic result. This is the junction between the glistening pink
mucosa and pale dry mucosa of the vermilion of the lip.

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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Technical Variations and Refinements in Head and Neck Surgery

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.

Fig. 5.4: Design of a transverse wedge excision of a lateral tongue lesion.

of resection by frozen section, repair of the defect should begin. This is


performed in two layers. The deep muscular repair is performed with a 2-0
absorbable suture, beginning at the apex of the wedge and working laterally toward its base. A deep muscular suture is placed, bringing the cut ends
of the muscles together and bringing the mucosal edges closer. The suture

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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.

SKIN GRAFTS IN THE ORAL CAVITY


Repair of mucosal defects in the oral cavity that cannot be repaired by primary
closure or that are likely to result in functional impairment of speech and
swallowing require consideration of several options. Simple mucosal defects
without a significant third dimension can be left open to heal by secondary
intention. Examples of these defects are excisions of mucosal lesions such as
leukoplakia (hyperkeratosis), in situ carcinoma, or very superficially invasive
squamous cell carcinoma located in the floor of the mouth, lateral border of
the tongue, buccal mucosa, or hard palate.
Larger defects with a third dimension that extend up to the underlying
musculature of the floor of the mouth (myelohyoid) or cheek (buccinator)
require a skin graft. In general, skin grafts should be avoided on the tongue.
Since skin grafts are not sensate, patients often traumatize them by biting
during mastication. In contrast, skin grafts may be used in the relatively immobile surfaces in the oral cavity, such as the floor of the mouth, alveolar ridge,
buccal mucosa, retromolar region, and hard palate. Whenever a split-thickness skin graft is used in the oral cavity, it should be quite thick (0.025 inch
or 0.60 mm). Very thin split-thickness skin grafts in the oral cavity undergo
dissolution, appearing to melt away. They slough quickly, and the defect
eventually heals by secondary intention. Although 100% take of the skin graft
is seldom achieved in the oral cavity, thicker split-thickness grafts are more
able to resist the shearing forces of mastication and have a higher probability
of surviving in this otherwise hostile environment.
Larger three-dimensional defects in the oral cavitysuch as those after
glossectomy involving more than 40% of the tongue, through-and-through
resection of the floor of the mouth, and deep resection of the cheek and
retromolar region into the masticator spaceall generally require a free flap

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Technical Variations and Refinements in Head and Neck Surgery

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.

MANAGEMENT OF THE MANDIBLE:


SEGMENTAL MANDIBULECTOMY
Lesions in the oral cavity that either involve the mandible or are in proximity
to the mandible require consideration of issues regarding management of the
mandible. Thus, the mandible may require a mandibulectomy or mandibulotomy.
Mandibulectomy is either segmental or marginal. Segmental mandibulectomy is required for primary tumors of the mandible, such as sarcoma or
ameloblastoma, and for destruction or invasion of the cancellous part of the
mandible from mucosal cancers of the oral cavity. Segmental mandibulectomy may also be required for massive soft tissue disease surrounding the
mandible, even if there is no bone destruction. When a segmental mandibulectomy is performed, consideration should be given to immediate mandible
reconstruction with a free flap.
Confirming histologically clear margins on the mandible by use of intraoperative frozen section is difficult because of the inability to section bone;
true evaluation of invasive squamous cell cancer in mandibular bone requires
1 week for decalcification, so that the hard tissue can be sectioned. Therefore, frozen section cannot be relied upon. If possible, a 1 cm margin of bone
should be resected. The cancellous bone of the cut edge can then be curetted
and smears sent for standard frozen section, with the understanding that this
tissue sampling is, by necessity, not perfectly sensitive. If the proximal stump
of the inferior alveolar nerve is identifiable, this can also be sent for frozen
section, although, again, this technique does not have perfect sensitivity, and
if the results are positive only for microscopic (and not for gross) disease,
additional resection may not reliably convert the margin to negative.
When a segmental mandibulectomy is performed, with immediate
reconstruction of the mandible planned, the bone cuts on the mandible are
made in such a fashion as to facilitate a mechanically strong and esthetically
pleasing reconstruction. To address these issues, several site-specific points
need to be followed. The specific sites to be considered are: (1) the condyle
and temporomandibular joint; (2) the ascending ramus; (3) the angle; (4) the
body; and (5) the symphysis and parasymphyseal region.
If resection of the tumor requires excision of the entire ascending ramus
of the mandible, the mandible should be disarticulated from the temporomandibular joint. If the condyle of the mandible is uninvolved, it may be
excised from the specimen and plated to the bone of the free flap, to recreate
a new TM joint. Even though the replanted condyle does undergo some
resorption during the next several months, it creates a pseudoarthrosis of the

Oral Cavity

temporomandibular joint for better function. On the other hand, if resection


of the ascending ramus is performed for intraoral lesions, such as those of the
retromolar region or tonsil, then a segmental mandibulectomy is performed
in conjunction with marginal resection of the ascending ramus, excising
the coronoid process and the anterior half of the ascending ramus of the
mandible and preserving the TM joint and the posterior rim of the ascending
ramus. This permits reconstruction of the mandible by fixing the free bone
flap to the remnant posterior rim of the ascending ramus. Thus, the natural
TM joint is preserved, avoiding malocclusion, and the facial contour remains
unaltered, owing to the preservation of the lower border of the natural angle
of the mandible.
Similarly, if the ascending ramus does not need to be sacrificed for tumor
resection, a right-angle cut is made through the ascending ramus, preserving
the lower border of the angle for esthetic reasons (Fig. 5.5). However, if resection of the mandible is performed through the body of the mandible, then a
straight, 90-degree cut is made through the body to facilitate fit with the free
flap. For esthetic reasons, similar consideration is given to preservation of the
lower border of the mandible in the region of the chin. To facilitate flap insertion while maintaining the contour of the chin, one may consider a stepped
osteotomy here. Overall, it is important to realize that the facial contour is
retained by preservation of the lower border of the mandible at the angle or in
the region of the symphysis. When resection of the tooth-bearing mandible is
performed, the bone cuts should be made through the socket of an extracted
tooth, rather than between two teeth. In the latter case, the remaining tooth

Fig. 5.5: Design of a segmental mandibulectomy, with osteotomies preserving the


angle of the mandible.

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Technical Variations and Refinements in Head and Neck Surgery

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.

MANAGEMENT OF THE MANDIBLE:


MARGINAL MANDIBULECTOMY
When there is no gross bone destruction but tumor is either adherent to
or in close proximity to the mandible, a marginal mandibulectomy may be

Oral Cavity

performed. Examples of these situations are tumors of the alveolar process


or gingiva, buccal mucosa, or floor of the mouth. There are several anatomic
and technical issues that must be considered when performing an anatomically, oncologically and structurally safe marginal mandibulectomy. The
primary blood supply to the mandible is the inferior alveolar artery, which
is located in the mandibular canal. In addition, secondary blood supply is
provided from the periosteal blood vessels. The distance between the lower
border of the mandible and the alveolar canal in the adult dentate mandible
is approximately 11 mm. Therefore, an alveolectomy or an oblique marginal
mandibulectomy (including the alveolus and lingual plate of the mandible)
can be safely performed, preserving the alveolar canal and, thus, the blood
supply to the remaining mandible (Figs 5.7A to D).

B
Figs 5.7A and B

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Technical Variations and Refinements in Head and Neck Surgery

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

Fig. 5.8: When a marginal mandibulectomy is performed in an edentulous patient,


with minimal remaining bone height, the risk of fracture can be reduced by using
a low-profile miniplate to support the remnant mandible which will be subjected to
masticatory forces.

On the other hand, when a marginal mandibulectomy is performed in


an edentulous patient who has not undergone radiation, mechanical support
to the remaining mandible should be strongly considered, to minimize the
risk of fracture. This is easily provided by the use of a miniplate that supports
the region of the angle of the mandible (the most vulnerable site for fracture,
where the body and ramus are subject to masticatory forces). A long miniplate
should be used, with screws to stabilize the plate, in the ascending ramus of
the mandible and in the body of the mandible, extending well anterior to the
angle (Fig. 5.8).
Repair of the lining and soft tissue defect after marginal mandibulectomy
can be accomplished by: (1) primary closure; (2) skin graft; or (3) free flap.
If sufficient mucosa of the floor of the mouth and the buccal region is
available, a primary closure of the mucosa can be performed over the marginally resected mandible. However, such a closure must be without tension,
otherwise the suture line will break down, exposing the bone and causing
delay in healing. If mucosal loss will not permit primary closure, a skin graft
or a free flap will be required. A split-thickness skin graft will heal over the
marginally resected mandible as long as it is properly retained in position.
This may require circummandibular retention sutures to secure a bolster over
the graft (Fig. 5.9). If a free flap is used, a fasciocutaneous radial forearm free
flap is the best choice.

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 5.9: Depiction of circummandibular retention sutures to reliably secure a bolster


over a skin graft placed over a marginal mandibulectomy site.

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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Technical Variations and Refinements in Head and Neck Surgery

Fig. 5.10: Design of a paramedian mandibulotomy. The mental nerve is preserved.


The bone cut is placed in between divergent tooth roots. The osteotomy is angulated to
minimize micromotion and lengthen the healing surface.

The mandibulotomy site is now marked out, with an angled cut to


prevent cephalocaudad displacement of the two segments of the mandible
after repair, which may lead to delayed union or malunion. The vertical cut
begins at the alveolar process, between the lateral incisor and canine teeth,
and extends downward, up to 35 millimeters below the apex of the roots
of these teeth. At that point, the bone cut is angled 45 toward the midline
(Fig. 5.11). The purpose of the angled bone cut is to increase the healing
surface of the bone and to limit cephalocaudal displacement of the bone
segments during healing.
The bone cut is made through nearly 80% of the thickness of the mandible.
At that point, two four-hole miniplates are used to predrill the screw holes on
the two sides of the mandible. Placement of these screw holes and adaptation
of the plates before the mandible is completely split allows preservation of
accurate occlusion of the teeth at the time of repair. A biplane fixation should
be used: one plate is adapted to the lateral cortex, and one plate is adapted
to the lower border of the mandible. To prevent the drill holes from penetrating a tooth socket, the plate on the lateral cortex is placed below the level
of the roots of the teeth. After the drill holes are made, the mandibulotomy
is completed.
The mandibular segments are retracted laterally, and a mucosal incision
is placed in the floor of the mouth, leaving at least 10 mm of mucosa attached
to the gingiva laterally. The mandible segments are retracted laterally to
expose the myelohyoid muscle. The myelohyoid sling is divided exactly in the

Oral Cavity

Fig. 5.11: Panoramic radiograph demonstrating the mandibulotomy performed in


Figure 5.10.

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).

OPTIMIZING THE LIP-SPLITTING INCISION


Superior esthetic results are obtained by bringing the lip-splitting incision
down the midline of the chin. In lighter-skinned patients without significant

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 5.12: Postoperative panoramic radiograph after paramedian mandibulotomy,


demonstrating alignment of the mandible segments with two miniplates.

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

Fig. 5.14: Postoperative result of the incision outlined in Figure 5.13.

If a neck dissection is not being performed and vessels do not require


exposure for microvascular anastomosisfor example, in the case of a minor
salivary gland tumor at the base of the tonguethe incision can be limited to
simply the vertical lip-split and submental incision down to the hyoid bone,
without a lateral extension.

PALATAL FENESTRATION FOR HARD PALATE TUMORS


Small tumors (T1 and T2) of the mucosa of the hard palate, either superficial squamous cell carcinomas or minor salivary gland tumors, can be often
removed without creating a through-and-through communication with the
nasal cavity.
Central palatal lesions can be removed completely without the need to
sacrifice the uninvolved alveolar process. This is often the case for tumors of
minor salivary gland origin. If the palatal bone is involved, then a throughand-through resection is required, 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 by the tumor and
the bone appears normal on imaging studies, a through-and-through resection can be avoided. Although the bone is resected as deep margin of the
specimen, the nasal mucosa is preserved. Clearly, this is preferable, since it
will avoid the need for an obturator.
To avoid a full-thickness defect, the mucosa of the floor of the nasal cavity
must be preserved, without perforating it during resection. At the beginning

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Technical Variations and Refinements in Head and Neck Surgery

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.

REPAIR OF THE CENTRAL PALATAL DEFECT


Small through-and-through defects in the hard palate can be repaired by use
of a mucoperiosteal or myomucosal flap from the soft palate; the flap is based
on the vascular pedicle from one or both greater palatine arteries. This can
be performed at the time of resection or secondarily. The ability of such a
reconstruction to completely obliterate the oronasal defect depends on the
size and location of the palatal defect (see Fig. 3.5). 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
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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Technical Variations and Refinements in Head and Neck Surgery

ADVANCED LARYNGEAL TUMORS


Advanced tumors of the larynx (T3 and T4), particularly those requiring
total laryngectomy, are now managed in nearly all patients with a larynxpreservation treatment program of sequential or concurrent chemotherapy
and radiation therapy. Excellent rates of larynx preservation have been
reported from several well-controlled randomized clinical trials, and thus,
these treatment programs have become the standards of care for laryngeal
and hypopharyngeal cancers that require total laryngectomy. It follows
that upfront total laryngectomy is used only in very select circumstances.
These are:
Locally advanced cancers of the larynx or hypopharynx with cartilage
destruction (T4a)
Select cases with extensive invasion of the base of the tongue from a
laryngeal primary cancer
Select cases with extensive hypopharyngeal carcinoma extending to the
postcricoid region or the cervical esophagus
Patients with a dysfunctional larynx for whom an organ-preservation
protocol will not preserve a functioning laryngopharynx
Cancers of nonsquamous histologic profile, such as those of minor
salivary gland origin, or soft tissue sarcomas
Patients unable to receive chemoradiation therapy.

It must be kept in mind that 2040% of patients receiving chemoradiation treatment for larynx preservation will not respond to treatment, will
experience locoregional recurrence, or will develop a dysfunctional laryngopharynx, thereby requiring salvage surgery. These patients present a unique
set of circumstances requiring special considerations in the salvage surgical
management of their persistent or recurrent cancer. The issues to be consi
dered in the management of these patients are:
The diagnosis of persistent tumor may sometimes be difficult. Persistent
disease may be submucosal, and superficial mucosal biopsies may not
confirm the histologic diagnosis.
Although a positive positron emission tomography (PET)/computed
tomography (CT) scan finding substantially raises the suspicion of persistent tumor, the standardized uptake value (SUV) on the PET scan is often
borderline, making the scan findings equivocal.
Soft tissues and skin of the neck have significant postchemoradiation
changes and compromised vascularity, leading to poor healing and an
increased risk of wound breakdown and fistula formation.
Serious consideration should be given to bringing in nonirradiated
vascularized tissue to buttress the pharyngeal suture line. This may take
the form of a pectoralis major muscle flap or a free radial forearm flap.
Laryngectomy incisions should be planned in such a fashion as to minimize the risk of wound breakdown.

Larynx, Hypopharynx and Trachea

TOTAL LARYNGECTOMY OR PHARYNGOLARYNGECTOMY


A successful total laryngectomy or pharyngolaryngectomy results in primary
healing of the wound, with satisfactory restoration of swallowing and a
sufficient pharyngeal reservoir to permit successful rehabilitation of speech
through a tracheoesophageal voice prosthesis performed either primarily
or secondarily. To accomplish this goal, several technical issues must be
considered.

Incision
Several incisions have been described for performance of a total laryngectomy. These are described below.

Midline Vertical Incision


A midline vertical incision starting at the level of the hyoid bone and ending
at the upper end of the permanent tracheostome has been used in the past.
This incision is poorly designed, as it makes any extension of the incision
for a neck dissection or any reconstruction with a flap extremely difficult. In
addition, if the pharyngeal suture line breaks down, resulting in a fistula, the
salivary leakage drains directly into the tracheostome, leading to aspiration.
Therefore, this incision is not recommended (Fig. 6.1).

Fig. 6.1: Incisions for laryngectomy, historical. Midline vertical incisionnot recommended.

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Technical Variations and Refinements in Head and Neck Surgery

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

Fig. 6.2: Incisions for laryngectomy, historical. Apron incisionnot recommended.

Larynx, Hypopharynx and Trachea

Fig. 6.3: Incisions for laryngectomy, historical. H-incision.

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).

Single Transverse Incision


This is the ideal incision for laryngectomy with or without unilateral or
bilateral neck dissection. The incision is placed at the level of the thyrohyoid
membrane and is extended laterally on one or both sides, as far as necessary. The incision is anatomically sound, since the blood supply to the skin
flaps is robust (derived from the facial and occipital arteries for the upper
flap and from the internal mammary and transverse cervical arteries for the
lower flap). The tracheostome is made in the suprasternal notch, excising a
disc of skin measuring approximately 2.5 cm in diameter. To maximize the
blood supply to this bridge of tissue, care must be taken to keep a distance of
at least 3 cm between the neck incision and the upper border of the tracheostome (Fig. 6.4).
If the pharyngeal suture line breaks down, leading to a fistula, the
accumulating saliva can be drained to the exterior by opening the skin
incision directly at that site, ideally at a lateralized location away from the
tracheostome. This allows the tracheostoma to remain uninvolved with the
fistula. Insertion of a pectoralis flap for reconstruction or as a buttress to the
suture line can be easily performed by raising the neck and chest skin flaps

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 6.4: Incision for laryngectomy. Single transverse incision (preferred).

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.

Larynx, Hypopharynx and Trachea


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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Technical Variations and Refinements in Head and Neck Surgery

A free flap is used for circumferential reconstruction of the pharyngoesophageal region


A gastric pull-up is performed for reconstruction
Extensive dissection is performed in the tracheoesophageal plane, separating the membranous trachea from the esophagus
The tissues near the tracheostome appear devascularized, scarred, and
not healthy, raising the risk for wound breakdown.

The use of primary TEP in patients who have previously received radiation therapy is highly variable among different centers. The rationale for
delaying TEP in these cases is to reduce the high risk of pharyngocutaneous
fistula.

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.

Larynx, Hypopharynx and Trachea

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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resisted. Further reduction in tension on the suture line is obtained by partial


flexion of the neck.
Once it appears that the two segments of the trachea can be approximated easily, anastomosis is begun. This is performed with long-lasting
absorbable sutures such as 2-0 Vicryl, with all knots external to the trachea.
The posterior half of the suture line (membranous trachea) is completed
first. The remaining sutures are placed close enough to each other to secure a
watertight anastomosis. This is checked in the following manner: The surgical
field is flooded with saline, to immerse the trachea in saline. The anesthesio
logist is asked to deflate the balloon of the endotracheal tube and ventilate
the patient with an Ambu bag. If no air bubbles are observed leaking from
the suture line, the anastomosis is secure. On the other hand, if air leak is
observed, additional sutures are placed to secure an airtight suture line.
The neck is kept in partial flexion, with a heavy nylon or silk suture
between the skin and soft tissues of the chin and the presternal region
(if possible, this suture is placed through the periosteum of the sternum and
of the mentum). The guardian stitch serves to provide partial flexion, and
more importantly, to avoid neck extension. The neck should not be flexed
more than 15-30 degrees. The patient should be extubated as soon as spontaneous breathing upon recovery from anesthesia is observed. A nasogastric
feeding tube is required for 23 days; thereafter, the patient is able to tolerate
oral feedings. The suture keeping the neck in flexion is retained for at least
2 weeks. At that point, the tracheal anastomosis is healed, and a normal
airway is established. A tracheostomy is not necessary and should not be
performed.
When a longer segment of the trachea is involved by the tumor and a
primary anastomosis is not possible (after resection of a segment of the
trachea), a very detailed assessment of the circumferential extent of the
tumor is necessary, to plan resection and reconstruction. This may involve
partial resection of the tracheal wall (window resection) and reconstruction
with tracheal rotation or a regional or free flap, or a thoracic procedure such
as bronchial reimplantation.

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.

LYMPH NODE BIOPSY


When a clinically or radiologically suspicious lymph node is identified in
the neck, tissue diagnosis by either cytologic or histologic analysis is necessary. Ideally, a fine needle aspiration biopsy is performed first. In general,
a 25-gauge needle is used, and multiple passes (generally without applying
suction) are performed to obtain the necessary sample for cytologic interpretation. If the sample is not satisfactory or is nondiagnostic, a fine needle
aspiration biopsy may be repeated once more. If the results of this remain
unsatisfactory or indeterminate, a core needle biopsy may be helpful in some
cases. Often, however, an open biopsy is required at this point. Similarly, an
open biopsy is often requested for accurate diagnosis of lymphoma, owing to
the need to examine architecture. In either case, if the lymph node is small

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Technical Variations and Refinements in Head and Neck Surgery

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).

(< 2 cm), it is generally preferable to perform an excisional biopsy and


remove the entire lymph node. On the other hand, if the lymph node mass
is large, an incisional biopsy is preferable. It must be kept in mind that the
principal objective is obtaining diagnostic material, rather than extirpating
the entire nodal mass, which is not necessary if doing so would unnecessarily
endanger local structures.

When planning an open biopsy, the location of the incision is critical. The
importance of this cannot be overstated. Improper placement of the biopsy
incision will create a situation wherein a subsequent neck dissection incision
cannot incorporate the biopsy scar. An example of such poorly placed incision is shown in Figure 7.1. Therefore, it is crucial to place the biopsy incision
in such a fashion that it can be easily extended or incorporated into a subsequent neck dissection incision.

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).

EXTENT OF NECK DISSECTION


On the basis of accumulated knowledge of patterns of neck metastases, a
variety of modifications in neck dissection have been developed. These are
generally described under two broad categories: (1) comprehensive, where all
five levels of lymph nodes in the lateral neck are dissected; and (2) selective,

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Technical Variations and Refinements in Head and Neck Surgery

where only a select group of lymph node levels are dissected. Several operations are described under these two broad categories.

Comprehensive Neck Dissections





Classical radical neck dissection


Modified comprehensive neck dissection, Type I (only one structure, the
accessory nerve, is preserved)
Modified comprehensive neck dissection, Type II (two structures, the
accessory nerve and the sternocleidomastoid muscle, are preserved)
Modified comprehensive neck dissection, Type III (three structures, the
accessory nerve, the sternocleidomastoid muscle and the internal jugular
vein, are preserved)

Selective Neck Dissections


Supraomohyoid neck dissection (levels I, II and III)
Jugular node or lateral neck dissection (levels II, III and IV)
Anterolateral neck dissection (levels I, II, III and IV)
Posterolateral neck dissection (levels II, III, IV, V and suboccipital nodes)
Central compartment neck dissection (levels VI and VII)

These types of neck dissection are well described, and this terminology
is widespread. However, in the contemporary nomenclature for neck dissection, it is most preferable to use the terms radical neck dissection or modified
radical neck dissection (specifying the structures preserved and sacrificed) or
selective neck dissection (specifying the nodal levels removed).

PRESERVATION OF THE MARGINAL MANDIBULAR


BRANCH OF THE FACIAL NERVE
The marginal mandibular branch of the facial nerve can be easily injured
during elevation of the superior subplatysmal flap. The surgeon must remain
cognizant of the location of the nerve ramus, which runs in the plane of the
fascia of the submandibular gland. In young patients, the nerve runs at the
level of the inferior margin of the mandible; however, particularly in older
patients, a ptotic submandibular gland can displace the nerve inferiorly.
As the flap is elevated, dissection must be kept as close as possible to the
platysma muscle. The nerve can then be identified as it dips just below the
lower margin of the mandible, running in the fascia of the submandibular
gland. Alternatively, the nerve can be identified by careful dissection of tissue
at the angle of the mandible, where the nerve dips below the inferior margin
of the mandible. If all else fails, the cervical branch of the facial nerve can be
traced retrograde to identify the marginal mandibular branch. Once identified, it can be transposed cephalad.

The Neck

Alternatively, the facial vein can be ligated and reflected superiorly


together with the fascia of the gland, protecting the nerve (which runs superficial to the vein) in a soft tissue envelopethis has been called the Hayes
Martin maneuver. In this approach, the submandibular gland fascia is incised
low on the gland and dissected superiorly together with the nerve. However,
this maneuver precludes dissection of perivascular lymph nodes, and it
is preferable to dissect these in patients with oral cavity primary cancers
(Figs 7.3A and B).

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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Technical Variations and Refinements in Head and Neck Surgery

PRESERVATION OF SKIN SENSATION


When performing any of the modified comprehensive neck dissections
or selective node dissections, the cutaneous branches of the cervical roots
should be carefully preserved. The plane of dissection in the posterior triangle
is just superficial to the cutaneous nerves. Since there are no lymph nodes
located posterior to the plane of the cutaneous nerves, the cutaneous nerves
can be safely preserved, retaining skin sensation and reducing the area of
numbness in the neck. Clearly, if there are grossly enlarged metastatic nodes
in the vicinity of the cutaneous nerves, they should be sacrificed, to avoid
compromising the oncologic completeness of the operation.

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

SELECTIVE NECK DISSECTION IN THE


POSTCHEMORADIATION SALVAGE SETTING
A majority of patients with laryngeal or pharyngeal squamous cell cancer,
with metastatic lymph nodes in the neck, who are treated with chemoradiation therapy respond well and show no evidence of residual disease, which is
confirmed by a negative clinical examination and negative imaging studies,
such as post-treatment contrast-enhanced computed tomography (CT) and
positron emission tomography (PET)/CT scan. In these patients, planned
neck dissection is no longer advocated, and the neck can be safely left to
observation.

However, a small group of patients with residual disease identified clinically or on imaging studies will require a salvage neck dissection. Some of
these patients have nonviable tumor cells in fibrotic lymph nodes, and there
is mounting evidence that residual disease, if present, is generally confined
to the level of index nodal involvement. Therefore, the philosophy of superselective nodal dissectionessentially a nidusectomyhas evolved. In this
setting, only the demonstrable gross abnormality is resected (in a monobloc
fashion) and is subjected to pathologic analysis. Even when there is viable
residual disease in this type of specimen, other lymph nodes are almost never
involved. Thus, one may avoid the need for completion nodal dissection, as
well as its potential complications and morbidity.
Needless to say, if gross metastases are present after chemoradiation
therapy or if multiple levels harbor involved lymph nodes, a comprehensive
neck dissection (modified radical, radical or extended neck dissection) may
be necessary.

Avoidance of Chyle Leak


The thoracic duct is rarely encountered as a single structure and, in fact, is
generally encountered as a series of distributaries. These branches will be
identified low in level IV of the left side of the neck, below the transverse
cervical vessels, very close to the phrenic nerve, running toward the internal
jugular vein.

Adequate exposure low in the neck is critical. The sternocleidomastoid
muscle must be skeletonized all the way down to the sternal notch. This
part of the neck dissection must be performed meticulously, from lateral
to medial, ligating all soft tissue at the base of level IV between the phrenic
nerve and jugular vein, regardless of whether branches of the thoracic duct
are visible. After completion of the neck dissection, the integrity of the area
can be confirmed by both the use of the Valsalva maneuver and the application of abdominal pressure. If a leak is visualized, the least traumatic option
is to oversew it, taking care to avoid injury to the nearby phrenic nerve.

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CENTRAL-COMPARTMENT NODE DISSECTION


The incidence of micrometastases from papillary carcinoma of the thyroid
gland in the central-compartment lymph nodes is significant, approaching
3050% in various reports. The advocates of elective central-compartment
node dissection use this incidence to justify the elective operation. However,
the prognostic implication or potential benefit to the patient remains to be
proven. At the present time, there is no evidence that such a practice reduces
the risk of recurrence or death in these patients. In addition, the operation
carries significant morbidity, with a high incidence of permanent hypoparathyroidism and increased risk of injury to the recurrent laryngeal nerves. We
therefore do not recommend elective central-compartment nodal dissection.
On the other hand, when central-compartment lymph nodes are
demonstrated on preoperative imaging (ultrasound or CT scan) to be grossly
enlarged, a systematic central-compartment lymph node dissection should
be performed to clear lymph nodes from levels VI and VII. This implies
clearance of lymph nodes from the level of the hyoid bone superiorly to the
innominate artery in the anterior superior mediastinum inferiorly, and from
carotid artery to carotid artery. This encompasses clearance of lymph nodes
from the pretracheal region in the midline and bilateral paratracheal and
tracheoesophageal groove lymph nodes. Lymph nodes should be excised in
a systematic fashion, medial, lateral, anterior and posterior to the recurrent
laryngeal nerves (Fig. 7.4).

Fig. 7.4: A complete central compartment lymph node dissection, systematically

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.

PLACEMENT OF SUCTION DRAINS


Traditionally, suction drains are used after most types of neck dissections.
They prevent hematoma and seroma formation and allow the skin flaps to
adhere to the deeper tissues expeditiously. In general, these suction drains
are introduced through separate puncture wounds in the lower part of the
neck, in the supraclavicular region, or sometimes on the anterior chest wall
in the infraclavicular location. In some patients, after removal of the drains,
the puncture wound heals with a hypertrophic scar, leaving an obvious
nubbing of scar, which is esthetically unpleasant (particularly in young
women). We recommend that the puncture wounds to introduce the suction
drains be placed through the skin overlying the mastoid process, posterior to
the lobule of the ear, which is a relatively inconspicuous site. Regardless of
how these puncture wounds heal, they are either not readily visible or can be
covered with hair among women.

77

Chapter
Thyroid and
Parathyroid Glands

INTRODUCTION

A steep increase in the incidence of papillary thyroid carcinoma has been


observed in the US and around the world during the last 1015 years. For
the most part, this increase in incidence is attributable to tumors less than
2 cm in size, most of which have been incidentally discovered on ultrasound,
computed tomography (CT), magnetic resonance imaging (MRI) or positron
emission tomography (PET)/CT scan performed for nonthyroid diagnoses.
A majority of these small papillary cancers occur in younger women, and
nearly all of them have an excellent prognosis.
Because of excellent long-term outcomes and prognoses, attention has
turned to the functional and esthetic sequelae of thyroid surgery. This has led
to the improvisation of surgical techniques with smaller incisions in the neck,
to endoscopic and video-assisted thyroidectomies, and even to transaxillary
robotic thyroidectomies to avoid an incision in the neck.

THYROID LOBECTOMY OR TOTAL THYROIDECTOMY

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

Thyroid and Parathyroid Glands

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

Thyroid and Parathyroid Glands

every thyroidectomy. It is important to confirm integrity of the nerve before


moving to dissect the contralateral thyroid lobe; if nerve integrity cannot be
confirmed, the surgeon should carefully consider whether it is safe to perform
the contralateral hemithyroidectomy.

There are also a multitude of valid approaches to postoperative calcium
management after total thyroidectomy, ranging from routine supplementation to selective supplementation based on serum calcium levels and/or postoperative rapid parathyroid hormone (PTH) measurements. Our approach
has been to rely on the most cost-effective strategy, which is routine supplementation with over-the-counter calcium carbonate (serum calcium level is
checked once at 12 hours postoperation, before discharge home). Calcium
supplementation is then tapered off over the course of several weeks. This
approach identifies nearly all patients who are going to develop significant
postoperative hypocalcemia and require additional supplementation or
hospitalization. However, a number of approaches have been described that
work well.

THYROIDECTOMY AND NECK DISSECTION


If a central-compartment or lateral neck dissection is required, the incision
is extended along the same skin crease unilaterally or bilaterally, as needed.
There is generally no additional exposure achieved by using a U-shaped incision that extends up to the mastoid process; however, this vertical extension
produces an unsightly scar. Extension of the transverse incision along the
same skin crease as far posteriorly as necessary to obtain the required exposure produces an excellent esthetic result (Fig. 8.2).

SURGERY FOR LARGE THYROID TUMORS AND


RETROSTERNAL GOITERS
Clearly, larger thyroid tumors and large retrosternal goiters require larger
incisions. However, these incisions can still be located in natural skin creases
close to the cricoid cartilage. In these operations, we generally recommend
that both the sternohyoid and sternothyroid muscles be sacrificed bilaterally to enhance wide exposure. Thus, they are divided high, at the level of the
cricoid cartilage superiorly and at the level of the sternal notch inferiorly. In
so doing, the tightly packed large thyroid mass in the central compartment is
released, facilitating subsequent dissection.

Nearly all previously unoperated-on and benign retrosternal goiters can
be removed in an en bloc fashion using the cervical approach. After transection of the strap muscles, the blood supply to the thyroid is sequentially and
meticulously divided and ligated. This includes the vessels at the lower pole,
which are carefully isolated by gentle finger dissection, mobilizing the goiter

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 8.2: Extension of the transverse thyroidectomy incision is adequate to provide

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.

Thyroid and Parathyroid Glands

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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Technical Variations and Refinements in Head and Neck Surgery

Despite appropriate placement, the electrodes may still malfunction


sometimes. In these cases, palpation of the cricothyroid joint during
stimulation of the nerve at 1 mA will allow the surgeon to feel a definitive twitch of the larynx. We recommend that surgeons familiarize themselves with this laryngeal kick early on, so that this maneuver can be
called on in cases in which the electrodes are not working.

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.

MINIMALLY INVASIVE PARATHYROIDECTOMY


If a single adenoma can be localized on preoperative imaging and if intraoperative PTH monitoring is available, a minimally invasive parathyroidectomy
can be performed. In most cases, we prefer the lateral approach, as this is
the most direct route to the parathyroid glands and as it minimizes the need
for mobilization and retraction of the thyroid lobe. These explorations can be
performed under general anesthesia or under local and regional anesthesia,
with (or without) sedation, using described techniques of blocking sensory
nerves along the posterior border of the sternocleidomastoid muscle as well
as within the local field (Fig. 8.3). If local and regional anesthesia is chosen,
parathyroidectomy can be comfortably performed with little or no sedation,
and the patient is able to go home shortly after surgery.
The incision is planned in a naturally occurring skin crease, is 23 cm
in length, and extends from the midline on the side of the adenoma
(Fig. 8.4). If an ultrasound machine is available in the operating room, it is
very helpful to re-localize the adenoma on the table, and mark the incision
directly overlying it. We mark the contralateral incision on the skin but do not
use this incision unless it is needed for contralateral exploration. The incision
is carried through the platysma, and the subplatysmal flaps do not need to
be elevated. Dissection proceeds in the plane between the lateral border of
the sternohyoid and sternothyroid muscles and the medial border of the
sternocleidomastoid muscle. The middle thyroid vein does not universally

Thyroid and Parathyroid Glands

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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Technical Variations and Refinements in Head and Neck Surgery

Fig. 8.5: Cross sectional view of the lateral approach to parathyroid glands, used

for minimally invasive parathyroidectomy. Here, a superior parathyroid adenoma is


depicted. One retractor displaces the thyroid gland medially; a second retractor, the
carotid artery laterally.

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.

FOUR-GLAND EXPLORATION AND


SUBTOTAL PARATHYROIDECTOMY
If preoperative imaging does not reveal a single adenoma, the patient
may harbor multigland disease (either double adenoma or four-gland

Thyroid and Parathyroid Glands

hyperplasia), or imaging may simply have been falsely negative. Four-gland


exploration may also be preferred in settings where intraoperative PTH testing
is not available. If intraoperative PTH testing is available, we recommend
determining PTH levels from both internal jugular veins, low in the neck, at
the start of anesthesia, as doing so may be helpful in selecting a side on which
to begin exploration.
When a four-gland exploration is needed, a midline incision is used,
rather than a shortened, lateral incision. The thyroid gland is approached
from the midline of the strap muscles, as in thyroidectomy. As the thyroid
gland is mobilized medially, the embryologic (anterior/posterior) anatomic
relationships of the superior and inferior glands should be kept in mind. In
four-gland explorations, we recommend identifying the recurrent laryngeal
nerve, as doing so expedites safe exploration of the parathyroid glands.
If an obvious adenoma is not encountered and the surgeon suspects
four-gland hyperplasia, we recommend identifying and examining all four
glands before resecting any of them. Once this is done, the diagnosis of fourgland hyperplasia should be confirmed visually, as no obvious adenoma has
been identified. If a small adenoma is suspected, the affected gland can be
resected, and intraoperative PTH levels are obtained. If four-gland disease
is suspected and one or more glands become dusky in appearance or otherwise appear to be nonviable, it is preferable to resect these glands, in order
to leave a viable remnant behind. In general, it is preferable to subtotally
resect an inferior gland, as the inferior glands are more anteriorly located and
easier to locate in the reoperative setting. In the patient with renal failure and
secondary or tertiary hyperparathyroidism, the risk of recurrence is higher,
and we recommend either subtotal resection of an inferior gland or total
resection, with reimplantation in an easily accessible location, such as the
brachioradialis muscle.

In cases in which there is insufficient decrease in the PTH level and there
is a missing gland, we use a number of approaches tailored to the deduced
identity of the missing gland (superior vs inferior). If an inferior gland cannot
be identified, we recommend performing a cervical thymectomy, dissecting
free and removing nodal and thymic tissue from low in level VI and the superior mediastinum. Other locations for ectopic glands include a superior
gland that has migrated inferiorly (these will be posterior to the nerve, in
the tracheoesophageal groove, but lower in the neck), a gland nestled in the
thyroid capsule, and, less commonly, a gland located in the carotid sheath or
retroesophageal locations.

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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

Fig. 9.1: Tragal incision for parotidectomy.

Fig. 9.2: Postoperative appearance of the incision used in Figure 9.1.

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.

Elevation of Skin Flap


Elevation of the anterior skin flap during superficial parotidectomy can be
expeditiously performed with an electrocautery device. After the skin incision is made, the electrocautery device is used to deepen the incision through
subcutaneous fat, before elevating the skin flap anteriorly. All subcutaneous
fatty tissue should be preserved on the skin flap, such that the plane of dissection is immediately over the parotid fascia, since there is no parotid glandular
tissue superficial to the parotid fascia. Preservation of all of the subcutaneous fat, leading to the use of a thick skin flap, is important to reduce the
postoperative soft tissue deficit and esthetic deformity. Elevation of the skin
flap can be performed safely and bloodlessly with the use of electrocautery,
but care must be taken to avoid dissection anterior to the gland, as the facial
nerve branches emerge from the parotid gland and run within the fascia of
the masseter muscle; the nerve branches are visible in this layer and can be
inadvertently injured, and this extent of dissection is not needed for parotidectomy. The inferior (cervical) portion of the skin flap is raised in a subplatysmal plane. The superior margin of the platysma will be encountered over
the mandible. As the platysma is contiguous with the superficial musculoaponeurotic system of the face, it is found one layer superficial to the parotid
fascia. Therefore, a transition in dissection plane must occur at the superior
edge of the platysma. Once again, care must be taken to not extend dissection
too far anteriorly, as the marginal mandibular branch of the facial nerve may
be inadvertently injured after its exit from the parotid gland.

Management of the Great Auricular Nerve


In most patients, the great auricular nerve emerges from the posterior border
of the sternocleidomastoid muscle at Erbs point. This location can be approximated on the skin using surface landmarks. A line is drawn from the mastoid
tip to the angle of the mandible. A second line, orthogonal to and bisecting
the first line, will intersect the posterior border of the sternocleidomastoid
muscle at approximately Erbs point. These landmarks are helpful in anticipating the location of the great auricular nerve branches during creation of
the skin incision and raising of the subplatysmal flaps (Figs 9.3A and B).

The great auricular nerve then wraps around the posterior border of the
muscle, traverses its surface, and heads toward the superficial portion of
the inferior parotid gland. The nerve is usually a single trunk that separates

Salivary Glands

Figs 9.3A and B: Surface landmarks (dotted black lines) helpful in identifying the

anticipated location of the greater auricular nerve, approximately 1 cm superior to Erbs


point.

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Technical Variations and Refinements in Head and Neck Surgery

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.

Initial Dissection of the Parotid Gland


Mobilization of the posterior border of the superficial lobe of the parotid gland
can be easily performed using an electrocautery device, achieving excellent
hemostasis and in an expeditious manner. To do this, the first step is to isolate
the anterior border of the sternocleidomastoid muscle. Dissection proceeds
along this border separating the superficial lobe, which is retracted anteriorly.
To identify the posterior belly of the digastric muscle, the separation of the
parotid gland from the sternomastoid muscle continues in a deeper plane. It
is necessary to identify only the posterior belly of the digastric muscle at the
level of the anterior border of the sternocleidomastoid muscle, and not more
posteriorly. The digastric muscle is a key landmark, corresponding with the
depth of the main trunk of the facial nerve.

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.

Identification of the Main Trunk of the Facial Nerve


The facial nerve exits the temporal bone through the stylomastoid foramen;
therefore, the extracranial portion of the facial nerve has a constant anatomic
location. The landmarks used to locate and identify the main trunk of the
facial nerve are: (1) the superior surface of the posterior belly of the digastric muscle; (2) the tip of the mastoid process; and (3) the anteroinferior
surface of the cartilaginous external auditory canal (Fig. 9.5). An additional
point of orientation is the tympanomastoid suture line, which is palpable and
approximately superficial to the stylomastoid foramen. The tragal pointer
is less useful, as it is both distant from the main trunk and cartilaginous and
mobile, making its relationship to the nerve less constant.

Once these landmarks have been identified, the main trunk of the facial
nerve is found at the confluence of these three structures, at the depth of the
posterior belly of the digastric muscle. As these structures are identified, very
delicate and meticulous dissection is performed through the parotid tissue
to prevent any inadvertent injury to the facial nerve. Thin layers of tissue are
divided with the bipolar cautery device. As dissection proceeds, it is helpful to
mobilize the parotid gland anteriorly on as broad a front as possible, resisting
the temptation to dissect only in the anticipated location of the facial nerve.
Mobilizing the parotid gland in this manner maximizes exposure of the main
trunk once it is identified.

In nearly all cases, a branch of the posterior auricular artery is located
just superficial to the main trunk of the facial nerve. This branch should be
diligently looked for, isolated, and divided. This vessel provides a good lead
to the facial nerve, which is invariably located 23 mm deeper.

At this point, further dissection of the peripheral branches of the facial
nerve proceeds in a systematic manner, with the use of a fine clamp for dissection and separation of the parotid tissue; bipolar cautery for hemostasis; and
sharp division of the parotid tissue with a scalpel or scissors, keeping the
underlying facial nerve under constant vision.

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 9.5: Landmarks helpful in identifying the main trunk of the facial nerve during
parotidectomy.

PAROTIDECTOMY AND EXCISION OF


DEEP LOBE PAROTID TUMOR
Excision of a tumor confined to the deep lobe of the parotid gland usually
amounts to local excision or enucleation of the tumor while keeping its
pseudocapsule intact. Regardless of whether a superficial parotidectomy is
performed, the deep lobe tumor is generally excised separately, with blunt
and sharp dissection and judicious digital dissection to remove the intact
tumor in a monobloc fashion. In these cases, removal of all parotid glandular
tissue deep to the facial nerve is not necessary and, in fact, poses significant
risk to the nerve branches.

Classically, it was recommended to first perform a superficial parotidectomy before excising a deep lobe tumor. The rationale for doing so was to
maximize the safety of the facial nerve during and after excision of the deep
lobe tumor. However, as long as the integrity of the facial nerve is preserved,
the need to perform a formal superficial parotidectomy is questionable. In
fact, preservation of the superficial lobe of the parotid gland will minimize
the esthetic deformity resulting from the soft tissue deficit in the preauricular region. Thus, when possible, we generally prefer to avoid performing a
formal superficial parotidectomy in patients with a well-encapsulated tumor
confined to the deep lobe of the parotid gland.

We have, however, found that preservation of the superficial lobe of the
parotid gland does come at a cost: a higher incidence of first bite syndrome.
First bite syndrome is the feeling of sharp lancinating pain in the parotid
region upon the first bite of a meal, diminishing with subsequent bites.
This syndrome is attributable to postsurgical interruption of sympathetic

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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Technical Variations and Refinements in Head and Neck Surgery

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.

Sacrifice of the Facial Nerve


With rare exceptions, if the facial nerve is functioning preoperatively, every
attempt is made to preserve it, regardless of tumor extent and tumor histologic profile, even in the case of proven malignancy. However, gross tumor
should not be left on the nerve; the goal of surgery is to leave no tumor or

Salivary Glands

only microscopic disease behind on the functioning nerve. In these cases,


adjuvant radiation therapy is generally mandated.
In some cases, the nerve is encased with tumor or is not functioning
preoperatively. In these cases, both the proximal and the distal nerve margins
should be evaluated by use of frozen section, to assess the feasibility of a
nerve graft.

Management of the Eye in Facial Paralysis


If the upper division of the nerve is to be sacrificed, and if this can be anticipated at the time of surgery, we will generally plan to also include procedures
to aid with eye closure. If not performed in the same setting, these procedures
will be performed in the early postoperative period. In most cases, a gold
weight is inserted into the upper eyelid, together with the performance of a
lower-lid-shortening procedure, such as a lateral tarsal strip. It is important to
address both the upper and the lower eyelids, as the lower lid will develop a
paralytic ectropion, leading to impaired coverage of the globe and epiphora,
owing to the lack of a platform for tears.
The gold weight should be measured with dummy weights preoperatively. If this is not possible, a 1.0 gram weight is appropriate for most women,
and a 1.2 gram weight is appropriate for most men. The upper eyelid incision
should ideally be marked, with the patient sitting upright, in a natural upper
eyelid crease, taking care to mark the medial limbus of the eye, which may
not be located intraoperatively if a corneal shield is in place. The incision is
carried through the orbicularis oculi muscle, with care taken not to disrupt
the levator aponeurosis deep to the orbicularis. A suborbicularis plane is
then developed over the tarsal plate, down to within 1 mm of the eyelids
lower margin. The gold weight is centered over the medial limbus of the eye
with fine absorbable suture, and the incision is closed.
The lateral tarsal strip requires a lateral canthotomy incision, again in
a natural skin crease, followed by division of the inferior canthal tendon
right at its lateral insertion onto the periosteum. The lateral tarsal tendon is
then dissected for 25 mm, depending on how much laxity the lower eyelid
exhibits. Skin, muscle and conjunctiva are then trimmed from the tarsal plate.
This is then sutured to periosteum of the lateral orbital rim, slightly superior
to the insertion of the superior canthal tendon, using a fine double-armed
permanent suture.

EXCISION OF THE SUBMANDIBULAR


GLAND FOR SIALOLITHIASIS
Resection of the submandibular salivary gland for neoplasms is a relatively
straightforward operation in which Whartons duct is ligated near the lateral
border of the mylohyoid muscle. In general, Whartons duct is not excised

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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

10

CAROTID BODY TUMORS AND PARAGANGLIOMAS


Resection of carotid body tumors and other paragangliomas, such as those
arising from the vagus nerve or the sympathetic chain, require meticulous
attention to detail to minimize hemorrhage and to avoid injury to other
cranial nerves during surgical resection.
In general, despite their intense vascularity, these tumors do not have
a single solitary feeding vessel, since most of the blood supply comes from
the vasa vasorum of the adventitia of the carotid artery. Therefore, we have
not found that routine preoperative embolization of these tumors minimizes
bleeding. In fact, the embolic material causes inflammation in the tumor
tissue and makes the dissection more difficult. Therefore, we do not recommend routine embolization for paragangliomas in the head and neck.
The main requirement for safe conduct of these operations is excellent cross-sectional imaging, to demonstrate the anatomic dimensions of
the tumor as well as its location and relationship to major vessels and other
cranial nerves. This is best accomplished with a contrast-enhanced CT scan
and/or a contrast-enhanced MRI (Fig. 10.1).
For instrumentation, a bipolar electrocautery device with fine tips is
the sine qua non for the safe conduct of this operation. Similarly, appropriate dissecting instruments must be available. These include a blunt
Penfield dissector (Penfield #4, normally used for elevation of the dura), a
Freer elevator, a fine-tipped tenotomy scissor, a fine Adson clamp, and micro
hemostats (Figs 10.2 and 10.3). Before the start of the operative procedure,
Fogarty catheters, vascular clamps and vascular shunts should be available
in the OR. Similarly, if the surgeon doing the procedure is not comfortable
with vascular repair of an inadvertent injury to the vessel, a vascular surgeon
should be available on standby.
The patients must be maintained at a relatively low systolic pressure
of approximately 90 mm Hg. An upper neck skin crease is used to place a
transverse incision, and the skin flaps are elevated in the usual fashion. To
maximally expose the carotid sheath and the tumor, the first step is to remove

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Technical Variations and Refinements in Head and Neck Surgery

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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tortuous, premature blood vessels in the adventitia of the artery. However,


these fine immature vessels can be easily controlled with bipolar cautery.
The common carotid artery is circumferentially mobilized, and a vessel loop
is passed around it for control of accidental hemorrhage from the distal part
of the carotid system.
Dissection proceeds in a subadventitial plane proximal to the tumor,
through the adventitia of the common carotid artery. The usual mode
of dissection is to use the bipolar cautery device first, up to a segment of
34 mm of adventitia, which is then elevated with either a Penfield elevator
or a micro hemostat and separated from the tunica media of the carotid
artery and sharply divided with tenotomy scissors. Dissection for carotid
body tumors thus proceeds meticulously and slowly along the external
and internal carotid branches distal to the carotid bulb. A Freer elevator is
used to dissect the tumor off the external and internal carotid arteries, parti
cularly in patients with a Shamblin type II tumor. When this technique of
bipolar cautery is used for the adventitial vessels, subadventitial dissection
and sharp division allow excellent mobilization and delivery of the carotid
vessels off the tumor or from the tumor, to facilitate a safe and complete
tumor excision. This technique is used even for Shamblin type III tumors.
The tumor is split in the region where it is thinnest over the carotid artery,
maintaining complete hemostasis, and the carotid artery is delivered from
the tumor intact, allowing excision of the tumor. Rarely ever does one need to
resect the carotid artery and use a vascular graft to replace the vessel.

Chapter
Transoral Surgery and
Endoscopic Techniques

11

TRANSORAL LASER MICROSURGERY AND


TRANSORAL ROBOTIC SURGERY
Advances in technology have facilitated minimally invasive transoral
approaches to the larynx, hypopharynx and oropharynx. Transoral laser
microsurgery (TLM) and transoral robotic surgery (TORS) use different
instrumentation, but both offer the ability to resect tumors of the laryngopharynx without an external approach, such as mandibulotomy or laryngofissure. Decision-making regarding indications and candidacy for these
procedures is beyond the scope of this text, and readers are referred to the
published reports of groups experienced with transoral laser and robotic
surgery.

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.

Evaluating Candidacy for Transoral Exposure


However, for both TLM and TORS, a critical determinant of candidacy for
surgery is the patients anatomy. The key factors that strongly determine the
amount of access the surgeon can obtain with a laryngoscope (or laryngopharyngoscope), delineated by the Washington University TLM group as
the 8 Ts, are:

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Technical Variations and Refinements in Head and Neck Surgery

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

Safety, Setup and Exposure


Close communication with the anesthesiologist is critical for safe and expeditious transoral surgery. Both TORS and TLM are performed best with the bed
turned 180 from the anesthesiologist, to accommodate the necessary instrumentation. This underscores the need for both the surgeon and the anesthesiologist to share the airway. Live video of the operative procedure should
be televised in the room so that the assistants and anesthesiologist can follow
the progress of the procedure and anticipate needs as they arise.
Airway fires during transoral laser surgery are catastrophic and should
never occur. For TLM cases, we recommend performing an additional preoperative timeout or pause specifically for laser safety before starting surgery.
During this time, members of the operative team and OR staff verify that it is
safe to proceed with laser surgery. This will generally involve ensuring that
all OR staff have protective glasses, that the patients face and nearby anesthesia tubing are completely covered with moistened towels, and that a lasersafe endotracheal tube, if available, has been used. The fraction of inspired
oxygen (FIO2) delivered with anesthesia should ideally be kept under 27% at
all times; below this level, the risk of airway fire is extremely low. This may
necessitate tolerating a patient blood oxygen saturation slightly lower than
100%. Nitrous oxide should be avoided.
Before starting, a selection of laryngoscopes, laryngopharyngoscopes
and transoral retractors should be available in the OR, as it cannot always be
predicted which instrument will provide optimal exposure. At a minimum,
we recommend a selection of laser laryngoscopes, the FK (Feyh-Kastenbauer) laryngopharyngoscope (Fig. 11.1), bivalve supraglottiscope (Fig. 11.2),
and a standard Crowe-Davis tonsillectomy retractor. These instruments will
provide access to the tonsil, base of tongue, and supraglottic and glottic larynx.

Transoral Surgery and Endoscopic Techniques

Fig. 11.1: The F-K (Feyh-Kastenbauer) laryngopharyngoscope.

Fig. 11.2: The bivalve supraglottiscope.

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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Fig. 11.3: Suspension using the Gttingen suspension arm.

blades, but this time investment is worthwhile as it creates exposure for


tumor resection and minimizes the number of times the scope or retractor
will need to be repositioned during the case.
Complete paralysis is mandatory for effective exposure. The head will be
extended at the atlanto-occipital joint. For larynx exposure, flexing the neck
often provides better exposure; for base of tongue exposure, extending the
neck is generally better. Again, it is critical to spend time optimizing exposure
before beginning the resection.
Setup of instruments can also be optimized for expeditious surgery.
For TLM cases, where the surgeon sits at the head of the bed, it is important to avoid pedal confusion. For this reason, we advise separating the
pedals corresponding to the laser, the bipolar cautery device, and the suction
cautery device and delegating the cautery pedals to one assistant each
(Fig. 11.4). Before starting surgery, it is important to make sure that two
suction lines are functioning, that endoscopic clip appliers of various sizes
(5 mm most commonly) are available for use, and that the cautery devices
(suction cautery and endoscopic bipolar cautery) are ready for use. In lieu
of endoscopic bipolar cautery, a standard monopolar cautery device can be
touched to small insulated alligator forceps, which are used to grasp small
vessels. A smoke evacuator is required to keep the field clear; it can be
attached to the scope or to a red rubber catheter that is passed through the
nose and situated in the pharynx.
A larger (laparoscopic) clip applier should be available in the room at all
times, although not necessarily opened on the sterile field, for the uncommon

Transoral Surgery and Endoscopic Techniques

Fig. 11.4: Delegation of different instrument pedals to assistants is critical to avoid


pedal confusion during transoral surgery.

situations in which a large bleeding vessel cannot be adequately controlled


with the standard endoscopic clips.
For TORS cases, the FK laryngopharyngoscope is the preferred means
of exposure, although a Crowe-Davis tonsillectomy rectractor will also work
well for tonsil tumors. The bedside assistant is a critical and often underappreciated member of the surgical team, as a provider of retraction and
suctioning and for applying a bipolar cautery device or clips. To maximize
visibility and to avoid collisions with the robotic arms, the bedside assistant
should work off the video screen and resist the temptation to work by looking
into the mouth (Fig. 11.5).
As in all laser cases, a sitting stool with adjustable armrests is needed to
provide a stable base for the arms and to avoid strain and tremor (Fig. 11.6).
Depending on surgeon preference and on availability, the free beam CO2
laser and the hollow-core CO2 laser fiber are both options for the delivery of
laser energy for TLM surgery. TORS surgery generally relies on monopolar
cautery, although laser attachments are available for both CO2 and thulium
lasers.

Piecemeal Resection with Margin Mapping


In TLM surgery, only very small tumors are removed en bloc (Fig. 11.7A).
The majority of space-occupying tumors of the larynx and oropharynx are
removed in a deliberate piecemeal fashion. This permits assessment of

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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

Transoral Surgery and Endoscopic Techniques

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.

appreciated, as the tumor will be charred by laser energy, in contrast to


normal tissue.
In all cases, it is critical that the surgeon personally ink the specimen,
to clarify orientation and to define which margins are actually deliberate
cuts through the tumor. To most accurately maintain orientation of the

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Technical Variations and Refinements in Head and Neck Surgery

Fig. 11.8: Initial transtumoral laser cut through the midpoint of an oropharyngeal tumor.

Fig. 11.9: Immediate mounting of the endoscopically removed specimen to preserve


orientation.

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).

Transoral Surgery and Endoscopic Techniques

Fig. 11.10: Immediate labeling of margin orientation with pins or ink in the operating
room.

Transoral Supraglottic Laryngectomy


Many supraglottic tumors can be approached via TLM or TORS, although
TLM offers superior exposure in some cases. If TLM is chosen, the best access
to supraglottic tumors is generally afforded by the bivalve laryngoscope.
These are available with side panels to prevent prolapse of the tongue into
the lumen of the scope; alternatively, a latex glove finger wrapped around the
scope can be used for this purpose (Fig. 11.11).
The patient is ideally intubated with a small (size 5.0 or 5.5) endotracheal
tube, and the bivalve scope is positioned, with the tip lifting up the hyoid
bone. A long piece of tape with gauze can be used to apply downward pressure on the laryngeal framework, or an assistant can provide pressure.
To expose the invasive base of a large, exophytic tumor, superficial
debulking may be necessary. In these cases, it is most helpful to leave a large
remnant of tumor, which is readily identifiable and easily retracted.
The initial cut for supraglottic resection is a midline cut through the
epiglottis, which is helpful in orienting the surgeon to the pre-epiglottic
space. As dissection continues through the depth of the tumor, the vocal
cord spreader instrument provides (Fig. 11.12) useful outward distraction of
the tumor and helps to visualize the depth of resection. Additional dissection through the pre-epiglottic space, along the inner perichondrium of the
thyroid cartilage, then follows.
As dissection proceeds laterally, the superior laryngeal artery should be
anticipated. It will be encountered within the trifold region, which is the

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Technical Variations and Refinements in Head and Neck Surgery

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.

Transoral Surgery and Endoscopic Techniques

If significant bleeding is encountered at the time of tumor resection,


it should be controlled in the standard fashion, and the superior laryngeal
artery should be ligated proximally at the time of neck dissection (if a neck
dissection is being performed in the same operative setting).

Transoral Surgery for Glottic Tumors


Glottic tumors are much more accessible via TLM approaches than TORS.
Small tumors of the vocal cord can be readily excised en bloc, but larger
tumors should be excised in a piecemeal fashion.
Care should be taken to optimize exposure before commencing resection. The false vocal cord can be resected first, if necessary, to enhance exposure. Following this, the initial tumor cut should be posterior, at the level of
the endotracheal tube. Any additional tumor posterior to this cut should be
removed last, after repositioning the tube by displacing it anteriorly. Tumors
involving both vocal cords will necessitate a split at the anterior commissure. When this is performed, it is advisable to leave a remnant at the anterior
commissure that is retractable.

Transoral Surgery for Base of Tongue Tumors


The FK laryngopharyngoscope or short bivalve laryngoscope provides
optimal access to base of tongue tumors, for either TLM or TORS (Fig. 11.13).
The FK retractor provides excellent exposure and working space for either
handheld laser fibers or robotic arms (Fig. 11.14). The critical aspect of base
of tongue resection is successful identification and management of the dorsal
branches of the lingual artery. These branches should be anticipated to enter
the surgical field laterally; they continue to run medial to the hyoglossus
muscle. It can be helpful to scrutinize the preoperative CT scans to map out
these branches, as well as to pause during resection to look for pulsations in
the tongue base, especially when working laterally. Clip appliers should be
available from the start of surgery.
As mentioned above, in the case of significant hemorrhage from one of
these branches, the corresponding artery (lingual or facial artery) should be
ligated proximally in the neck at the time of neck dissection.

Transoral Surgery for Tonsil Tumors


Similar principles to those used in exposure and piecemeal resection apply
here. For the smoke evacuator, inserting a large red rubber catheter transnasally is more effective than attaching the smoke evacuator to the retractor.
As with base of tongue surgery, endoscopic clip appliers should be available
from the start of the case.
In TORS operations in which en bloc resection is planned, the constrictor
muscle is taken as a deep margin. In TLM operations in which piecemeal

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Fig. 11.13: The FK retractor provides excellent access to base of tongue tumors, for
either TLM or TORS resection.

Fig. 11.14: Positioning of robotic arms through the FK retractor.

resection is planned, whether the constrictor muscle is resected is determined


on the basis of the depth of tumor invasion. In both cases, the styloglossus
and stylopharyngeus muscles will be identified immediately deep to the
constrictor musculature. The glossopharyngeal nerve runs in between these
two muscles and is generally visible transorally.

Transoral Surgery and Endoscopic Techniques

Transoral Approaches to Squamous Cell


Carcinoma of Unknown Primary Origin
In patients diagnosed with metastatic squamous cell carcinoma to the neck
of unknown primary origin, both TORS and TLM approaches offer enhanced
opportunities to diagnose and treat the primary site of tumor, commonly in
the oropharynx. Depending on the planned modalities of treatment, this may
be combined with a neck dissection if indicated.
In these cases, the patient is ideally nasally intubated. The sites of disease
in the oropharynx, including the palatine tonsil, glossotonsillar sulcus,
and base of tongue, are examined in the standard fashion with palpation and
laryngoscopy. The operating microscope is then brought into the field and
mucosal areas of the upper aerodigestive tract carefully examined under
microscopic vision, searching for telangiectasias, abnormalities in the
mucosa, or small palpable masses identified with a smooth suction tip. If any
suspicious masses are identified, they can be biopsied and then resected to
negative margins using either TLM or TORS techniques. Care should be taken
in the glossotonsillar sulcus to identify tonsillar branches of the facial artery
and clip these if needed. If no apparent primary tumor is identified, TLM or
TORS techniques can be used to excise both the palatine and lingual tonsils.
The lingual tonsil excision is carried down to a plane just superficial to tongue
muscle, and extended 1 cm past the midline of the tongue base. Pathologic
examination of these tissues will commonly identify a small primary tumor.

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.

115

116

Technical Variations and Refinements in Head and Neck Surgery

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.

Transoral Surgery and Endoscopic Techniques

Expeditiously open the stenosis by inserting a rigid bronchoscope


through the stenosis and ventilating through the bronchoscope.
Perform a tracheotomy.
Once the airway has been established and the patient is being well ventilated, attention can be turned to the dilation itself. The following steps are
followed:
1. Intravenous steroids are administered.
2. The laryngoscope is inserted with the tip of the scope slightly through
the true vocal cords. This positions the scope in the subglottis, enhances
exposure of the stenotic area, and avoids trauma to the vocal cords by
repeated insertion and removal of instruments. The laryngoscope is then
suspended. This technique, if performed carefully, does not lead to any
injury or edema of the true vocal cords.
3. The stenosis is brought into view by external manipulation of the trachea;
it can be carefully examined with the microscope, rigid telescopes or
flexible bronchoscope. To carefully examine the character, location,
grade and length of the stenosis, it is generally easiest to pass the flexible
bronchoscope into the trachea.
4. To minimize the formation of further scar tissue, the stenosis is incised
using a mucosal sparing technique. Usually, this requires three or four
radial incisions into the stenosis, which are made with the laser (either
handheld fiber or free-beam) attached to the microscope.
5. An esophageal dilation balloon of the desired diameter is then inserted
through the stenosis, alongside the telescope/bronchoscope or under
microscopic vision. Once the patient has been preoxygenated, the
balloon is inflated and kept inflated for at least 60 seconds.
6. The result is inspected, and further dilation is performed as indicated
(Figs 11.15A to E).
7. A postoperative chest radiograph is obtained to rule out pneumothorax.
In the trachea, esophageal dilation balloons (Fig. 11.16) generally function better than tracheal dilation balloons, as the esophageal balloons are
longer and less likely to slip during dilation.
There is no clear evidence in the literature supporting the use of either
mitomycin C or intralesional steroids, and these agents are rarely used.
For stenotic regions in the thoracic trachea or bronchi, suspension laryngoscopy may not be strictly necessary, although it does provide optimal and
secure ventilation and airway access. Alternate approaches are:
Rigid bronchoscopy with jet ventilation
Laryngeal mask airway with flexible bronchoscopy through the laryngeal
mask airway tube.

117

118

Technical Variations and Refinements in Head and Neck Surgery

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

Transoral Surgery and Endoscopic Techniques

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

119

120

Technical Variations and Refinements in Head and Neck Surgery

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.

Transoral Surgery and Endoscopic Techniques

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.

121

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

Canthal tendon, superior 97


Canthotomy incision, lateral 97
Carotid artery, adventitia of 101
Carotid body tumors 99
dissection of 100f
resection of 99
Cautery injury 83
Central
compartment
lymph node dissection 76f
node dissection 76
palatal defect, repair of 33, 58
Cephalocaudad 66
Cervical
esophagus 60
incision 78
spine deformities see Trismus
thymectomy 87
Cheek 45
Chemoradiation therapy 65
anticipation of 119
Chyle leak, avoidance of 75
Circummandibular retention sutures 52f
Closure after wedge excision of
auricle 24f
Comprehensive neck dissections 72
Contemporary operating room 2f
Contralateral
arm 4
nerve 83
Cricothyroid
joint 82
membrane 78
Crowe-Davis tonsillectomy
rectractor 104, 107
Crucial in surgical procedure 11
Cutaneous nerves 74

D
Debulk tumors 108
Deep lobe parotid tumor 96f
excision of 94
Dental obturator 32, 58

124

Technical Variations and Refinements in Head and Neck Surgery

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

Technical Variations and Refinements in Head and Neck Surgery

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

Technical Variations and Refinements in Head and Neck Surgery

supraglottic laryngectomy 111


surgery 103
for tongue tumors 113
for tonsil tumors 113
Transverse
dimensions of mandible 104
incision, single 63
thyroidectomy incision,
extension of 82f
wedge excision of lateral tongue
lesion, design of 44f
Trismus 59, 104
Trunk of facial nerve 92
identification of main 93
Tumor
cuts in transoral laser micro surgery 109f
other 99
Tympanomastoid suture line 93

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

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