Pearls and Pitfalls in Head and Neck Surgery

Pearls and Pitfalls in Head and Neck Surgery
Pearls and Pitfalls in

Head and Neck Surgery
Practical Tips to
Minimize Complications
Editor
Claudio R. Cernea, So Paulo
Associate Editors
Fernando L. Dias, Rio de Janeiro
Dan Fliss, Tel Aviv
Roberto A. Lima, Rio de Janeiro
Eugene N. Myers, Pittsburgh, Pa.
William I. Wei, Hong Kong
3 tables, 2008
Basel Freiburg Paris London New York

Bangalore Bangkok Shanghai Singapore Tokyo Sydney
Claudio R. Cernea
Department of Head and Neck Surgery,
University of So Paulo Medical School,
So Paulo, Brazil
Library of Congress Cataloging-in-Publication Data
Pearls and pitfalls in head and neck surgery : practical tips to minimize
complications / editor, Claudio R. Cernea ; associate editors, Fernando L. Dias ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-3-8055-8425-8 (hard cover : alk. paper)
1. Head--Surgery. 2. Neck--Surgery. I. Cernea, Claudio R. II. Dias, Fernando L.
[DNLM: 1. Head--surgery. 2. Head and Neck Neoplasms--surgery. 3.
Neck--surgery. WE 705 P359 2008]
RD521.P38 2008
617.51--dc22
2008015976
Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents and
Index Medicus.
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Copyright 2008 by S. Karger AG, P.O. Box, CH4009 Basel (Switzerland)

www.karger.com
Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel
ISBN 9783805584258
Contents
1 Preface
Thyroid and Parathyroid Glands

2 1.1 How to Avoid Injury of Inferior Laryngeal Nerve
Jacob Moalem, Orlo H. Clark (San Francisco, Calif.)
4 1.2 How to Avoid Injury of the External Branch of Superior Laryngeal Nerve
Claudio R. Cernea, Alberto R. Ferraz (So Paulo)
6 1.3 Recurrent Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery:
Technique for the NIM 2 System
David J. Lesnik (Boston, Mass.), Lenine Garcia Brandao (So Paulo), Gregory W. Randolph
(Boston, Mass.)
8 1.4 How to Preserve the Parathyroid Glands during Thyroid Surgery
Ashok R. Shaha, Vergilius Jos F. de Arajo Filho (New York, N.Y.)
10 1.5 Completion Thyroidectomy
Eveline Slotema, Jean-Franois Henry (Marseille)
12 1.6 Surgery for Intrathoracic Goiters
Ashok R. Shaha (New York, N.Y.), James L. Netterville, Nadir Ahmad (Nashville, Tenn.)
14 1.7 How to Decide the Extent of Thyroidectomy for Benign Diseases
Jeremy L. Freeman (Toronto, Ont.)
16 1.8 Minimally Invasive Video-Assisted Thyroidectomy
Erivelto M. Volpi, Gabrielle Matterazzi, Fernando L. Dias, Paolo Miccoli (So Paulo)
18 1.9 Video-Assisted Parathyroidectomy
William B. Inabnet (New York, N.Y.)
20 1.10 Limited Parathyroidectomy
Keith S. Heller (New York, N.Y.)
22 1.11 Practical Tips for the Surgical Management of Secondary Hyperparathyroidism
Fbio Luiz de Menezes Montenegro, Rodrigo Oliveira Santos, Ani Castro Cordeiro (So Paulo)
24 1.12 Reoperative Parathyroidectomy
Alfred Simental (Loma Linda, Calif.)
Contents V
26 1.13 Paratracheal Neck Dissection: Surgical Tips
A. Khafif (Tel Aviv), L.P. Kowalski (So Paulo), Dan M. Fliss (Tel Aviv)
28 1.14 Management of Lymph Nodes in Medullary Thyroid Cancer
Marcos R. Tavares (So Paulo)
30 1.15 How to Manage a Well-Differentiated Carcinoma with Recurrent Nerve Invasion
Patrick Sheahan, Jatin P. Shah (New York, N.Y.)
32 1.16 Management of Invasive Thyroid Cancer
Thomas V. McCaffrey (Tampa, Fla.)
Neck Metastases
34 2.1 Preoperative Workup of the Neck in Head and Neck Squamous Cell Carcinoma
Michiel van den Brekel, Frans J.M. Hilgers (Amsterdam)
36 2.2 N0 Neck in Oral Cancer: Wait and Watch
Yoav P. Talmi (Tel Aviv)
38 2.3 N0 Neck in Oral Cancer: Elective Neck Dissection
Fernando L. Dias, Roberto A. Lima (Rio de Janeiro)
40 2.4 Sentinel Node Biopsy in the Management of the N0 Oral Cancer
Francisco Civantos (Miami, Fla.)
42 2.5 Selective Neck Dissection in the Treatment of the N+ Neck in Cancers
of the Oral Cavity
Jesus E. Medina, Greg Krempl (Oklahoma City, Okla.)
44 2.6 How to Manage the XI Nerve in Neck Dissections
Lance E. Oxford, John C. OBrien, Jr. (Dallas, Tex.)
46 2.7 Preservation of the Marginal Mandibular Nerve in Neck Surgery
K. Thomas Robbins (Springfield, Ill.)
48 2.8 Bilateral Neck Dissections: Practical Tips
Jonas T. Johnson (Pittsburgh, Pa.)
50 2.9a How to Manage Retropharyngeal Lymph Nodes 1. Transoral Approach
James Cohen (Portland, Oreg.), Randal S. Weber (Houston, Tex.)
52 2.9b How to Manage Retropharyngeal Lymph Nodes 2. Transcervical Approach
Randal S. Weber (Houston, Tex.)
54 2.10 Management of the Node-Positive Neck in Patients Undergoing
Chemoradiotherapy
Rod P. Rezaee, Pierre Lavertu (Cleveland, Ohio)
56 2.11 How to Avoid Injury to Thoracic Duct during Surgical Resection of
Left Level IV Lymph Nodes
Gary L. Clayman (Houston, Tex.)
58 2.12 What Are the New Concepts in Functional Modified Neck Dissection?
Bhuvanesh Singh (New York, N.Y.)
VI Pearls and Pitfalls in Head and Neck Surgery

Oral/Oropharyngeal Tumors
60 3.1 How to Reconstruct Small Tongue and Floor of Mouth Defects
Remco de Bree, C. Ren Leemans (Amsterdam)
62 3.2 Reconstruction of Large Tongue and Floor of Mouth Defects
Neal D. Futran (Seattle, Wash.)
64 3.3 How to Evaluate Surgical Margins in Mandibular Resections
Richard J. Wong (New York, N.Y.)
66 3.4 How to Reconstruct Anterior Mandibular Defects in Patients
with Vascular Diseases
Matthew M. Hanasono (Houston, Tex.)
68 3.5 Adequate Surgical Margins in Resections of Carcinomas of the Tongue
Jacob Kligerman (Rio de Janeiro)
70 3.6 Practical Tips to Manage Mandibular Osteoradionecrosis
Sheng-Po Hao (Taoyuan, Taiwan)
Laryngeal Tumors
72 4.1 Practical Tips for Laser Resection of Laryngeal Cancer
F. Christopher Holsinger, N. Scott Howard (Houston, Tex.), Andrew McWhorter
(Baton Rouge, La.)
74 4.2 Practical Suggestions for Phonomicrosurgical Treatment of Benign Vocal Fold
Lesions
Steven M. Zeitels, Gerardo Lopez Guerra (Boston, Mass.)
76 4.3 Glottic Reconstruction after Partial Vertical Laryngectomy
Onivaldo Cervantes, Mrcio Abraho (So Paulo)
78 4.4 Suprahyoid Pharyngotomy
Eugene N. Myers, Robert L. Ferris (Pittsburgh, Pa.)
80 4.5 Intraoperative Maneuvers to Improve Functional Result after
Supraglottic Laryngectomy
Roberto A. Lima, Fernando L. Dias (Rio de Janeiro)
82 4.6 Practical Tips for Performing Supracricoid Partial Laryngectomy
Gregory S. Weinstein, F. Christopher Holsinger, Ollivier Laccourreye (Philadelphia, Pa.)
84 4.7 Intraoperative Maneuvers to Improve Functional Results after Total Laryngectomy
Javier Gaviln (Madrid), Jess Herranz (La Corua)
86 4.8 How to Manage Tracheostomal Recurrence
Dennis H. Kraus (New York, N.Y.)
88 4.9 Stenosis of the Tracheostoma following Total Laryngectomy
Eugene N. Myers (Pittsburgh, Pa.)
90 4.10 How to Prevent and Treat Pharyngocutaneous Fistulas after Laryngectomy
Bhuvanesh Singh (New York, N.Y.)
Contents VII
Hypopharyngeal Cancer
92 5.1 How to Treat Small Hypopharyngeal Primary Tumors with N3 Neck
Abro Rapoport, Marcos Brasilino de Carvalho (So Paulo)
94 5.2 Practical Tips to Reconstruct a Total Laryngectomy/Partial Pharyngectomy Defect
Dennis H. Kraus (New York, N.Y.)
96 5.3 Practical Tips for Voice Rehabilitation after Pharyngolaryngectomy
Frans J.M. Hilgers, Michiel van den Brekela (Amsterdam)
98 5.4 How to Choose the Reconstructive Method after Total Pharyngolaryngectomy
William I. Wei, Jimmy Y.W. Chan (Hong Kong)
Nasopharyngeal Cancer
100 6.1 Indications for Surgical Treatment of Nasopharyngeal Cancer
William I. Wei, Rockson Wei (Hong Kong)
102 6.2 Practical Tips to Perform a Maxillary Swing Approach
William I. Wei, Raymond W.M. Ng (Hong Kong)
104 6.3 Management of Neck Metastases of Nasopharyngeal Carcinoma
William I. Wei, W.K. Ho (Hong Kong)
Salivary Gland Tumors

106 7.1 Practical Tips to Identify the Main Trunk of the Facial Nerve
Fernando L. Dias, Roberto A. Lima (Rio de Janeiro), Jorge Pinho (Recife)
108 7.2 Retrograde Approach to Facial Nerve: Indications and Technique
Flavio C. Hojaij, Caio Plopper, Claudio R. Cernea (So Paulo)
110 7.3 Intraoperative Decisions for Sacrificing the Facial Nerve in Parotid Surgery
Randal S. Weber, F. Christopher Holsinger (Houston, Tex.)
112 7.4 When and How to Reconstruct the Resected Facial Nerve in Parotid Surgery
Peter C. Neligan (Seattle, Wash.)
114 7.5 Approaches to Deep Lobe Parotid Tumors
Richard V. Smith (Bronx, N.Y.)
116 7.6 Recurrent Parotid Pleomorphic Adenoma
Bruce J. Davidson (Washingston, D.C.)
118 7.7 How to Overcome Limitations of Fine Needle Aspiration and Frozen Section Biopsy
during Operations for Salivary Gland Tumors
Alfio Jos Tincani, Sanford Dubner (Campinas)
120 7.8 Practical Tips to Spare the Great Auricular Nerve in Parotidectomy
Randall P. Morton (Auckland)
122 7.9 Indications for Elective Neck Dissection in Parotid Cancers
Roberto A. Lima, Fernando L. Dias (Rio de Janeiro)
VIII Pearls and Pitfalls in Head and Neck Surgery

124 7.10 Indications for Tactical Parotidectomy in Nonsalivary Lesions
Caio Plopper, Claudio R. Cernea (So Paulo)
126 7.11 When Not to Operate on a Parotid Tumor
Jeffrey D. Spiro (Farmington, Conn.), Ronald H. Spiro (New York, N.Y.)
128 7.12 Practical Tips on Excision of the Submandibular Gland
Kwang Hyun Kim (Seoul)
Skull Base Tumors

130 8.1 Practical Tips to Perform the Subcranial Approach
Ziv Gil, Dan M. Fliss (Tel Aviv)
132 8.2 Facial Translocation Approach
Fernando Walder (So Paulo)
134 8.3 How to Manage Large Dural Defects in Skull Base Surgery
Eduardo Vellutini, Marcos Q.T. Gomes (So Paulo)
136 8.4 Which Is the Best Choice to Seal the Craniofacial Diaphragm?
138 8.5 Contraindications for Resection of Skull Base Tumors
Fernando L. Dias, Roberto A. Lima (Rio de Janeiro)
140 8.6 Practical Tips about Orbital Preservation and Exenteration
Ehab Hanna (Houston, Tex.)
142 8.7 Practical Tips to Approach the Cavernous Sinus
Marcos Q.T. Gomes, Eduardo Vellutini (So Paulo)
144 8.8 How to Reconstruct Large Cranial Base Defects
Patrick J. Gullane, Christine B. Novak, Kristen J. Otto (Toronto),
Peter C. Neligan (Seattle, Wash.)
146 8.9 Surgical Management of Recurrent Skull Base Tumors
Claudio R. Cernea (So Paulo), Ehab Hanna (Houston, Tex.)
148 8.10 Management of Extensive Fibro-Osseous Lesions of the Skull Base
Claudio R. Cernea (So Paulo), Bert W. OMalley, Jr. (Philadelphia, Pa.)
Vascular Tumors
150 9.1 Practical Tips to Manage Extensive Arteriovenous Malformations
Gresham T. Richter, James Y. Suen (Little Rock, Ark.)
152 9.2 How to Manage Extensive Lymphatic Malformations
James Y. Suen, Gresham T. Richter (Little Rock, Ark.)
154 9.3 How to Deal with Emergency Bleeding Episodes in Arteriovenous Malformations
Eduardo Noda Kihara, Mario Sergio Duarte Andrioli, Eduardo Noda Kihara Filho (So Paulo)
Contents IX
Congenital Tumors
156 10.1 Practical Tips to Manage Branchial Cleft Cysts and Fistulas
Marcelo D. Durazzo, Gilberto de Britto e Silva Filho (So Paulo)
158 10.2 How to Avoid Surprises in the Management of the Thyroglossal Duct Cyst
Nilton T. Herter (Porto Alegre)
Parapharyngeal Space Tumors

160 11.1 How to Manage Extensive Carotid Body Tumors
Nadir Ahmad, James L. Netterville (Nashville, Tenn.)
162 11.2 How to Manage Extensive Neurogenic Tumors
164 11.3 How to Choose a Surgical Approach to a Parapharyngeal Space Mass
Kerry D. Olsen (Rochester, Minn.)
Infections of Head and Neck

166 12.1 Practical Tips to Approach a Deep Neck Abscess
Flvio C. Hojaij, Caio Plopper (So Paulo)
168 12.2 Management of Necrotizing Fasciitis
Dorival De Carlucci Jr. (So Paulo)
Tracheotomy
170 13.1 Minimizing Complications in Tracheotomy
Eugene N. Myers (Pittsburgh, Pa.)
172 13.2 Emergency Upper Airway Obstruction: Cricothyroidotomy or Tracheotomy?
Carlos N. Lehn (So Paulo)
174 13.3 Avoidance of Complications in Conventional Tracheotomy and Percutaneous
Dilatational Tracheotomy
David W. Eisele (San Francisco, Calif.)
Reconstruction
176 14.1 Practical Tips to Perform a Microvascular Anterolateral Thigh Flap
Luiz Carlos Ishida, Luis Henrique Ishida (So Paulo)
178 14.2 Practical Tips to Perform a Deltopectoral Flap
Roberto A. Lima, Fernando L. Dias (Rio de Janeiro), Jorge Pinho Filho (Recife)
180 14.3 Practical Tips for Performing a Pectoralis Major Flap
Jos Magrim, Joo Gonalves Filho (So Paulo)
X Pearls and Pitfalls in Head and Neck Surgery

182 14.4 Practical Tips to Perform a Trapezius Flap
Richard E. Hayden (Scottsdale, Ariz.)
184 14.5 Latissimus Dorsi Myocutaneous Flap for Head and Neck Reconstruction
Gady Har-El (New York, N.Y.; Brooklyn, N.Y.), Michael Singer (Brooklyn, N.Y.)
186 14.6 Transverse Rectus Abdominis Flap
Julio Morais Besteiro (So Paulo)
188 14.7 Practical Tips to Perform a Microvascular Forearm Flap
Adam S. Jacobson, Mark L. Urken (New York, N.Y.)
190 14.8 Mandible Reconstruction with Fibula Microvascular Transfer
192 14.9 Practical Tips to Perform a Microvascular Iliac Crest Flap
Mario S.L. Galvao (Rio de Janeiro)
194 14.10 The Scapular Flap
196 14.11 Reconstruction of Pharyngoesophageal Defects with the Jejunal Free Autograft
John J. Coleman 3rd (Indianapolis, Ind.)
198 14.12 Practical Tips to Perform a Gastric Pull-Up
William I. Wei, Vivian Mok (Hong Kong)
Miscellaneous
200 15.1 Indications and Limitations of Fine Needle Aspiration Biopsy of
Lateral Cervical Masses
Paulo Campos Carneiro, Luiz Fernando Ferraz da Silva (So Paulo)
202 15.2 When and How to Perform an Open Neck Biopsy of a Lateral Cervical Mass
Pedro Michaluart Jr, Srgio Samir Arap (So Paulo)
204 15.3 Practical Tips in Managing Radiation-Associated Sarcoma of the Head and Neck
Thomas D. Shellenberger (Orlando, Fla.; Houston, Tex.), Erich M. Sturgis (Houston, Tex.)
206 15.4 Practical Tips for Performing Transoral Robotic Surgery
Gregory S. Weinstein, Bert W. OMalley, Jr. (Philadelphia, Pa.)
209 Corresponding Authors

213 Subject Index
Contents XI
Preface
The main objective of this book is to give the read- I would like to thank all authors for their ef-
er very concise and useful information on what forts to efficiently address their respective sub-
should and should not be done when dealing with jects in the limited space available. I believe that
specific diagnostic and therapeutic situations in they have done a terrific job.
head and neck surgery. This is not a conventional I would like to extend my deep gratitude to the
textbook, containing a comprehensive collection co-editors Dan Fliss, MD, Eugene N. Myers, MD,
of all material available, nor is it an atlas of anat- Fernando L. Dias, MD, Roberto A. Lima, MD and
omy or surgical techniques. Instead, a highly se- William I. Wei, MD, whose participation was vi-
lected group of top world experts was invited to tal for this book, not only because of the number
share their personal experiences about key sub- and quality of their contribution but also because
jects in the different areas of our specialty. All of their invaluable suggestions concerning revi-
agreed to discuss, in a very succinct chapter, their sions, topics and authors.
view, emphasizing useful tips and particularly Also, I would like to thank the publishers Ste-
warning against potentially hazardous pitfalls ven Karger (in memoriam) and Thomas Karger,
that could affect the diagnosis and treatment of who believed in this project and have made it re-
our patients. Moreover, all contributors were ality. My special recognition goes to Mrs. Elisa-
asked to recommend practical guidelines to help beth Anyawike, the extremely efficient Produc-
all of us in our everyday practice. tion Editor who assisted me in dealing with all the
The different sections of this book include the difficulties during the editing process.
vast majority of the diseases encountered by the Finally, my eternal gratitude goes to my be-
head and neck surgeon in his or her everyday loved wife, Selma S. Cernea, MD, for her serenity,
practice: (1) thyroid and parathyroid glands; (2) patience and support.
neck metastases; (3) oral and oropharyngeal tu-
mors; (4) laryngeal tumors; (5) hypopharyngeal Claudio R. Cernea, So Paulo
cancer; (6) nasopharyngeal cancer; (7) salivary
gland tumors; (8) skull base tumors; (9) vascular
tumors; (10) congenital tumors; (11) parapharyn-
geal space tumors; (12) infections of the head and
neck; (13) tracheotomy; (14) reconstruction, and
(15) miscellaneous.
Preface 1
Cernea CR, Dias FL, Fliss D, Lima RA, Myers EN, Wei WI (eds): Pearls and Pitfalls in Head and Neck Surgery. Basel, Karger, 2008, pp 23
1.1 How to Avoid Injury of Inferior Laryngeal

Nerve
Jacob Moalem, Orlo H. Clark
University of California, Division of Endocrine Surgery, San Francisco, Calif., USA

P E A R L S Introduction
The terms inferior and recurrent laryngeal
Detailed knowledge of the inferior laryngeal nerve nerve have been used interchangeably to describe
(ILN)s anatomic relationships and variations is a branch of the thoracic vagus that loops around
imperative to safely perform thyroidectomy or
parathyroidectomy.
the subclavian artery (on the right) or aortic arch
(on the left), and then ascends to terminally arbo-
Avoid mass ligature and stay as close as possible to
rize [1]. The ILN carries sensory, motor and para-
the thyroid gland at all times.
sympathetic fibers, and divides into an internal
Definitively identify the ILN prior to sacrificing branch (sensory to the vocal cords and subglottis)
branches of the inferior thyroid artery (ITA).
and external branch (motor to the intrinsic mus-
Maintain meticulous hemostasis and a clean dis- cles of the larynx except cricothyroid). In as many
secting field at all times for excellent visualization.
as 70% of cases, this branching is extralaryngeal,
Fully evaluate the thyroid gland and adjacent predisposing a branch of the nerve to injury. In
lymph nodes for suspicious nodules prior to per- the vast majority of these cases, this bifurcation
forming thyroidectomy or parathyroidectomy to
eliminate the potential for reoperation.
occurs more than 1.0 cm from the cricoid carti-
lage [2, 3].
Consider a you touch it you buy it policy: soften
ILN dysfunction is among the most common,
the indications for thyroid lobectomy any time a
lobe is exposed for another reason. feared and litigious complications of cervical ex-
plorations, and is associated with temporary or
Perform preoperative direct laryngoscopy on all
permanent vocal cord dysfunction. When bilat-
patients with dysphonia or risk factors for unilateral
vocal cord dysfunction at baseline. eral injury occurs, the morbidity is even more
dramatic, often requiring tracheostomy.

P I T F A L L S
Practical Tips
Injury to the ILN is up to 5-fold higher in reopera- Most authors assert that routine identification
tive surgery. This risk is even higher when operating of the ILN, as opposed to its avoidance, is the meth-
for malignancy as opposed to benign conditions. od of choice to reduce the chance of injury [4].
The most common site where the ILN is injured is In the modern surgical literature, the ILN has
near the ligament of Berry. Injury may occur be- never been reported to enter the fascia of the thy-
cause of excessive traction, cautery, a branched ILN, roid gland. However, the nerve can be surround-
or misplaced hemostatic sutures.
ed or displaced by a thyroid nodule or by an in-
vasive thyroid cancer.
2 Pearls and Pitfalls in Head and Neck Surgery

Many surgeons use relationships with the ITA, Recovery of function is possible in cases where
tracheoesophageal groove, and ligament of Berry
as anatomical landmarks to identify the nerve.
postoperative palsy occurs despite intraoperative
identification and preservation of the ILN. In this
1
However: group, vocal cord recovery is described in as
While the majority of ILNs lie posterior to many as 94.6% of patients at a mean of 31 days
the ITA, approximately 1/3 have been identified [4].
either anterior to, or interdigitating with, its
branches (1232.5 and 6.527%, respectively) Conclusion
[3, 5]. As is widely reported, consistently safe thyroid-
In approximately 2/3 of the cases the ILN lies ectomy is feasible, but relies upon a meticulous
within the tracheoesophageal groove. However, surgical technique. Surgeon experience, intimate
in approximately 1/3 of the cases the nerve is lat- familiarity with the anatomy of the ILN, magni-
eral to the trachea, and in approximately 1% the fication, and constant vigilance all minimize the
nerve is anterior to the trachea [3]. risk of highly morbid complications.
Autopsy studies demonstrate that the ILN is
usually located dorsolaterally to the ligament of
Berry, at a mean distance of 3 mm [6]. There are References
reports, however, where the nerve passes postero- 1 Mirilas P, Skandalakis JE: Benign anatomical mistakes: the cor-
rect anatomical term for the recurrent laryngeal nerve. Am Surg
medially to, or through, the ligament of Berry
2002;68:9597.
[7]. 2 Nemiroff PM, Katz AD: Extralaryngeal divisions of the recurrent
A particularly feared variant is the nonrecur- laryngeal nerve. Surgical and clinical significance. Am J Surg
1982;144:466469.
rent ILN (NRILN). Known to occur in 0.31.6% 3 Ardito G, Revelli L, DAlatri L, et al: Revisited anatomy of the
of cases, NRILN is virtually always encountered recurrent laryngeal nerves. Am J Surg 2004;187:249253.
on the right side where it is associated with (and 4 Chiang FY, Wang LF, Huang YF, et al: Recurrent laryngeal nerve
palsy after thyroidectomy with routine identification of the re-
may be predicted by [8]) an anomalous origin of current laryngeal nerve. Surgery 2005;137:342347.
the brachiocephalic artery. Of note, an NRILN 5 Steinberg JL, Khane GJ, Fernandes CM, et al: Anatomy of the re-
may be associated with the superior thyroid ar- current laryngeal nerve: a redescription. J Laryngol Otol 1986;
100:919927.
tery (type A) or with the ITA (type B) [8]. In either 6 Sasou S, Nakamura S, Kurihara H: Suspensory ligament of Berry:
case, its course is much more oblique (or even its relationship to recurrent laryngeal nerve and anatomic ex-
amination of 24 autopsies. Head Neck 1998;20:695698.
transverse) than expected. There are two reports 7 Yalcin B, Ozan H: Detailed investigation of the relationship be-
of left-sided NRILN, both in association with a tween the inferior laryngeal nerve including laryngeal branches
right-sided aortic arch [9]. and ligament of Berry. J Am Coll Surg 2006;202:291296.
8 Toniato A, Mazzarotto R, Piotto A, et al: Identification of the
The use of loupes with 2.53.5 magnification
nonrecurrent laryngeal nerve during thyroid surgery: 20-year
helps to optimize visualization and minimize experience. World J Surg 2004;28:659661.
risk of injury to the ILN. 9 Henry JF, Audiffret J, Denizot A, et al: The nonrecurrent inferior
laryngeal nerve: review of 33 cases, including two on the left side.
Although increasingly employed, there is no Surgery 1988;104:977984.
convincing evidence that routine use of intraop- 10 Dralle H, Sekulla C, Haerting J, et al: Risk factors of paralysis and
functional outcome after recurrent laryngeal nerve monitoring
erative ILN monitoring or stimulation results in
in thyroid surgery. Surgery 2004;136:13101322.
lower rates of nerve injury [10].
3
1.2 How to Avoid Injury of the External

Branch of Superior Laryngeal Nerve
Claudio R. Cernea, Alberto R. Ferraz
Department of Head and Neck Surgery, University of So Paulo Medical School, So Paulo, Brazil

P E A R L S it may cross the vessels closer or even inferiorly to
the border. This is the type 2b nerve [3], and in
Keep in mind that the external branch of superior this instance the nerve is more vulnerable to in-
laryngeal nerve (EBSLN) may be found in the opera- advertent injury during a thyroidectomy [4].
tive field of a thyroidectomy in 1520% of the cases.
Moreover, if the thyroid gland is markedly en-
Avoid mass ligatures of the superior thyroid pole larged, the superior thyroid pole is elevated, in-
vessels.
creasing the likelihood of a type 2b nerve and,
Use nerve monitoring or, at least, a nerve stimula- consequently, the risk of its injury as well [5]. In
tor, especially when performing a thyroidectomy in half of the cases who presented this complication
a voice professional.
after thyroidectomy, it was permanent [4], and no
effective treatment has been reported so far.

P I T F A L L S
Therefore, prevention of damage to the EBSLN
during thyroidectomy is strongly advised.
Risk of EBSLN injury is much higher in large goiters.
Excessive burning with the Bovie near the cricothy-
Practical Tips
roid muscle (CTM) can cause the same functional
impact on voice performance. Although it is probably not necessary to actively
search for the EBSLN during a routine thyroidec-
tomy in the majority of the cases, it is important
to keep in mind some situations that could in-
Introduction crease the risk of its injury and to be prepared to
The EBSLN is the main motor supply to the CTM. prevent it:
The contraction of this muscle stretches the vocal According to some authors, type 2b EBSLN is
fold, especially during the production of high fre- more prevalent among patients with short stature
quency sounds [1]. Therefore, EBSLN paralysis [6] and with large thyroid growth [5, 6].
leads to an important impairment of voice perfor- Ask your anesthesiologist not to paralyze your
mance, mainly among women and voice profes- patient.
sionals. Consider using some kind of nerve monitoring
This nerve crosses the superior thyroid ves- or, at least, a simple disposable nerve stimulator.
sels, usually more than 1 cm above the upper bor- If a nerve monitoring system is employed, the po-
der of the superior thyroid pole, before reaching tential noted after EBSLN stimulation, despite be-
the CTM, in a region defined as the sternothyroid ing much smaller than the recurrent nerve re-
triangle [2]. However, in 1520% of the instances, cord, is very typical. In addition, the contraction

of the CTM, in response to a simple 0.5-mA stim- Conclusion
ulus on the EBSLN is very easily demonstrated in
the surgical field. These measures are mandatory
In this chapter, the reader is introduced to a fre-
quently overlooked complication of thyroidecto-
1
when operating on a voice professional or within my, the injury of the EBSLN. The resulting pa-
a reoperative field. ralysis of CTM is often permanent. It is important
Always keep in mind that there is a 1520% to realize that 1520% of the nerves may be found
chance to find a type 2b nerve. Therefore, any an- during a thyroidectomy, and the surgeon must be
atomical structure resembling a small nerve going able to identify them, preferably with nerve mon-
towards the CTM should be carefully preserved. itoring or with a nerve stimulator, in order to
Magnification is advisable. Wide-angled sur- keep their integrity when dissecting the superior
gical loupes, with 2.53.5 magnifying lenses, thyroid pole.
help to identify the EBSLN.
Sectioning the sternothyroid muscle markedly
improves the visualization of the superior thyroid References
pole with no negative impact on voice perfor- 1 Kark AE, Kissin MW, Auerbach R, et al: Voice changes after thy-
roidectomy: role of the external laryngeal nerve. Br Med J (Clin
mance [7].
Res Ed) 1984;289:14121415.
Try to avoid mass ligatures of the superior thy- 2 Moosman DA, DeWeese MS: The external laryngeal nerve as
roid pedicle. Instead, identify and ligate separate- related to thyroidectomy. Surg Gynecol Obstet 1968;127:1011
1016.
ly the branches of the superior thyroid vessels. If 3 Cernea CR, Ferraz AR, Nishio S, et al: Surgical anatomy of the
a harmonic scalpel or a sealing device is used, be external branch of the superior laryngeal nerve. Head Neck
sure not to include the EBSLN in the instrument. 1992;14:380383.
4 Cernea CR, Ferraz AR, Furlani J, et al: Identification of the exter-
The anatomical classification of the EBSLN
nal branch of the superior laryngeal nerve during thyroidecto-
was created based upon a conventional thyroid- my. Am J Surg 1992;164:634639.
ectomy field. However, when performing a video- 5 Cernea CR, Nishio S, Hojaij FC: Identification of the external
branch of the superior laryngeal nerve (EBSLN) in large goiters.
assisted thyroidectomy, remember that the EB- Am J Otolaryngol 1995;16:307311.
SLN is greatly approximated to the superior thy- 6 Furlan JC, Cordeiro AC, Brandao LG: Study of some intrinsic
risk factors that can enhance an iatrogenic injury of the external
roid pole, because no hyperextension of the neck branch of the superior laryngeal nerve. Otolaryngol Head Neck
is exerted. On the other hand, the great magnifi- Surg 2003;128:396400.
cation offered by the endoscope helps to identify 7 Cernea CR, Ferraz AR, Cordeiro AC: Surgical anatomy of the su-
perior laryngeal nerve; in Randolph GW (ed): Surgery of the Thy-
and preserve the nerve in virtually all patients, as roid and Parathyroid Glands. Philadelphia, Saunders-Elsevier,
long as the surgeon is aware of this different po- 2003, pp 293299.
sitioning.
5
1.3 Recurrent Laryngeal Nerve Monitoring

in Thyroid and Parathyroid Surgery:
Technique for the NIM 2 System
David J. Lesnik a, Lenine Garcia Brandaob, Gregory W. Randolpha
a Massachusetts Eye and Ear Infirmary, Thyroid Surgical Division, Harvard Medical School, Boston, Mass., USA;
b Head and Neck Surgery, Hospital das Clnicas, University of So Paulo Medical School, So Paulo, Brazil

Injury to the RLN is a significant risk associated
The recurrent laryngeal nerve (RLN) monitoring will with thyroid and parathyroid surgery. While per-
aid in identification and protection of the RLN dur- manent deficit is rare, this postoperative compli-
ing thyroid and parathyroid surgery especially in
difficult or revision cases.
cation may lead to appreciable difficulties with
speech and swallowing. Numerous studies have
The nerve monitor may be used to localize the RLN
determined that routine identification of the RLN
prior to visual identification expediting surgery and
minimizing nerve dissection. is associated with lower rates of injury. Therefore,
RLN monitoring represents a useful technical de-
Monitoring may be used to prognosticate postop-
velopment that may greatly aid the surgeon in
erative function and impact the decision to perform
bilateral surgery. identifying and protecting the RLN during sur-
gery, especially in difficult cases, e.g. large or tox-
When using the NIM 2 system, attention to detail
ic goiter, malignancy, or reoperative cases.
and confirmation of tube position preoperatively is
essential. RLN monitoring has three functions: (1) to fa-
cilitate neural identification, (2) to aid in neural

P I T F A L L S dissection and (3) to prognosticate regarding
postoperative neural function. Monitoring may
The monitor is not a substitute for careful surgical reduce the incidence of nerve injury and yet, it is
technique and meticulous hemostasis. not used universally. Herein we describe our pre-
True negative RLN stimulation cannot be trusted ferred method of RLN identification and moni-
until definitive RLN identification and positive stim- toring and offer some tips for success.
ulation are achieved.
No structure in the lateral thyroid region should be NIM 2 Nerve Monitoring
clamped, ligated, or cut until the RLN is identified In our experience the NIM 2 system (Xomed
both visually and electrically. NIM 2, Jacksonville, Fla., USA) is the state of the
art in RLN monitoring. The NIM 2 system em-
ploys a specially designed endotracheal (ET) tube
(NIM 2 EMG ET tube) equipped with bilateral
surface electrodes that are in contact with the me-
dial aspect of the true vocal folds. A sterile, hand-

held stimulator probe is connected to a monitor Conclusions
and this is used to deliver the adjustable stimulus
(0.52 mA) to the RLN. This allows passive and
Nerve monitoring may assist the surgeon with
more rapid and confident identification of the
1
evoked monitoring of the thyroarytenoid muscles RLN during thyroid and parathyroid surgery. It
from monitor to the surgeon during thyroid or will also facilitate dissection along the RLN,
parathyroid surgery. which is especially useful in certain cases such as
An added benefit to using the NIM 2 system is a distally branching RLN.
often in initial nerve localization before definite If used properly, nerve monitoring may help
visual identification. The blunt-tipped stimulus the surgeon prevent postoperative RLN dysfunc-
probe may be used at higher intensity (e.g. 2 mA) tion.
to probe the soft tissue of the RLN triangle start-
ing at a more superficial level proceeding more
deeply. This technique often expedites identifica- References
tion of the proximal portion of the RLN without 1 Randolph GW: Surgical anatomy of the recurrent laryngeal
nerve; in Randolph GW (ed): Surgery of the Thyroid and Para-
more extensive dissection.
thyroid Glands. Philadelphia, Saunders-Elsevier, 2003, pp 316
320.
Practical Tips for the NIM 2 System [from 1] 2 Brando JSN, Brando LG, Cavalheiro BG, Sondermann A, Vitols
Succinylcholine or other short-acting para- I: Intraoperative monitoring of inferior laringeal nerve during
thyroidectomies and neck dissections. XIX Congresso Brasileiro
lytic agents allow full relaxation for good ET tube de Cirurgia de Cabea e Pescoo, Curitiba, 2003.
position with quick return of EMG activity. 3 Horn D, Rtzscher VM: Intraoperative electromyogram moni-
toring of the recurrent laryngeal nerve: experience with an intra-
Care must be taken to position the surface
laryngeal surface electrode. Langenbecks Arch Surg 1999;384:
electrodes at the level of the glottis and the ET 392395.
tube cuff in the subglottis. 4 Sasaki CT, Mitra S: Recurrent laryngeal nerve monitoring by cri-
copharyngeus contraction. Laryngoscope 2001;111:738739.
Position patient prior to securing ET tube. 5 Riddell V: Thyroidectomy: prevention of bilateral recurrent la-
Check for: ryngeal nerve palsy: results of identification of the nerve in over
23 consecutive years (19461969) with description of an addi-
a) Respiratory variation in baseline EMG trac- tional safety measure. Br J Surg 1970;57:111.
ing; this is universal and confirms good tube po- 6 Satoh I: Evoked electromyographic test applied for recurrent la-
sition. ryngeal nerve paralysis. Laryngoscope 1978;88:20222031.
7 Premachandra DJ, Radcliffe GJ, Stearns MP: Intraoperative iden-
b) Impedance of less than 5 k with imped- tification of the recurrent laryngeal nerve and demonstration of
ance imbalance of less than 1 k. its function. Laryngoscope 1990;100:9496.
Monitor settings: 8 Thomusch O, Dralle H: Advantages of intraoperative neuromon-
itoring in thyroid gland operations (in German). Dtsch Med
a) Event threshold (EMG response): 100 V. Wochenschr 2000;125:774.
b) Stimulator probe: 1 mA.
Surgical field notes:
a) Test stimulator on strap muscle to confirm
twitch and that current is received on Xomed
monitor.
b) Visually identify RLN and confirm true
positive before accepting any stimulation as neg-
ative.
7
1.4 How to Preserve the Parathyroid Glands

during Thyroid Surgery
Ashok R. Shaha, Vergilius Jos F. de Arajo Filho
Head and Neck Service, Memorial Sloan-Kettering Cancer Center, Cornell University Medical Center,
New York, N.Y., USA

Since Ivor Sandstrom described parathyroid
Incidence of temporary hypoparathyroidism is glands in humans, there has been considerable
2530%, while the incidence of permanent interest in their function and preservation, par-
hypoparathyroidism is 23% and depends upon
certain technical modifications, such as neck dissec-
ticularly during total thyroidectomy [1]. One of
tion, paratracheal lymph node dissection (level VI), the serious complications of total thyroidectomy
large and substernal goiters, or Hashimotos is temporary (2530%) or permanent hypopara-
thyroiditis. thyroidism (23%). The morbidity from perma-
Parathyroid blood supply from the inferior thyroid nent hypoparathyroidism is considerable, with a
artery, and occasionally from the superior thyroid lifetime requirement of calcium and vitamin D.
artery or directly from the thyroid vessels. Preserve These small, elusive glands are crucial to sustain
parathyroids with blood supply. good health in patients undergoing total thyroid-
Devascularized parathyroid should be autotrans- ectomy. Serial calcium levels are helpful and the
planted in the neck muscle. Parathyroid glands may trending of calcium levels between 8 and 23 h is
mimic lymph nodes, thyroid tissue, or fat.
helpful. Parathormone assay has also been help-
ful regarding safe discharge of the patients.

P I T F A L L S
Surgical Technique
Symptoms of hypoparathyroidism may be subtle.
Recognize normal and abnormal locations of
However, the symptoms may become serious,
especially with the development of tetany. parathyroids. They may occasionally be unde-
scended, located between the trachea and the
Severe hypocalcemia may occur even 23 days after
esophagus, in the superior mediastinum, or in-
the initial surgery.
side the thyroid gland.
Intravenous calcium supplement may have cardiac
The branches of the inferior thyroid artery
toxicity if given rapidly, and may irritate the skin if
infiltrated. should be ligated close to the thyroid capsule, so
that the minute branches supplying the parathy-
Large doses of oral calcium and vitamin D may lead
roid glands can be preserved [2, 3].
to iatrogenic hypercalcemia.
Avoid surface hematoma or retraction injury
of the parathyroid glands. Use electrocautery ju-
diciously. Anterior parathyroids on the surface of
the thyroid, receiving their blood supply directly

from the thyroid gland, may be very difficult to fects. Such patients will require increased dosage
preserve in situ and may require autotransplanta-
tion. Intense care should be taken to identify and
of calcium supplementation, approximately 500
mg of elemental calcium, 46 times/day. It is im-
1
preserve the parathyroid glands in patients un- portant to check the calcium levels 4872 h after
dergoing total thyroidectomy with neck dissec- this intensive supplementation to avoid iatrogen-
tion, surgery for large and substernal goiters, and ic hypercalcemia. A parathormone assay may be
Hashimotos thyroiditis. Patients undergoing to- helpful.
tal laryngopharyngectomy and total thyroidec-
tomy are at highest risk for permanent hypopara- Conclusion
thyroidism [4]. An understanding of the anatomy of normal
parathyroid glands, their variations, blood supply
Parathyroid Autotransplantation and preservation during total thyroidectomy is
During surgery, if the parathyroid gland appears crucial to avoid hypoparathyroidism. Every at-
to be devascularized by change of color or separa- tempt should be made to preserve the parathyroid
tion from the surrounding soft tissue, it should be glands and their blood supply, or autotransplant
autotransplanted after confirming with a small if necessary. The patients should be observed
piece on frozen section that it is parathyroid closely for hypoparathyroidism, and treated ex-
gland. Confirm the presence of parathyroid tis- peditiously to avoid severe symptoms of hypocal-
sue to avoid autotransplantation of a metastatic cemia.
thyroid carcinoma. The parathyroid gland should
be minced into small pieces and autotransplant-
ed, preferably in the contralateral sternomastoid References
muscle. There is no need to autotransplant the 1 Halsted WS, Evans HM: The parathyroid glandules: their blood
supply and their preservation in operations on the thyroid gland.
parathyroid gland in the forearm. Generally 60
Ann Surg 1907;46:489507.
70% of the autotransplanted parathyroid glands 2 Shaha AR, Jaffe BM: Parathyroid preservation during thyroid
will function within 612 weeks. surgery. Am J Otol 1988;19:113117.
3 Araujo Filho VJF, Silva Filho GB, Brandao LG, Santos LRM, Fer-
raz AR: The importance of the ligation of the inferior thyroid
Management of Temporary and Permanent artery in parathyroid function after subtotal thyroidectomy.
Hypoparathyroidism Clinics 2000;55:113120.
4 Alveryd A: Parathyroid glands in thyroid surgery. Acta Chir
The patient should be observed closely postop- Scand Suppl 1968;389:1120.
eratively. Check serial calcium levels 8 and 23 h 5 Roh JL, Park CI: Routine oral calcium and vitamin D supple-
postsurgery. Ionized calcium is a much better pa- ments for prevention of hypocalcemia after total thyroidectomy.
Am J Surg 2006;192:675678.
rameter. If the patient is asymptomatic, calcium 6 Chia SH, Weisman RA, Tieu D, Kelly C, Dillmann WH, Orloff LA:
replacement is generally not suggested. However, Prospective study of perioperative factors predicting hypocalce-
mia after thyroid and parathyroid surgery. Arch Otolaryngol
if calcium levels are below 7.5 mg/dl, calcium sup- Head Neck Surg 2006;132:4145.
plementation should be considered, as the pa-
tients may develop serious signs and symptoms of
hypocalcemia. Patients should be checked for
Chvosteks and Trousseaus signs [5, 6]. If the pa-
tient has severe symptoms, intravenous calcium
gluconate is recommended. Subsequent mainte-
nance calcium supplementation is recommended
with calcium and vitamin D. Generally, vitamin
D takes approximately 48 h for biochemical ef-
9
1.5 Completion Thyroidectomy

Eveline Slotema, Jean-Franois Henry
Department of Endocrine Surgery, University Hospital Marseille, Marseille, France

P E A R L S To avoid CT, try to obtain a correct diagnosis
before or during initial surgery with fine needle
Minimizing the need for reoperative surgery is the aspiration cytology (FNA), preoperative ultra-
most effective way to decrease operative risks. sound and frozen section (FS). Nevertheless, nei-
Consider each parathyroid gland (PT) as if it were ther FNA nor FS are absolutely reliable in the di-
the last one left, even in unilateral resection. agnosis of cancer, especially in follicular and on-
cocytic lesions [5]. Hence, for neoplasms >4 cm in

P I T F A L L S diameter with these FNA results, prophylactic to-
tal thyroidectomy may be considered [2].
Avoid reoperations in previously dissected planes
by neither performing subtotal lobectomies nor
enucleations. Practical Tips to Facilitate CT
To avoid reoperations in previously dissected
Contralateral lobe assessment by palpation is old-
planes, total unilateral lobectomies, always in-
fashioned and inferior to ultrasonic assessment.
cluding isthmus and Lallouettes pyramid, are
preferred to subtotal resections. Assessing lymph
nodes during initial operation is important.
Introduction The recurrent and superior laryngeal nerves
Completion thyroidectomy (CT) is a unilateral re- and both PTs should be preserved at the original
operation on a previously unoperated thyroid lobe operation. The inferior thyroid artery (TA) should
(TL) to avoid the risk of recurrence on the contra- therefore not be ligated. A devascularized gland
lateral lobe. The incidence of bilateral thyroid car- should be autotransplanted. Consider each PT as
cinoma reported in the literature ranges from 30 if it were the last one left, even in unilateral resec-
to 88% [1, 2]. No initial tumor feature reliably pre- tion.
dicts the presence of tumor on the second side [3], Intraoperative assessment of contralateral lobe
except multifocality. CT is recommended for all via palpation is useless. Ultrasonography is much
patients with differentiated cancer (>10 mm) who more accurate. Do not dissect between the ster-
have significant residual thyroid tissue remaining nothyroid muscle (STM) and the thyroid gland.
in the neck (131I uptake >5% over 24 h) [2]. The use If palpation is deemed necessary, it should be
of postoperative radioiodine therapy decreases re- done between STM and sternohyoid muscles
currence rate and distant metastasis, improving (SHM) to prevent adhesions along the thyroid
survival when compared with unilateral thyroid capsula [6].
lobectomy [4]. Finally, CT permits tumor surveil-
lance by thyroglobulin measurements.

Practical Tips to Perform CT Conclusion
The timing of CT can substantially contribute to
surgical difficulty. Within 1 week, no dense ad-
When a unilateral thyroid lobectomy is indicated,
the surgeon and cytopathologist should be careful
1
hesions occur. Therefore, reoperation should be to avoid or at least to facilitate possible CT. This
performed no later than 5 days postoperatively or implies obtaining a correct diagnosis at initial
postponed for at least 3 months [7]. Psychologi- surgery, performing nothing but a total lobectomy
cally, it is in the patients best interest to reoperate with preservation of both PTs and RLN, and
as soon as possible. avoiding any dissection into the contralateral side.
Direct laryngoscopy should be performed in Therefore, when indicated, CT is simply a unilat-
all cases before CT, because 3040% of unilateral eral operation on a previously undissected TL and
recurrent laryngeal nerve (RLN) paralysis is a procedure that can be performed safely.
asymptomatic [6]. Transient palsy can be a tem-
porary contraindication for reoperation. In pa-
tients with definitive RLN palsy the indication of References
CT must be discussed considering the risk of bi- 1 Clark OH: Total thyroidectomy: the treatment of choice for pa-
tients with differentiated thyroid cancer. Ann Surg 1982;196:361
lateral RLN palsy and the need for tracheostomy.
370.
In such cases electromyographic monitoring of 2 Pasieka JL, Thompson NW, McLeod MK, Burney RE, Macha M:
the RLN is strongly advised, if not in all reopera- The incidence of bilateral well-differentiated thyroid cancer
found at completion thyroidectomy. World J Surg 1992;16:711
tive thyroid surgery [8]. 716.
Preferably, the original scar is incised for ac- 3 DeGroot LJ, Kaplan EL: Second operations for completion of
cess to the thyroid. Strap muscles are dissected in thyroidectomy in treatment of differentiated thyroid cancer.
Surgery 1991;110:936939.
the midline and retracted laterally, if they did not 4 Hamming JF, Van de Velde CJ, Goslings BM, Schelfhout LJ, Fleu-
adhere to the TL as a result of former proper sur- ren GJ, Hermans J, Zwaveling A: Prognosis and morbidity after
gery. This is the ideal situation. In moderate ad- total thyroidectomy for papillary, follicular and medullary thy-
roid cancer. Eur J Cancer Clin Oncol 1989;25:13171323.
hesions, access is gained between the SHM and 5 Raber W, Kaserer K, Niederle B, Vierhapper H: Risk factors for
STM. If there is dense fibrosis, a posterolateral malignancy of thyroid nodules initially identified as follicular
neoplasia by fine-needle aspiration: results of a prospective
approach by Henry and Sebag [9] may be used. study of one hundred twenty patients. Thyroid 2000;10:709
Direct RLN visualization is mandatory. In case 712.
of adhesions, the RLN is to be identified in a pre- 6 Pasieka JL: Reoperative thyroid surgery; in Randolph GW (ed):
Surgery of the Thyroid and Parathyroid Glands. Philadephia,
viously undissected area and then followed into Saunders, 2003, pp 385391.
the dissected area. The nerve may be identified 7 Tan MP, Agarwal G, Reeve TS, Barraclough BH, Delbridge LW:
inferiorly, below the inferior TA, in the tracheo- Impact of timing on completion thyroidectomy for thyroid can-
cer. Br J Surg 2002;89:802804.
esophageal groove, and then followed upwards, or 8 Timmermann W, Dralle H, Hamelmann W, Thomusch O, Sekul-
superiorly, after division of the superior TA, with la C, Meyer T, Timm S, Thiede A. Does intraoperative nerve
monitoring reduce the rate of recurrent nerve palsies during thy-
subsequent lateral and downward traction of the
roid surgery? Zentralbl Chir 2002;127:395399.
superior thyroid pole, identified at its entry point. 9 Henry JF, Sebag F: Lateral endoscopic approach for thyroid and
Then, it may be followed downwards. parathyroid surgery. Ann Chir 2006;131:5156.
A meticulous review of previous operative
notes and pathology for possible symmetry of
parathyroids can be useful. To autotransplant de-
vascularized PT the operative specimen should
be examined carefully before passing it on for
pathological analysis.
11
1.6 Surgery for Intrathoracic Goiters

Ashok R. Shahaa, James L. Nettervilleb, Nadir Ahmad b
a CornellUniversity Medical College, Memorial Sloan-Kettering Cancer Center, New York, N.Y., and
b Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville,
Tenn., USA

Intrathoracic or substernal goiter (SG) is defined
Total thyroidectomy (TT) is the optimal manage- as a goiter with 50% or more of its mass in the
ment. mediastinum (MS) [1]. Its incidence ranges be-
Symptoms related to pressure effects are the main tween 2 and 19% of patients undergoing thyroid-
indication for surgery, but potential malignancy is ectomy [13]. IG should always be considered in
also a concern.
the differential diagnosis of both neck and ante-
Cervical approach is usually sufficient to manage rior mediastinal masses.
large intrathoracic goiters (IG) and sternal split (SS) The origin of IG is commonly an extension of
is rarely indicated.
the cervical thyroid gland into the MS, rather
Large incision, transection of the strap muscles, and than an abnormal growth of a mediastinal-based
ligation of the inferior thyroid vessels are recom-
gland. The cervical source of blood supply to IG
mended.
attests to its cervical origin in most cases. The
Preoperative CT scan determines both location and majority of IG are benign and can remain asymp-
extension of the goiter and its relationship to
surrounding structures, especially the recurrent
tomatic for many years. Symptoms typically arise
laryngeal nerve (RLN). from tracheoesophageal compression.
IGs often extend into the anterosuperior MS,
Despite significant tracheal deviation and compres-
keeping the RLN in its normal configuration.
sion, tracheomalacia is very rare.
However, IG involving the posterior MS (12%)
displace the nerve anteriorly. Preoperative imag-

P I T F A L L S
ing with CT scan is important.
Intraoperative bleeding may be a major concern. Complications inherent to thyroidectomy are
more common after IG operations, but still low in
Risk of RLN injury is much higher though it is
experienced hands. Tracheomalacia secondary to
usually located in the normal anatomic position.
long-term compression is surprisingly rare [1].
Parathyroid glands (PG) may be quite difficult to
However, other reports state that it can occur,
identify.
suggesting to keep a patient intubated for 24
Aggressive, rather than gentle blunt finger
48 h, with controlled extubation [2, 3].
dissection is dangerous.
Approximately 10% of these patients may present
with acute airway issues.

Practical Tips Most of the patients can be extubated in the
Nontraumatic intubation with No. 6 or 7 tube
is a must. A majority of these patients can be eas-
operating room; however, if there is any concern,
the tube should remain in place for 24 h.
1
ily intubated since the larynx is generally in its Suction drain is recommended.
normal position. Technical variations, such as retrieving the
The endotracheal tube should be well below SG with spoons, or morcellation, have been de-
the vocal cords, as there is a frequent tendency for scribed, but are not used [2, 3].
the tube to slide back.
The patient should be totally paralyzed during Conclusions
surgery for full relaxation. SGs form 219% of all goiters. The main surgical
A wide skin excision and transection of the indication is compression. Approximately 10% of
strap muscles is recommended for better expo- SGs may harbor malignancy. The vast majority
sure. can be retrieved through the neck. TT is usually
The dissection in the neck should begin with indicated. The surgeon should be familiar with
ligation of the middle thyroid vein, ligation of the intraoperative manipulation of large SGs and
superior thyroid vessels, and dissection along the technical variations to retrieve the goiter from the
lateral border of the thyroid. The area between neck. The major complication is hemorrhage in
the anterior border of the trachea and the lateral the superior MS.
border of the thyroid should be exposed under
vision.
There are several inferior thyroid veins which References
should be ligated carefully. This procedure can 1 Netterville JL, Coleman SC, Smith JC, et al: Management of sub-
sternal goiter. Laryngoscope 1998;108:16111617.
lead to unwarranted bleeding which may be ex-
2 Newman E, Shaha AR: Substernal goiter. J Surg Oncol 1995;60:
tremely difficult to control. Hemoclips, bipolar 207212.
electrocautery or Ligasure may assist in this por- 3 Singh B, Lucente FE, Shaha AR: Substernal goiter: a clinical re-
view. Am J Otolaryngol 1994;15:409416.
tion of the surgical procedure. 4 Shaha AR: Surgery for benign thyroid disease causing tracheo-
The RLN is better identified after retrieving esophageal compression. Otolaryngol Clin North Am 1990;23:
the thyroid gland from the substernal region. 391401.
5 Shaha A, Alfonso A, Jaffe BM: Acute airway distress due to thy-
Rarely, a retrograde technique of dissecting the roid pathology. Surgery 1987;102:10681074.
RLN may be necessary, where the nerve is identi- 6 Shaha AR, Burnett C, Alfonso A, Jaffe BM: Goiters and airway
fied near the ligament of Berry and dissected ret- problems. Am J Surg 1989;158:378381.
7 Katlic MR, Wang C, Grillo HC: Substernal goiter. Ann Thorac
rograde using a toboggan technique. Surg 1985;39:391399.
PGs are difficult to identify, and if devascular-
ized may occasionally require autotransplanta-
tion in the sternomastoid muscle.
SS is seldom necessary, and can involve partial

(manubriectomy) or clamshell thoracotomy. A
full SS is essential if the thyroid is adherent to the
surrounding structures or there is suspicion of
malignancy.
13
1.7 How to Decide the Extent of

Thyroidectomy for Benign Diseases
Jeremy L. Freeman
Mount Sinai Hospital, University of Toronto, Toronto, Ont., Canada

P E A R L S Structural problems of the thyroid can be di-
vided into those cases treated for cosmetic rea-
Hyperthyroidism is best treated with total thyroid- sons, compressive symptoms or risk of cancer.
ectomy. Patients with cosmetically unsightly goiters or
Compressive and cosmetic problems are best compression of foodway and/or airway are best
treated with total thyroidectomy. managed by total thyroidectomy. Usually those
Low-risk nodular disease is best treated with large thyroids entering the mediastinum can be
subtotal thyroidectomy with the option to total retrieved through a neck approach but those goi-
depending on intraoperative pathology. ters that have grown deeply into the mediastinum
High-risk nodular disease is best treated with total (i.e. to the level of the carina) may have to be man-
thyroidectomy. aged surgically through a sternal split [2].
Although controversial, we feel that cancer

P I T F A L L S cases are best managed with total thyroidectomy
although there is a school of thought that less
Lack of knowledge of risk factors results in inade-
than total thyroidectomy is appropriate for low-
quate surgery in the high-risk patient or too aggres-
sive surgery (total thyroidectomy) in the low-risk risk cancer cases such as small nodules in young-
patient. er individuals [3]. The literature suggests that
outcomes (survival/recurrence) are enhanced by
total thyroidectomy [4].
The problems in decision-making arise in pa-
Introduction tients presenting with thyroid nodular disease
Diseases of the thyroid can be divided into func- without a definite preoperative diagnosis. Patients
tional and structural. Functional problems in- presenting with thyroid nodular disease should
clude hypo- and hyperthyroid states. Hypothy- have a comprehensive history and physical exam-
roidism generally is managed with administra- ination, a fine needle aspirate biopsy and ultra-
tion of thyroid hormone. Hyperthyroid states can sonic examination of the neck. Patients can then
be treated with a surgical resection primarily or be classified into low- and high-risk disease based
secondarily in cases refractory to management on risk factors (table 1) [5]. Low-risk patients have
with medication and/or radioactive iodine. Hy- few risk factors usually of minor import whereas
perthyroid surgical cases are best managed by to- higher-risk patients have several risk factors or
tal thyroidectomy to ensure eradication of all dis- one or two significant ones. Patients with no def-
eased tissue mitigating against persistence [1]. inite tissue diagnosis of cancer with nodular dis-

Table 1. Risk factors
Patient risk factors Tumor risk factors Imaging risk factors 1

Age (very young or very old) Rapid size increase Metastatic nodes1
Place of birth (e.g. Belarus)1 Lymphadenopathy1 Stippled calcification1
Ethnicity (e.g. Filipino)1 Vocal cord paresis1 Invasive primary lesion1
Radiation exposure1 Dysphagia
Familial syndrome (e.g. Cowden syndrome)1 Firm/fixed nodule
Family history of thyroid cancer Suspicious/atypical/positive cytology1
Elevated serum calcitonin1 Size >4 cm
1
Denotes major risk factor.
ease in a low-risk category may be treated with An elevated serum calcitonin in a patient with
partial thyroidectomy with the option to proceed thyroid nodular disease necessitates a total thy-
to total thyroidectomy depending on intraopera- roidectomy with appropriate neck dissection for
tive pathology. Sometimes intraoperative pathol- probable medullary thyroid cancer [6].
ogy is not available or conclusive at which time
definitive cancers diagnosed subsequently may be Conclusion
managed with completion thyroidectomy. This Hyperthyroidism treated surgically is best treat-
approach mitigates against total thyroidectomy ed by total thyroidectomy.
for benign disease and thus reduces the risk of Structural problems including unsightly cos-
complication and the need for subsequent supple- metic goiters, compressive symptoms and cancer
mentation with thyroid hormone. are treated with total thyroidectomy.
A further decision-making challenge is the pa- Nodular lesions with benign or indeterminate
tient with a putative solitary nodule which is be- cytopathology are then viewed from the perspec-
nign who undergoes surgery and during the pro- tive of risk stratification and extent of thyroidec-
cedure, on palpation of the opposite lobe, is found tomy is based on whether patients fall into low- or
to have more nodules of significant size which are high-risk categories.
of indeterminate pathology. It is prudent to pro-
ceed with removal of the opposite lobe in these
cases to deal with possible undetected malignan- References
cy and/or to avoid diagnostic dilemmas in the fu- 1 Barakate MS, Agarwal G, Reeve TS, et al: Total thyroidectomy is
now the preferred option for the surgical management of Graves
ture given nodular disease in the opposite lobe of
disease. ANZ J Surg 2002;72:321324.
an operated thyroid field. Palpation should be 2 de Perrot M, Fadel E, Mercier O, et al: Surgical management of
done over the strap muscles in order to avoid un- mediastinal goiters: when is a sternotomy required? Thorac Car-
diovasc Surg 2007;55:3943.
necessary fibrosis rendering future surgery more 3 Shah JP, Loree TR, Dharkar D, et al: Lobectomy versus total thy-
technically difficult. roidectomy for differentiated carcinoma of the thyroid: a
It is wise to remove the pyramidal lobe with matched-pair analysis. Am J Surg 1993;166:331335.
4 Mazzaferri EL, Massoll N: Management of papillary and follicu-
any surgery be it subtotal or total thyroidectomy lar (differentiated) thyroid cancer: new paradigms using recom-
to avoid leaving hard-to-find thyroid tissue in the binant human thyrotropin. Endocr Relat Cancer 2002;9:227
event that the patient would require a completion 247.
5 Cooper DS, Doherty GM, Haugen BR, et al: Management guide-
procedure in the future. In addition, if the disease lines for patients with thyroid nodules and differentiated thyroid
turns out to be malignant, as much thyroid tissue cancer. Thyroid 2006;16:109142.
6 Clark JR, Fridman TR, Odell MJ, et al: Prognostic variables and
as possible would have been removed to allow calcitonin in medullary thyroid cancer. Laryngoscope 2005;115:
maximum effect of radioactive iodine adminis- 14451450.
tration.
15
1.8 Minimally Invasive Video-Assisted

Thyroidectomy
Erivelto M. Volpi, Gabrielle Matterazzi, Fernando L. Dias, Paolo Miccoli
Head and Neck Surgery Department, School of Medicine, University of So Paulo, So Paulo, Brazil

MIVAT was developed at the University of Pisa
A careful preoperative selection of the patients is by Paolo Miccoli [1, 2]. When a new surgical pro-
the only guarantee of a low complication rate. cedure, like MIVAT, is introduced, especially if
Minimally invasive, video-assisted thyroidectomy the operative technique employs innovative in-
(MIVAT) allows an excellent endoscopic visualiza- struments and is based on peculiar surgical steps,
tion of nerves and parathyroid glands (PG) and a
there will be a natural learning curve for the sur-
good control of major vessels.
geons. At the beginning, operative time and com-
When using Harmonic Scalpel (HS), keep the tip far plication rate may rise, but after an adequate pe-
from the nerves (more than 5 mm) and, if necessary,
do not hesitate to use a clip.
riod of training, results can be compared with
conventional operation.
Do not prolong the endoscopic dissection too
much. Once the nerves and PGs are identified and
dissected, extract the lobe and continue resection Practical Tips
under direct vision. A careful selection of the patients results in a low
complication rate and a good outcome. Only a
Better postoperative course and cosmetic outcome
minority of the cases are eligible for an MIVAT
are major benefits of MIVAT.
[35].
MIVAT is performed by a unique central inci-

P I T F A L L S
sion of 1.5 cm, 2 cm above the sternal notch.
Unexpected thyroiditis or the presence of meta- The operative space is maintained by external
static lymph nodes in the central compartment are retraction; no gas insufflation is utilized. Subcu-
the most frequent reasons for conversion. taneous fat and platysma are carefully dissected
At the beginning, operative time and complication to avoid any minimum bleeding. The midline is
rate might be higher. divided longitudinally as much as possible (3
Improper use of HS can jeopardize tracheal surface 4 cm).
(avoid neck hyperextension). A 30 5-mm endoscope is inserted through the
skin incision. Under endoscopic vision the dis-
section of the thyrotracheal groove is completed
by using small (2 mm in diameter) instruments:
atraumatic spatulas, spatula-shaped aspirator,

ear-nose-throat forceps and scissors. Hemostasis outlet; during MIVAT, this area can be difficult
is achieved by HS and small (3 mm) vascular
clips.
to visualize; the nerve can be found near the mid-
dle part of the thyroid gland.
1
Section of the upper pedicle is performed en- Always remember to keep the inactive blade of
doscopically as the first step. The orientation of the HS oriented to avoid jeopardizing the nerve,
the endoscope is of paramount importance. It which is very sensitive to heat transmission. A
must now be held on a line almost parallel to the minimal distance (5 mm) between the inactive
neurovascular trunk, with the 30 rotated up- blade and the nerve must be kept.
ward, looking at the roof of the operative space,
thus offering the best view of the field. After vi- Conclusion
sualizing the external branch of the superior la- In selected cases, MIVAT offers the same results
ryngeal nerve (EBSLN), the branches of the supe- as conventional thyroidectomy, with best cosmet-
rior thyroid pedicle will be selectively and safely ic outcome, less postoperative pain and best post-
sectioned. operative recovery.
In most cases the EBSLN can be much more
easily identified near the upper pedicle than dur-
ing the standard procedure. Also PGs are easily References
visualized by endoscopic magnification and their 1 Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C: Minimally
invasive surgery for small thyroid nodules: preliminary report.
manipulation by spatulas is more delicate.
J Endocrinol Invest 1999;22:849851.
The inferior laryngeal nerve (ILN) can also be 2 Terris DJ: Minimally invasive thyroidectomy: an emerging stan-
simply identified during MIVAT thanks to the dard of care. Minerva Chir 2007;62:327333.
3 Miccoli P, Berti P, Frustaci GL, Ambrosini CE, Materazzi G: Vid-
magnification of the endoscope. During this eo-assisted thyroidectomy: indications and results. Langen-
phase of the operation, the endoscope must be becks Arch Surg 2006;391:6871.
held in an orthogonal position with the thyroid 4 Miccoli P, Berti P, Materazzi G, Minuto M, Barellini L: Minimal-
ly invasive video-assisted thyroidectomy: five years of experi-
lobe and neurovascular trunk, with the 30 di- ence. J Am Coll Surg 2004;199:243248.
rected downward. Look for the ILN near the pos- 5 Shimizu K, Akira S, Jasmi AY, Kitamura Y, Kitagawa W, Akasu
terior lobe of the thyroid (Zuckerkandl tubercu- H, Tanaka S: Video-assisted neck surgery: endoscopic resection
of thyroid tumors with a very minimal neck wound. J Am Coll
lum). In conventional surgery the ILN is gener- Surg 1999;188:697703.
ally identified at its emergence from the thoracic
17
1.9 Video-Assisted Parathyroidectomy

William B. Inabnet
Columbia University, New York, N.Y., USA

Video-assisted endocrine neck surgery has gained
Prior to making the initial incision, place a clear a strong foothold in the surgical armamentarium
dressing over the skin to prevent abrasions or heat of parathyroid surgeons. Advantages over con-
injury to the skin surface.
ventional parathyroid surgery and other mini-
Use an angled 30 or 45 endoscope. mally invasive techniques include improved illu-
Never grasp the adenoma in order to avoid viola- mination of the operative field, access to deep and
tion of the parathyroid capsule. ectopic locations, and uniform visualization of
For high superior parathyroid adenomas, a lateral the operation by all members of the operative
backdoor approach can be used to gain access to team.
the parathyroid basin by developing the space be-
tween the carotid artery and the lateral border of
Surgical Technique and Practical Tips
the strap muscles [1].
Before proceeding with parathyroidectomy,
For parathyroid adenomas located in the superior the diagnosis of primary hyperparathyroidism
mediastinum, insert a table-mounted sternal retrac-
tor to elevate the sternum to increase the working
(PHPT) must be firmly established. Elevated total
space [2]. and/or ionized calcium and intact parathyroid
hormone (PTH) levels support a diagnosis of
PHPT. Twenty-four hour urine calcium levels

P I T F A L L S
may be normal or elevated. Video-assisted para-
Video-assisted parathyroidectomy requires multi- thyroidectomy is not recommended for patients
ple assistants with a knowledge of video-assisted with risk factors for multigland disease, such as
techniques. patients with multiple endocrine neoplasia or fa-
Since the surgical field is a small space, the tip of milial hyperparathyroidism, as these cases may
the camera may get smudged by touching sur- be more complex and have a higher incidence of
rounding tissue leading to impaired visualization parathyroid hyperplasia.
and the need for frequent cleaning of the endo-
Preoperative localization plays an important
scope.
role for patient selection, especially early in the
The dissection of the adenoma can seem unnatural
surgeons experience. Patients with a solitary
as the working space requires different ergonomics
than with conventional or focused open parathy- parathyroid adenoma visualized on ultrasonog-
roidectomy. raphy and/or sestamibi scanning are ideally situ-
ated for a video-assisted approach. Once the sur-
geon has increased experience with video-assist-
ed parathyroidectomy, bilateral neck exploration

may be permissible in patients with PHPT and is determined by a combination of intraoperative
negative imaging [3]. Be aware that the incidence
of multigland disease is higher in patients with
findings and IOPTH levels. If IOPTH levels de-
crease by greater than 50% of the highest preexci-
1
negative sestamibi scans [1]. Video-assisted para- sion value, the operation is concluded without ex-
thyroidectomy should not be performed in pa- ploring the other quadrants of the neck. If IOPTH
tients with parathyroid adenomas that appear to monitoring is not available or is being used selec-
be greater than 5 g on preoperative ultrasonogra- tively due to cost constraints, video-assisted 4-
phy, as the large size of the adenoma may interfere gland exploration can be performed with excel-
with intraoperative visualization. lent results [3].
Video-assisted parathyroidectomy can be per- Skin closure is in layers and the patient may be
formed under either local anesthesia with con- discharged to home the same day of surgery.
scious sedation or general anesthesia [4]. When
local anesthesia is used, a combined deep and su- Conclusions
perficial cervical block is recommended using a Video-assisted parathyroidectomy permits fo-
solution of 0.5% lidocaine and 0.25% bupiva- cused parathyroid exploration through the small-
caine. est possible incision with excellent visualization.
A small 1.5- to 2-cm incision is made 23 fin-
ger breadths above the sternal notch. The strap
muscles are separated at the midline without rais- References
ing myocutaneous flaps. Narrow retractors are 1 Sebag F, Hubbard JG, Maweja S, et al: Negative preoperative lo-
calization studies are highly predictive of multiglandular dis-
inserted laterally and medially and an angled en-
ease in sporadic primary hyperparathyroidism. Surgery 2003;
doscope is inserted directly through the small in- 134:10381042.
cision [5]. 2 Inabnet WB, Chu CA: Transcervical endoscopic-assisted medi-
Using flat spatulated instruments, the thyroid astinal parathyroidectomy with intraoperative parathyroid hor-
mone monitoring. Surg Endosc 2003;17:1678.
lobe is mobilized until the targeted parathyroid 3 Miccoli P, Berti P, Materazzi G, et al: Endoscopic bilateral neck
gland is visualized. A small hook cautery may be exploration versus quick intraoperative parathormone assay
(qPTHa) during endoscopic parathyroidectomy: a prospective
useful as well as a small aspirator. After identify- randomized trial. Surg Endosc 2007, E-pub ahead of print.
ing the recurrent laryngeal nerve, the vascular 4 Miccoli P, Barellini L, Monchik JM, et al: Randomized clinical
pedicle of the adenoma is isolated, clipped and trial comparing regional and general anaesthesia in minimally
invasive video-assisted parathyroidectomy. Br J Surg 2005;92:
divided. A gentle lateral retraction of the adeno- 814818.
ma may facilitate visualization of the vascular 5 Barczynski M, Cichon S, Konturek A, et al: Minimally invasive
video-assisted parathyroidectomy versus open minimally inva-
pedicle. sive parathyroidectomy for a solitary parathyroid adenoma: a
Intraoperative PTH (IOPTH) monitoring is prospective, randomized, blinded trial. World J Surg 2006;30:
recommended in all cases. Levels are drawn at 721731.
6 Lee JA, Inabnet WB 3rd: The surgeons armamentarium to the
baseline and 0, 5 and 10 min following parathy- surgical treatment of primary hyperparathyroidism. J Surg On-
roid excision [6]. The extent of neck exploration col 2005;89:130135.
19
1.10 Limited Parathyroidectomy

Keith S. Heller
New York University School of Medicine, New York, N.Y., USA

FMIP can be performed because 85% of cases of
Preoperative imaging can localize the adenoma in primary hyperparathyroidism are due to a soli-
90% of cases. tary adenoma. Imaging studies can predict the
Focused minimally invasive parathyroidectomy location of solitary adenomas in up to 90% of cas-
(FMIP) can be performed under local/regional es. Patients with multigland disease can only be
anesthesia as an outpatient.
identified in 50% of cases [1, 2]. For this reason,
Position the patient with the head turned away the removal of all hyperfunctioning parathyroid
from the side of the adenoma. (PT) tissue needs to be confirmed by intraopera-
Make the incision slightly off center, positioned tive PTH measurement. Focused PTX can be ac-
higher or lower in the neck based on the position of complished by several different surgical ap-
the adenoma determined by imaging.
proaches. I use conventional surgical techniques
Go through or lateral to the strap muscles, not and instruments working through an incision
through the midline. about 2.5 cm in length.

P I T F A L L S Practical Tips
Intraoperative PTH Measurement. It is prefer-
Imaging frequently fails to detect multiple gland
able that the assay be performed in the operating
involvement.
room suite rather than in the central chemistry
Pneumothorax can occur in parathyroidectomies
laboratory to minimize delay. Blood samples are
(PTX) performed under local anesthesia.
obtained from a peripheral intravenous catheter
The recurrent laryngeal nerve (RLN) can be very when possible or from an intra-arterial catheter,
close to adenomas on the undersurface of the
thyroid.
but never directly from the jugular vein. A base-
line sample is drawn when the patient is first
Intraoperative PTH spike due to manipulation of
brought into the operating room, before the neck
the adenoma can be misleading.
is manipulated to avoid an inappropriately elevat-
ed baseline PTH due to massaging the adenoma.
Additional samples are drawn when the adenoma
is removed and at 5-min intervals thereafter. Oc-
casionally, there is a marked spike in the PTH
level at the time the adenoma is removed. Failure
to recognize this spike could result in the errone-

ous conclusion that additional hyperfunctioning just medial to the carotid sheath. The retroesoph-
PT tissue is present if the 5-min sample is the
same as the baseline. Adequacy of PTX is assured
ageal space can then be explored without having
to mobilize the thyroid. To expose PT lying any-
1
when the PTH value falls more than 50% from where behind the thyroid, the carotid sheath is
the baseline value and into the normal range. A retracted laterally and the thyroid medially. It is
50% decrease that plateaus at a level above normal occasionally necessary to divide the middle thy-
is indicative of another abnormal PT and should roid vein. Although the RLN may be near adeno-
prompt a conventional bilateral exploration. mas lying in the tracheal-esophageal groove, I do
Anesthesia. My preference is to use local/re- not routinely identify the nerve. Blunt dissection
gional anesthesia. Contraindications include is employed and tissues are spread rather than
obesity, sleep apnea syndrome, and significant divided. The adenoma is within a thin layer of
gastroesophageal reflux. The technique described fascia. Dissection under this layer will free the PT
by LoGerfo and Kim [3] is used. Intravenous se- from its surrounding tissues and leave it hanging
dation using propofol minimizes patient anxiety. on its vascular pedicle, which then can be clipped.
Transient (several hours) vocal cord paralysis re- The nerve can cross directly over the PT. It can be
sulting from inadvertent vagus nerve block can easily recognized and bluntly dissected away
occur. Pneumothorax occurs in 1% of patients from the adenoma.
after PTX under local/regional anesthesia due to Postoperative Care. Patients are discharged af-
negative intrathoracic pressure in spontaneous ter 3 h of observation on oral calcium supple-
breathing. ments (1,000 mg/day).
Surgery. The patient is positioned supine with
the head extended and turned away from the side
of the adenoma. A horizontal incision measuring References
24 cm, slightly lateral to the midline, is planned. 1 Johnson NA, Tublin ME, Ogilvie JB: Parathyroid imaging: tech-
nique and role in the preoperative evaluation of primary hyper-
The location of the incision is based on preopera-
parathyroidism. AJR Am J Roentgenol 2007;188:17061715.
tive imaging. Skin flaps are elevated. The fibers 2 Bergson EJ, Sznyter LA, Dubner S, Palestro CJ, Heller KS: Sesta-
of the strap muscle are separated longitudinally. mibi scans and intraoperative parathyroid hormone measure-
ment in the treatment of primary hyperparathyroidism. Arch
If the adenoma is in an inferior PT located infe- Otolaryngol Head Neck Surg 2004;130:8791.
rior to the thyroid, the muscles are separated in 3 LoGerfo P, Kim LJ: Technique for regional anesthesia: thyroidec-
the midline or close to it. If the adenoma is in the tomy and parathyroidectomy. Oper Tech Gen Surg 1999;1:95
102.
retroesophageal location, the muscles are sepa-
rated more laterally and dissection is continued
21
1.11 Practical Tips for the

Surgical Management of Secondary
Hyperparathyroidism
Fbio Luiz de Menezes Montenegroa, Rodrigo Oliveira Santosb,
Ani Castro Cordeiroa
a Department of Head and Neck Surgery, University of So Paulo Medical School and
b Department of Otolaryngology-Head and Neck Surgery, Federal University of So Paulo, So Paulo, Brazil

P E A R L S an adequate bone metabolism in patients with
CKD. However, prolonged stimulation of para-
Ultrasound (US) may be helpful to disclose thyroid cells may induce parathyroid autonomy,
associated thyroid disorders or intrathyroidal i.e. loss of physiological response. Excessive secre-
parathyroids.
tion of PTH is often associated with deleterious
Intraoperative parathyroid hormone (PTH)
effects.
monitoring may indicate a supernumerary
hyperfunctioning gland. In the past, bone complications of osteitis fi-
Implant of cryopreserved parathyroid tissue may brosa with fractures and pain were the major con-
revert postoperative hypoparathyroidism. cern. At present, it is well recognized that other
mineral metabolism conditions are also impor-

P I T F A L L S tant as regards morbidity and mortality of renal
patients. Hyperphosphatemia and vascular calci-
Not all patients with chronic kidney disease (CKD) fications are associated with an increased risk of
and elevation of PTH levels are candidates for para-
cardiovascular events [1].
thyroidectomy (PTX).
The denomination of 3HPT is usually em-
There is a high risk of hypocalcemia after PTX due
ployed in patients with hyperparathyroidism af-
to the hungry bone syndrome.
Decrease of renal graft function after PTX may ter successful kidney transplantation. In the text
occur in some cases with tertiary hyperparathyroid- below, 2HPT will refer to patients with CKD on
ism (3HPT). dialysis and 3HPT will be restricted to renal
Autotransplantation of nodular areas increases the transplant cases.
chance of recurrence.
Practical Tips
Introduction Indication of PTX: Under specific conditions,
Parathyroid hyperfunction due to a previous PTX will significantly improve quality of life and
metabolic derangement is characterized as sec- prolong survival. Contrariwise, worsening is ex-
ondary hyperparathyroidism (2HPT). The com- pected if PTX is performed in patients with dis-
monest cause is CKD. turbances and complaints not related to hyper-
As renal function decreases, PTH increases. A parathyroidism. In 2HPT, the Guidelines of the
mild elevation of the PTH level is necessary for National Kidney Foundation (K/DOQI) establish

that PTX is indicated in patients with persistent Postoperative care: Right after surgery for
serum levels of PTH higher than 800 pg/ml (88.0
pmol/l) which are associated with hypercalcemia
2HPT, a continuous infusion of calcium in a small
volume of saline or dextrose is started. Usually,
1
and/or hyperphosphatemia that are refractory to 900 mg of elemental calcium of calcium gluco-
medical therapy [2]. In 3HPT, increased PTH and nate are diluted in 200250 ml. The concentrated
persistent hypercalcemia after kidney transplan- solution can cause chemical phlebitis if it is in-
tation suggest that PTX is required. fused into a peripheral vein. As soon as possible,
Preoperative imaging: Even though all hyper- oral calcium and calcitriol are added in large dai-
functioning parathyroid tissue must be inspect- ly doses (4.07.0 g of calcium salts and 24 g of
ed and the sensitivity of imaging studies is vari- calcitriol) [8]. Hypoparathyroidism may be re-
able, preoperative US and technetium-sestamibi verted by autotransplantation of cryopreserved
(MIBI) scanning may represent a helpful tool in tissue [9]. In 3HPT, hypocalcemia is less pro-
intraoperative decision making. US may identify nounced and lower doses of calcium and calcitri-
associated thyroid disease as papillary thyroid ol are required. Renal function should be evalu-
carcinoma [3]. Although not frequent, intrathy- ated closely. There is evidence that acute PTH
roidal parathyroid glands can be suggested by ul- reduction affects renal function [10].
trasonography [4]. Rarely does the MIBI scan de-
tect all hyperfunctioning parathyroid glands, but References
it may provide information about ectopic glands 1 Moe SM, Dreke T, Lameire N, Eknoyan G: Chronic kidney dis-
ease-mineral-bone disorder: a new paradigm. Adv Chronic Kid-
(mediastinal, high cervical, retropharyngeal).
ney Dis 2007;14:312.
Preoperative care: Comorbidities are common 2 National Kidney Foundation: Clinical practice guidelines for
and they must be evaluated before surgery. Dialy- bone metabolism and disease in chronic kidney disease. Am J
Kidney Dis 2003;42(suppl 3):s1s201. http://www.kidney.org/
sis is performed the day before the operation, and professionals/kdoqi/guidelines_bone/index.htm.
a lower heparin dose is advised. 3 Montenegro FLM, Smith RB, Castro IV, Tavares MR, Cordeiro
Intraoperative care: Nephrotoxic drugs and AC, Ferraz AR: Association of papillary thyroid carcinoma and
hyperparathyroidism. Rev Col Bras Cir 2005;32:115119.
hypotension must be avoided in patients with 4 Montenegro FLM, Tavares MR, Cordeiro AC, Ferraz AR, Ianhez
3HPT. If feasible, intraoperative PTH should be LE, Buchpiguel CA: Intrathyroidal supernumerary parathyroid
employed. Reduction of 80% of basal levels after gland in hyperparathyroidism after renal transplantation.
Nephrol Dial Transplant 2007;22:293295.
1020 min seems to indicate an adequate excision 5 Ohe MN, Santos RO, Kunii IS, Abrahao M, Cervantes O, Car-
[5]. A failure to achieve this level is indicative of a valho AB, Lazaretti-Castro M, Vieira JG: Usefulness of intraop-
erative PTH measurement in primary and secondary hyperpara-
supernumerary hyperfunctioning parathyroid. thyroidism: experience with 109 patients. Arq Bras Endocrinol
Extent of the surgery: There is no consensus in Metab 2006;50:869875.
the literature about the best approach to 2HPT 6 Cordeiro AC, Montenegro FLM, Kulcsar MAV, Dellanegra LA,
Tavares MR, Michaluart P, Ferraz AF: Parathyroid carcinoma.
and 3HPT. Subtotal PTX and total PTX with im- Am J Surg 1998;175:5255.
mediate heterotopic autotransplantation are re- 7 Montenegro FLM, Tavares MR, Durazzo MD, Cernea CR, Cor-
ported with good results. Forearm and presternal deiro AC, Ferraz AR: Clinical suspicion and parathyroid carci-
noma management. Sao Paulo Med J 2006;124:4244.
autotransplantation are acceptable techniques. 8 Cozzolino M, Gallieni M, Corsi C, Bastagli A, Brancaccio D:
Areas of nodular hyperplasia should be avoided Management of calcium refilling post-parathyroidectomy in
end-stage renal disease. J Nephrol 2004;17:38.
for autotransplantation, as they carry an increased
9 Montenegro FLM, Custdio MR, Arap SS, Reis LM, Sonohara S,
risk of graft-dependent recurrence. The risk of Castro IV, Jorgetti V, Cordeiro AC, Ferraz AR: Successful implant
malignant tissue transplantation is rare as para- of long-term cryopreserved parathyroid glands after total para-
thyroidectomy. Head Neck 2007;29:296300.
thyroid carcinoma is rather infrequent in both 10 Schwarz A, Rustien G, Merkel S, Radermacher J, Haller H: De-
2HPT and 3HPT [6, 7]. creased renal transplant function after parathyroidectomy.
Nephrol Dial Transplant 2007;22:584591.
23
1.12 Reoperative Parathyroidectomy

Alfred Simental
Otolaryngology Head Neck Surgery, Loma Linda University, Loma Linda, Calif., USA

P E A R L S reexploration and surgical correction of the hy-
perparathyroid state, especially in younger pa-
Confirm initial diagnosis. tients.
Maximize localization techniques. Reexploration for HPT is complicated by pre-
Read previous operative and pathology reports. vious scarring, higher incidence of tumors in
ectopic locations, multigland hyperplasia, and
Work in previously undissected field first where
may be associated with recurrence of parathy-
scarring is least and probability of finding affected
gland is highest. roid carcinoma. Ectopic parathyroid locations in-
clude thymus, thyroid, carotid sheath, retroesoph-
Develop an organized dissection pattern and
ageal, superior mediastinum, tracheoesophageal
understand ectopic locations.
groove, submandibular, and posterior mediasti-
Remove concomitant thyroid pathology.
num [1, 2].
Patients and physicians should understand

P I T F A L L S
that reoperative surgery has inherently increased
risks. Reoperation in a scarred field increases the
Risk of failing to recognize improper diagnosis.
risk of injury to the recurrent laryngeal and supe-
Risk of permanent hypocalcemia and vocal cord
rior laryngeal nerves, resulting in subsequent
paralysis is greatly increased in reoperative surgery.
dysphonia. In addition, the incidence of either
Risk of removing normal parathyroid glands. postoperative hypoparathyroidism or persistent
Risk of pharyngoesophageal injury. HPT is increased and may approach 10% [3]. Lo-
calization studies may aid in identifying ectopic
and hyperfunctioning glands, while reducing the
morbidity of reexploration [4].
Introduction
Hyperparathyroidism (HPT) can be surgically Practical Tips
cured on initial exploration in greater than 90% Before embarking on a rigorous reoperative
of cases, and in experienced hands greater than surgery, the initial diagnosis of HPT should be
95%. However, uncontrolled HPT in patients with confirmed taking care to rule out medications,
unsuccessful explorations may result in severe os- dietary contributions, or any secondary reason to
teoporosis, fatigue, depression, nephrolithiasis, have hypercalcemia, especially benign familial
renal failure, hypertension, and increased cardio- hypocalciuric hypercalcemia. The patient should
vascular risk. This necessitates consideration for be evaluated by an endocrinologist who can con-

firm the diagnosis and determine whether medi- tematically undertaken. Any intrathyroidal le-
cal management may be effective. Reexploration
should be delayed at least 69 months to allow
sions should prompt thyroidectomy as these may
represent intrathyroidal parathyroid glands, es-
1
inflammation to subside and increase the efficacy pecially in the face of unsuccessful exploration.
of repeat imaging studies. Early exploration of the superior mediastinum
The previous operative and pathological re- with resection of thymus should be considered
ports should be reviewed to determine previous after the routine areas have been explored.
sites of exploration, pathological confirmation of
removed tissues, and other intraoperative find- Conclusion
ings. In situations of unilateral exploration, the Reoperative surgery for HPT is associated with
unexplored side is utilized unless localization an increased incidence of complications includ-
studies suggest that the initial side is active. ing vocal fold paralysis, permanent hypoparathy-
Imaging studies should be repeated and should roidism, and persistent hypercalcemia. The use of
include sestamibi imaging to look for new or ec- nuclear medicine imaging, ultrasound and high
topic activity [5]. Ultrasound examination should resolution CT/MRI may aid in surgical planning.
determine the presence of thyroid nodules and However, knowledge of potential ectopic loca-
paratracheal masses, which may represent en- tions and a well-planned surgical approach from
larged parathyroid glands. Computed tomogra- lateral to medial are critical in ensuring adequate
phy (CT) or MRI may also be considered to eval- resection, which may be verified by intraopera-
uate the mediastinal and retroesophageal regions tive parathyroid hormone monitoring.
that may not be visualized by ultrasound [6]. Se-
lective venous sampling by interventional radiol-
ogy may help determine laterality and possibly References
venous outflow location of the most active gland 1 Phitayakorn R, McHenry CR: Incidence and location of ectopic
abnormal parathyroid glands. Am J Surg 2006;191:418423.
[7].
2 Shen W, Duren M, Morita E, et al: Reoperation for persistent or
Intraoperative parathyroid hormone monitor- recurrent primary hyperparathyroidism. Arch Surg 1996;131:
ing should be employed to determine adequacy of 861869.
3 Allendorf J, Digorgi M, Spanknebel K, et al: 1112 consecutive bi-
resection, beginning with a preincision defined lateral neck explorations for primary hyperparathyroidism.
baseline level [8]. Postresection intraoperative World J Surg 2007, E-pub ahead of print.
PTH levels drawn at 10 min should be at least re- 4 Rodriguez JM, Tezelman S, Siperstein AE, et al: Localization
procedures in patients with persistent or recurrent hyperpara-
duced by 50% unless the level is within the nor- thyroidism. Arch Surg 1994;129:870875.
mal range. A draw at 15 min should continue to 5 Chen CC, Skarulis MC, Fraker DL, et al: Technetium-99m-sesta-
reveal a drop of 2530% as an additional half-life mibi imaging before reoperation for primary hyperparathyroid-
ism. J Nucl Med 1995;36:21862191.
has occurred. 6 Rodgers SE, Hunter GJ, Hamberg LM, et al: Improved preopera-
Reoperative strategy should routinely begin by tive planning for directed parathyroidectomy with 4-dimen-
sional computed tomography. Surgery 2006;140:932940.
exposing the carotid artery, then working from 7 Ogilvie CM, Brown PL, Matson M, et al: Selective parathyroid
lateral to medial towards the cricoid cartilage. venous sampling in patients with complicated hyperparathy-
The recurrent laryngeal nerve should be identi- roidism. Eur J Endocrinol 2006;155:813821.
8 Riss P, Kaczirek K, Heinz G, et al: A defined baseline in PTH
fied early, either just inferior to the cricoid carti- monitoring increases surgical success in patients with multiple
lage or lower in the lateral paratracheal region gland disease. Surgery 2007;142:398404.
where scarring is minimal. Once the carotid and
recurrent nerve are dissected, exploration of the
paratracheal region, retropharyngeal, retrothy-
roid, and superior mediastinum should be sys-
25
1.13 Paratracheal Neck Dissection:

Surgical Tips
A. Khafif a, L.P. Kowalskib, Dan M. Flissa
a
Department of Otolaryngology-Head and Neck Surgery, Tel Aviv Sourasky Medical Center (affiliated to the
Sackler Faculty of Medicine), Tel Aviv University, Tel Aviv, Israel;
b
Department of Head and Neck Surgery and Otorhinolaryngology, Hospital A.C. Camargo, So Paulo, Brazil

Therapeutic paratracheal neck dissection (PTND)
Gentle endotracheal intubation by experienced is common practice for the treatment of positive
anesthesiologist. nodes at levels VIVII originating from well-dif-
Divide the sternothyroid muscle if necessary to get ferentiated and medullary thyroid carcinoma.
a good exposure. The high rate of recurrence following berry pick-
Identify the recurrent laryngeal nerve (RLN) ing, presumably due to subclinical involvement
through its entire course in all patients. of lymph nodes, has led to routine performance
Left RLN is more vertical and dissection of this side of a formal unilateral or bilateral PTND in pa-
may necessitate retraction of the RLN using a nerve tients with clinically positive nodes in the para-
hook. tracheal region [1,2]. It has also been indicated as
Identify and preserve well-vascularized parathyroid an elective procedure for patients with positive
glands. jugular chain adenopathy [3], especially in high-
Implants of parathyroid glands may be necessary if risk patients with well-differentiated thyroid car-
they are ischemic by the end of the dissection. cinoma (older male patients with aggressive tu-
Do not coagulate near the nerve. mors) and certainly for patients with medullary
carcinoma. Dissection of this region does not
Treat hypocalcemia aggressively.
necessarily carry an increased risk of RLN injury
[3, 4]; however, the rates of postoperative hypo-

P I T F A L L S
calcemia can be as high as 25% [5].
Risk of hypocalcemia is much higher in reopera-
tions and when a neck dissection is performed Practical Tips for PTND
simultaneously. Intubation should be done by an experienced
Nerve monitoring can be used, especially in reop- anesthesiologist, preferably with a soft endotra-
erations, but identification of the RLN is always cheal tube to avoid injury to the vocal cords.
mandatory. PTND starts with dissection of the carotid ar-
tery and internal jugular vein through their en-
tire course into the mediastinum. Remember, the
RLN passes underneath the artery and is thus
safe at this point.

The RLN has to be identified in all patients
Postoperatively, hypocalcemia is more com-
through its entire course in the paratracheal re-
gion from the upper mediastinum to the crico-
mon in reoperations, and oral supplementation of
calcium should be considered even prior to the
1
thyroid membrane. Remember that nerve moni- development of hypocalcemia in these patients.
toring is not a substitute for proper identification Aggressive supplementation may help with early
of the nerve. hospital discharge.
Exposure of the left RLN may necessitate com- At times, edema of the ipsilateral side of the
plete sharp dissection of the nerve through its cir- larynx may be anticipated and treated with a
cumference and retraction using a nerve hook, to short course of corticosteroids.
facilitate removal of the specimen underneath the
nerve towards the trachea. At times, the specimen Conclusions
may be separated to avoid injury to the RLN dur- PTND may be a complicated maneuver and care
ing retraction. must be taken during the procedure to minimize
For better exposure of the paratracheal region, the morbidity. When performed properly the
the sternothyroid muscle can be divided, prefer- morbidity is relatively low [3] even in reopera-
ably at its uppermost attachment to the thyroid tions [4].
cartilage.
If the parathyroid glands are devascularized
during dissection, they should be resected and re- References
implanted in the sternocleidomastoid muscle. 1 Watkinson JC, Franklyn JA, Olliff JF: Detection and surgical
While dissecting the upper mediastinum, care treatment of cervical lymph nodes in differentiated thyroid can-
cer. Thyroid 2006;16:187194.
must be taken to avoid injury to the subclavian or 2 Shaha AR: Management of the neck in thyroid cancer. Otol Clin
innominate arteries. These vessels serve as the North Am 1998;31:823831.
3 Khafif A, Ben Yosef R, Abergel A, Kesler A, Landsberg R, Fliss
lowermost limit of our dissection. DM: Elective paratracheal neck dissection for lateral metastases
Remember, the right common carotid artery from papillary carcinoma of the thyroid: is it indicated? Head
may have a somewhat oblique course inferiorly Neck 2007, E-pub ahead of print.
4 Kim MK, Mandel SH, Baloch Z, Livolsi VA, Langer JE, Didonato
and may cross the trachea towards the innomi- L, Fish S, Webber RS: Morbidity following central compartment
nate artery. Care is taken not to injure this vessel reoperation for recurrent or persistent thyroid cancer. Arch Oto-
at this last step of the dissection. laryngol Head Neck Surg 2004;130:12141216.
5 Filho JG, Kowalski LP: Postoperative complications of thyroidec-
tomy for differentiated thyroid carcinoma. Am J Otolaryngol
2004;25:225230.
27
1.14 Management of Lymph Nodes in

Medullary Thyroid Cancer
Marcos R. Tavares

MTC occurs in sporadic or familial clinical set-
Lymph node metastasis is frequent in medullary tings and corresponds to 5% of thyroid carcino-
thyroid cancer (MTC) (70%). mas and as much as 63% of them present initially
Preoperative thyroid and lymph node evaluation with lymph node metastasis [1]. Complete surgi-
by ultrasound and computed tomography is very cal resection is critical for cure because cervical
useful.
reoperation for persistent or recurrent disease
Parathyroid glands are better identified during benefits only select patients [2]. Total thyroidec-
thyroidectomy. tomy and neck dissection are mandatory when
Elective dissection of the lateral compartment of metastases are clinically evident, and it is accept-
the neck may be postponed until a second time. ed by consensus that dissection of the central
Reoperation is indicated if serum calcitonin is compartment of the neck is the minimal adequate
elevated after adequate initial treatment and after initial treatment, even when neck metastases are
confirmation of the disease in the neck by fine not identified [3]. Dissection of the central com-
needle aspiration cytology, without distant
metastasis.
partment of the neck is risky for the parathyroid
glands and laryngeal recurrent nerves, and must
Dissection of the level I is unnecessary.
be performed by an experienced head and neck
surgeon.

P I T F A L L S
Practical Tips
Inadequate clinical and pathological evaluation of
Dissection of the central neck must be per-
the neck.
formed in virtually all patients to avoid damage
Insufficient dissection of the central compartment
done by reoperation in this anatomical site. The
of the neck.
only exception that might be considered is in a
Assumption of cure without a negative stimulated
patient with low-risk RET mutation at the age of
calcitonin test.
5 years or below and with negative stimulated cal-
Parathyroid function is more frequently impaired citonin test.
after dissection of the central neck.
All tissue between the carotid arteries laterally
RET test not performed in patients with MTC and and between the hyoid bone and the brachioce-
first degree relatives of those with a positive test.
phalic venous trunk is to be removed.
Dissection of the lateral neck without localization of Parathyroid glands are better identified at the
persistent or recurrent disease. time of the thyroidectomy. It is recommended to
remove and to transplant them, since parathyroid

adenoma occurs in about 50% of the patients with References
familial disease [3] and it is hard to preserve its
function with an aggressive dissection of the cen-
1 Moley JF, DeBenedetti MK: Patterns of nodal metastases in pal-
pable medullary thyroid carcinoma. Recommendations for ex- 1
tent of node dissection. Ann Surg 1999;229:880888.
tral neck. 2 You YN, Lakhani V, Wells SA Jr, Moley JF: Medullary thyroid
Dissection of the lateral neck must be per- cancer. Surg Oncol Clin N Am 2006;15:639660.
3 Brandi ML, Gagel RF, Angeli A, Bilezikian PB, Bordi C, Conte-
formed for positive neck and may be modified; it Devolx B, Flachetti A, Giheri RG, Libroia A, Lips CJM, Lombardi
is unnecessary to include the submandibular ech- C, Mannelli M, Pacini F, Ponder BAJ, Raue F, Skojeseid GT, Tam-
elon in the specimen. Elective dissection of the burrano G, Thakker RV, Thompson PT, Tonelli F, Wells S Jr,
Marx S: Guidelines for diagnosis and therapy of MEN type 1 and
lateral compartment may be postponed as a sec- type 2. J Clin Endocrinol Metab 2001;86:55685571.
ond staged procedure. 4 Giraudet AL, Vanel D, Leboulleux S, Auprin A, Dromain C,
Reoperation is indicated if calcitonin does not Chami L, Tovo NN, Lumbroso J, Lassau N, Bonniaud G, Hartl D,
Travagli JP, Baudin E, Schlumberger M: Imaging medullary thy-
reach a low level. Dissection of the lateral neck roid carcinoma with persistent elevated calcitonin levels. J Clin
(levels IIV) is performed only after detection of Endocrinol Metab 2007;92:41854190.
the disease by fine needle aspiration or a positive
MIBI test, as long as distant metastases are ruled
out. The most efficient imaging workup for de-
picting MTC tumor sites includes a neck US,
chest CT, liver MRI, bone scintigraphy and axial
skeleton MRI. FDG-PET scan appears to be less
sensitive with low prognostic value [4].
29
1.15 How to Manage a Well-Differentiated

Carcinoma with Recurrent Nerve Invasion
Patrick Sheahan, Jatin P. Shah
Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, N.Y., USA

P E A R L S tion of all gross disease is the cornerstone thera-
py; however, resection of the RLN may lead to
In patients who have a preoperative vocal cord significant long-term sequelae. Thus, the man-
paralysis (VCP) secondary to tumor involvement of agement of the RLN invaded by WDTC is a con-
the recurrent laryngeal nerve (RLN), resection of the
RLN should be performed.
tentious area.
RLN invasion usually occurs either in the
With functioning vocal cords (VCs), every effort
region of Berrys ligament or in the tracheoesoph-
should be made to preserve the RLN, not leaving
gross tumor behind. ageal groove from tumor in metastatic paratra-
cheal lymph nodes [2]. Male sex, older age, and
When there is RLN invasion, the minimum
aggressive histological subtypes of papillary car-
operation should be a total thyroidectomy (TT), to
use postoperative radioiodine treatment. cinoma are associated with increased risk of RLN
invasion [3, 4].
In cases of bilateral RLN invasion, at least one RLN
should be preserved.
Practical Tips
When an invaded RLN is found, explore the contra-
RLN invasion may or may not lead to VCP.
lateral side, to ensure the integrity of the contralat-
eral RLN, prior to considering sacrifice of the Preoperative indirect or flexible laryngoscopy is
involved RLN. mandatory in patients with suspected thyroid
cancer.
The presence of RLN invasion implies extra-

P I T F A L L
thyroid spread of tumor, and upstages the tumor
Gross disease should never be left behind, as this to T4 [1]. However, in contrast to invasion of the
leads to a high local failure rate, often with transfor- larynx, trachea, or esophagus [3], this does not
mation to a more aggressive histology.
necessarily portend a poor prognosis [2].
WDTC with extrathyroid extension is best
treated with complete resection of all gross dis-
ease. Margins of only a few millimeters are gener-
Introduction ally adequate.
The reported incidence of extrathyroid extension Removal of all gross tumor leaving behind mi-
of well-differentiated thyroid cancer (WDTC) croscopic disease does not necessarily lead to an
varies from 1 to 15% [1]. After the strap muscles, increased failure rate, as long as postoperative
the RLN is the next most commonly invaded treatment with radioiodine or external beam ra-
structure by WDTC [2]. Complete surgical resec- diotherapy is administered.

Patients with preoperative VCP rarely regain Conclusion
VC movement. Thus, there is little benefit in pre-
serving the RLN in them.
The management of the RLN invaded by WDTC
is an important issue. As a general rule, a para-
1
In patients with normal VC function preop- lyzed nerve should be resected, whereas every ef-
eratively, RLN resection per se does not necessar- fort should be made to preserve a functioning
ily lead to improved local control or survival [5 nerve. However, preservation should only be at-
7]. Therefore, every effort should be made to pre- tempted without leaving gross tumor behind. In
serve the functioning RLN. all cases, TT facilitates postoperative adjunctive
When the RLN is sacrificed, an adequate three- treatment with radioiodine.
dimensional resection should be performed to se-
cure clear margins.
The surgeon should endeavor to preserve the References
nerve on at least one side, if feasible. Prior to sac- 1 Morton RP, Ahmad Z: Thyroid cancer invasion of neck struc-
tures: epidemiology, evaluation, staging and management. Curr
rificing an invaded nerve, integrity of contralat-
Opin Otolaryngol Head Neck Surg 2007;15:8994.
eral RLN should be ensured. The immediate ef- 2 McCaffrey TV, Bergstralh EJ, Hay ID: Locally invasive papillary
fect of bilateral RLN sacrifice or injury is stridor, thyroid carcinoma: 19401990. Head Neck 1994;16:165172.
3 Shaha A: Implications of prognostic factors and risk groups in
which usually necessitates re-intubation. Trache- the management of differentiated thyroid cancer. Laryngoscope
ostomy should be performed as soon as feasible. 2004;114:393402.
Postoperative adjuvant treatment with radio- 4 Kebebew E, Clark OH: Locally advanced differentiated thyroid
cancer. Surg Oncol 2003;12:9199.
iodine or external beam radiotherapy (in cases 5 Chan WF, Lo CY, Lam KY, Wan KY: Recurrent laryngeal nerve
with poorly differentiated histology, massive ex- palsy in well-differentiated thyroid carcinoma: clinicopatholog-
trathyroid extension, or older age) or both im- ical features and outcome study. World J Surg 2004:10931098.
6 Nishida T, Nakao K, Hamaji M, Kamiike W, Kurozumi K, Mat-
proves local control and survival. Hence, TT is suda H: Preservation of recurrent laryngeal nerve invaded by
the minimum operation. differentiated thyroid cancer. Ann Surg 1997;226:8591.
Symptoms of unilateral VCP (breathy voice 7 Falk SA, McCaffrey TV: Management of the recurrent laryngeal
nerve in suspected and proven thyroid cancer. Otolaryngol Head
and/or aspiration of thin liquids) are variable and Neck Surg 1995;113:4248.
may initially fluctuate. As most patients will 8 Yumoto E, Sanuki T, Kumai Y: Immediate recurrent laryngeal
nerve reconstruction and vocal outcome. Laryngoscope 2006;
experience spontaneous improvement, surgical 116:16571661.
medialization should be delayed for several 9 Chou FF, Su CY, Jeng SF, Hsu KL, Lu KY: Neurorrhaphy of the
months. recurrent laryngeal nerve. J Am Coll Surg 2003;197:5257.
Immediate RLN reconstruction by either di-
rect repair or cable grafting has been advocated
by some [8]. Despite not leading to any return in
VC movement, it may improve voice by prevent-
ing muscle atrophy [8, 9].
31
1.16 Management of Invasive Thyroid Cancer

Thomas V. McCaffrey
Department of Otolaryngology, Head and Neck Surgery, University of South Florida, Tampa, Fla., USA

P E A R L S in 39% of cases. Control of ITC is therefore an
important clinical problem, and it would be ex-
Hoarseness, airway obstruction and particularly pected that successful treatment of ITC would in-
hemoptysis are signs of upper aerodigestive tract clude survival and reduced morbidity. ITC can
(UADT) invasion by thyroid cancer.
produce symptoms as a result of paralysis of one
Laryngeal function can often be preserved by or both recurrent laryngeal nerves (LN) resulting
partial laryngectomy procedures even if invasion
in hoarseness or airway obstruction, direct inva-
has occurred.
sion of the trachea or larynx with the potential of
Postoperative external beam radiation therapy airway obstruction and bleeding, invasion of the
(EBRT) may control unresectable invasive thyroid
cancer (ITC) and preserve laryngeal function.
esophagus resulting in bleeding and dysphagia.
Treatment goals for ITC include the prevention of
hemorrhage and air obstruction, preservation of

P I T F A L L S
the function of the UADT, prevention of local/re-
Inadequate resection of ITC will result in severe gional recurrence, and optimally long-term sur-
morbidities of airway obstruction, hemoptysis and vival.
dysphagia.
Overestimating the need for radical resection may Practical Tips
lead to the loss of salvageable laryngeal function.
Surgical Techniques
Larynx. Invasion can occur by direct extension
and erosion of the laryngeal cartilage or by inva-
sion around the posterior and inferior aspects of
Introduction the thyroid cartilage into the paraglottic space.
Well-differentiated carcinoma of the thyroid Often, it is unilateral, permitting conservative
(WDTC) is a generally curable disease with a operations (e.g., partial vertical laryngectomy,
mortality rate quoted as between 11 and 17%. PVL). If the mucosa is not directly involved, re-
When WDTC extends beyond the thyroid cap- moval of the thyroid cartilage without entering
sule and produces invasion of the UADT struc- the airway is also possible. LN invasion presents
tures, it is the cause of considerable increased special problems. If paralysis has occurred, LN is
morbidity and increased mortality. resected with the tumor. Rehabilitation by thyro-
In a review by McConahey et al. [1], cause of plasty offers an excellent result. However, in some
death from WDTC was related to untreatable lo- cases, perineural invasion occurs without paraly-
cal disease in 36% of cases and metastatic disease sis of the nerve. Although some controversy ex-

ists, peeling of tumor from the nerve preserving sults in a similar disease-free survival [3]. Pres-
its function does not appear to result in reduced
survival.
ently, the final word is not yet established. Cer-
tainly, in elderly patients or those who have other
1
Trachea. Invasion may be relatively superficial morbidities which may limit their survival, a less
with erosion or invasion of the cartilage rings invasive, less traumatic procedure may be of ben-
without mucosal involvement, or it may be deep efit. Younger patients, in whom eradication of
with intraluminal extension (IE). When IE oc- disease could extend survival, would benefit from
curs, full-thickness resection (FTR) of the trachea more aggressive resections. This still remains an
is the optimal treatment, occasionally as a win- individual surgical decision.
dow resection if the invasion is localized. The de- EBRT has become more widely used in treat-
fect can be repaired with a myofacial flap from ing ITC. There are no controlled trials, although
the sternocleidomastoid or other adjacent mus- anecdotal results indicate that it may be helpful
cles. If the invasion is circumferential, tracheal in selected cases [4].
resection is indicated, eventually extended up to
include part of the cricoid, if necessary. Conclusion
Pharynx/Esophagus. Because of the loose sub- WDTC invading the UADT and LN causes sig-
mucosal layer, tumor may involve the muscle coat nificant morbidity/mortality. Successful treat-
without invasion through the underlying muco- ment is possible while preserving function. PVL,
sa. This usually permits stripping of the muscle tracheal resections, SR and EBRT eliminate mor-
with preservation of the mucosa. If limited mu- bidity, preserve function, reduce local recurrence
cosal invasion does occur, resection with primary and may improve survival.
repair is possible. Extensive esophageal invasion
may require laryngopharyngectomy and recon-
struction with a jejunal or cutaneous free flap. References
Shave Resection (SR) versus FTR. Some contro- 1 McConahey WM, Woolner LB, van Heerden JA, Taylor WF: Pap-
illary thyroid cancer treated at the Mayo Clinic, 19461970: ini-
versy still remains on the appropriate resection of
tial manifestations, pathological findings, therapy, and outcome.
minimally invasive tumors. Advocates for FTR of Mayo Clin Proc 1986;61:978996.
the airway state that, although the tumor may ap- 2 Grillo HC, Suen HC, Mathisen DJ, Wain JC: Resectional manage-
ment of thyroid cancer invading the airway. Ann Thorac Surg
pear to be superficially invasive, usually exten- 1992;54:39.
sion into the submucosal plane occurs and that 3 Lipton RJ, McCaffrey TV, van Heerden: Surgical treatment of in-
leaving a tumor behind results in higher recur- vasion of the upper aerodigestive tract by well-differentiated
thyroid carcinoma. Am J Surg 1987;154:363367.
rence rate [2]. Proponents of SR argue that there 4 Brierley JD, Tsang RW: External beam radiation therapy in the
is no evidence to indicate survival improvement treatment of differentiated thyroid cancer. Semin Surg Oncol
by FTR and that adding postoperative EBRT re- 1999;16:4249.
33
Neck Metastases
2.1 Preoperative Workup of the Neck in Head

and Neck Squamous Cell Carcinoma
Michiel van den Brekel, Frans J.M. Hilgers
Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital and Academic Medical Center,
University of Amsterdam, Amsterdam, The Netherlands

Pretreatment workup of the neck is important to
Imaging is crucial in evaluating the extent of decide on indication and extent of the treatment.
metastatic disease and can play a pivotal role in An important use of pretreatment imaging is the
treatment planning.
assessment of the extent of neck disease or the
Imaging, especially PET-CT and US-FNAC, can infiltration into crucial structures, in order to de-
detect occult metastases if larger than 56 mm.
termine operability. Tumors with encasement of
Only an invasive technique further improves detec- the carotid artery over more than 270 are rarely
tion of occult metastases: a sentinel node biopsy. operable. Other important issues for prognostica-
Prediction of the metastatic potential of a tumor tion are: assessment of necrosis, tumor volume,
might soon be available in the form of gene extranodal spread, involvement of levels IV and
expression profiling.
V, retropharyngeal lymph nodes or paratracheal
lymph nodes.

P I T F A L L S
Although for individual patients it is an ad-
vantage when occult metastases are detected with
The majority of occult metastases cannot be
CT or MRI, the unreliable criteria to assess small
detected using the current imaging techniques.
nonpalpable metastases make these techniques
Not treating the neck electively with either surgery
unreliable for the detection of metastases smaller
or radiotherapy is only warranted in tumors with a
moderate to low risk of occult metastases and when than 89 mm. The advent of PET and PET-CT
adequate imaging follow-up is ensured. has certainly increased the sensitivity and speci-
ficity, but metastases smaller than 5 mm are sel-
As the pathology of neck dissection specimens is
dom detected [1]. As US-FNAC is an ideal tech-
not very accurate either, a negative pathology
report does not guarantee that no metastases are nique both for initial assessment and follow-up,
present. it has been widely studied for the assessment of
the N0 neck [2]. However, the reported sensitivity
of US-guided FNAC in the N0 neck varies from
42 to 73%. In a routine setting we recently found
that the sensitivity of US-FNAC in small (T1) oral
carcinomas treated with transoral excision and a
wait and see strategy for the neck was signifi-
cantly lower (18%) than in patients who had an

elective neck dissection for T23 oral carcinomas Although the levels IIII are at risk in most
(27%) or T23 oropharyngeal carcinomas (50%). head and neck carcinomas, special attention
Sentinel node biopsy is reported to be a very should be given to retropharyngeal and paratra-
sensitive technique. The major disadvantage, of cheal nodes. Any node larger than 56 mm in
course, is that the sentinel node procedure impli- these areas is suspicious.
cates a surgical procedure that has to be followed
by a completion neck dissection when the SN is Conclusion
tumor positive. Although in the last decades imaging has tremen- 2
dously increased our ability to stage tumors and
Practical Tips optimize treatment planning, we are still unable
As no currently available imaging technique to detect small metastases that frequently occur
can reliably detect small metastases, in treatment in early-stage head and neck cancers. Recent ad-
planning one should consider the risk of occult vances in the prediction of neck metastases using
metastases and either treat the neck electively or gene expression profiling or detection using sen-
use a very stringent follow-up protocol, including tinel node biopsy might help us solve this prob-
imaging, at regular intervals. lem in the future. Imaging does have a place in
As a wait and see policy for the N0 neck leads evaluating tumor extent, assessing operability
to delayed detection of neck metastases in 15 and determining optimal treatment.
40% of the patients (depending on the accuracy
of imaging and patient population), these patients
are treated at a later stage, either implicating more References
extensive treatment or a poorer prognosis. A very 1 Brouwer J, De Bree R, Comans EF, Castelijns JA, Hoekstra OS,
Leemans CR: Positron emission tomography using [18F] fluoro-
strict follow-up using US-FNAC leads to a similar
deoxyglucose (FDG-PET) in the clinically negative neck: is it
prognosis. likely to be superior? Eur Arch Otorhinolaryngol 2004;261:479
To obtain well-interpretable images, CT and 483.
2 van den Brekel MW, Castelijns JA: What the clinician wants to
MRI should be done with intravenous contrast know: surgical perspective and ultrasound for lymph node imag-
agents and thin slices (34 mm) or spiral CT. ing of the neck. Cancer Imaging 2005;5(suppl):S41S49.
Ultrasound is only trustworthy if performed
by a skilled ultrasonographer, either the surgeon
or the radiologist. The same holds true for the in-
terpretation of the cytology.
35
Neck Metastases
2.2 N0 Neck in Oral Cancer:

Wait and Watch
Yoav P. Talmi
Department of Otorhinolaryngology Head and Neck Surgery, Chaim Sheba Medical Center, Tel Hashomer,
and Department of Otorhinolaryngology, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel

P E A R L S ommended that when the probability of occult
cervical lymph node metastasis is more than 20%,
Wait and Watch Policy the neck should be electively treated either by sur-
Avoid performing surgery not indicated in the gery or radiotherapy. Both, however, are associ-
majority of patients. ated with adverse effects.
Avoid complications of surgery and irradiation. The argument in favor of observation is that
with elective treatment, the majority of patients
Keep the option of surgery and/or radiation for
receive an intervention that is necessary only in
recurrences/second primaries.
2530%. While morbidity of elective ND is usu-
Reduce cost.
ally minimal, a neck intervention in the future
may be hampered by former surgery. Radiation
Active Neck Treatment treatment is not without consequences either, i.e.
Complications and sequelae of selective neck local effects or induction of second primaries,
dissection (ND) are minimal. and we may also deny the patients the opportu-
Delayed neck presentation may be rapid and in a nity of such interventions in the future.
more advanced stage. The assumption that the N0 neck can be read-
More extended ND procedures indicated when ily observed and treated when the patient devel-
treating delayed neck recurrences. ops early regional N1 metastatic disease has often
Incidence of neck recurrence is significantly been proven erroneous. Forty-nine percent of pa-
reduced when treated simultaneously. tients who underwent salvage neck surgery after
Chances of cure are significantly elevated. a close watch and wait policy were found to have
advanced neck disease (N2b) [1].
In a group of 137 patients [2] with T1/T2, N0
tongue cancer, patients that required ND when
Introduction becoming N+ had a significantly greater number
Cervical metastases are the worst prognostic in- of positive nodes, a higher incidence of extracap-
dicator apart from distant metastases in patients sular spread, and decreased survival compared to
with cancer of the head and neck, decreasing sur- patients undergoing simultaneous ND.
vival by approximately 50%. In a group [3] where elective ND and watchful
The incidence of occult nodes was reported in waiting in stage I/II oral tongue squamous cell
the range of 2145% of oral cavity cases. It is rec- cancer (SCC) was compared, the regional recur-

rence rate was 47% (23% mortality) in N0 patients Conclusion
who had no ND. Elective ND significantly re- It is my view that a selective ND should be per-
duced the regional recurrence rate to 9% (3% formed in the majority of the N0 necks, which is
mortality). supported by the literature cited. However, in cas-
In a group of 233 patients with stage I/II oral es where a sentinel node biopsy was negative, a
cavity SCC treated by brachytherapy [4], 47% un- careful watch and wait approach may be justified.
derwent elective ND and 53% were only followed Also, in superficial T1 lesions with a depth rang-
and underwent ND in case of relapses. In the first ing to no more than 46 mm, or anterior tongue 2
group, salvage treatment was successful in 47% of small lesions, a watch and wait policy may be rea-
cases and it was successful in 62% of the second sonable.
group. Ten-year survival, however, was 37 and
31%, respectively.
Increased patient morbidity associated with References
salvage surgery was due to the need for more rad- 1 Andersen PE, Cambronero E, Shaha AR, Shah JP: The extent of
neck disease after regional failure during observation of the N0
ical forms of ND in established neck disease and
neck. Am J Surg 1996;172:689691.
the need for postoperative radiotherapy [5]. 2 Haddadin KJ, Soutar DS, Oliver RJ, Webster MH, Robertson AG,
A significant decrease in survival in high-risk MacDonald DG: Improved survival for patients with clinically
T1/T2, N0 tongue tumors undergoing a prophylactic neck dis-
patients was reported [6]. Among the cases that section. Head Neck 1999;21:517525.
had metastases at follow-up, 50% were not even 3 Yuen AP, Wei WI, Wong YM, Tang KC: Elective neck dissection
candidates for salvage treatment. Kligerman et al. versus observation in the treatment of early oral tongue carci-
noma. Head Neck 1997;19:583588.
[7] stipulated that ND remains mandatory in the 4 Piedbois P, Mazeron JJ, Haddad E, Coste A, Martin M, Levy C, et
early stage of oral SCC because of better survival al: Stage III squamous cell carcinoma of the oral cavity treated
rates compared to resection alone and the poor by iridium-192: is elective neck dissection indicated? Radiother
Oncol 1991;21:100106.
salvage rate. This was noted in particular in pa- 5 Shasha D, Harrison LB: Elective irradiation of the N0 neck in
tients with tumor thickness >4 mm. squamous cell carcinoma of the upper aerodigestive tract. Oto-
laryngol Clin North Am 1998;31:803813.
In a group of 156 similar patients [8] elective 6 Kowalski LP, Bagietto R, Lara JR, Santos RL, Silva JF Jr, Magrin
ND increased survival to 55% compared with J: Prognostic significance of the distribution of neck node metas-
33% with observation. Wei et al. [9] reviewed the tasis from oral carcinoma. Head Neck 2000;22:207214.
7 Kligerman J, Lima RA, Soares JR, Prado L, Dias FL, Freitas EQ,
accepted approaches to the N0 neck summarizing et al: Supraomohyoid neck dissection in the treatment of T1/T2
the issues at hand. squamous cell carcinoma of oral cavity. Am J Surg 1994;168:391
An approach of close ultrasound follow-up 394.
8 Lydiatt DD, Robbins KT, Byers RM, Wolf PF: Treatment of stage
with FNA cytology has been suggested and may I and II oral tongue cancer. Head Neck 1993;15:308312.
be of value in watch and wait cases. Sentinel node 9 Wei WI, Ferlito A, Rinaldo A, Gourin CG, Lowry J, Ho WK, et al:
Management of the N0 neck reference or preference. Oral On-
biopsy in selected cases may also change our ap-
col 2006;42:115122.
proach to a more conservative one. A negative
sentinel node biopsy may obviate the need to per-
form ND whereas if the sampled node or nodes
are positive, there is no question regarding the
need for ND.
37
Neck Metastases
2.3 N0 Neck in Oral Cancer:

Elective Neck Dissection
Fernando L. Dias, Roberto A. Lima
Head and Neck Surgery Department, Brazilian National Cancer Institute and Postgraduation School of Medicine,
Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil

P E A R L S Practical Tips
Tumors more than 1 cm away from the midline
Consider elective supraomohyoid neck dissection present a low risk of bilateral/contralateral LNM
in early oral tongue and floor of mouth squamous (7%). Tumors crossing the midline by less than
cell carcinoma (SCC).
1 cm have a risk increased to 16%, which reaches
Consider extending supraomohyoid neck dissec- 46% in those patients where the crossing is more
tion to level IV in SCC of the posterior 1/3 of the
than 1 cm.
tongue.
The depth of invasion and thickness, the char-
Identification of the posterior belly of the digastric acteristics of the tumor-normal tissue boundary
muscle will ease the dissection of level IIab.
(i.e., well-demarcated vs. diffuse invasion at the
boundary), lymphatic or vascular space invasion,

P I T F A L L S
perineural invasion, and the degree of inflamma-
tory (lymphoplasmacytic) response are consid-
Avoid traction of nerve XI while dissecting level IIb.
ered predictive factors for LNM as well as its di-
Avoid dissection of level II before identification of
ameter and grade [6].
nerve XI.
The incision is placed in an upper neck skin
crease extending from the posterior border of the
sternocleidomastoid muscle towards the hyoid
bone up to the midline (at least two finger breadths
below the angle of the mandible).
Nerves at risk during supraomohyoid neck dis-
Introduction section are marginal mandibular branch of the
Lymph node metastasis (LNM) from oral cavity facial nerve (MBFN), lingual nerve, hypoglossal
(OC) SCC occurs in a predictable and sequential nerve, spinal accessory nerve, cutaneous and
fashion. For primary tumors of the OC the first muscular branches of the cervical plexus, and
echelon lymph node at highest risk for early dis- great auricular nerve. They should be carefully
semination includes levels I, II and III [15]. identified and preserved [4, 7].
Poor salvage rates for regional recurrence Start dissecting the anterior border of the ster-
ranging from 11 to 40%, despite the use of aggres- nomastoid muscle from its intersection with the
sive therapy, emphasize the role of elective treat- omohyoid muscle (posterior belly) up to the mas-
ment of the neck in OC SCC [6]. toid tip. This maneuver will ease the identifica-

tion of the posterior belly of the digastric muscle To facilitate accurate description of the excised
and, consequently, the dissection of the apex of LN, it is important to apply numerical tags to the
the posterior triangle. LN depicting each level.
Nerve XI usually runs parallel and deep to the
great auricular nerve. Avoid traction on nerve XI Conclusion
while dissecting level IIb. The limitations for the identification of occult
There is a close relationship between the MBFN cervical metastases and the negative impact of re-
and the facial vessels. A surgical maneuver attrib- current disease in the neck are important issues 2
uted to Hayes Martin, i.e. keeping the cranial in the management of OC SCC [13]. Elective
stumps of facial vessels retracted upward during treatment of the neck must be strongly consid-
the dissection of the submandibular triangle, ered in OC, even in early stages when the prima-
helps to protect the nerve. The use of nerve mon- ry tumor is located at the tongue and/or floor of
itoring and magnification can be of help [7]. the mouth.
Only after the identification of the MBFN is
exposure of the prevascular facial LN (level Ib)
accomplished. References
A brisk hemorrhage is expected during dissec- 1 Shah JP, Candela FC, Poddar AK: The patterns of cervical lymph
node metastases from squamous carcinoma of the oral cavity.
tion along the lower border of the body of the
Cancer 1990;66:109113.
mandible up to the attachment of the anterior 2 Dias FL, Kligerman J, Matos de S G, et al: Elective neck dissec-
belly of the digastric muscle [4]. tion versus observation in stage I squamous cell carcinomas of
Adequate exposure of the undersurface of the the tongue and floor of the mouth. Otolaryngol Head Neck Surg
2001;125:2329.
floor of the mouth is achieved with gentle traction 3 Laubenbacher C, Saumweber D, Wagner-Manslau C, et al: Com-
of the submandibular gland downward and me- parison of fluorine-18-fluorodeoxyglucose PET, MRI and endos-
copy for staging head and neck squamous carcinomas. J Nucl
dial retraction of the lateral border of the mylo- Med 1995;36:17471757.
hyoid muscle. Such exposure allows precise iden- 4 Shah JP, Patel SG: Cervical lymph nodes; in Shah JP, Patel SG
tification of the hypoglossal and lingual nerves as (eds): Head and Neck Surgery and Oncology, ed 3. Edinburgh,
Mosby, 2003, pp 353394.
well as its secretomotor fibers to the submandibu- 5 Dias FL, Lima RA, Kligerman J, et al: Relevance of skip metasta-
lar gland and the Whartons duct. Once the lin- ses for squamous cell carcinoma of the oral tongue and floor of
the mouth. Otolaryngol Head Neck Surg 2006;136:460465.
gual nerve is clearly identified, the secretomotor 6 Dias FL, Lima RA: Cancer of the floor of the mouth. Oper Tech
fibers to the submandibular gland can be safely Otolaryngol Head Neck Surg 2005;16:1017.
divided between clamps and ligated. 7 Dias FL, Lima RA, Cernea CR: Management of tumors of the sub-
mandibular and sublingual glands; in Myers EN, Ferris RL (eds):
In N0 neck, levels IV and V LN are generally

Salivary Gland Disorders. Berlin, Springer, 2007, pp 339376.
not at risk of harboring micrometastasis. The ex-
ception to this observation are SCC of the poste-
rior 1/3 lateral border of the tongue in which lev-
el IV may be at risk of occult LNM [4, 5].
39
Neck Metastases
2.4 Sentinel Node Biopsy in the Management

of the N0 Oral Cancer
Francisco Civantos
Department of Otolaryngology, Head and Neck Surgery, Sylvester Cancer Center, University of Miami,
Miami, Fla., USA

P E A R L S Sentinel lymph node biopsy (SLNB) could
consign this debate to history, as accrued experi-
Select early lesions without extremely deep ence demonstrates that micrometastases can be
invasion. accurately detected with this less invasive tech-
Use preoperative contrasted CT or MRI to detect nique. More than 60 single institution trials, two
grossly involved lymph nodes (LN). international conference consensus documents, a
Accurate radiotracer injection requires a comfort- meta-analysis, and a rigorous cooperative group
able patient. validation trial have evaluated this technique for
Inject closely into normal tissue around the lesion. oral cancer [46]. The negative predictive value
Manage background activity from the primary site. of SLNB approximates 95%; step sectioning and
Tag identified nerves. immunohistochemistry prove essential and lead
Exhaustive step sectioning and immunohisto- to significant upstaging, and unexpected patterns
chemistry. of drainage can occur [7].
Close follow-up.
Practical Tips
Patient Selection. Select T1 and smaller T2 le-

P I T F A L L S
sions. Rule out nonpalpable gross disease through
Counsel patients regarding potential reexploration. strictly interpreted imaging. SLNB will detect
Avoid large lesions as an excessive number of nodes micrometastases, but not nonfunctional, grossly
will result. involved nodes.
Radionuclide Injection and Imaging of the Pri-
Use of the gamma probe is not intuitive.
mary Tumor. Avoid direct injection of the tumor
Do not inject local anesthetic directly into the
with local anesthetic as it affects radionuclide up-
primary tumor.
take. Narrow injection circumferentially encom-
Avoid blue dye for mucosal lesions.
passes the lesion with an additional injection in
Avoid paralysis.
the center of the lesion. Use 500 mCi on the morn-
ing of surgery, or a slightly higher dose the night
Introduction before. We prefer unfiltered 99Tc sulfur colloid.
Traditional watchful waiting minimized mor- The optional radiologic imaging can provide an
bidity in the majority of patients [1]. However, re- anatomic guide and improve preoperative coun-
cent opinion favors neck dissection (ND) in pa- seling.
tients at risk for cervical metastases [2, 3].

Removal of the Primary Tumor. We resect the uation to permit early reexploration prior to onset
primary tumor transorally first to reduce back- of inflammation.
ground activity.
Gamma Probe-Guided SLNB. The incision Conclusions
must be consistent with possible ND. Small flaps Though less morbid than radical dissections,
are elevated. Palpate the open neck to detect un- SND has measurable morbidity [810]. Morbidity
anticipated gross disease. is much less with SLNB [7].
Initial readings are taken of the precordium, At issue is our limited ability to immediately 2
back table, and primary resection bed, to assess evaluate SN. For a minority of patients we must
background. The probe is gradually passed over reexplore a recently operated wound.
the neck while assessing the auditory input. Avoid SLNB has an increasing role for early oral can-
rapid or unsteady movement which leads to false- cers. We encourage surgeons to gain experience
ly higher readings. The probe is moved radially with cutaneous malignancies, early oral cancers,
across each hot spot, indicating the direction in and gamma probe-guided ND for more invasive
which to proceed. Angling the probe indicates cancers.
depth. Using a fine hemostat, the surgeon bluntly
dissects towards the sentinel node (SN). Bipolar
cautery is used to divide tissues. Avoid paralysis References
and unipolar electrocautery. Tag identified nerves 1 Spiro RH, Strong EW: Epidermoid carcinoma of the mobile
tongue. Treatment by partial glossectomy alone. Am J Surg 1971;
with permanent suture to facilitate identification
122:707710.
if reexploration is necessary. 2 Shah JP, Andersen PE: Evolving role of modifications in neck dis-
The SN is excised and ex vivo readings are tak- section for oral squamous carcinoma. Br J Oral Maxillofac Surg
1995;33:38.
en. Repeat readings of the lymphatic bed seeking 3 Kligerman J, Lima RA, Soares JR, et al: Supraomohyoid neck dis-
additional SN. Any LN exhibiting 10% or more of section in the treatment of T1/T2 squamous cell carcinoma of
the radioactivity of the most radioactive node oral cavity. Am J Surg 1994;168:391392.
4 Ross GL, Soutar DS, Gordon MacDonald D, Shoaib T, Camilleri
will be harvested. Greater than six highly radio- I, Roberton AG, Sorensen JA, Thomsen J, Grupe P, Alvarez J, Bar-
active nodes represent technical failure and call bier L, Santamaria J, Poli T, Massarelli O, Sesenna E, Kovacs AF,
for SN dissection (SND). Rarely, a hot node oc- Grunwald F, Barzan L, Sulfaro S, Alberti F: Sentinel node biopsy
in head and neck cancer: preliminary results of a multicenter
curs in a completely separate anatomic region trial. Ann Surg Oncol 2004;11:690696.
(i.e. submental vs. level II) that does not reach 5 Paleri V, Rees G, Arullendran P, Shoaib T, Krishman S: Sentinel
node biopsy in squamous cell cancer of the oral cavity and oral
10% of the radioactivity of the hottest node but pharynx: a diagnostic meta-analysis. Head Neck 2005;27:739
is significantly radioactive above background. It 747.
may represent drainage from a different portion 6 Civantos FJ, Moffat FL, Goodwin WJ: Lymphatic mapping and
sentinel lymphadenectomy for 106 head and neck lesions: con-
of the tumor and should be harvested. trasts between oral cavity and cutaneous malignancy. Laryngo-
To assess level I nodes with floor of mouth tu- scope 2006;112(suppl 109):115.
mors, the surgeon may dissect below the margin- 7 Civantos FJ, Zitsch R, Schuller D, Agrawal A, Smith R, Nason R,
Petruzelli G, Gourin C, Yarbrough W, Ridge JD, Myers J: Sentinel
al mandibular nerve towards the mylohyoid mus- node biopsy for oral cancer: a multi-center validation trial (ab-
cle, mobilizing the nodes away from the oral cav- stract). Arch Otolaryngol Head Neck Surg 2006;132:8.
8 Chepeha DB, Taylor RJ, Chepeha JC, et al: Functional assessment
ity. The gamma probe is introduced into the
using Constants Shoulder Scale after modified radical and selec-
tunnel created and directed inferiorly. tive neck dissection. Head Neck 2002;24:432436.
Rigorous Histopathologic Assessment of the SN. 9 Kuntz AL, Weymuller EA Jr: Impact of neck dissection on qual-
ity of life. Laryngoscope 1999;109:13341338.
Fine sectioning and immunohistochemistry 10 Rogers SN, Ferlito A, Pelliteri PK, Shaha AR, Rinaldo A: Quality
should be performed. Accelerate pathologic eval- of life following neck dissections. Acta Otolaryngol 2004;124:
231236.
41
Neck Metastases
2.5 Selective Neck Dissection in the

Treatment of the N+ Neck in Cancers of
the Oral Cavity
Jesus E. Medina, Greg Krempl
Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla., USA

P E A R L S subclinical metastases is reasonably high. In the
presence of palpable LNM, a radical or modified
Patients with cancer of the oral cavity (COC) rarely radical neck dissection is the preferred operation.
have isolated lymph node metastasis (LNM) in SNDs are being used with increasing frequency
levels IV or V.
in selected N+ patients, either alone or in combi-
A selective neck dissection (SND) is an appropriate nation with PORDT [110].
operation for the management of selected patients
Since the use of these operations in the treat-
with an N+ neck.
ment of the N+ neck is still controversial, we re-
Postoperative radiation (PORDT) is usually indicated viewed our experience and attempt to outline the
with an SND in such cases.
appropriate role of SND in the management of
the N+ neck in patients with cancers of the oral

P I T F A L L
cavity.
Lack of appropriate informed consent may hinder
Practical Tips
the surgeons ability to extend the operation when
necessary to remove all the disease encountered At least levels I, II and III must be included.
in the neck. In a cohort of 164 patients with oral cancer, who
had a single clinically positive node (N1 or N2a),
Kowalski and Carvalho [8] found no isolated
LNM in levels IV or V. Furthermore, in patients
Introduction with clinically N1 neck disease involving levels I
An SND consists of the en bloc removal of the or II, these nodes were histopathologically nega-
lymph node groups that are most likely to harbor tive (pN0) in 57.4% of the cases.
metastases depending upon the location of the In other reports the prevalence of metastases
primary tumor. The goal of such operation is to in level IV in clinically N+ cases is 17%, suggest-
remove the nodes at risk while preserving func- ing that it is a safer practice to include level IV
tion and minimizing morbidity. A selective dis- whenever an SND is done for an N+ neck in pa-
section of the nodes of levels I, II and III/IV (su- tients with COC.
praomohyoid neck dissection) is currently the The prevalence of LNM in level V is so low in
preferred operation for the initial management of such patients (0.5% in cN0 and 3% in cN+) that
the neck in patients with COC who have no clin- dissection of this region of the neck is rarely nec-
ical evidence of LNM, but in whom the risk of essary.

PORDT is beneficial in terms of locoregional Conclusion
control of tumor in pN+ patients, particularly in This review and other investigations reported
cases with adverse prognostic factors such as in the literature suggest that SND has a role in
multiple metastatic lymph nodes or extracapsular the management of patients with COC who
spread [8]. Furthermore, when SND is used in have clinically positive LNM in level I or II, par-
combination with PORDT, survival and recur- ticularly when appropriately combined with
rence results are comparable to those obtained PORDT.
with comprehensive neck dissections [7]. 2
Results References
We analyzed our results in a cohort of 22 con- 1 Byers RM, Wolf PF, Ballantyne AJ: Rationale for elective modi-
fied neck dissection. Head Neck Surg 1988;10:160167.
secutive patients with COC who had limited pN+
2 Traynor SJ, Cohen JI, Gray J, et al: Selective neck dissection and
(13 pN1, 1 pN2a and 8 pN2) confined to levels I the management of the node-positive neck. Am J Surg 1996;172:
and II, and underwent an SND. The primary tu- 654657.
3 Davidson J, Khan Y, Gilbert R, et al: Is selective neck dissection
mor was in the oral tongue in 7 patients, the low- sufficient treatment for the N0/Np+ neck? J Otolaryngol 1997;26:
er lip in 6, the floor of the mouth in 4, the alveolar 229231.
ridge in 2, the retromolar trigone in 2, and the 4 Pellitteri PK, Robbins KT, Neuman T: Expanded application of
selective neck dissection with regard to nodal status. Head Neck
buccal mucosa in 1 patient. In the majority of pa- 1997;19:260265.
tients (72.7%) the dissection included levels IIII 5 Muzaffar K: Therapeutic selective neck dissection: a 25-year re-
(11/50%) or levels IIV (5/22.7%). Six patients had view. Laryngoscope 2003;113:14601465.
6 Ambrosch P, Kron M, Pradier O, et al: Efficacy of selective neck
received radiation to the neck previously and 8 dissection: a review of 503 cases of elective and therapeutic treat-
patients received PORDT. With a mean follow-up ment of the neck in squamous cell carcinoma of the upper aerodi-
gestive tract. Otolaryngol Head Neck Surg 2001;124:180187.
of 28 months, a recurrence in the neck occurred 7 Andersen PE, Warren F, Spiro J, et al: Results of selective neck
in 3 patients (13.6%), all of whom had received dissection in management of the node-positive neck. Arch Oto-
PORDT. In a previous review we encountered a laryngol Head Neck Surg 2002;128:11801184.
8 Kowalski LP, Carvalho AL: Feasibility of supraomohyoid neck
similar neck recurrence rate of 12.5% in 53 pa- dissection in N1 and N2a oral cancer patients. Head Neck 2002;
tients with pathological N+ disease undergoing 24:921924.
SND and radiotherapy. Ambrosch et al. [6] re- 9 Shah JP: Patterns of cervical lymph node metastasis from squa-
mous carcinomas of the upper aerodigestive tract. Am J Surg
ported a recurrence in the dissected neck in 6.6% 1990;160:405409.
of patients with pN+ necks. More recently, the 10 Medina JE, Byers RM: Supraomohyoid neck dissection: ratio-
nale, indications, and surgical technique. Head Neck 1989;11:111
same group reported their results with therapeu-
122.
tic SND. The 3-year regional recurrence rate was
4.9% among pN1 cases and 12.1% among pN2
cases [8].
43
Neck Metastases
2.6 How to Manage the XI Nerve in Neck

Dissections
Lance E. Oxford, John C. OBrien, Jr.
Sammons Cancer Center, Baylor University Medical Center, Dallas, Tex., USA

P E A R L S The SAN travels from the jugular foramen to
enter the upper one third of the sternocleidomas-
Where there are nodes in the posterior triangle, toid (SCM). The transverse process of the atlas
there you will find the spinal accessory nerve (SAN). (C1 vertebra) is a good landmark [1]. The internal
Raise the posterior triangle skin flap carefully. jugular vein passes anterior to this prominence;
Dissect over the veins and nerves. the SAN is lateral to the vein. The SAN passes
Preserve the innervation to the levator scapulae through the SCM giving off muscular branches.
and the cervical nerve root contributions to the It exits posteriorly, approximately 1 cm superior
SAN that may provide innervation to the trapezius. to Erbs point [2]. The SAN travels posteroinferi-
orly through the posterior triangle neck to enter

P I T F A L L S deep to the free edge of the trapezius approxi-
mately 25 cm superior to the clavicle. The supra-
The SAN is more superficial than you think.
clavicular nerves are superficial and the SAN
Avoid traction and the use of electrocautery around deep to the trapezius.
the SAN.
The SAN is identified as it enters the SCM by
The potential for postoperative irradiation does not dissecting the fascia off of the medial aspect of
justify inadequate surgery. the superior SCM. Vascular landmarks have been
reported to help localize the SAN [3, 4]. In the
lower neck, the SAN is identified by dissecting
Introduction the fascia along the anterior edge of the trapezius,
The head and neck surgeon should be able to approximately two finger breadths superior to
identify the SAN in multiple locations through- the clavicle. There are multiple terminal branches
out its course. Primary tumors, nodal metastases of the SAN that must be preserved. The SAN
and prior chemoradiotherapy may distort the can be traced proximally. With gentle traction on
neck anatomy, which can dictate the initial ap- the SAN with vessel loops, the contributions
proach to the identification of the SAN. of the cervical nerve roots to the nerve can be
Careful elevation of the posterior skin flaps identified by the fixation points where the fibers
is crucial to prevent injury. Dorsal to the free enter.
edge of the platysma, the SAN may be injured if A nerve stimulator can be utilized to confirm
thick skin flaps are elevated. Dissect over the the SAN. Some authors recommend SAN moni-
nerves and veins that are found during the dissec- toring similar to that which is done for the recur-
tion. rent laryngeal and facial nerves [5].

Practical Tips Conclusion
Identification of the SAN is a standard compo- Preservation of SAN can be done safely in prop-
nent in a neck dissection: erly selected patients. The ability to choose pa-
Surface landmarks such as the junction of the tients with the appropriate indications, knowl-
superior and middle thirds of the SCM estimate edge of anatomy, and careful dissection can result
the location of the SAN; however, surface land- in excellent results from an oncologic and func-
marks are not always reliable [5]. tional endpoint. There is no SAN worth the life of
If the SAN is sacrificed, the sural nerve may be a patient. 2
used to reconstruct it. A cervical sensory nerve
may also be used as a donor; however, the nerve
should be widely clear of nodal disease often References
making the great auricular nerve a poor candi- 1 Sheen TS, Chung TT, Snyderman CH: Transverse process of the
atlas (C1) an important surgical landmark of the upper neck.
date. Margins of the SAN should be evaluated
Head Neck 1997;19:3740.
with frozen section prior to grafting. 2 Eisele DW, Weymuller EA, Price JC: Spinal accessory nerve pres-
In postirradiation patients who are treated ervation during neck dissection. Laryngoscope 1991;101:433
435.
with surgery, the surgeon must be more aggres- 3 Rafferty MA, Goldstein DP, Brown DH, Irish JC: The sternomas-
sive in resection of recurrent nodal disease. This toid branch of the occipital artery: a surgical landmark for the
often results in sacrifice of the SAN. spinal accessory nerve in selective neck dissections. Otolaryngol
Head Neck Surg 2005;133:874876.
Avoid excessive traction and the use of the
4 Chaukar DA, Pai A, DCruz AK: A technique to identify and pre-
electrocautery near the SAN. serve the spinal accessory nerve during neck dissection. J Laryn-
Preserve the cervical nerve root contributions gol Otol 2006;120:494496.
5 Witt R, Gillis G, Pratt R Jr: Spinal accessory nerve monitoring
to the accessory nerve. The C3 nerve roots to the with clinical outcomes measures. Ear Nose Throat J 2006;85:540
levator scapulae help support the shoulder and 544.
6 Symes A, Ellis H: Variations in the surface anatomy of the spinal
preserve function. accessory nerve in the posterior triangle. Surg Radiol Anat 2005;
27:404408.
45
Neck Metastases
2.7 Preservation of the Marginal Mandibular

Nerve in Neck Surgery
K. Thomas Robbins
Otolaryngology Head and Neck Surgery, SimmonsCooper Cancer Institute, Southern Illinois University
School of Medicine, Springfield, Ill., USA

Surgery performed in the upper neck carries the
Proper draping of the patient with exposure of the risk of injury to the marginal mandibular nerve
surface anatomy of the neck and lower face helps to (MMN) resulting in a cosmetic deformity caused
maintain proper orientation.
by interruption of nerve fibers to the depressor
Carefully monitor the placement of retractors by anguli oris and the depressor labii inferioris.
your assistant in order to avoid direct compression
However, division of the platysma muscle and in
of the ramus.
some cases the cervical branch of the facial nerve
Preoperative counseling of patients is important to can result in pseudoparalysis of the MMN that
inform them of the slight risk of developing paresis
of the lower facial mimetic muscles.
usually recovers spontaneously [1]. The reported
rate of mandibular nerve injury varies from 0 to
20% following submandibular gland removal [2].

P I T F A L L S
Following neck dissection involving level I, tem-
Paralysis of the patient will preclude the effective porary apraxia was found in 29% of patients and
use of a nerve stimulator. persistent paralysis in 16% [3]. Temporary dys-
function usually resolves in 36 months.
Beware of patients with ptosis of the submandibu-
lar gland because the marginal branch of the facial
nerve may lie lower than usual. Practical Tips
Always locate the ramus mandibularis when dis- Two or more rami of the mandibular branch of
secting the perifacial and buccinator lymph nodes. the facial nerve can be found in the region of the
angle of the mandible always crossing the super-
ficial surface of the anterior facial vein [4]. In the
region immediately posterior to the junction of
the facial artery and the mandible, the nerve lies
above the inferior border of the mandible in 81%
of specimens, and 1 cm or less below the inferior
border of the mandible in 19% [4]. Anterior to the
facial artery and mandible junction, all branches
of the MMN lie above the inferior border of the
mandible. However, in elderly patients with ptosis
of the neck structures, the nerve could lie as low
as 34 cm below this point [5].

Incisions made in the upper neck must be References
made for optimal exposure of the surgical bed. 1 Tulley P, Webb A, Chana JS, Tan T, Hudson D, Grobbelaar AO,
Harrison DH: Paralysis of the marginal mandibular branch of
However, the planning of the incisions must take
the facial nerve: treatment options. Br J Plast Surg 2000;53:378
into account the location of the MMN. A safe rule 385.
is to make the incision parallel to the pathway of 2 Hald J, Andreassen UK: Submandibular gland excision: short-
and long-term complications. ORL J Otorhinolaryngol Relat
the nerve located 3 cm inferior to the lower bor- Spec 1994;56:8791.
der of the mandible. The neck flaps should be lift- 3 Nasan RW, Binahmed A, Torchia MG, Thliversis J: Clinical ob-
ed in the plane, immediately below the platysma servations of the anatomy and function of the marginal man-
dibular nerve. Int J Oral Maxillofac 2007;36:712715.
2
muscle. 4 Dingman RO, Grabb WC: Surgical anatomy of the mandibular
The traditional maneuver designed to protect ramus of the facial nerve based on the dissection of 100 facial
the MMN was to identify the anterior facial vein, halves. Plast Reconstr Surg 1962;29:266272.
5 Baker DC, Conley J: Avoiding facial nerve injuries in rhytidec-
ligate it and lift it superiorly. In recent years I have tomy. Plast Reconstr Surg 1979;64:781795.
abandoned this indirect technique for one that I 6 Sadoughi B, Hans S, de Mons E, Brasnu DF: Preservation of the
marginal mandibular branch of the facial nerve using a plexus
would term the direct approach. I prefer to iden- block nerve stimulator. Laryngoscope 2006;116:17131716.
tify the nerve by careful separation of the tissue 7 Mohd S, Zaidi S: A simple nerve dissecting technique for identi-
overlying the angle of the mandible until the fication of marginal mandibular nerve in radical neck dissec-
tion. J Surg Oncol 2007;96:7172.
small whitish nerve branch is visualized. This can
be facilitated with a nerve stimulator to help lo-
calize the exact pathway of the nerve [6]. Next, it
is important to skeletonize the nerve for a short
distance (23 cm) in order to determine its direc-
tion and to facilitate transposing it away from the
surgical bed if necessary. Alternatively, retro-
grade dissection of the cervical branch upwards
will usually help to identify the MMN since both
nerves arise from a common trunk [7].
47
Neck Metastases
2.8 Bilateral Neck Dissections:

Practical Tips
Jonas T. Johnson
Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pa., USA

Surgical care of cervical metastatic disease re-
The side with less disease should be dissected first mains a mainstay in the treatment of patients
to assure preservation of at least 1 internal jugular with cancer involving structures of the head and
vein (IJV).
neck. All primary tumors, irrespective of lateral-
The incision employed should reflect the need for ity, may on occasion be associated with contralat-
exposure and resection of the primary tumor as
eral metastases. Many head and neck sites includ-
applicable.
ing anterior floor of mouth, tongue base, supra-
Bilateral neck dissection (BND) can be accom- glottic larynx, and pharynx are commonly
plished simultaneously in the vast majority of
patients.
associated with a significant risk for bilateral cer-
vical metastases.
Reconstruction of one IJV should be considered if
These considerations mandate that head and
the tumor burden requires bilateral resection of
both IJVs. neck surgeons be prepared to offer patients simul-
taneous treatment to both sides of the neck under
circumstances which are commonly encoun-

P I T F A L L S
tered.
Bilateral occlusion of both IJVs will be associated
with extensive, prolonged edema of the face and Practical Tips
neck. Modified selective BND can be safely accom-
Bilateral simultaneous occlusion of both IJVs may plished in a single session for the majority of pa-
be associated with dangerous increase in intracra- tients. BND results in approximately 90 min of
nial pressure and even blindness and death. extra surgery and less than 1 unit of blood loss. It
should not be expected to extend the hospital stay
[1].
The particular incision employed to expose
the neck for BND should be chosen according to
the needs of the particular patient. There is no
universally accepted approach. I recommend that
an incision be chosen which allows adequate ex-
posure for both necks as well as resection of the
primary tumor. For patients with cancer involv-
ing the thyroid gland or larynx, a superiorly based

apron flap seems most convenient. When work- This is characterized by pale edematous optic
ing on a primary in the oral cavity (OC), it may nerves with increased intraocular pressure. Un-
be appropriate to use a shorter apron, allowing a fortunately, staging radical BND may not com-
tracheotomy to be placed through a separate inci- pletely obviate the risk [2].
sion if needed. A short apron flap may be used to Radical BND can be safety accomplished in
deglove the mandible if the surgeon prefers this most circumstances when staged 6 weeks apart.
exposure for OC resection. In some cases, two Alternatively, a number of reconstructive meth-
separate utility incisions may be used. ods are available which would allow repair of a 2
I prefer to operate upon the side with the least single IJV electively. This would allow BND to
tumor burden first. This is especially important proceed simultaneously.
if the surgeon plans to resect the IJV on the con- Patients undergoing BND may benefit from
tralateral side. In so doing, it is possible for the perioperative prophylactic antibiotic administra-
surgical team to reassure themselves that one IJV tion even when the wound is not contaminated by
has been preserved before the contralateral vein exposure to the OC or pharynx [3].
is sacrificed intentionally. If the IJV is inadver-
tently injured or sacrificed, the surgical team can Conclusion
then decide to either resect and reconstruct the BND is frequently indicated in patients treated
contralateral side or stage the second ND. for cancer of the structures of the head and neck.
Bilateral simultaneous resection of both IJVs This can be safely accomplished in most patients
results in almost certain severe facial edema with who require modified or selective ND. When ex-
potential for obstruction of the airway, swallow- cessive tumor burden is present bilaterally, con-
ing, and the Eustachian tubes. Tracheotomy is al- sideration should be given to reconstruction of a
ways required. Increased intracranial pressure, single JV or staging the procedure 6 weeks
blindness, and even death may be encountered in apart.
some patients under these circumstances [2]. Ac-
cordingly, radical BND with occlusion of both IJVs
should not be accomplished in a single session. References
Blindness is, fortunately, very rarely encountered 1 Weber PC, Johnson JT, Myers EN: Impact of bilateral neck dis-
section on recovery following supraglottic laryngectomy. Arch
following BND. The pathophysiologic cause is
Otolaryngol Head Neck Surg 1993;119:6164.
controversial and is perhaps variable according to 2 Worrell L, Rowe M, Petti G: Amaurosis: a complication of bilat-
the patients particular situation. Blindness may eral radical neck dissection. Am J Otolaryngol 2002;23:5659.
3 Seven H, Sayin I, Turgut S: Antibiotic prophylaxis in clean neck
be due to hypotension secondary to excessive dissections. J Laryngol Otol 2004;118:213216.
blood loss. Another potential mechanism for
blindness is anterior ischemic optic neuropathy.
49
Neck Metastases
2.9a How to Manage Retropharyngeal

Lymph Nodes 1. Transoral Approach
James Cohena, Randal S. Weberb
a Department of Otolaryngology/Head and Neck Surgery, Oregon Health Sciences University, PV-01,
Portland, Oreg., and
b Department of Head and Neck Surgery, Unit 441, University of Texas M.D. Anderson Cancer Center,
Houston, Tex., USA

P E A R L S cer metastases, which usually lack macroscopic
extracapsular spread (as compared to the extra-
Tumor histology (thyroid vs. squamous cell carcino- capsular spread usually seen with squamous cell
ma) and nodal configuration by imaging (CT, MRI) metastasis to this location), make a direct trans-
determine the likelihood of extracapsular exten-
sion, which in turn determines whether the
oral approach to their removal technically fea-
transoral or transcervical approach to excision sible and oncologically sound.
should be used.
Practical Tips
Identification of the internal carotid artery (ICA)
CT and MRI are the principle means of detect-
and superior sympathetic trunk is essential to safe
removal of this nodal group. ing disease within the RPLN as they are usual-
ly asymptomatic. Nodes being considered for

P I T F A L L S transoral removal should be well circumscribed
without radiographic evidence of extracapsular
Nodes that are not palpable transorally are very spread. Nodes that are greater than 1 cm in
difficult to excise with the transoral approach. size, particularly if asymmetrically enlarged, or
Adequate illumination, loupe magnification and those with central lucency should be considered
meticulous hemostasis are essential for safe suspicious for disease [3, 4]. Where doubt exists
transoral removal.
transoral FNA is possible, in the clinic for larger
nodes that are palpable, or in the operating room
with ultrasound guidance if needed.
Surgical excision should only be considered for
Introduction those nodes that are clinically palpable transoral-
Retropharyngeal lymph node (RPLN) metastasis ly after the patient is appropriately positioned in
by thyroid cancer has been suggested to occur ei- the operating room with the head slightly extend-
ther by retrograde spread from the lymphatic ed on the neck and a Crowe-Davis or similar
pathways of the jugular chain and paratracheal tongue-retracting mouth gag inserted. Otherwise
nodes or through the superior thyroid pole [1, 2]. they can be extremely difficult to locate surgi-
The proximity of the RPLN to the posterior oro- cally since the lateral RPLN sit in the groove lat-
pharyngeal mucosa and the generally well-cir- eral to the prominence of the central portion of
cumscribed, noninvasive nature of thyroid can- the vertebral body and tend to be pushed later-

ally into this groove by palpation or retracted lat- Antibiotics are administered preoperatively.
erally with the carotid artery at the time of surgi- The patient is allowed to eat a regular diet in the
cal exposure. immediate postoperative period and is discharged
Exposure of the nodes is best achieved by ver- on the same day or the next morning.
tically incising the mucosa of the posterior pha-
ryngeal wall and the constrictor muscles just pos- Conclusions
terior to the posterior tonsillar from the level of The RPLN represent a nodal group at risk for
the inferior tonsillar pole to just above the level of metastatic spread from cancers of the head and 2
the soft palate [5]. The ICA is then located by pal- neck region. Detection of metastasis occurs al-
pating its pulse lateral to the nodes and the buc- most entirely by imaging (CT or MRI). With ap-
copharyngeal fascia overlying the nodes is incised propriate patient selection based on histology,
just medial to the artery. The nodes are separated nodal size and configuration, metastatic disease
from the undersurface of the fascia by sharp and can be safely excised from this location with a
blunt dissection and excised. The superior sym- minimum of patient morbidity.
pathetic ganglion can be mistaken for an RPLN
if care is not taken to ensure that the mass is not
continuous with a nerve inferiorly. Beginning the References
nodal dissection inferiorly ensures that the node 1 Robbins KT, Woodson GE: Thyroid carcinoma presenting as a
parapharyngeal mass. Head Neck Surg 1985;7:434436.
will not be mistaken for the superior sympathetic
2 Dileo MD, Baker KB, Deschler DG, Hayden RE: Metastatic pap-
ganglion. illary thyroid carcinoma presenting as a retropharyngeal mass.
Meticulously hemostasis is critical to prevent a Am J Otol 1998;19:404406.
3 Morrissey DD, Talbot JM, Cohen JI, Wax MK, Anderson PE: Ac-
retropharyngeal hematoma and is facilitated curacy of computed tomography in determining the presence or
throughout the dissection by the use of monopo- absence of metastatic retropharyngeal adenopathy. Arch Otolar-
lar and bipolar cautery combined with loupe yngol Head Neck Surg 2000;126:14781481.
4 Davis WL, Harnsberger HR, Smoker WRK, Watanabe AS: Retro-
magnification and a headlight for best visualiza- pharyngeal space: evaluation of normal anatomy and diseases
tion. The incision is closed with interrupted chro- with CT and MR imaging. Radiology 1990;174:5064.
mic sutures as a single layer incorporating fascia, 5 Le TD, Cohen JI: Transoral approach to removal of the retropha-
ryngeal lymph nodes in well differentiated thyroid cancer. La-
muscle, and mucosa in each bite. No more than ryngoscope 2007;117:11551158.
34 sutures are required. If hemostasis is ques-
tionable, the superior aspect of the incision that
lies in the nasopharynx behind the soft palate is
left open to prevent formation of a hematoma.
51
Neck Metastases
2.9b How to Manage Retropharyngeal

Lymph Nodes 2. Transcervical Approach
Randal S. Weber
Department of Head and Neck Surgery, Unit 441, University of Texas M.D. Anderson Cancer Center,
Houston, Tex., USA

P E A R L S sympathetic chain. For squamous cell carcinoma
arising from the pharyngeal walls the incidence
The transcervical approach is used for metastasis to of RPLN metastasis is 44% [1, 2]. In the absence
the retropharyngeal lymph nodes (RPLN) from of pathologic involvement the RPLN are not usu-
primary tumors of the pharynx and thyroid or
lymph nodes that display extracapsular spread
ally visible on CT or MRI. In the setting of malig-
where a transoral approach would be hazardous. nant disease of the upper aerodigestive tract or
thyroid, RPLN that are visible should be consid-
Identification of the internal carotid artery (ICA) and
ered to harbor metastatic disease.
superior sympathetic trunk is essential for safe
removal of this nodal group. TRPLND is not frequently performed today
because many cancers of the pharynx are treated
Take down the digastric and styloid muscles, follow
with primary radiotherapy with or without che-
the ICA to the skull base and resect the areolar
tissue and lymph nodes medially to the ICA. motherapy and the RPLN lie within the radiation
field. This procedure is reserved for patients with

P I T F A L L S RPLN metastasis from tumors of the upper
aerodigestive tract or thyroid who will undergo
Adequate illumination, loupe magnification and primary surgical resection and have radiograph-
meticulous hemostasis are essential for the trans- ically positive lymph nodes in the retropharynx.
cervical retropharyngeal lymph node dissection
At times patients with metastatic thyroid cancer
(TRPLND).
who have RPLN metastasis display bulky nodal
Inform the patient about first bite syndrome, disease or evidence of extracapsular spread that
Horners syndrome and the possibility of
would make a transoral resection hazardous. The
dysphagia.
latter group should undergo TRPLND.
Practical Tips
CT and MRI are the imaging modalities for
detecting RPLN.
Introduction Most often TRPLND is performed through an
RPLN lie within the retropharynx and have a me- external approach for squamous cell carcinoma
dial and lateral group. The lateral RPLN that oc- of the pharyngeal walls [3]. The external approach
cur near the base of skull are of greatest clinical is facilitated in patients undergoing laryngophar-
significance. They lie adjacent to the ICA and the yngectomy or composite resection. The need for

an isolated RPLND without resection of the pri- Conclusions
mary tumor for squamous cell carcinoma is in- The RPLN represent a nodal group at risk for
frequent. metastatic spread from cancers of the head and
Key to TRPLND is to first perform a lateral neck region. Detection of metastasis occurs al-
neck dissection including all levels of the neck at most entirely by imaging (CT or MRI). Selection
risk for occult or apparent metastasis. The pri- of the TRPLND depends upon the primary tu-
mary tumor should be resected as indicated prior mor site and the presence or absence of extracap-
to the TRPLND. The lateral neck and the TRPLND sular spread. With appropriate patient selection 2
do not need to be done in continuity. based on histology, nodal size and configuration,
First complete the lateral neck dissection. Iden- metastatic disease can be safely excised from this
tify the ICA and place a vascular loop around the location with a minimum of patient morbidity.
vessel for control. Skeletonize the internal jugular
vein, ligate the common facial vein and the inter-
nal jugular vein branches in the upper neck. References
Completely dissect the XIIth nerve and ligate any 1 Ballantyne AJ: Principles of surgical management of cancer of
the pharyngeal walls. Cancer 1967;20:663667.
of the external carotid artery branches that pre-
2 Saito H, Sato T, Yamashita Y, Amagasa T: Topographical analysis
vent superior dissection of the ICA. of lymphatic pathways from the meso- and hypopharynx based
Divide the posterior belly of the digastric mus- on minute cadaveric dissections: possible application to neck
dissection in pharyngeal cancer surgery. Surg Radiol Anat 2002;
cle and the styloid musculature. Follow the inter- 24:3849.
nal carotid to the skull base and reflect the fibro- 3 Hasegawa Y, Matsuura H: Retropharyngeal node dissection in
fatty tissue medially. Search for the IXth nerve at cancer of the oropharynx and hypopharynx. Head Neck 1994;16:
173180.
or near the tip of the styloid process and preserve
it if at all possible.
To facilitate superior dissection medial to the
mandible, divide the stylomandibular ligament.
This will allow distraction of the mandible ante-
riorly by placing a bone hook or retractor on the
angle.
Dissect the fibroareolar tissue from the supe-
rior constrictor and the prevertebral fascia to the
midline. This will include the RPLN within this
tissue compartment.
53
Neck Metastases
2.10 Management of the Node-Positive Neck in

Patients Undergoing Chemoradiotherapy
Rod P. Rezaee, Pierre Lavertu
Department of Otolaryngology Head and Neck Surgery, University Hospitals Case Medical Center,
Ireland Cancer Center, Cleveland, Ohio, USA

P E A R L S liver curative doses to the disease fields while re-
ducing patient morbidity. Organ preservation
Obtain appropriate posttreatment imaging to aug- protocols using chemotherapy with modern ra-
ment the physical exam for accurate assessment. diation have raised a discussion of the evolving
The role of neck dissection (ND) continues to evolve need, role and timing of ND in the patient un-
and must be individualized based on the patient, dergoing chemoradiotherapy [3]. Management
institutional resources available, and physician
schemes for these patients include planned ND
factors.
based on initial patient staging or ND based on
Selective ND may be utilized in the posttreatment response to treatment.
setting [1].
Little controversy exists when considering ND
in the N1 patient. The role of ND should be re-

P I T F A L L S
served for those with less than complete clinical
response (CR) or those requiring surgical salvage
Suboptimal timing of posttreatment imaging
for persistence or recurrence at the primary site.
(CT/PET) leads to treatment dilemmas.
Controversy surrounds the management
Neck management schemes remain controversial in
scheme for the patient initially staged with N2
the patient undergoing chemoradiotherapy.
N3 disease. Planned ND continues to be advo-
Viability of positive posttreatment neck specimen
cated by some, regardless of response to treat-
has been questioned [2].
ment [4]. Rationale is based on the concept that it
can be difficult to diagnose neck recurrence and
that when found, the disease is often unresect-
It is of paramount importance to have an appre- able, precluding successful salvage neck surgery
ciation for the prognostic significance of the pres- (SNS) [5]. Furthermore, when subsequently look-
ence, persistence or recurrence of nodal disease ing at potential factors to determine pathologic
in the head and neck cancer patient (HNCP). As complete response (pCR), the same authors failed
such, a sound management scheme for addressing to identify reliable clinical predictors. Thus, rec-
and treating the nodal basins at risk is critical to ommendation for ND for all N2N3 necks re-
maximizing the potential for successful patient gardless of response to treatment was made [6]. In
outcomes. patients with N2N3 disease treated with chemo-
The introduction of intensity-modulated ra- radiotherapy, regional control was significantly
diation therapy has enhanced the ability to de- inferior at 5 years in 49 patients not treated with

ND compared to the 100 that did undergo dissec- Control of nodal disease is a critically impor-
tion (82.0 vs. 93.9%, respectively, p = 0.028). This, tant aspect of treatment of the HNCP. It is essen-
however, was based on positive pathologic find- tial to consider key concepts when making treat-
ings. The viability of these cells has been ques- ment decisions. Planned ND for N2N3 disease
tioned, thus clouding their significance. Addi- remains a viable option for these patients. Ad-
tionally, SNS was rarely successful, thus support- vances in treatment and imaging have created a
ing planned ND in the N2N3 neck [7]. subset of patients that now may be just ob-
Observation exists as an alternative to planned served. 2
ND and is based on patient response to treatment.
Clinical exam alone is not a reliable indicator of
pCR and should be combined with imaging stud- References
ies when making a decision for neck surgery. 1 Robbins KT, Shannon K, Viera F: Is there a role for selective neck
dissection after chemoradiotherapy for head and neck cancer? J
While combined PET/CT is emerging as the im-
Am Coll Surg 2004;199:913916.
aging modality of choice, a variety of acceptable 2 Strasser MD, Gleich LL, Miller MA, et al: Management implica-
imaging techniques exists. tions of evaluating the N2 and N3 neck after organ preservation
therapy. Laryngoscope 1999;109:17761780.
Liauw et al. [8] used CT scan 4 weeks post- 3 Pellitteri PK, Ferlito A, Rinaldo A, et al: Planned neck dissection
treatment to indicate ND. They defined radio- following chemoradiotherapy for advanced head and neck can-
graphic complete response (rCR) using strict cri- cer: is it necessary for all? Head Neck 2006;28:166175.
4 Sewall GK, Palazzi-Churas KL, Richards GM, et al: Planned post-
teria of nodal size <1.5 cm with no focal abnor- radiotherapy neck dissection: rationale and clinical outcomes.
mality and with negative predictive value (NPV) Laryngoscope 2007;117:121128.
of 94%. They recommended observation of all pa- 5 Lavertu P, Adelstein DJ, Saxton JP, et al: Management of the neck
in a randomized trial comparing concurrent chemotherapy and
tients with rCR, regardless of initial N stage. radiotherapy alone in respectable stage III and IV squamous cell
These patients showed no significant decrease in head and neck cancer. Head Neck 1997;19:559566.
6 McHam SA, Adelstein DJ, Rybicki LA, et al: Who merits a neck
5-year survival rate compared with those with dissection after definitive chemoradiotherapy for N2N3 squa-
negative posttreatment ND (97 vs. 98%, respec- mous cell head and neck cancer? Head Neck 2003;10:791798.
tively). 7 Adelstein DJ, Saxton JP, Rybicki LA, et al: Multiagent concurrent
chemoradiotherapy for locoregionally advanced squamous cell
The use of PET or PET/CT has been shown to head and neck cancer: mature results from a single institution. J
be an effective method. Studies have concluded Clin Oncol 2006;24:10641071.
that PET imaging has a low false-negative rate 8 Liauw SL, Mancuso AA, Amdur RJ, et al: Postradiotherapy neck
dissection for lymph node-positive head and neck cancer: the use
and thus a high NPV of 97% and positive predic- of computed tomography to manage the neck. J Clin Oncol
tive value (PPV) approaching 70%. Problems with 2006;24:14211427.
9 Nayak VN, Walvekar RR, Andrade RS, et al: Deferring planned
high false-positive rates generally are due to the
neck dissection following chemoradiotherapy for stage IV head
timing of the scan and the continued inflamma- and neck cancer: the utility of PET-CT. Laryngoscope 2007;117:
tory effects of treatment. To allow these effects to 16.
10 Porceddu SV, Jarmolowski E, Hicks RJ, et al: Utility of positron
dissipate, it is recommended that PET or PET-CT emission tomography for the detection of disease in residual
be obtained at least 812 weeks posttreatment [9]. neck nodes after chemoradiotherapy in head and neck cancer.
If the PET scan is positive at 812 weeks, then ND Head Neck 2005;27:175181.
is indicated. If negative, then the patient may
safely be observed [10].
55
Neck Metastases
2.11 How to Avoid Injury to Thoracic Duct

during Surgical Resection of Left Level IV
Lymph Nodes
Gary L. Clayman
Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center,
Houston, Tex., USA

The TD is an endothelial lined vascular structure
The thoracic duct (TD) is usually not a single ductal transporting chylous material from the left TD
structure. It is usually a series of arborized vessels
into the inferior portion of the internal jugular
containing chylous and lymphatic drainage.
Meticulous surgery in the inferior level III through vein (IJV). Although generally named a single
inferior-most level IV lymphatics is required with vascular structure, the TD is frequently an arbo-
vascular ligatures on all retained deep structures. rized series of chylous vessels intermingled with
Although the TD is located within the left neck, lymphatic drainage structures. The immediate
similar chylous and lymphatic structures are located proximity of this deeply penetrating structure to
within the right level IV lymphatics.
the phrentic nerve (PN) must be appreciated to
Loupe magnification improves visualization and adequately control this vessel as well as maintain
control of these lymph and chylous-containing
PN function.
vessels.
The complex and beautiful anatomy of level
IV within the left neck must be appreciated. The

P I T F A L L S
anatomic variations of location of the subclavian
vein (SV), PN, IJV, branches of the TD, common
TD injury is most common in metastatic thyroid
carotid artery, and vertebral system must be ap-
cancer cases with metastases located in the poste-
rior carotid/vertebral junction areas. Blunt dissec- preciated. Generally speaking, the identification
tion of metastatic disease within inferior level IV of the transverse cervical artery (TCA) and vein
lymphatics may cause injury to the TD and difficulty is usually the superior-most recognition of the
in obtaining proximal control of this structure.
potential distal entry of the TD into the IJV. Nev-
Drain placement overlying the TD may increase the ertheless, this is only an approximation.
risk for delayed chylous drainage. Probably most important, although the TD
does not in fact exist within the right neck, simi-
lar chylous structures can be present and lead to
chylous leakage. Meticulous attention in the left
as well as right level IV and deep lymphatic struc-
tures must be strongly advised.

Practical Tips included. This is where the TD vessels are placed
Meticulous surgical technique is the best meth- at greatest risk. To avoid damage or leakage from
od of which I am aware in preventing chylous these vessels, a lateral to medial approach with
leakage. In general, I utilize 3.5 loupe magnifica- ligation of all fibrous and fatty/lymphatic struc-
tion for modified neck dissections (MND). tures in the infraclavicular area is undertaken.
As the left MND is performed, which is dis- The SV is dissected to be the inferior aspect of the
secting the level IV lymphatics (and similarly ex- dissection. From lateral to medial, the clamping
ecuted on the right side as well), the sternocleido- and cutting is completed inferiorly along the dis- 2
mastoic muscle is skeletonized along its entire section which has already been accomplished by
length to the sternal notch. As the ventral surface identifying the lateral border of the IJV. Once the
of the muscle is also skeletonized, the transition inferior aspect is completed, the posterior medial
to the dissection of the anterior component of the dissection of the carotid/vertebral area needs to
inferior level V lymphatics is also included in be performed. Again, meticulous clamping and
most comprehensive dissections of this area. tying is undertaken to at least the level of the TCA
The transverse cervical vessels are usually en- takeoff. This clamping and tying is performed
countered in level IV and visible through the fas- even if the surgeon does not visualize ductal
cia overlying the deep scalene musculature (ex- structures in the vicinity. The PN, vagus nerve,
cept in obese individuals). The anterior surface of and carotid and vertebral arteries must be care-
the IJV is dissected with careful attention to its fully dissected and preserved.
lateral border. It is critically important that the Following completion of dissection the area
dissection be performed on the vein adventitia. must be dry during Valsalva. No suction drains
For thyroid malignancies, the lymphatics of should directly contact the area of the chylous
the medial aspect of level IV, overlying the PN vessels. To prevent suction drain trauma, a small
and extending even more medially to the poste- piece of gelfoam or similar barrier can be utilized
rior carotid sheath and vertebral vessel, must be in the posterior carotid sheath area.
57
Neck Metastases
2.12 What Are the New Concepts in Functional

Modified Neck Dissection?
Bhuvanesh Singh
Laboratory of Epithelial Cancer Biology, Head and Neck Service, Memorial Sloan-Kettering Cancer Center,
New York, N.Y., USA

As our understanding of the patterns of nodal
Neck nodal metastasis from nonnasopharyngeal metastasis has emerged, we have progressively
head and neck squamous cell carcinomas (HNSCC) modified neck dissections to address the nodal
involves level V of the neck in fewer than 5% of
cases. The vast majority (>90%) of incidences of
basins at risk for metastasis from HNSCC [1]. As
level V metastasis involves the infra-accessory a consequence, radical neck dissections (RND)
nerve lymphatics (primarily level Vb). are rarely performed, physicians opting instead
Adjuvant therapy (either radiation or chemoradia- for selective or modified dissections based on the
tion) is required in most cases with metastasis to location of the primary tumor and the extent of
the regional lymphatics. nodal metastasis [26]. While modifications to
All nodal basins at risk can be adequately addressed the classical RND have not improved overall sur-
with removal of levels IIV and Vb lymphatics. vival, they have reduced sequelae resulting from
classical RND including winging of the scapula

P I T F A L L S and resultant chronic pain. Although less morbid
than RND, modified neck dissections are not
Even with anatomic preservation of the accessory without significant sequelae, uniformly resulting
nerve, functional deficit can still occur conse- in sensory losses due to sacrifice of cutaneous
quently to devascularization and stretch injury
nerves, as well as functional loss due to devascu-
during modified neck dissections.
larization and/or stretch injury consequent to
All nodal levels must be examined intraoperatively dissection of the accessory nerve.
prior to proceeding with a functional modified neck
dissection (fMND).
Understanding the patterns of level V neck
metastasis allows us to consider further modifi-
cations of neck dissection that do not compro-
mise tumor control while allowing enhanced sen-
sory and motor preservation. Overall, level V me-
tastasis is very rare, occurring in fewer than 5%
of all cases of HNSCC. Published data and our
own experience suggest that the vast majority of
level V metastasis occurs in level Vb, or more pre-
cisely, in the infra-accessory lymphatic chain
[1, 2]. Accordingly, we now routinely perform a

fMND on patients with HNSCC, removing lym- Conclusions
phatic-bearing tissue in levels IIV and Vb, while Modifications in neck dissection have allowed
preserving the accessory nerve without devascu- improvements in functional outcome without
larization injury, sternocleidomastoid muscle compromising tumor outcomes. Given the pat-
(SCM), internal jugular vein, as well as the sen- terns of metastasis to level V from HNSCC,
sory spinal rootlets and the ansa cervicalis. The fMND can be performed to include nodal basins
fMND tumor outcomes are not compromised, at highest risk for metastasis (levels IIV and Vb)
while functional outcomes are optimized. resulting in improved functional outcomes with- 2
out compromising tumor control. The fMND is
Practical Tips also applicable to papillary thyroid carcinomas.
Surgical access is achieved through a single
horizontal incision that approximates a skin
crease. If level I lymphatics are to be removed, the References
incision is extended beyond the midline to allow 1 Shah JP: Patterns of cervical lymph node metastasis from squa-
mous carcinomas of the upper aerodigestive tract. Am J Surg
easier access to this region. Flaps are elevated in
1990;160:405409.
a routine manner. 2 Davidson BJ, Kulkarny V, Delacure MD, Shah JP: Posterior tri-
The fascia investing the SCM is elevated off in angle metastases of squamous cell carcinoma of the upper
aerodigestive tract. Am J Surg 1993;166:395398.
a circumferential manner, thereby allowing ac- 3 Byers RM: Neck dissection: concepts, controversies, and tech-
cess to the level V lymphatics in a plane deep to nique. Semin Surg Oncol 1991;7:913.
the muscle. The accessory nerve is elevated in the 4 End results of a prospective trial on elective lateral neck dissec-
tion vs type III modified radical neck dissection in the manage-
flap. Care must be taken not to injure the acces- ment of supraglottic and transglottic carcinomas. Brazilian
sory nerve as it exits the SCM in level V. Head and Neck Cancer Study Group. Head Neck 1999;21:694
All nodal basins are carefully examined to as- 702.
5 Ferlito A, Rinaldo A, Silver CE, et al: Elective and therapeutic
sure the absence of detectable metastasis to level selective neck dissection. Oral Oncol 2006;42:1425.
Va. 6 Martins EP, Filho JG, Agra IM, et al: Preservation of the internal
The lymph node-bearing tissue can be dissect- jugular vein in the radical treatment of node-positive neck is it
safe? Ann Surg Oncol 2007;15:364370.
ed in level V starting from the trapezius muscle.
As the dissection proceeds anteriorly, the spi-
nal sensory rootlets are identified and preserved,
while meticulously removing all node-bearing
tissue.
The spinal contribution to the ansa is identi-
fied and preserved, as is the descending hypo-
glossi.
Node-bearing tissue is removed in levels IIV
as performed in the supraomohyoid neck dissec-
tion.
59
3.1 How to Reconstruct Small Tongue and

Floor of Mouth Defects
Remco de Bree, C. Ren Leemans
Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center (VUmc),
Amsterdam, The Netherlands

P E A R L S [1]. Postoperative radiotherapy may result in un-
predictable fibrosis, hampering tongue move-
In the planning of surgical treatment of tumors in ments.
the oral cavity, reconstructive options also have to Several techniques have been developed for re-
be considered.
construction of the oral cavity: secondary inten-
Reconstructive objectives include adequate wound tion, primary closure, skin grafts, local transposi-
healing, optimal residual function, and restoration
tions of skin, mucosa or muscle, regional flaps
of sensation.
and free vascularized flaps. Primary closure and
To restore function, even small defects may need secondary intention cannot strictly be catego-
flap reconstruction.
rized as reconstructive techniques, but they play
a prominent role. Skin grafts are a good alterna-

P I T F A L L S
tive for primary closure or granulation when
there is a well-vascularized wound bed [2]. In se-
Primary closure or secondary healing harbors the
lected cases, uni- or bilateral nasolabial flaps or
risk of tethering the tongue.
infrahyoid myocutaneous flap can be used for
Inadequate reconstruction may have a severe
floor of mouth defects [3, 4].
impact on swallowing and speech and thus on
quality of life. Regional flaps, e.g., the pectoralis major flap
and temporalis muscle flap, still play a role in the
reconstruction of medium-sized and larger
defects in many institutions. The bulk of the pec-
Introduction toralis major flap frequently leads to modest
Resection of early tongue and floor of mouth can- functional results [5]. Free vascularized fasciocu-
cers results in defects of soft tissues, sometimes taneous flaps (e.g., radial forearm flap and the
in combination with jaw bone. Reconstructive anterolateral thigh flap) may be especially useful
objectives include adequate wound healing, opti- in reconstruction of medium-sized and larger
mal residual function, and restoration of sensa- oral defects [6].
tion. Because it is not feasible to replace excised
tissues with tissue that mimics its complex move- Practical Tips
ments and changes in shape, the aim of these re- The main challenge in reconstruction is to avoid
constructions is to attempt to maximize the pa- tethering, which may hamper normal speech and
tients possibility for compensatory mechanisms swallowing.

Small defects of the lateral mobile tongue are Conclusion
often closed primarily with good functional re- In this chapter, an overview of the reconstruc-
sults. Healing by secondary intention is a good tions of small tongue and floor of mouth defects
alternative. is presented and general rules and tips are given.
A defect of the tip of the tongue is one of the Any given defect, however, has its own options for
most difficult defects to reconstruct, because of- reconstruction, which warrants individualized
ten adequate contralateral functioning muscle treatment planning. Reconstruction with preser-
tissue is lacking. Only if the defect is very small is vation of the tongue mobility is the ultimate goal,
primary closure or healing by secondary inten- although challenging. Postoperative radiothera-
tion possible. In larger defects reconstruction py may result in unpredictable fibrosis hamper-
using a fasciocutaneous free flap is often indicating tongue movements.
ed to ensure optimal mobility of the remnant
tongue.
If the floor of mouth is involved the main chal- References
3
lenge is avoidance of tethering of the tongue to the 1 de Bree R, Rinaldo A, Genden EM, Surez C, Pablo Rodrigo J,
Fagan JJ, Kowalski LP, Ferlito A, Leemans CR: Modern recon-
floor of mouth. Primary closure should therefore
struction techniques for oral and pharyngeal defects after tumor
be avoided. Secondary healing harbors the risk of resection. Eur Arch Otorhinolaryngol 2008;265:19.
adhesion to wound surfaces. If the neck is entered 2 McGregor IA, McGrouther DA: Skin-graft reconstruction in car-
cinoma of the tongue. Head Neck Surg 1978;1:4751.
reconstruction using a flap is mandatory. 3 Cohen IK, Edgerton MT: Transbuccal flap for reconstruction of
Split-thickness skin grafts are useful in super- the floor of mouth. Plast Reconstr Surg 1971;48:810.
ficial defects of the floor of mouth. These skin 4 Deganello A, Manciocco V, Dolivet G, Leemans CR, Spriano G:
Infrahyoid fascio-myocutaneous flap as an alternative to free ra-
grafts are sutured to the mucosal margins of the dial forearm flap in head and neck reconstruction. Head Neck
defects, leaving the sutures long enough to tie a 2007;29:285291.
sponge on the graft for fixation to the underlying 5 Ariyan S: The pectoralis major myocutaneous flap. A versatile
flap for reconstruction in the head and neck. Plast Reconstr Surg
wound. This graft may prevent adhesion of the 1979;63:7381.
tongue to the floor of mouth. The take of the graft 6 Soutar DS, Scheker LR, Tanner NS, McGregor IA: The radial
forearm flap. A versatile method for intra-oral reconstruction.
may be improved by using fibrin glue and quilt- Br J Plast Surg 1983;36:18.
ing sutures. 7 Urken ML, Biller HF: A new bilobed design for the sensate radial
Generally, the fasciocutaneous skin is qua- forearm flap to preserve tongue mobility following significant
glossectomy. Arch Otolaryngol Head Neck Surg 1994;120:26
drangular shaped, but in anterior defects involv- 31.
ing floor of mouth and tongue, a bilobed design 8 Urken ML: Composite free flaps in oromandibular reconstruc-
can preserve tongue mobility more efficiently tion. Arch Otolaryngol Head Neck Surg 1991;117:724732.
[7].
Free vascularized osteocutaneous flaps, e.g.,
fibula flap, make it possible to use an adaptable
approach for each type of bony defect, allowing
dental rehabilitation [8]. An alternative method
in lateral mandibular defects involves the use of
mandibular reconstruction plates to bridge the
defect between two segments with or without
soft-tissue free flaps.
A feeding tube is often advised to facilitate
wound healing.
61
3.2 Reconstruction of Large Tongue and Floor

of Mouth Defects
Neal D. Futran
Department of Otolaryngology/Head and Neck Surgery, University of Washington School of Medicine,
Seattle, Wash., USA

P E A R L S protection from aspiration [1]. Specific to the
floor of mouth, goals include (1) minimizing al-
Maintaining mobility of the reconstructed tongue veolar and floor of mouth soft tissue thickness
and floor of mouth optimizes speech and and mobility, and (2) recreation of gingivolingual
swallowing.
and gingivolabial sulci depth [2].
Proper tissue bulk is critical in the choice of the The normally mobile tongue may compensate
reconstructive flap.
for loss of some volume. As the loss increases,
Free tissue transfer provides appropriate choices for food bolus manipulation and articulation prob-
each particular defect. lems result. While the residual tongue may have
unimpaired mobility, the deficient size prevents

P I T F A L L S palatal and dental contact, efficient pharyngeal
pressure pump activity, and effective bolus ma-
Nonvascularized tissue reconstruction in defects
nipulation within the oral cavity. When signifi-
greater than 1/3 of the tongue and floor of mouth
yields poor functional results. cant portions of the mobile tongue and floor of
mouth have been resected, some residual motion
Improper design of the reconstructive flap can
in the tongue base is critical to achieve an optimal
result in impaired tongue mobility and misplaced
tissue bulk. functional result. Reconstructive choices should
address these issues.
Practical Tips
When 1/3 of the tongue is resected, the recon-
Introduction structive focus is on mobility and sensory restora-
The soft tissues of the oral cavity are integral to tion. Vascularized and pliable tissue is ideal. Tis-
speech and swallowing. Major goals to recon- sue that tends to contract, such as a skin graft,
struct these tissues include (1) retention of mobil- limits tongue mobility.
ity in the native and reconstructed tongue, (2) With defects from 1/3 to 1/2 of the mobile
restoration of lost volume, (3) maintenance of tongue, restoration of tongue volume is para-
neo-tongue height, (4) separation of the tongue mount. Enough bulk must be restored to allow
and floor of mouth components, (5) restoration the patient to contact the palate with the neo-
of sensation, and (6) maximization of laryngeal tongue.

Although a variety of tissues are available, the The greatest hindrance to resumption of an
radial forearm flap has emerged as the workhorse oral diet is protection of the larynx from aspira-
flap [3, 4]. It has a thin, supple skin paddle, avail- tion during the pharyngeal phase of swallowing.
able subcutaneous tissue for added volume if Adjunctive measures including laryngeal suspen-
needed, long pedicle, large vessels, innervation sion, epiglottoplasty, cricopharyngeal myotomy,
potential, and easy, two-team harvest. or laryngoplasty may be helpful in providing a
The design of the flap should include a consid- safe resumption of an oral diet.
eration of the geography of the defect. A bilobed
design which separates the tongue and floor of Conclusions
mouth components is particularly useful for glos- Optimal reconstruction with vascularized tissue
sectomy defects which extend onto the floor of creates the best opportunity for functional resto-
mouth [5]. A predictable level of sensory recovery ration. The unique attributes of the radial fore-
occurs when the antebrachial cutaneous nerve is
sutured to the proximal lingual nerve stump [6].
arm flap make it a primary choice for smaller oral
cavity defects with bulkier tissue needed as defect
3
The thickness of this flap also varies among size increases. Flap choice should be dictated by
different individuals and across different areas of the needs of the patient and those of the site to be
the forearm. It tends to be thinner on the distal reconstructed.
aspect of the volar forearm in all patients.
The anticipated dental rehabilitation is impor-
tant in reconstruction planning. A tissue-borne References
denture will not function if resting upon a thick, 1 Urken ML, Moscoso JF, Lawson W, Biller HF: A systematic ap-
proach to functional reconstruction of the oral cavity following
mobile soft tissue bed with inadequate gingivola-
partial and total glossectomy. Arch Otolaryngol Head Neck Surg
bial and gingivolingual sulci stabilization. Osseo- 1994;120:589601.
integrated implants may be required for stable 2 Yousif JN, Matloub HS, Sanger JR, Campbell B: Soft-tissue recon-
struction of the oral cavity. Clin Plast Surg 1994;21:1523.
dentition. 3 Futran ND, Gal TJ, Farwell DG: Radial forearm free flap. Oral
When greater than 1/2 of the tongue and floor Maxillofac Surg Clin North Am 2003;15:577591.
of mouth volume is resected, rehabilitation focus- 4 Soutar DS, Scheker LR, Tanner NSB, McGregor IA: The radial
forearm flap: a versatile method for intraoral reconstruction. Br
es on the provision of a neo-tongue that allows J Plast Surg 1983;36:18.
enough anterior volume to permit contact with 5 Uwiera T, Seikaly H, Rieger J, Chau J, Harris JR: Functional out-
the palate, and enough posterior volume for the comes after hemiglossectomy and reconstruction with a bilobed
radial forearm free flap. J Otolaryngol 2004;33:356359.
neo-tongue base to provide some protection of 6 Urken ML: The restoration or preservation of sensation in the
the laryngeal inlet and assist in the pharyngeal oral cavity following ablative surgery. Arch Otolaryngol Head
Neck Surg 1995;121:607612.
phase of swallowing. The latissimus dorsi and 7 Lyos AT, Evans GRD, Perez D, Schusterman MA: Tongue recon-
rectus abdominis flaps offer maximal bulk [7]. struction: outcomes with the rectus abdominus flap. Plast Re-
More recently the anterolateral thigh has sup- constr Surg 1999;103:442449.
8 Yu P: Reinnervated anterolateral thigh flap for tongue recon-
planted these choices due to its ease of harvest struction. Head Neck 2004;26:10381044.
and minimal donor site morbidity [8].
63
3.3 How to Evaluate Surgical Margins in

Mandibular Resections
Richard J. Wong
Head and Neck Service, C-1069, Department of Surgery, Memorial Sloan-Kettering Cancer Center,
New York, N.Y., USA

P E A R L S OCSCCs may gain entry into the mandible
along the occlusal surface, or through open tooth
Oral cavity squamous cell carcinoma (OCSCC) may sockets [1]. In cases of prior radiation therapy,
histologically invade the mandible in an erosive (EP) routes of entry into the mandible are more vari-
or infiltrative pattern (IP). The IP is associated with
higher rates of positive mandibular bone margins
able as the periosteum loses its barrier function
(MBM), recurrence, and poor outcome. [1]. Once in the medullary space, SCC may prog-
ress within the mandible in one of three histo-
Preoperative radiographic imaging may reflect the
logic patterns [2, 3]: EP (sharp interface between
histologic pattern of invasion.
tumor and bone and a broad expansive tumor
Intraoperative frozen section (IFS) of (1) MBM by
front), IP (nests of tumor cells with finger-like
curetting cancellous bone and (2) the proximal
inferior alveolar nerve (IAN) stump may accurately projections along an irregular tumor front) and a
reflect final margin status. mixed pattern.
The IP is correlated with higher tumor grade,

P I T F A L L S positive MBM, higher primary recurrence rates,
and poorer disease-free survival [4]. Plain film
Wide MBMs should be considered for tumors with radiographs of the mandible may exhibit IP or EP
radiographic IP of invasion, which is associated with correlated with histologic patterns of invasion as
a higher positive bone margin rate.
well [5].
It may be very difficult to achieve a negative proxi- IFS of bone has been historically problematic
mal IAN margin if an intraoperative biopsy returns due to the inability of the cryotome to section it.
positive on frozen section analysis.
The assessment of MBM by conventional means
involves a lengthy period of decalcification last-
ing from 7 to 10 days that allows the specimen to
Introduction soften for sectioning. Achieving final negative
The potential of OCSCCs to invade the mandible margins is an important goal from an oncologic
may lead to significant cosmetic and functional standpoint. Furthermore, in the era of mandibu-
deficits, posing a reconstructive challenge. Man- lar reconstruction using microvascular flaps, re-
dibular invasion also has a significant adverse resection for a positive MBM that is identified on
prognostic implication, and invasion through final pathology becomes problematic. Therefore
cortical bone meets criteria for T4a status by 2003 the potential application of IFS for mandibular
AJCC staging criteria. specimens is an issue of great clinical relevance.

Examine preoperative plain films and CT An approach towards planning MBM and per-
scans of the mandible to assess for a possible IP forming IFS of them is presented. Curettings of
or EP of invasion. If irregular, ragged edges are cancellous mandibular bone from the margins
noted around the lesion suggesting an IP, plan a and a section of the proximal IAN stump can be
1.5- to 2-cm resection margin of bone around the readily processed and sectioned using standard
lesion. A 1-cm margin is probably adequate for IFS techniques to provide important intraopera-
lesions with an EP. tive information regarding margin status. In the
Segmental mandibulectomy is considered ap- era of microvascular flap reconstruction, such in-
propriate for any OCSCC breaching the outer formation assisting in securing negative MBM is
mandibular cortex and reaching the medullary important in avoiding the need for re-resection in
space, or causing dysfunction or numbness of the the setting of complex reconstruction.
IAN.
After performing a segmental mandibulecto-
3
my, curette the cancellous bone on each end of the References
remaining mandible and send the material for 1 McGregor AD, MacDonald DG: Routes of entry of squamous cell
carcinoma to the mandible. Head Neck Surg 1988;10:294301.
IFS. The pathologist should process it in a stan-
2 Carter RL, Tsao SW, Burman JF, Pittam MR, Clifford P, Shaw HJ:
dard cryotome. This technique is accurate and Patterns and mechanisms of bone invasion by squamous carci-
comparable to final pathology assessment of nomas of the head and neck. Am J Surg 1983;146:451455.
3 Slootweg PJ, Muller H: Mandibular invasion by oral squamous
MBM [6]. cell carcinoma. J Craniomaxillofac Surg 1989;17:6974.
Identify the proximal stump of the IAN with- 4 Wong RJ, Keel SB, Glynn RJ, Varvares MA: Histological pattern
in the proximal portion of the canal, and excise a of mandibular invasion by oral squamous cell carcinoma. Laryn-
goscope 2000;110:6572.
segment for IFS. However, in the event that it re- 5 Totsuka Y, Usui Y, Tei K, Fukuda H, Shindo M, Iizuka T, Ame-
turns positive for carcinoma, neural invasion by miya A: Mandibular involvement by squamous cell carcinoma of
the SCC may track proximally to a variable ex- the lower alveolus: analysis and comparative study of histologic
and radiologic features. Head Neck 1991;13:4050.
tent, and re-resection of the proximal mandible 6 Forrest LA, Schuller DE, Lucas JG, Sullivan MJ: Rapid analysis of
does not insure achieving a negative final nerve mandibular margins. Laryngoscope 1995;105:475477.
7 Weisberger EC, Hilburn M, Johnson B, Nguyen C: Intraoperative
margin. microwave processing of bone margins during resection of head
Alternate novel methods of assessing MBM and neck cancer. Arch Otolaryngol Head Neck Surg 2001;127:790
have been and will continue to be described: mi- 793.
8 Jeries W, Swinson B, Johnson KS, Thomas GJ, Hopper C: Assess-
crowave processing with rapid decalcification [7], ment of bony resection margins in oral cancer using elastic scat-
as well as elastic scattering spectroscopy for opti- tering spectroscopy: a study on archival material. Arch Oral Biol
cal assessment of formalin-fixed margins [8]. 2005;50:361366.
However, their technology may not be readily

available, and their application should be consid-
ered experimental.
65
3.4 How to Reconstruct Anterior Mandibular

Defects in Patients with Vascular Diseases
Matthew M. Hanasono
Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Tex., USA

P E A R L S that is disfiguring and associated with impaired
mastication, pooling of saliva, and loss of oral
Vascularized bone flaps are indicated for anterior competence.
mandibular reconstruction whenever possible. In patients who are questionable candidates
Preoperative angiography or magnetic resonance for reconstruction with microvascular free bone
angiography should be obtained in patients with flaps, it is tempting to perform reconstruction
an abnormal lower extremity physical exam.
with titanium reconstruction plates, alone or in
combination with soft tissue flaps such as the

P I T F A L L S
pectoralis major flap. However, complication
rates with this technique are reported to be be-
Complication rates are high in reconstruction of
tween 21 and 87% [1]. Anterior defects are associ-
anterior defects with titanium reconstruction
plates, alone or with soft tissue flaps. ated with a higher rate of plate extrusion than lat-
eral defects, especially in patients treated with ra-
Nonvascularized bone grafts are indicated only for
diation therapy. Mandibular reconstruction that
short defects in nonirradiated wounds.
results in early fracture or plate exposure may re-
In patients with very poor vascular status or a
sult in a situation that is more challenging to treat
limited life expectancy, mandibular reconstruction
plates with pedicled pectoralis major flap coverage than the initial defect due to difficult dissection
can be considered. of recipient vessels and an inability to restore ac-
In cases of free flap loss, a thorough investigation curate occlusion [2].
for the cause of flap loss should be performed. Autogenous bone grafts have also been used
If the cause is correctable, a second free flap is for mandibular reconstruction. Nonvascularized
performed. bone grafts are used in defects less than 5 cm
long. High failure rates are generally seen in an-
terior defects and longer grafts. Pre- or postop-
erative radiation therapy is considered a contra-
indication due to high rates of extrusion, resorp-
Introduction tion, and infection.
Anterior segmental mandibular defects resulting
from oncologic resection are reconstructed with Practical Tips
vascularized bone whenever possible. Failure to The fibula osseous/osteocutaneous free flap is
reconstruct the anterior mandible results in the usually our first choice for anterior mandibular
so-called Andy Gump deformity, a condition reconstruction in the cancer patient [3]. Preop-

erative physical examination of both lower ex- Conclusion
tremities, including palpation for dorsalis pedis For anterior mandibular reconstruction, the fib-
and posterior tibial pulses, is performed to deter- ula free flap is our method of choice. If there is
mine whether a patient is a candidate for harvest stenosis or hypoplasia of the vessels supplying the
of this flap [4, 5]. When lower extremity circula- foot, alternative reconstructive methods must be
tion is questionable, angiography or magnetic considered. Reconstruction of the anterior man-
resonance angiography should be performed [6]. dible is challenging but important in maintaining
In addition to pathologic conditions, it is impor- quality of life even in patients with advanced ma-
tant to rule out a peronea magna artery, an ana- lignancies.
tomic variant, present in up to 5% of patients, in
which the peroneal artery is the single dominant
artery supplying the distal lower extremity [7]. References
Alternatives to the fibula free flap include the
iliac crest and scapula free flaps. However, the il-
1 Mariani PB, Kowalski LP, Magrin J: Reconstruction of large de-
fects postmandibulectomy for oral cancer using plates and myo- 3
cutaneous flaps: a long-term follow-up. Int J Oral Maxillofac
iac crest flap is based on the deep circumflex iliac Surg 2006;35:427432.
artery, which may be stenotic in patients with 2 Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen H: Com-
plications after reconstruction by plate and soft tissue free flap
lower extremity vascular disease. In contrast, the in composite mandibular defects and secondary salvage recon-
scapula flap is based on the circumflex scapular struction with osseocutaneous flap. Plast Reconstr Surg 2003;
artery, which is typically spared in atherosclerot- 112:3742.
3 Cordeiro PG, Disa JJ, Hidalgo DA, Hu Q: Reconstruction of the
ic vascular disease. The major drawback is that mandible with osseous free flaps: a 10 year experience with 150
the location of the scapula on the back precludes consecutive patients. Plast Reconstr Surg 1999;104:13141320.
a two-teamed approach to harvesting the flap and 4 Disa JJ, Cordeiro PG: The current role of preoperative arteriog-
raphy in free fibula flaps. Plast Reconstr Surg 1998;102:1083
preparation of the recipient site. 1088.
The osteocutaneous radial forearm free flap is 5 Lutz B, Wei FC, Ng SH, Chen IH, Chen SHT: Routine donor leg
angiography before vascularized free fibula transplantation is
typically not favored for anterior mandibular re- not necessary: a prospective study in 120 clinical cases. Plast
construction due to the limited thickness of the Reconstr Surg 1999;103:121127.
bone that may be harvested and the risk for ra- 6 Lorenz RR, Esclamado R: Preoperative magnetic resonance an-
giography in fibular-free flap reconstruction of head and neck
dial bone fracture in the forearm after harvest. defects. Head Neck 2001;23:844850.
However, some authors report good outcomes 7 Kim D, Orron DE, Skillman JJ: Surgical significance of popliteal
with this technique [8]. artery variants: a unified angiographic classification. Ann Surg
1989;210:776781.
The pectoralis major muscle with rib or ster- 8 Thoma A, Levis C, Young JEM: Oromandibular reconstruction
num can be used for anterior mandibular recon- after cancer resection. Clin Plast Surg 2005;32:361375.
9 Robertson GA: The role of sternum in osteomyocutaneous re-
struction [9]. The lack of reliability, limited abil-
construction of major mandibular defects. Am J Surg 1986;
ity to shape the soft tissue and bony flap compo- 152:367370.
nents, and limited reach make this flap a
secondary option after free bone flaps. These
flaps may be considered in patients with very
poor vascular status. However, distal flow to the
bony component of these flaps is likely to be com-
promised in such patients resulting in an in-
creased risk for flap failure.
67
3.5 Adequate Surgical Margins in Resections

of Carcinomas of the Tongue
Jacob Kligerman
Instituto Nacional de Cncer, Rio de Janeiro, Brazil

P E A R L S mor-free surgical margin is the usual recommen-
dation, although there has been some discussion
5 mm is the shortest ex vivo surgical margin recom- in the literature on whether such a margin is or is
mended in resections for tongue carcinomas. not effective in the local control of the disease
Ideally, the mucosal margins should be free of [16]. The well-documented fact that 1030% of
preinvasive atypical epithelial alterations. the cases with histopathologically free margins
Intraoperative frozen section examination is do recur is the fuel that keeps this discussion
conventionally the technique of choice to deter- alive. In recent years, molecular biology studies
mine the adequacy of the margins. have been performed to explain this occurrence
Tumors with infiltrative edge require careful [5, 7, 8]. The role of atypical preinvasive epithelial
measurement of the margins from the longest lesions in the margins has also been investigated
tumoral projection.
by some authors [3, 9]. Since molecular technol-
ogy is not available for intraoperative evaluation

P I T F A L L S
in a reasonable time frame [7, 10] and it has not
yet been validated in prospective studies with a
Stretching of the tongue while demarcating the
significant number of cases followed for at least 5
resection lines may lead to erroneous evaluation of
the margins size. years, we still adhere to the 5-mm margin as a safe
parameter to avoid recurrences. Nonetheless, we
Inclination of the surgical blades as you cut deep
do believe that this molecular approach will make
into the muscle layer to get a cuneiform fragment
usually diminishes the amount of tumor-free tissue a great contribution to the understanding of tu-
between the edge of the tumor and the resection mor behavior and to the treatment as well, as we
line below the mucosa. are sure that its use in everyday practice is quite
The deep surgical margin is the most difficult to close to becoming reality.
assess at the time of resection, being usually much
shorter than expected. Practical Tips
Always draw the line of resection measuring
between 7 and 10 mm tissue-free using visual
Introduction evaluation of the mucosa and palpation of deeper
The adequacy of surgical resection of a primary tissues around the lesion.
carcinoma of the tongue is conventionally deter- If you stretch the tongue too much to draw
mined intraoperatively by frozen section exami- your resection line, you may have underestimated
nation using histopathologic criteria. A 5-mm tu- the margins.

Remember that there will be a natural retrac- References
tion of the tissues due to the extensive muscular 1 Spiro RH, Guillamondegui O Jr, Paulino AF, Huvos AG: Pattern
of invasion and margin assessment in patients with oral tongue
component, which may reach between 25 and
cancer. Head Neck 1999;21:408413.
30% less than the in vivo evaluation. 2 Weijers M, Snow GB, van der Wal JE, van de Waal I: The status of
The recommended 5-mm margin should be the deep surgical margins in tongue and floor of the mouth squa-
mous cell carcinoma and risk of local recurrence: an analysis of
measured ex vivo. 68 patients. Int J Oral Maxillofac Surg 2004;33:146149.
The deeper you go, the more difficult it gets to 3 Weijers M, Snow GB, Bezemer PD, van der Wal JE, van de Waal
calculate the amount of tumor-free tissue. I: The clinical relevance of epithelial dysplasia in surgical mar-
gins of tongue and floor of mouth squamous cell carcinoma: an
Never forget to mark orientation points in the
analysis of 37 patients. J Oral Pathol Med 2002;31:1115.
specimen before sending it to the pathologist, so 4 Brandwein-Gensler M, Teixeira MS, Lewis CM, Lee B, Rolnitzky
that he or she can determine exactly where you L, Hille JJ, Genden E, Urken ML, Wang BY: Oral squamous cell
carcinoma: histologic risk assessment, but not margin status, is
should extend your incision. strongly predictive of local disease-free and overall survival. Am
It is quite useful to have the pathologist in the
operating room while you are removing the tu-
J Surg Pathol 2005;29:167178.
5 Upile T, Fisher C, Jerjes W, El Maayatah M, Singh S, Sudhoff H, 3
Searle A, Archer D, Michaels L, Hopper C, Rhys-Evans P, Wright
mor despite the fact that demarcation of orienta- HD: Recent technological developments: in situ histopathologi-
tion points in the specimen is still necessary. cal interrogation of surgical tissues and resection margins. Head
Face Med 2007;1:313.
Before taking the decision of extending your
6 Bradley PJ, MacLennan K, Brakenhoff RH, Leemans CR: Status
resection, carefully evaluate the defect you are of primary tumor surgical margins in squamous head and neck
about to impose on your patient and think of al- cancer: prognostic implications. Curr Opin Otolaryngol Head
Neck Surg 2007;15:7481.
ternative therapies that could be more effective in 7 Rodrigo JP, Ferlito A, Suarez C, Shaha AR, Silver CE, Devaney
situations such as very large tumors, tumors at KO, Bradley PJ, Bocker JM, McLaren KM, Grnman R, Rinaldo
A: New molecular methods in head and neck cancer. Head Neck
the base of the tongue, or lesions of the lingual
2005;21:9951003.
nerve. 8 Braakhuis BJM, Tabor MP, Kummer JA, Leemans CR, Braken-
hoff RH: A genetic explanation of Slaughters concept of field
cancerization. Cancer Res 2003;63:17271730.
9 van Es RJ, van Nieuw AN, Egyedi P: Resection margin as a pre-
dictor of recurrence at the primary site for T1 and T2 oral can-
cers. Evaluation of histopathologic variables. Arch Otolaryngol
Head Neck Surg 1996;122:521525.
10 Goldenberg G, Harden S, Masayesva BG, Ha P, Benoit N, Westr
WH, Koch WM, Sidransky D, Califano JA: Intraoperative mo-
lecular margin analysis in head and neck cancer. Arch Otolaryn-
gol Head Neck Surg 2004;130:3944.
69
3.6 Practical Tips to Manage Mandibular

Osteoradionecrosis
Sheng-Po Hao
Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan

ORN can have iatrogenic causes (81%) such as
Prevention is the key. surgical trauma, tooth extraction, and poor oral
Avoid elective oral surgical procedures within an hygiene, whereas only 19% are spontaneous [2].
irradiated field; preoperative hyperbaric oxygen Mandibular ORN commonly presents as an
therapy (HBO) may be considered. exposed necrotic mandible or a discharged fis-
Early recognition and prompt management are tula right under the area of disease with foul odor
mandatory. or severe pain [3].
Surgery is the mainstay treatment for osteoradio- Recurrent or persistent cancer may present as
necrosis (ORN). It is not possible that the nonvital a chronic unhealed wound and exposed necrotic
sequestrum becomes vital after HBO. bone, which may mimic ORN. Currently, there is
no useful clinical means to definitely differentiate

P I T F A L L S mandibular ORN from recurrent cancer. As
much as 21% of initial ORN diagnoses are cor-
Keep in mind the difficulties to differentiate
rected to recurrent cancer after several attempts
recurrent cancer from ORN.
of debridement or radical surgery [2].
Occasionally, the correct diagnosis is reached only The treatment of ORN begins with preven-
after radical surgery.
tion. Patients with exposed bone and a lack of soft
tissue coverage who undergo irradiation will in-
variably develop ORN. During surgery, undue
soft tissue tension over the bone should be avoid-
ed. This kind of poor wound healing will directly
expose the irradiated bone to contamination in
the oral cavity or external environment. Mandib-
Introduction ular ORN should be managed in a systemic and
Irradiation may cause the 3 H status hypoxia, stepwise approach [2]. The first step is to diagnose
hypovascularity, hypocellularity and impair and delineate the extent of the disease. We prefer
normal collagen synthesis and cell production, magnetic resonance imaging because of its su-
which leads to tissue breakdown and a chronic perb ability to define bone marrow and surround-
nonhealing wound. ORN has been defined as ex- ing soft tissue changes of ORN.
posed irradiated bone that fails to heal over a pe- Conservative management is indicated in mild
riod of 3 months [1]. ORN cases with repeated limited sequestrectomy

and HBO. It is crucial to send the sequestrum for full thickness of the bone and the full extent of
pathology proof. ORN should not be deemed as a the diseased surrounding soft tissue is usually
disease of the bone only: the surrounding soft tis- necessary.
sue is part of the disease process too.
The management of overlying soft tissue Conclusion
should be carried out carefully. Only diseased ORN of the mandible is a serious and devastating
mucosa and granuloma are removed. Every effort complication of radiation therapy. Prevention is
should be made to retain its vascularity, and fur- the key. Once developed, early recognition and
ther tears of or injury to the normal mucosa prompt management are mandatory. Always keep
should be avoided. Primary closure of the muco- in mind the possibility of recurrent cancer. Man-
sal defect or closure with a rotational flap har- dibular ORN should be managed with a systemic
vested from a neighboring area within the irradi- and stepwise approach with conservative seques-
ated field is not recommended. HBO can elevate
the oxygen tension within the tissue and may
trectomy coupled with HBO and may be followed
by radical sequestrectomy and distant flap recon-
3
stimulate collagen synthesis and fibroblastic pro- struction. Radical sequestrectomy is indicated in
liferation, thus facilitating the process of wound cases of severe or extensive mandibular ORN and
healing. HBO can minimize the extent of surgery the tissue should be reconstructed with healthy
and should be an adjunct to an aggressive man- vascularized tissue with its pedicle outside the ra-
agement of ORN. Attempts to use HBO alone diation field.
were generally unsuccessful. HBO cannot revital-
ize necrotic bone. The dead sequestra need to be
surgically removed. Surgery is still the mainstay References
treatment for ORN. 1 Mark RE: Osteoradionecrosis: a new concept of its pathophysiol-
ogy. J Oral Maxillofac Surg 1983;41:283288.
We recommend radical sequestrectomy and
2 Hao SP, Chen HC, Wei FC, et al: Systematic management of os-
vascularized flap reconstruction in cases of se- teoradionecrosis in the head and neck. Laryngoscope 1999;109:
vere, extensive ORN of the mandible, such as co- 13241327.
3 Hao SP, Tsang NM, Chang KP, Chen CK, Chao WC: Osteoradio-
existent fracture, multiple discharging fistula, necrosis of external auditory canal in nasopharyngeal carcino-
and a large area of exposed bone [4]. The key to ma. Chang Gung Med J 2007;30:116121.
successful treatment in these extensive ORN cas- 4 Santamaria E, Wei FC, Chen HC: Fibula osteoseptocutaneous
flap for reconstruction of osteoradionecrosis of the mandible.
es is adequate and radical sequestrectomy with Plast Reconstr Surg 1998;101:921929.
vascularized flap reconstruction. Removal of the
71
Laryngeal Tumors
4.1 Practical Tips for Laser Resection of

Laryngeal Cancer
F. Christopher Holsinger a, N. Scott Howard a, Andrew McWhorter b
a Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Tex., and
b LSUVoice Center, Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health
Sciences Center, Our Lady of the Lake Hospital, Baton Rouge, La., USA

Strong and Jako [1] first introduced the carbon
Laryngeal mobility is in part determined by muscle dioxide laser to the head and neck surgeon in
infiltration. Arytenoid fixation is predictive of deep 1972, when they declared that the transoral laser
invasion of the paraglottic space and is a contra-
indication for conservation surgery.
microsurgery was ready for clinical trial. Steiner
and Ambrosch [2] have successfully adapted the
Videostroboscopy and speech therapy assessment
fundamental aspects of open procedures to the
of rehabilitative potential are essential. Early speech
therapy to prevent arytenoid ankylosis and repeat endoscope with excellent results. The carbon di-
videostroboscopy to detect subtle hyperplasia, oxide laser is used because water absorbs this fre-
scar tissue, or vocal fold changes that may indicate quency of light (10,600 nm), minimizing collat-
recurrence should be routinely performed. eral damage to nearby structures.
Maintaining one functional cricoarytenoid complex Conservation surgery of laryngeal cancer has
and sensory innervation reduces the risk of post- excellent 5-year local control rates and good func-
operative aspiration. tional outcomes when compared with total laryn-
gectomy, chemoradiation or radiation alone.

P I T F A L L S Compared to open techniques, laser surgical pro-
cedures are less invasive, allow for a more rapid
Poor exposure is the most common cause of failure.
return to voice use, and reduce swallowing dys-
Previously irradiated tissues will have edema and function.
submucosal fibrosis and there will be difficulty in Margins vary with the primary site of the tu-
differentiating tumor from healthy tissue.
mor. For the glottic larynx, 13 mm may be ade-
At the anterior commissure, there is no conus quate. Larger margins of 510 mm are more ap-
elasticus or perichondrium, which provides a
propriate in the supraglottis. For patients under-
diminished natural barrier to spread. In addition,
ossified cartilage has reduced resistance to going TLM after radiation failure, even larger
tumor spread. margins of resection should be taken.
Close collaboration intraoperatively with the
pathologist is of paramount concern, in order to
maintain proper orientation of the specimens.
Reconstruction is not typically performed and
healing occurs by secondary intention. Granula-

tion tissue forms, followed by contraction and re- Assessment of tumor extent following radia-
mucosalization with the contracture process tion therapy is difficult to evaluate due to fibrosis
helping to eliminate dead space [3]. and edema causing TVC motion abnormalities,
changes in imaging characteristics, and difficulty
Practical Tips distinguishing between radionecrosis and tumor
Staging operative endoscopy should be per- recurrence.
formed to determine extent of disease prior to For optimal functional and oncologic out-
consideration of laser surgery. 0, 30 and 70 en- comes in laryngeal cancer, a multidisciplinary
doscopy provides the gold standard assessment of team approach is recommended: speech language
disease extent. pathology, radiation therapy, medical oncology,
CT or MRI of larynx should be performed to and dental oncology.
evaluate the extent of primary tumor, any evi-
dence of spread to the preepiglottic or paraglottic Recovery and Follow-Up
space or cartilage invasion. Oral diet may generally be resumed on the day
Consider a modified barium study/FEES or after surgery. Wound healing is usually complete
esophagoscopy if obstructive symptoms exist or after 34 weeks. Video strobe assessment is sched-
if there is interarytenoid or posterior involve- uled at 46 weeks following surgery. Second-look
ment. procedures with excision of scar tissue to evaluate
Intraoperatively, the microscope allows for a for residual carcinoma rests are performed at 36 4
better view of the surgical field and assessment of weeks.
dysplastic or neoplastic changes. Intraoperative
judgment afforded by this technique enables safe
but close margins, while preserving as much nor- References
mal tissue as possible to optimize functional out- 1 Strong MS, Jako GJ: Laser surgery in the larynx. Early clinical
experience with continuous CO2 laser. Ann Otol Rhinol Laryn-
come.
gol 1972;81:791798.
Infusion of saline solution into Reinkes space 2 Steiner W, Ambrosch P: Endoscopic Laser Surgery of the Upper
may allow for improved differentiation of Tis and Aerodigestive Tract with Special Emphasis on Cancer Surgery.
New York, Thieme, 2000.
early invasive disease. 3 McWhorter AJ, Hoffman HT: Transoral laser microsurgery for
The use of a pulsed, rather than a continuous, laryngeal malignancies. Curr Probl Cancer 2005;29:180189.
mode provides better tissue handling properties 4 Niemz MH: Laser-Tissue Interactions: Fundamentals and Appli-
cations (Biological and Medical Physics, Biomedical Engineer-
under microscopic visualization. Short pulses of ing). New York, Springer, 2000.
laser irradiation leave a smaller thermal damage 5 Kirchner J: Atlas on the Surgical Anatomy of Laryngeal Cancer.
zone, which may lead to faster healing. Pulsed la- San Diego, Singular Publishing, 1998.
ser settings decrease carbonization and improve

the ability of the surgeon to discern tumor from
normal mucosa during microsurgery [4].
Anterior commissure lesions may extend down
the thyroid cartilage and extend anteriorly
through the cricothyroid membrane [5]. An in-
frapetiolar release and exposure of the superior
inner thyroid perichondrium of the thyroid car-
tilage may be required for proper exposure of this
difficult area.
73
Laryngeal Tumors
4.2 Practical Suggestions for

Phonomicrosurgical Treatment of
Benign Vocal Fold Lesions
Steven M. Zeitels, Gerardo Lopez Guerra
Harvard Medical School, Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital,
Boston, Mass., USA

P E A R L S membranous vocal fold since membrane is over-
lying all structures of the larynx. The epithelium
The superficial lamina propria (SLP) is the primary provides negligible vibratory characteristics and
structural layer responsible for mucosal wave assumes the viscoelastic properties of whatever
vibration, not the epithelium overlying it.
aerodigestive tract tissue it encapsulates. When
Most microlaryngoscopic procedures are facilitated treating PM lesions, it is of paramount impor-
by a subepithelial infusion using saline with
tance to minimize trauma to uninvolved epithe-
epinephrine, which helps to preserve the critically
important SLP. lium and underlying SLP [13]. Most benign le-
sions are associated with phonotrauma and vocal
The 532-nm KTP laser is a key state-of-the-art
overuse and arise within the SLP (polyps, nod-
instrument for treating phonatory mucosa (PM)
lesions associated with aberrant microcirculation. ules, cysts, ectasias varices). Papillomatosis [2, 4]
and dysplasia [2, 4, 5] are the key noncancerous
epithelial lesions.

P I T F A L L S
Most unresolved hoarseness results from dimin- Practical Tips

ished pliability of the PM (not from aerodynamic It is important to place the largest laryngoscope
glottal valvular incompetence), and this is the most speculum [2, 6] that can fit from the oral cavity to
common disabling complication from phonomicro-
the glottis, preferably a triangular shape.
surgery of benign vocal fold lesions.
Use a true suspension gallows [2, 5, 7, 8] rather
Disturbing the vocal ligament (VL) is not the etiol- than a fulcrum laryngoscope holder, external
ogy of postoperative PM scarring and stiffness;
it is caused by injudicious disturbance of the
counterpressure with tape to enhance exposure
subepithelial SLP. [7].
Whenever possible, the VL should not be ex-
posed, since that would mean that the SLP has
been unfavorably traumatized.
Introduction Polyps, nodules, and cysts [2, 3, 9] are opti-
Benign vocal fold lesions primarily occur within mally resected by means of a subepithelial resec-
the PM [13], which is comprised of the SLP and tion technique. Amputating the lesion with the
the overlying epithelium. We refer to PM as the overlying epithelium leaving epithelial deficits
musculomembranous region rather than the results in increased mucosal scarring.

Subsequent to the subepithelial infusion [2, 3, Most recalcitrant arytenoid granulomas are
5], an epithelial cordotomy should be done at the best treated by means of botulinum toxin injec-
cephalad edge of the polyp, nodule, or cyst. The tions in the lateral paraglottic musculature along
interface of the deep aspect of the benign lesion with antireflux management and voice therapy.
from the underlying normal SLP must be identi- Surgical resection is minimally helpful unless
fied, so that it can be dissected meticulously there is substantial airway obstruction or the
[2, 3]. granuloma arises from a narrow pedicle.
Anterior-commissure synechia will not occur In the not-so-distant future, SLP substitutes
unless there is bilateral loss of epithelium on the will be available that will restore lost mucosal pli-
medial surface of the anterior commissure [2]. ability, which will revolutionize phonomicrosur-
Positioning epithelial incisions laterally and gery for both benign and malignant lesions [1,
away from medial lesions to avoid an incision 10].
near the medial edge is a flawed philosophy, since
postoperative mucosal pliability is primarily
based on not disturbing normal SLP. References
When treating benign SLP lesions with the 1 Zeitels SM, Healy GB: Laryngology and phonosurgery. N Engl J
Med 2003;349:882892.
532-nm KTP laser, it should be done with a 0.3- to
2 Zeitels SM: Atlas of Phonomicrosurgery and Other Endolaryn-
0.4-mm fiber, 450525 mJ, a 15-ms pulse width geal Procedures for Benign and Malignant Disease. San Diego,
and a 1- to 3-mm fiber-to-tissue distance [4]. Singular, 2001.
3 Zeitels SM, Hillman RE, Desloge RB, Mauri M, Doyle PB: Phono-
4
The pulsed KTP laser employs very precise se-
microsurgery in singers and performing artists: treatment out-
lective photoangiolysis, which provides the first comes, management theories, and future directions. Ann Otol
opportunity for involution of ectasias and varices Rhinol Laryngol 2002;111(suppl 190):2140.
4 Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, An-
without substantially disturbing the overlying derson RR: Office-based 532-nm pulsed KTP laser treatment of
epithelium and the extravascular SLP [2, 9]. glottal papillomatosis and dysplasia. Ann Otol Rhinol Laryngol
Reinkes edema [2] is comprised of excessive 2006;115:679685.
5 Zeitels SM: Premalignant epithelium and microinvasive cancer
SLP and can be resected bilaterally as long as the of the vocal fold: the evolution of phonomicrosurgical manage-
incisions are confined to the superior surface. ment. Laryngoscope 1995;105(suppl 67):151.
6 Zeitels SM: A universal modular glottiscope system: the evolu-
The goal of phonomicrosurgery of Reinkes ede- tion of a century of design and technique for direct laryngoscopy.
ma is to diminish the mass and volume of the in- Ann Otol Rhinol Laryngol 1999;108(suppl 179):124.
creased mass and volume of SLP, yet leaving the 7 Zeitels SM, Vaughan CW: External counter-pressure and inter-
nal distension for optimal laryngoscopic exposure of the ante-
patient with mildly large vocal folds. If the VL is rior glottal commissure. Ann Otol Rhinol Laryngol 1994;103:
exposed, especially on the medial surface, severe 669675.
and permanent strained hoarseness can result. 8 Zeitels SM, Burns JA, Dailey SH: Suspension laryngoscopy re-
visited. Ann Otol Rhinol Laryngol 2004;113:1622.
This is a worse liability than the low-pitched com- 9 Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, An-
fortable preoperative voice. derson RR: Pulsed angiolytic laser treatment of ectasias and var-
The key objective in the treatment of epithelial ices in singers. Ann Otol Rhinol Laryngol 2006;115:571580.
10 Zeitels SM, Blitzer A, Hillman RE, Anderson RR: Foresight in
diseases such as glottal papillomatosis [2, 4, 5] or laryngology and laryngeal surgery: a 2020 vision. Ann Otol Rhi-
dysplasia is to resect the pathological epithelium nol Laryngol 2007;116(suppl 198):116.
while minimally disturbing the underlying SLP
or by involuting the subepithelial microcircula-
This work was generously supported by the Eugene B.
tion with an angiolytic (i.e. 532-nm pulsed KTP) Casey Foundation and the Institute of Laryngology and
laser. Voice Restoration.
75
Laryngeal Tumors
4.3 Glottic Reconstruction after Partial

Vertical Laryngectomy
Onivaldo Cervantes, Mrcio Abraho
Otorhinolaryngology and Head and Neck Department of Federal University of So Paulo
Escola Paulista de Medicina, So Paulo, Brazil

The treatment of early glottic tumors is controver-
Laryngeal reconstruction after partial vertical laryn- sial: surgery or radiotherapy. The treatment plan
gectomy (PVL) is crucial for a good quality of voice. depends on preoperative evaluation of the larynx,
Reconstruction avoids chondritis and formation of histology, staging (UICC, 2002), the surgical
granulomas. teams experience, the patients overall clinical
Initiate surgical incision with a reconstruction plan condition, informed consent, patient education
in mind. and postoperative smoking cessation. Treatment
goals are: total resection of the tumor with preser-

P I T F A L L S vation of laryngeal physiology and function as
much as possible, maintaining optimum post-
Laryngoscopic evaluation may underestimate the operative voice quality and low rates of morbi-
extent of the tumor.
dity.
Computed tomography may overestimate the In general, partial laryngectomies enable pa-
extent of the tumor.
tients to recover faster, both from the point of
The surgeon should describe the planned view of respiratory and phonatory functions. In
procedure to the patient, making clear that a total addition, they offer rewarding outcome results. A
laryngectomy may be required. The final decision,
however, can be made only at the time of surgery
laryngoscopic evaluation, meticulous examina-
under direct visualization and with frozen-section tion, and if necessary computed tomography are
pathologic confirmation. needed to assess glottic tumors. Surgical consider-
ations must always be planned in conjunction
If the patient is not willing to give consent under
with reconstructive options. PVLs are indicated
these circumstances, limited resection should be
avoided. mainly for T1, T2, and perhaps some carefully
selected T3 tumors. The main goal is larynx pres-
ervation and function.
Frontolateral laryngectomy is indicated for
glottic tumors involving the anterior commis-
sure, or tumors that compromise both vocal folds
(with preserved mobility). Such an approach can
be extended posteriorly when arytenoid cartilage
involvement is confirmed.

Surgical margin assessment is fundamental to ally, the keel must be resected. Careful opening of
achieve complete tumor resection. the cartilage is completed with parallel incisions,
and opening of the glottis by hand against the
Practical Tips side of the lesion. This allows tumor assessment
Some important aspects of partial laryngecto- and dissection of the internal perichondrium,
mies should be highlighted: survival rates vary and further resection with ample margins.
according to the tumor site; glottic cancer is high- An excellent option for glottal reconstruction
ly curable; the staging of the disease and not the is the sternohyoid muscle, which is dissected ear-
actual treatment is critical; the first treatment and ly on when performing a partial laryngectomy.
clinical condition are important; the first treat- Also, preserve most of the perichondrium of the
ment anticipates problems later; combination thyroid cartilage, which must be sutured to the
therapy is warranted in specific situations; pa- muscle with absorbable stitches. Other options
tient selection is key; reconstruction consider- for glottic reconstruction are: (1) lowering of the
ations are paramount after resection; consistent ipsilateral vestibular mucosal fold; (2) sternohy-
and methodical follow-up is critical for rehabili- oid muscle flap with external perichondrium,
tation and final outcome of surgery. However, the and (3) lowering of the epiglottis with a myocuta-
patients life is more important than the larynx. neous platysma flap.
Avoid communication between the laryngec- Reconstruction with local mucosa will lead to
tomy incision and the tracheotomy incision. This an improved voice quality, offering adequate 4
will prevent subcutaneous emphysema and col- postoperative vibration.
lection of secretions, potentially preventing infec- Resection of an arytenoid often leads to poorer
tion. Tracheotomy performed on the third ring voice quality, predisposing to dysphagia with as-
precludes communication between the inci- piration, often leading to pulmonary infection.
sions.
Start thinking about the incision at the same Conclusions
time you review your laryngeal reconstructive PVL is a straightforward technically simple pro-
options, which is critical for the best outcomes. cedure that allows rapid recovery and voice reha-
Surgical planning is crucial, bearing in mind the bilitation. It should always include skillful recon-
different techniques available. struction of the glottis. Protective tracheotomy
The thyroid cartilage should be opened bear- with early withdrawal should be performed to
ing in mind the type of resection planned. Usu- preserve glottic reconstruction.
77
Laryngeal Tumors
4.4 Suprahyoid Pharyngotomy

Eugene N. Myers, Robert L. Ferris
Department of Otolaryngology, University of Pittsburgh, School of Medicine, Pittsburgh, Pa., USA

P E A R L S lent cosmetic results are the other important fea-
tures. In 1974, Barbosa [2] of Brazil included the
Proper patient selection and accurate tumor stag- classic description of SP in his textbook. The use
ing will result in adequate tumor resection together of other surgical techniques such as segmental
with excellent cosmesis and good quality of life.
mandibulectomy, mandibulotomy and lateral
There is no substitute for meticulous surgical tech- pharyngotomy may interfere with deglutition, of-
nique.
ten resulting in disabling aspiration [3].
Identification, careful dissection and retraction of We have used the SP in the management of
the neurovascular bundle will result in good T12 squamous cell carcinoma of the BOT for
function of the tongue.
many years resulting in an excellent cure rate and
good functional and cosmetic results [4]. We have

P I T F A L L S
also employed it in the management of benign
and other malignant tumors of the BOT, lingual
Understaging the tumor may result in inadequate
thyroid, posterior pharyngeal wall, and epiglot-
tumor excision.
tis. This approach may be used in performing a
Subjecting a patient with marginal motivation and
TG with preservation of the larynx [5].
significant comorbidities to a total glossectomy
(TG), leaving the larynx in place, will result in recur-
rent pneumonia and possible death. Practical Tips
Accurate preoperative staging is essential to de-
Failure to isolate and protect the hypoglossal
nerves and lingual arteries may result in necrosis or termine whether SP is the best approach since this
crippling of the tongue. technique is contraindicated for tumors of the
BOT approaching the circumvallate papilla.
Physical examination, especially palpation of
the tongue for tumor extent, remains the key to
decision making.
Introduction MRI is the most sensitive imaging modality,
The suprahyoid pharyngotomy (SP), introduced providing excellent soft tissue definition for pre-
in the 19th century by Jeremitsch [1], provides ex- operative planning.
cellent exposure for excision of small benign and Direct laryngoscopy with direct visualization
malignant tumors arising in the base of the tongue of the tumor, especially for early lesions of the epi-
(BOT), posterior pharyngeal wall and epiglottis. glottis and posterior pharyngeal wall, is essential
Little, if any, disturbance in function and excel- for preoperative planning.

Evaluation of the patients performance status, Intraoperative frozen section control is funda-
especially pulmonary function, is critical since mental to assure complete tumor excision.
some aspiration in the early postoperative period TG may be performed by undermining the mu-
is expected. coperiosteum of the lingual surface of the man-
A temporary tracheostomy is important to dible and incising the mucosa of the floor of the
maintain the airway in the perioperative setting mouth, thereby delivering the entire tongue and
and to allow adequate tracheobronchial toilet. floor of the mouth.
An incision in the most superior skin fold in A nasogastric tube should be inserted prior to
the neck provides adequate exposure for excision closing the wound.
of oropharyngeal lesions and good cosmesis.
A superiorly based apron flap is used to provide Conclusion
adequate exposure for the SP and to incorporate The SP in carefully selected patients is a valuable
unilateral or bilateral neck dissections when ap- technique in small benign or malignant lesions of
propriate. the BOT, posterior pharyngeal wall or epiglottis.
The hypoglossal nerves and lingual arteries Achieving good results with this procedure re-
must be identified and dissected distally until quires strict adherence to details in preoperative
they enter the tongue. This technique of mobiliza- evaluation and in surgical technique. Underesti-
tion and gentle retraction helps to avoid injury to mating the extent of the tumor or the patients
these structures during the pharyngotomy. A functional status may lead to inadequate tumor 4
Penrose drain may be looped around this neuro- resection or difficult to manage complications.
vascular bundle to help with gentle retraction
during excision of the BOT.
An incision across the mucosa of the vallecula References
provides entry into the pharynx. A tenaculum is 1 Blassingame CD: The suprahyoid approach to surgical lesions at
the base of tongue. Ann Otol Rhinol Laryngol 1952;61:483489.
then placed on the posterior aspect of the tongue
2 Barbosa JF: Surgical Treatment of Head and Neck Tumors. New
drawing this structure into the wound. The lesion York, Grune & Stratton, 1974.
is then excised and the defect closed primarily. 3 Johnson JT: Mandibulotomy and oral cavity resection; in Myers
Pharyngeal defects may be left to heal by sec- EN (ed): Operative Otolaryngology: Head and Neck Surgery. Phil-
adelphia, Saunders, 1997, pp 304308.
ond intention or by resurfacing with a split thick- 4 Ferris RL, Myers EN: Suprahyoid pharyngotomy. Oper Tech Oto-
ness skin graft or dermal graft. The disadvantage laryngol 2003;16:4954.
5 Myers EN: Suprahyoid pharyngotomy; in Myers EN (ed): Opera-
of using a skin graft is that the gauze bolus stabi- tive Otolaryngology: Head and Neck Surgery, ed 1. Philadelphia,
lizing the graft must be removed 57 days later, Saunders, 1997, p 242.
requiring another general anesthesia.
79
Laryngeal Tumors
4.5 Intraoperative Maneuvers to Improve

Functional Result after
Supraglottic Laryngectomy
Roberto A. Lima, Fernando L. Dias
Head and Neck Service, Brazilian National Cancer Institute/INCA and Head and Neck Surgery,

P E A R L S Supraglottic laryngectomy (horizontal partial
laryngectomy) is indicated in primary lesions of
Elevate the remaining larynx by suturing the thy- the epiglottis, located either in lingual or laryn-
roid cartilage to the tongue musculature. Avoid geal surface. The extent of the lesion to the base
including the lingual mucosa.
of the tongue, aryepiglottic fold or superior as-
Suture the submucosa of the lateral edge of the pects of the false cord can be included in this sur-
vocal fold to the remaining superior border of the
gical technique. The resection of barriers to aspi-
thyroid cartilage.
ration and the supraglottic sensation may lead to
improper deglutition and aspiration [3].

P I T F A L L S
The major problem after supraglottic laryn-
gectomy is the deglutition without aspiration.
The point of section of the thyroid cartilage should
The resection of supraglottic structures removes
be carefully identified. A wrong cut of the cartilage
may permanently prevent speech. the anatomical protection of the larynx tube and
Perform the cricopharyngeal myotomy (CM) at the interrupts the sequential sensory input of the
posterior midline, reducing the risks of recurrent swallowing mechanism [4]. This deficiency in
laryngeal nerve damage. sensory reception can be compensated by the re-
maining structures, and damage to the external
branch of the superior laryngeal nerve and to the
recurrent laryngeal nerve should be avoided. Ad-
Introduction equate intraoperative maneuvers can prevent im-
Alonso [1] in 1947 introduced the supraglottic portant postoperative aspiration and facilitate re-
laryngectomy to treat selected cases of supraglot- covery.
tic tumors. The oncologic results are near those
achieved by total laryngectomy, with preserva- Practical Tips
tion of the voice and deglutition. Sessions et al. [2] Do not enter the larynx through the vallecula
in a study including 438 patients who underwent in cases of lingual surface lesions. If the vallecula
supraglottic laryngectomy, total laryngectomy is free of tumor, it is the most convenient site to
and radiotherapy for supraglottic cancer reported enter the larynx because it affords better tumor
78.2, 79.8 and 75.9% rates of normal/asymptom- visualization.
atic deglutition, respectively.

The point of section of the thyroid cartilage CM may improve deglutition reducing any hy-
should be carefully identified. Generally, in wom- popharyngeal resistance to swallowing. Never-
en, the anterior commissure is at the level of the theless, there is no evidence that CM improves
upper third and lower two thirds of the thyroid swallowing after supraglottic laryngectomy.
cartilage anteriorly, as measured from the base of However, a study [10] suggested that CM helps to
the thyroid notch to the inferior anterior border normalize the upper esophageal sphincter in cas-
of the thyroid cartilage. A wrong cut of the carti- es of cricopharyngeal dysfunction.
lage may permanently prevent speech [5]. The CM should be done at the posterior mid-
In extended supraglottic laryngectomy with line to avoid lesion of the laryngeal recurrent
one arytenoid resection, it is important to prevent nerve.
aspiration placing the remaining vocal cord in
medialization by suturing it to the cricoid carti-
lage. References
Avoid including the lingual mucosa in the su- 1 Alonso JM: Conservative surgery of cancer of the larynx. Trans
Am Acad Ophthalmol Otolaryngol 1947;51:633642.
ture to the remaining larynx, making the suture
2 Sessions DG, Lenox J, Spector GJ: Supraglottic laryngeal cancer:
only to the tongue muscles [6]. Position the re- analysis of treatment results. Laryngoscope 2005;115:1402
maining larynx as far superior and anterior un- 1410.
3 Logemann JA, Gibbons P, Rademaker AW, et al: Mechanisms of
der the base of the tongue. This can prevent ex-
cessive aspiration [7]. Calcaterra [8] advocated
recovery of swallow after supraglottic laryngectomy. J Speech
Hear Res 1994;37:965974.
4 Tucker HM: Deglutition following partial laryngectomy; in
4
suspension of the larynx fixing the thyroid carti-
Silver CE (ed): Laryngeal Cancer. New York, Thieme, 1991, pp
lage to the mentum or to the digastric muscles. 197200.
We prefer to fix the thyroid cartilage to the tongue 5 Thawley SE, Sessions DG, Deddins AE: Surgical therapy of su-
musculature. praglottic tumors; in Thawley SE, Panje WR, Batsakis JG, Lind-
berg RD (eds): Comprehensive Management of Head and Neck
Preserving the external branch of the superior Tumors. Philadelphia, Saunders, 1999, pp 10061038.
laryngeal nerve to the cricothyroid muscle is pos- 6 Tucker HM: The Larynx, ed 2. New York, Thieme Medical Pub-
lishers, 1993.
sible with careful dissection of the superior cor- 7 Schweinfurth JM, Silver SM: Patterns of swallowing after supra-
nus of the thyroid cartilage. Avoiding injury to glottic laryngectomy. Laryngoscope 2000;110:12661270.
the superior laryngeal nerve improves the recov- 8 Calcaterra TC: Laryngeal suspension after supraglottic laryn-
gectomy. Arch Otolaryngol 1971;94:306309.
ery of swallowing [9]. 9 Tufano RP: Open supraglottic laryngectomy; Weinstein GS (ed):
Suture the submucosa of the lateral edge of the Operative Techniques in Otolaryngology-Head and Neck Sur-
vocal fold to the remaining superior border of the gery. Philadelphia, Saunders, 2003, pp 2226.
10 Yip HT, Leonard R, Kendall KA: Cricopharyngeal myotomy nor-
thyroid cartilage. This helps to keep the tension malizes the opening size of the upper esophageal sphincter in
of the vocal cord. cricopharyngeal dysfunction. Laryngoscope 2006;116:9396.
81
Laryngeal Tumors
4.6 Practical Tips for Performing Supracricoid

Partial Laryngectomy
Gregory S. Weinstein, F. Christopher Holsinger, Ollivier Laccourreye
Department of Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pa., USA

P E A R L S ing SCPL are speech and swallowing without a
permanent tracheostomy or gastrostomy tube.
Preserve both recurrent and superior laryngeal Although there is a commonality in terms of re-
nerves. section in both procedures, there are differences
The fine points of closure, which are important to both in the resection and the reconstruction. For
ensure good function postoperatively, include both SCPL-CHP and SCPL-CHEP, the entire thy-
repositioning of the arytenoids and pyriform sinus-
roid cartilage, both false cords and true cords are
es as well as proper placement of the pexy sutures.
resected, while preserving at least one arytenoid.
Use the retroarytenoid mucosa and corniculate In the SCPL with CHEP, which is utilized for se-
cartilage to reconstruct a neoarytenoid when one
arytenoid cartilage is resected.
lected glottic carcinomas, the petiole is also re-
sected. In the SCPL with CHP, the entire epiglot-
tic and preepiglottic space is removed. In both

P I T F A L L S
SCPLs, three sutures are placed around the cri-
Do not operate on patients with severe chronic coid. For the SCPL with CHEP, the sutures are
obstructive pulmonary disease. placed through the epiglottis, tongue base and
preepiglottic space. For the SCPL-CHP, there is
Swallowing rehabilitation is significantly delayed
no epiglottis and the three sutures are passed
when the patient has had prior laryngeal radiation
therapy. around the hyoid into the tongue base. There is a
vast worldwide literature available confirming
both the oncologic and functional efficacy of the
SCPLs. There are now numerous and thorough
reviews of the perioperative management and
procedure itself. This chapter will focus on spe-
cific practical points that will optimize function-
Introduction al outcomes.
There are two types of supracricoid partial laryn-
gectomy (SCPL) which are utilized for clearly dis- Practical Tips
tinct indications, namely the SCPL with cricohy- Preoperative patient selection is critical, and
oidopexy (CHP) and the SCPL with cricohyoido- the key issue is to avoid performing SCPL on pa-
epiglottopexy (CHEP) [1]. While oncologically, tients with severe chronic obstructive pulmonary
the primary goals are local control of glottic and disease. The clinical test which is most useful is
supraglottic cancer, the functional goals follow- to assess the patients ability to climb two sets of

stairs without becoming short of breath. Pulmo- seen as an outpatient by a speech-language pa-
nary function tests are not routinely ordered pre- thologist for swallowing rehabilitation on ap-
operatively. proximately postoperative day 10. The tracheos-
The surgeon should be aware of the anatomic tomy is downsized and corked and removed when
locations of both the superior and recurrent la- the patient tolerates corking and/or the airway
ryngeal nerves and avoid damaging these nerves looked clinically patent via indirect laryngosco-
during the procedure on both the ipsilateral and py. In France where prolonged hospitalization is
contralateral sides relative to the cancer [2]. the norm a more aggressive decannulation and
During the reconstruction it is important to swallowing regimen has been safely pursued.
resuspend the arytenoid cartilages with a stitch
that is essentially an air knot with a 4-0 Vicryl Conclusion
suture placed between the vocal process of the In this chapter the reader was exposed to the key
arytenoids and the superior-lateral aspect of the points for optimizing functional outcome follow-
cricoid cartilage. ing SCPL. If attention is given to both patient se-
When placing the CHP or CHEP pexy sutures, lection as well as consistent focus on intraopera-
it is critical to avoid going beyond 1 cm from the tive details the chance for excellent outcomes is
midline to avoid damaging the tongue neurovas- improved.
cular bundle.
Reapproximation of the constrictor muscles is 4
done by placing a half vertical mattress suture References
through the cut edge of the constrictor muscles 1 Weinstein GS, Laccourreye O, Brasnu D, Laccourreye H: Organ
Preservation Surgery for Laryngeal Cancer. San Diego, Singular
bilaterally [3].
Publishing, 1999.
The rehabilitation regimen at the University of 2 Rassekh CH, Driscoll BP, Seikaly H, Laccourreye O, Calhoun KH,
Pennsylvania at present is as follows. With rare Weinstein GS: Preservation of the superior laryngeal nerve in
supraglottic and supracricoid partial laryngectomy. Laryngo-
exception, all patients undergo preoperative per- scope 1998;108:445447.
cutaneous gastrostomy. The cuffed tracheostomy 3 Naudo P, Laccourreye O, Weinstein G, Hans S, Laccourreye H,
is changed to a cuffless No. 6 tracheostomy on Brasnu D: Functional outcome and prognosis after supracricoid
partial laryngectomy with cricohyoidopexy. Ann Otol Rhinol
postoperative day 3. The patient is discharged Laryngol 1997;106:291296.
from the hospital on postoperative day 5 and is
83
Laryngeal Tumors
4.7 Intraoperative Maneuvers to

Improve Functional Results after
Total Laryngectomy
Javier Gaviln a, Jess Herranz b
a Department of Otorhinolaryngology, La Paz University Hospital, Madrid, and
b Juan Canalejo Hospital, La Corua, Spain

P E A R L S Tips for a Watertight Hypopharyngeal Suture
Pharyngocutaneous fistula (PCF) is the most
A careful tension-free suture of the hypopharynx common complication following TL. It is associ-
is crucial to prevent the development of
ated with prolonged hospitalization and delayed
hypopharyngeal fistula.
oral feeding with subsequent increase in cost and
Create a stable, well-shaped, adequately sized and discomfort for the patient. Its incidence ranges be-
accessible stoma.
tween 8 and 22% [1, 2].
Remember that voice rehabilitation can be There are two keystones to prevent PCF: me-
achieved at the same time as total laryngectomy
ticulous closure of the hypopharynx and tension-
(TL) or at a later stage. Fit the procedure to the
patients needs and desires. free suture line.
When the resection preserves a sufficient
amount of pharyngeal mucosa for direct closure,

P I T F A L L S
the tobacco pouch technique described in 1945
Do not attempt a primary hypopharyngeal closure by Garca-Hormaeche [3] is a good alternative to
if there is not enough remaining mucosa. the classic T-shaped closure. To create the tobac-
co pouch two parallel continuous absorbable su-
Leaving tracheal cartilage uncovered at the level of
tures are placed around the hypopharyngeal
the stoma results in delayed healing and infection.
opening. The first stitch begins below the level of
the hyoid bone and is placed 23 mm lateral to the
mucosal edge. The second suture starts above the
level of the hyoid bone and runs 5 mm lateral and
parallel to the first stitch. By gently pulling from
Introduction both ends of the sutures the mucosal edges are ap-
In spite of a more conservative approach for the proximated and turned inwards, creating a safe
treatment of patients with cancer of the larynx, TL primary closure of the hypopharynx [4].
is still the final option for many patients. A lung- When the surgeon deals with insufficient hy-
powered voice may also be achieved through a popharyngeal mucosa for direct closure, the apron
surgically created tracheoesophageal shunt. Some platysma myocutaneous flap is a fast and reliable
technical details may result in better postopera- reconstructive method with no added morbidity.
tive functional results. Reconstruction begins by suturing the base of the

tongue to the superior base of the apron platysma Perform a posteromedial myotomy from the
flap. The lateral and inferior edges of the remain- lower level of the oropharynx to the level of the
ing strip of hypopharyngeal mucosa are sutured tracheoesophageal shunt. Once sectioned, the
to the inner surface of the apron flap [5]. The an- constrictor muscles are dissected from the sub-
terior wall of the neopharynx allows a wide food mucosa and retracted 12 cm laterally. This cre-
passage in spite of the small amount of remaining ates a wider and less resistant hypopharynx, fa-
pharyngeal mucosa. cilitating air passage through the TEP [6].
Finally, leaving a Jackson-Pratt drain along the
pharyngeal suture line provides early information
about the development of PCF, allowing prompt References
intervention. 1 Herranz J, Sarandeses A, Fernndez MF, Barro CV, Vidal JM,
Gaviln J: Complications after total laryngectomy in nonradiat-
ed laryngeal and hypopharyngeal carcinomas. Otolaryngol
Tips for Creating a Good Stoma Head Neck Surg 2000;122:892898.
A stable, adequate-sized, accessible stoma signifi- 2 Markou KD, Vlachtsis KC, Nikolaou AC, Petridis DG, Kouloulas
AI, Daniilidis IC: Incidence and predisposing factors of pharyn-
cantly improves the quality of life of the laryngec- gocutaneous fistula formation after total laryngectomy. Is there
tomized patient. Some technical tips may help the a relationship with tumor recurrence? Eur Arch Otorhinolaryn-
creation of a correct stoma. gol 2004;261:6167.
3 Garca-Hormaeche D: Avance sobre un nuevo procedimiento de
Sectioning the sternal insertion of the sterno-
cleidomastoid muscle on both sides results in a
tcnica quirrgica para realizar las laringuectomas subtotales y
totales. Rev Esp Am Laringol Otol Rinol 1945;3:99120.
4 Gaviln C, Cerdeira MA, Gaviln J: Pharyngeal closure following
4
more superficial and accessible stoma, facilitating
total laryngectomy: the tobacco pouch technique. Oper Tech
cleaning maneuvers and occlusion in patients Otolaryngol Head Neck Surg 1993;4:292302.
with voice prosthesis and speaking valves. 5 Bernldez R, Cerdeira MA, Gaviln J: Pharyngeal reconstruction
Creating a half-moon section line in the supe- with the apron platysma myocutaneous flap. Oper Tech Otolar-
yngol Head Neck Surg 1993;4:303305.
rior skin flap at the level of the trachea results in 6 Herranz J, Martnez-Vidal J: Primary tracheoesophageal punc-
a circular-shaped stoma. This also helps further ture with pharyngoesophageal myotomy. Oper Tech Otolaryngol
Head Neck Surg 1993;4:291295.
manipulation of the stoma.
Using vertical mattress stitches in the skin of
the stoma provides cutaneous coverage of the tra-
cheal cartilage, preventing cartilage exposure and
subsequent infection.
Tips for Surgical Speech Rehabilitation

Tracheoesophageal puncture (TEP) is the most
common speech rehabilitation procedure after
TL. It can be performed at the same time as tumor
removal (primary TEP) or at a later stage (second-
ary TEP). The following tips refer mainly to pri-
mary TEP.
Try to place the puncture in the midline, 1 cm
below the resection border of the trachea.
When the puncture is performed from outside
to inside, always protect the posterior wall of the
esophagus to prevent injury of the mucosa (a
spoon inside the esophagus is a very useful tool).
85
Laryngeal Tumors
4.8 How to Manage Tracheostomal Recurrence

Dennis H. Kraus
Memorial Sloan-Kettering Cancer Center, Head and Neck Service, New York, N.Y., USA

P E A R L S groove. Surgical management is feasible in the
minority of patients and the ability to cure is rel-
Perform cross-sectional imaging to determine atively remote.
involvement of the carotid artery, pharynx, trachea, Patients who are considered for surgical man-
innominate artery, and mediastinum to assess
resectability.
agement should suffer limited medical comorbid-
ities. Utilizing the Sisson staging system, stage I
Perform PET/CT imaging to exclude distant meta-
(suprastomal disease without pharyngeal involve-
static disease.
ment) or stage II (suprastomal disease with in-
Access to reconstructive surgery for pharyngeal volvement of the pharynx) is far preferable to
reconstruction and extended skin replacement and
thoracic surgery expertise for management of the
stage III (infrastomal disease without great vessel
trachea and mediastinum. involvement) or stage IV (infrastomal disease
with great vessel involvement) disease. Patients
require complete resection of the tracheostomal

P I T F A L L S
disease, a portion of the trachea, pharyngeal
Imaging often grossly underestimates extent of resection, and all involved cervical skin. Recon-
disease and fails to identify the invasive nature of struction focuses on reestablishment of the phar-
recurrent disease after laryngectomy. ynx, reconstruction of the cervical skin, and
Wound complications, including flap necrosis and reconstitution of the stoma.
fistula formation, can manifest life-endangering Postoperative complications can be life-threat-
events. ening. Wound breakdown can lead to fistula for-
Cure occurs only in 2530% of selected patients mation and the risk of rupture of the carotid and/
undergoing surgical management. or innominate artery. Patients undergoing suc-
cessful management may be considered for re-ir-
radiation, possibly with chemotherapy. Even with
aggressive treatment, approximately 2530% pa-
tients are cured of their disease. Distant metasta-
Introduction ses remain a significant risk.
Tracheostomal recurrence after laryngectomy is
an extremely challenging problem. The vast ma- Practical Tips
jority of these patients will have undergone A well-constructed plan is essential for the surgi-
chemoradiation and salvage laryngectomy. Tra- cal management of patients with tracheostomal
cheostomal disease typically represents recur- recurrence after prior laryngectomy. The follow-
rence of nodal disease in the tracheoesophageal ing suggestions should be considered:

Cross-sectional imaging to elucidate the local Conclusion
extent of disease. Absolute contraindications in- Surgical management of tracheostomal recur-
clude prevertebral fascia invasion, carotid or in- rence requires considerable judgment and skill.
nominate artery encasement, or massive medias- Patients must be evaluated to exclude those who
tinal involvement. have surgically unresectable disease or metastat-
PET/CT imaging to exclude distant metasta- ic disease. Patients best suited for this operation
ses. have limited medical comorbidities and stage I or
Preoperative esophagoscopy excludes exten- II disease.
sive esophageal invasion. The majority of patients Access to appropriate surgical colleagues, in-
will require some form of pharyngeal reconstruc- cluding plastic and reconstructive surgery, and
tion. For circumferential defects, a jejunal free potentially thoracic surgery, are integral to the
flap is employed. For anterior wall defects, a soft success of this procedure. Patients must undergo
tissue free flap can be employed. complete extirpation of the tumor if there is any
Resection of the trachea is associated with cer- hope for cure. Disease is often more extensive
vical skin resection; either pectoralis major or than what is anticipated based on preoperative
deltopectoral flap is employed to reconstruct the imaging. Patients must undergo immediate re-
cervical skin defect and affords tracheostoma reconstruction of the pharynx, the external cervical
construction. In this authors opinion, efforts at skin and the stoma. Utilizing this approach, ap-
mediastinal tracheostomy are rarely successful proximately 2530% of patients with this ad- 4
and these patients almost uniformly die of post- vanced stage disease will have long-term disease
operative complications. control.
Ipsilateral neck dissection should be performed
in instances where it was not performed previ-
ously, including aggressive dissection of the tra- References
cheoesophageal groove and upper mediastinum. 1 Baldwin CJ, Liddington MI: An approach to complex tracheosto-
mal complications. J Plast Reconstr Aesthet Surg 2007, E-pub
Preservation of both the jugular vein and the ca-
ahead of print.
rotid arterial system allows for microvascular 2 Breneman JC, Bradshaw A, Gluckman J, Aron BS: Prevention of
flap reconstruction. stomal recurrence in patients requiring emergency tracheosto-
A watertight closure of the reconstructed phar- my for advanced laryngeal and pharyngeal tumors. Cancer 1988;
62:802805.
ynx, as fistula formation with salivary leak is as- 3 Bignardi L, Gavioli C, Staffieri A: Tracheostomal recurrences af-
sociated with life-endangering carotid or innom- ter laryngectomy. Arch Otorhinolaryngol 1983;238:107113.
4 Gluckman JL, Hamaker RC, Schuller DE, Weissler MC, Charles
inate artery hemorrhage. GA: Surgical salvage for stomal recurrence: a multi-institutional
Barium swallow is utilized to assess for pha- experience. Laryngoscope 1987;97:10251029.
ryngeal leak. Prolonged enteral feeding can be 5 McCarthy CM, Kraus DH, Cordeiro PG: Tracheostomal and cer-
vical esophageal reconstruction with combined deltopectoral
utilized when necessary. flap and microvascular free jejunal transfer after central neck
A significant proportion of patients develops exenteration. Plast Reconstr Surg 2005;115:13041310.
6 Sisson GA Sr: 1989 Ogura memorial lecture: mediastinal dissec-
both postoperative hypocalcemia and hypothy- tion. Laryngoscope 1989;99:12621266.
roidism and requires appropriate replacement. 7 Yuen AP, Ho CM, Wei WI, Lam LK: Prognosis of recurrent laryn-
Consideration of re-irradiation with or with- geal carcinoma after laryngectomy. Head Neck 1995;17:526
530.
out chemotherapy is performed on a case-by-case 8 Yuen AP, Wei WI, Ho WK, Hui Y: Risk factors of tracheostomal
basis. recurrence after laryngectomy for laryngeal carcinoma. Am J
Utilizing this aggressive approach, approxi- Surg 1996;172:263266.
mately 2530% of these selected patients will be

salvaged.
87
Laryngeal Tumors
4.9 Stenosis of the Tracheostoma following

Total Laryngectomy
Eugene N. Myers

P E A R L S sema [1], difficulty in expelling mucus, the poten-
tial for complete obstruction due to excessive
Every effort should be made to prevent tracheosto- crusting or a mucous plug and inability to remove
mal stenosis. and insert the speaking valve.
Patients with tracheostomal stenosis should receive Factors contributing to tracheostomal stenosis
a trial of conservative treatment using progressively include radiation therapy, wound dehiscence
larger diameter laryngectomy tubes and stents.
with healing by second intention, inadequate ex-
The surgical techniques used should be as simple as cision of redundant peristomal skin and adipose
possible. tissue, devascularization of the trachea, postop-
erative infection, and excessive scar tissue forma-

P I T F A L L S tion. Stomal recurrence of cancer should be ruled
out in patients with apparent peristomal stenosis.
Peristomal recurrence of cancer should be ruled out
Modifications of technique may help to prevent
prior to contemplating revision surgery.
peristomal stenosis.
Patients who have been treated with radiation
therapy should not be considered candidates for
surgical revision because of the probability of poor Practical Tips
healing and restenosis. Every effort should be made to rule out peri-
stomal recurrence of cancer prior to embarking
Poor nutrition leads to poor wound healing so
on a treatment program.
the nutritional status of the patient should be
optimized prior to revision surgery. Prevention of stomal stenosis should be a part
of preoperative planning. Patients who have risk
factors for stomal stenosis demand special atten-
tion to prevent this problem.
Technical modifications to prevent stenosis
Introduction should include oblique section of the tracheal
Stenosis of the tracheostoma is an infrequent but stump to increase the diameter of the stoma, exci-
vexing problem which may occur despite meticu- sion of excess adipose tissue from the peristomal
lous attention to the construction of the tracheo- skin and complete coverage of the cut edge of the
stoma. Although stenosis usually occurs within trachea with skin.
months following laryngectomy, it may also oc- The patient is instructed to wear a No. 8 laryn-
cur years later. Tracheostomal stenosis may cause gectomy tube at night for 6 months while the sto-
respiratory insufficiency in patients with emphy- ma is maturing. During the day a soft silastic

stent is worn in which an opening has been placed Conclusion
in its posterior aspect, which makes it possible to Tracheostomal stenosis is usually preventable.
use the speaking valve. However, when it occurs, conservative treatment
Initial management of tracheostomal stenosis with a laryngectomy tube usually suffices. A few
should be conservative. This includes dilation of patients will require revision surgery which
the stoma with the insertion of progressively larg- should be kept as simple as possible. Revision sur-
er laryngectomy tubes and the eventual insertion gery is contraindicated in radiated patients. Peri-
of a plastic stomal button. stomal recurrence of cancer should be ruled out
Patients who have had radiation therapy to the prior to formulating a treatment program.
larynx should be managed conservatively rather
than surgically since the radiated tissues do not
heal well. References
The most common type of stenosis is a band of 1 Wax MK, Touma J, Ramadan HH: Tracheostoma stenosis after
laryngectomy: incidence and predisposing factors. Otolaryngol
scar tissue which is shelf-like in appearance and
Head Neck Surg 1995;113:242247.
concentrically narrows the stoma. The goals of 2 Myers EN, Gallia LJ: Tracheostomal stenosis following total lar-
revision surgery are to excise the concentric skin yngectomy. Ann Otol Rhinol Laryngol 1982;91:450453.
and to prevent it from recurring.
The surgical technique we first described [2]
has proved to be very simple and reliable in solv- 4
ing the problem of tracheal stomal stenosis. This
technique includes excising the shelf-like scar, de-
fatting the surrounding skin and meticulously
approximating the skin to the trachea making
certain that the cartilage is completely covered. A
1-cm incision is made in the membranous poste-
rior wall of the trachea and a small pedicle flap
derived from the skin posterior to the stoma is
sewn into the incision in the posterior wall of the
trachea to prevent restenosis.
A smaller flap is necessary in patients with a
tracheoesophageal speaking valve.
89
Laryngeal Tumors
4.10 How to Prevent and Treat

Pharyngocutaneous Fistulas after
Laryngectomy
Bhuvanesh Singh
Laboratory of Epithelial Cancer Biology, Head and Neck Service, Memorial Sloan-Kettering Cancer Center,
New York, N.Y., USA

P E A R L S deliver chemotherapy concomitantly with radia-
tion, which rarely allows for early detection of fail-
The rate of fistula formation (FF) nearly doubles in ures [13]. The benefits from concomitant chemo-
the setting of prior chemoradiation treatment.
radiation treatment are tempered by higher rates
Prevention of FF is the best treatment and starts of short- and long-term treatment-related sequel-
with an atraumatic surgical technique. ae. This is particularly relevant in patients that fail
A stepwise approach to pharyngeal reconstruction to respond to this treatment approach, having to
is advocated, beginning with tension-free horizon- endure the adverse effects of treatment without
tal closure, reinforcement of the suture line with
any appreciable benefit. Salvage laryngeal surgery
suprahyoid and pharyngeal constrictor muscula-
ture, bolstering the closure with a pectoralis poses a complex problem for the head and neck
muscle-only flap and using free flaps for larger surgeon [4]. The tissue is less vascularized and of-
defects. ten has a reduced healing capacity, increasing the
risk of FF [58]. Published results and our own

P I T F A L L S experience suggest that the fistula rate is doubled
in this setting, prompting changes in standard ap-
Tension or T closures are prone to FF. proaches to pharyngeal closure.
Lack of introduction of vascularized tissue can
increase risk of fistulization. Practical Tips
Several intraoperative measures should be un-
dertaken to minimize risk of FF.
a) Minimize mucosal devascularization. It is
Introduction imperative to minimize the manipulation of mu-
Once considered the cornerstone for the manage- cosa during the course of resection. In addition,
ment of advanced larynx cancer, laryngectomies all mucosal incisions should be made with the
are now reserved for large tumors with extrala- cutting current of the Bovie (or cold steel).
ryngeal extension or, more commonly, for salvage b) Maximize mucosal preservation. A tension-
after failure of either radiation or chemoradiation free closure is an essential component in prevent-
treatment. Although the initial organ preserva- ing FF. This is best accomplished by preserving as
tion trials allowed selection of patients for early much of the mucosa as is oncologically safe. Spe-
salvage surgery, the current state of the art is to cific attention must be paid to preservation of the

pyriform sinuses and the mucosa of the lingual diated patients, and a PEG tube should be consid-
surface of the epiglottis. ered to maintain nutrition. Wound care and
Closure of the pharyngeal defect is also a key packing should be continued until the fistula re-
consideration. solves.
a) As discussed above, vascularized mucosa c) In cases of larger or refractory fistulas, op-
and a tension-free closure are of paramount im- erative correction using vascularized tissue
portance. Prior to starting the closure, examine should be considered after all infection is
the mucosal edges and resect any nonviable or cleared.
poorly vascularized mucosa.
b) A horizontal closure is preferred over a T Conclusions
closure. This also has the benefit of maximizing Salvage laryngectomy after concomitant chemo-
the nasopharyngeal aperture. radiation is associated with an increased risk of
c) A second layer of sutures is advocated to FF. A graded approach, beginning with care of the
bolster the closure. This can be performed by ap- local tissue during reaction, attention to the pha-
proximating the pharyngeal constrictors to the ryngeal closure and early introduction of visual-
suprahyoid and tongue-based musculature. ized tissues, is required to optimize surgical re-
Introduction of vascularized tissues should be sults.
considered for any nonoptimal pharyngeal clo-
sures. 4
a) If adequate mucosa is present, a muscle-only References
pectoralis flap is an excellent way to reinforce the 1 Pfister DG, Laurie SA, Weinstein GS, et al: American Society of
Clinical Oncology clinical practice guideline for the use of lar-
pharyngeal closure, while simultaneously intro-
ynx-preservation strategies in the treatment of laryngeal cancer.
ducing well-vascularized, nonirradiated tissues J Clin Oncol 2006;24:36933704.
to the neck. 2 Induction chemotherapy plus radiation compared with surgery
plus radiation in patients with advanced laryngeal cancer. The
b) In general, when inadequate mucosa is pres- Department of Veterans Affairs Laryngeal Cancer Study Group.
ent for a tension-free closure, a patch-type clo- N Engl J Med 1991;324:16851690.
sure of the defect either with a regional or free 3 Forastiere AA, Goepfert H, Maor M, et al: Concurrent chemo-
therapy and radiotherapy for organ preservation in advanced la-
flap is not advocated. In this setting, separations ryngeal cancer. N Engl J Med 2003;349:20912098.
between the native tissue and that brought in by 4 Ganly I, Patel S, Matsuo J, et al: Postoperative complications of
the flap are a high risk. salvage total laryngectomy. Cancer 2005;103:20732081.
5 Disa JJ, Pusic AL, Mehrara BJ: Reconstruction of the hypophar-
c) A total laryngopharyngectomy is often a ynx with the free jejunum transfer. J Surg Oncol 2006;94:466
better option in cases where inadequate mucosa 470.
6 Gilbert RW, Neligan PC: Microsurgical laryngotracheal recon-
remains. Reconstruction can be performed using struction. Clin Plast Surg 2005;32:293301.
a variety of free flaps, including the jejunum and 7 Teknos TN, Myers LL, Bradford CR, Chepeha DB: Free tissue re-
tubed cutaneous (lateral thigh) or mucosal (gas- construction of the hypopharynx after organ preservation ther-
apy: analysis of wound complications. Laryngoscope 2001;111:
troomental) flaps. 11921196.
Once a fistula develops, aggressive manage- 8 Fung K, Teknos TN, Vandenberg CD, et al: Prevention of wound
ment is required. complications following salvage laryngectomy using free vascu-
larized tissue. Head Neck 2007;29:425430.
a) Most fistulas will manifest within 410
days. Delayed fistulas can occur in chemoirradi-
ated patients up to 4 weeks after surgery.
b) If a fistula is suspected, the wound should
be controlled by widely opening and packing the
wound. Healing is usually delayed in chemoirra-
91
5.1 How to Treat Small Hypopharyngeal

Primary Tumors with N3 Neck
Abro Rapoport, Marcos Brasilino de Carvalho
Head and Neck Surgeons, Hospital Heliopolis, So Paulo, Brazil

Epidermoid carcinoma of the hypopharynx is one
In malnourished patients, endeavor to reverse the of the most lethal types of cancer in the head and
process of weight loss before instituting any onco- neck region. Because of its anatomical location
logical therapeutic measure. Patients presenting
cachexia do not benefit from standard oncological
very close to the larynx, the therapeutic planning
treatment; palliative measures for nutritional is almost always based on surgery and postopera-
support and pain control offer better quality of life. tive radiotherapy, usually including total laryn-
gectomy in order to obtain adequate surgical

P I T F A L L S margins [1]. This type of cancer develops in the
mucosa of a region that is in permanent motion
Patients with hypopharyngeal cancer are often and presents a rich network of lymphatic capillar-
chronic alcoholics. If surgical treatment is decided ies that are quickly reached by the infiltration of
on, they may become uncooperative during the
the lesion. These factors, together with the fact
immediate postoperative period, removing the
nasoenteral tube, adopting an inappropriate that these tumors are generally less differentiated,
oral diet, neglecting bandage hygiene and also explain why voluminous regional metastases re-
manifesting alcohol withdrawal symptoms. lated to relatively small primary lesions are fre-
Large metastatic lymph nodes in hypopharyngeal quently observed. Because the presence of lymph
carcinoma cases are often at level III. Extracapsular node metastases is the single prognostic factor
invasion may involve the carotid bulb, making the that has the greatest impact, and considering that
lymph nodes irresectable. The results after shaving macroscopic rupture of the capsule drastically re-
the carotid sheath with the aim of reducing the
duces disease control rates, specialists are often
tumor mass are ineffective in preventing recur-
rence, even with associated radiotherapy, and this faced with the dilemma of recommending aggres-
may predispose towards vessel rupture. sive treatment comprising surgery, radiotherapy
and/or chemotherapy, with all the associated
Patients with advanced metastatic disease present
morbidity, disproportionately set against an un-
a great risk of recurrence, both regional and distant.
satisfactory quality of life and short survival [2].
Many studies have shown survival results equiva-
lent to classical surgical treatment with postop-
erative radiotherapy, using organ preservation
protocols based on a combination of chemother-
apy and radiotherapy, among patients with ad-
vanced yet resectable tumors [3].

Small hypopharyngeal tumors presenting If, when a dose of 4,000 cGy is reached, the
with advanced cervical metastasis should be can- lymph node has reduced in size and has turned
didates for treatment plans that offer the best pos- out to be mobile, the opportunity to remove it
sible quality of life. Therefore, partial pharyngec- may be taken, leaving a 2-week interval in the ir-
tomy with total laryngectomy should be avoided, radiation program.
because the extent of the regional dissemination
is an ominous prognostic factor. It is not justifi- Conclusion
able to be preoccupied with the evolution of the Initial neoplasia of the hypopharynx associated
primary lesion, as ultimately the condition of the with advanced metastatic disease presents a
lymph nodes will define the outcome. The pres- poor prognosis, independent of the treatment
ence of an N3 neck usually impairs regional dis- method.
ease control. Concomitant chemoradiotherapy
regimens may offer better preservation of speech
and swallowing. If, by the end of the irradiation, References
the lymph node metastasis has responded com- 1 Moyer JS, Wolf GT, Bradford CR: Current thoughts on the role of
chemotherapy and radiation in advanced head and neck cancer.
pletely or has reduced in size and become mobile,
Curr Opin Otolaryngol Head Neck Surg 2004;12:8287.
planned selective neck dissection may be indicat- 2 Carvalho MB: Quantitative analysis of the extent of extracapsu-
ed, in order to remove the lymph node chains that lar invasion and its prognostic significance: prospective study of
170 cases of carcinoma of larynx and hypopharynx. Head Neck
potentially have the greatest possibility of con- 1998;20:1621.
taining residual disease. Small primary lesions 3 Koch WM, Lee DJ, Eisele DW, Miller D, Poole M, Cummings CW,
generally respond well to preservation regimens, Forastiere A: Chemoradiotherapy for organ preservation in oral
and pharyngeal carcinoma. Arch Otolayngol Head Neck Surg
but advanced metastases present a high risk of 1995;121:974980.
regional and distant recurrence [4]. 4 Clark J, Li W, Smith G, Jackson M, Tin MM, OBrian C: Outcome
of treatment for advanced cervical metastatic squamous cell car-
Practical Tips
cinoma. Head Neck 2005;27:8794.
5 Goldstein DP, Karnell LH, Christensen AJ, Funk GF: Health re-
5
Patients with advanced metastatic disease gener- lated quality of life profiles based on survivorship status for head
and neck cancer patients. Head Neck 2007;29:221229.
ally progress with inoperable regional recurrence 6 Funk GF, Karnell LH, Smith RB, Christensen AJ: Clinical sig-
that rapidly becomes ulcerated and necrotic, with nificance of health status assessment measures in head and neck
bleeding. This leads to death with great suffering, cancer. What do quality-of-life scores mean? Arch Otolaryngol
Head Neck Surg 2004;130:825829.
due to cachexia or hemorrhage caused by inva-
sion and rupture of the carotid artery. Thus, it is
recommendable to anticipate these events when-
ever possible, so as to control or delay them, given
that advanced metastatic cervical disease short-
ens survival and reduces the quality of the re-
maining life [5].
The patients who come for treatment already
present a significant degree of malnutrition. In-
sertion of a nasoenteral tube right at the first con-
sultation may reduce the weight loss and enables
the patients to receive the full irradiation dose
planned [6].
93
5.2 Practical Tips to Reconstruct a Total

Laryngectomy/Partial Pharyngectomy
Defect
Dennis H. Kraus
Memorial Sloan-Kettering Cancer Center, Head and Neck Service, New York, N.Y., USA

P E A R L S with recurrent tumors in this setting. Even with
the use of nonirradiated tissue transfer to close
Endoscopic assessment preoperatively to deter- the defect, there is severe wound healing impair-
mine extent of disease is critical. ment, and many patients will develop a transient
Access to reconstructive techniques, such as a fistula.
pedicle flap (pectoralis major myocutaneous flap) Extreme care must be taken in performing
or free tissue transfer (radial forearm or lateral thigh
closure of the combined laryngectomy/partial
free flap) will be necessary in most patients.
pharyngectomy defect. Submucosal disease is ex-
Rarely is a tension-free, primary closure feasible, tremely common and determination of recon-
given that the majority of patients represent
structive technique should not be performed un-
radiation failures. The risk of fistula is extremely
high, even when a flap closure is performed. til tumor-free margins have been obtained on
frozen section. The ability to perform primary
closure is extremely limited. Approximately 90

P I T F A L L S
95% of patients will require a patch closure of the
Many radiation or chemoradiation failure patients soft tissue defect. The decision to utilize a pecto-
have extensive submucosal diseases, which is often ralis flap versus a free tissue transfer will be based
underestimated. on a number of factors: expertise and preference
The majority of patients are severely malnourished, of the reconstructive surgeon, patient comorbidi-
due to the impact of dysphagia from prior ties, and availability of donor free flap vessels.
radiation-based treatment. Despite all the described precautions, patients
Impaired wound healing is associated with recur- undergoing reconstruction of a laryngectomy/
rent disease in the postradiation setting, even with pharyngectomy defect remain at a high risk of
the use of nonirradiated flap reconstruction. fistula formation. Many of these fistulas will re-
solve with conservative management.
Introduction Practical Tips

The vast majority of patients who undergo laryn- Closure/reconstruction of a partial pharyngec-
gectomy with partial pharyngectomy represent tomy/laryngectomy defect is a formidable under-
chemoradiation failures. Thus, the vast majority taking. The following suggestions should be
of them will require flap reconstruction of employed to minimize fistula formation/wound
the large soft tissue defect, which is associated complications:

Endoscopic/laryngoscopic assessment of tu- In patients in whom fistulas become evident,
mor extent is critical. The propensity for submu- there should be wide opening of the skin. Appro-
cosal disease often leads to underestimation of priate wound packing should be performed with
the extent of partial pharyngectomy. acute use of antibiotics. In the majority of pa-
Use of frozen section margins is essential to tients, the fistula will resolve without additional
avoid microscopic or intralymphatic residual dis- surgery. A small proportion of patients will re-
ease. quire a secondary flap closure.
Flap choice for closure of the defect is critical. Due to the high risk of fistula formation, sec-
Patients who have undergone previous bilateral ondary tracheoesophageal puncture is often the
neck dissections or those with extensive medical treatment choice for this author.
comorbidities are better served with a pectoralis
major myocutaneous flap reconstruction. Conclusion
Use of free tissue transfer is most commonly In this chapter, the reader was exposed to the
associated with patients who have limited medi- challenging management of patients undergoing
cal comorbidities and have not undergone prior total laryngectomy with partial pharyngectomy.
bilateral neck dissections. In performing neck The vast majority of these patients will require
dissection, every effort should be made to pre- flap closure. Despite all the previously identified
serve the internal jugular vein and branches of precautions, a significant portion of these pa-
the external carotid artery. tients will develop fistulas and in some cases, sec-
A tension-free, water-tight seal should be per- ondary surgeries.
formed between the native pharynx and the
transferred flap. Often, localized tissues, such as
the strap muscles or the sternocleidomastoid References
muscle, are used as a second layer closure over the
anastomosis site.
1 Kraus DH, Pfister DG, Harrison CB, Spiro RH, Strong EW, Zelef-
sky M, Bosl GJ, Shah JP: Salvage laryngectomy for unsuccessful 5
larynx preservation therapy. Ann Otol Rhinol Laryngol 1995;
The majority of patients have had prior place- 104:936941.
ment of a PEG feeding tube, and this allows for 2 Lydiatt W, Kraus DH, Cordeiro P, Hidalgo D, Shah JP: Posterior
pharyngeal carcinoma resection with larynx preservation and
reinstitution of enteral feeding within 2448 h of radical forearm free flap reconstruction: a preliminary report.
surgery. In addition, many patients are at high Head Neck Surg 1996;18:501505.
risk for hypothyroidism and consideration should 3 Ganly I, Patel S, Matsuo J, Singh B, Kraus DH, Boyle JO, Wong R,
Lee N, Pfister DG, Shaha A, Shah JP: Postoperative complications
be given to thyroid replacement. of salvage total laryngectomy. Cancer 2005;103:20732081.
Due to the high risk of fistula formation, per- 4 Cheng E, Ho ML, Ganz C, Shaha A, Boyle JO, Singh B, Wong R,
oral feeding is delayed for 26 weeks. Barium Patel SG, Shah JP, Branski RC, Kraus DH: Outcomes of primary
and secondary tracheoesophageal puncture: a 16-year retrospec-
swallow will successfully identify a small suture tive analysis. Ear Nose Throat J 2006;85:262, 264267.
dehiscence, and oral feeding can be delayed an
additional 23 months.
95
5.3 Practical Tips for Voice Rehabilitation

after Pharyngolaryngectomy
Frans J.M. Hilgersac, Michiel van den Brekel a, b
a Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, b Academic Medical Center and
c Institute of Phonetic Sciences, University of Amsterdam, Amsterdam, The Netherlands

P E A R L S ic voice quality, and a method optimal for creat-
ing a functional food passage might not be opti-
Prosthetic voice rehabilitation, also after total mal for prosthetic voicing.
pharyngolaryngectomy, is the method of choice for
restoration of oral communication.
Practical Tips
When deciding about the optimal reconstruction Primary puncture with immediate insertion of
method for the pharynx, the quality of the pros-
an indwelling voice prosthesis is almost always an
thetic voice and the possibility to restore functional
speech should be taken into account, in addition to option, as long as the puncture site in the esopha-
the obvious concern to restore oral intake, e.g. the gus is intact, and if still present, always myoto-
use of a tubed fasciocutaneous flap instead of a mize the cricopharyngeus muscle to prevent
jejunum transfer. hypertonicity [2]. Only after a gastric pull-up,
secondary puncture is to be preferred.

P I T F A L L There are several options to reestablish a pat-
ent pharynx:
Although in most instances primary tracheoesoph- After total laryngectomy, with only a strip of
ageal puncture (TEP) with immediate insertion of
an indwelling prosthesis is feasible, in case of a
mucosa left that is inadequate for a circumferen-
gastric pull-up, secondary tracheogastric puncture tial closure (<23 cm wide), use a pectoralis major
with immediate prosthesis insertion (e.g. after 4 myocutaneous flap as a patch to form the ante-
weeks) is advisable to limit the risk of nonunion of rior wall of the neopharynx. If not prohibited for
the posterior wall of the trachea and the gastric oncological reasons, leaving this strip of mucosa
tube.
in situ, because of its similar vibratory behavior
as in a primarily closed pharynx, will result in
good voice quality in many patients.
After circumferential pharyngectomy without
Introduction gastric pull-up, several options are available. A
With the advent of voice prostheses, prosthetic free revascularized jejunum interposition in com-
vocal rehabilitation has gained widespread popu- bination with a voice prosthesis is not ideal. The
larity, also after extensive pharyngeal resections voice is often wet and bubbly due to the continu-
and reconstructions [1]. The pharynx reconstruc- ous production of intestinal fluids and the voice
tion method plays an important role in prosthet- is regularly blocked by the untreatable autono-

mous peristalsis. Occasionally, swallowing is store speech after this major surgery. The overall
problematic due to a siphon-like deformation of results are comparable to those achievable after
the graft. A better option is a free revascularized standard total laryngectomy, but the voice qual-
graft of the tubed greater curvature of the stom- ity is somewhat lower [6]. Nevertheless, prosthet-
ach [3]. Harvesting a portion of the greater cur- ic voice rehabilitation should be attempted in the
vature and stapling this into a tubular 3-cm di- vast majority of patients, in order to improve
ameter flap is not more difficult than obtaining a quality of life.
free jejunum graft. However, most head and neck
surgeons do not want to increase the morbidity of
the surgery by adding an abdominal procedure, References
and therefore prefer tubed revascularized skin 1 Hilgers FJM, Hoorweg JJ, Kroon BBR, Schaeffer B, de Boer JB,
Balm AJM: Prosthetic voice rehabilitation with the Provox sys-
flaps, e.g. the radial forearm flap or the anterolat-
tem after extensive pharyngeal resection and reconstruction; in
eral thigh flap [4, 5]. With both flaps, acceptable Algaba J (ed): 6th International Congress on Surgical and Pros-
voice quality and swallowing results have been thetic Voice Restoration after Total Laryngectomy. Excerpta
Medica International Congress Series, San Sebastian, 1995, pp
described. The risk of stenosis should not be un- 111120.
derestimated, and some form of fish mouthing 2 Op de Coul BM, van den Hoogen FJ, Van As CJ, Marres HA,
the flap into the inferior (esophageal) suture line Joosten FB, Manni JJ, Hilgers FJ: Evaluation of the effects of pri-
mary myotomy in total laryngectomy on the neoglottis with the
should be attempted. use of quantitative videofluoroscopy. Arch Otolaryngol Head
When circumferential pharyngolaryngectomy Neck Surg 2003;129:10001005.
and esophagectomy are indicated, a gastric pull- 3 Genden EM, Kaufman MR, Katz B, Vine A, Urken ML: Tubed
gastro-omental free flap for pharyngoesophageal reconstruc-
up is required; a tubed stomach transfer is to be tion. Arch Otolaryngol Head Neck Surg 2001;127:847853.
preferred over transposition of the complete 4 Kelly KE, Anthony JP, Singer M: Pharyngoesophageal recon-
struction using the radial forearm fasciocutaneous free flap: pre-
stomach, because of the easier transfer through liminary results. Otolaryngol Head Neck Surg 1994;111:1624.
the mediastinum and a better diameter for pros-
thetic voicing. Secondary tracheogastric punc-
5 Murray DJ, Gilbert RW, Vesely MJ, Novak CB, Zaitlin-Gencher S,
Clark JR, Gullane PJ, Neligan PC: Functional outcomes and do-
5
nor site morbidity following circumferential pharyngoesopha-
ture and insertion of a mostly 12.5 mm indwell- geal reconstruction using an anterolateral thigh flap and sali-
ing voice prosthesis are carried out after wound vary bypass tube. Head Neck 2007;29:147154.
healing has been completed. In case of postop- 6 Op de Coul BM, Hilgers FJ, Balm AJ, Tan IB, van den Hoogen FJ,
van TH: A decade of postlaryngectomy vocal rehabilitation in
erative radiotherapy (RT), the prosthesis should 318 patients: a single institutions experience with consistent ap-
be inserted prior to that or, alternatively, 810 plication of provox indwelling voice prostheses. Arch Otolaryn-
weeks post-RT. Even if the trachea and tubed
stomach have not completely grown together dur-
ing secondary TEP, the sturdy flanges of an in-
dwelling prosthesis will keep the walls together.
Conclusion
Prosthetic voice rehabilitation after extensive
pharyngolaryngectomy, just like after standard
total laryngectomy, is the method of choice for
reestablishing oral communication. Poor onco-
logical prognosis, in the past often used as an ar-
gument to mainly worry about oral intake, but
not about oral communication, actually is an ex-
tra valid reason to do whatever is possible to re-
97
5.4 How to Choose the Reconstructive Method

after Total Pharyngolaryngectomy
William I. Wei, Jimmy Y.W. Chan
Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, SAR, China

The laryngopharyngeal region might be involved
The reconstruction options are only determined by malignant disease. This includes squamous
after assessing the defect following adequate cell carcinoma and very occasionally extensive
resection of the primary pathology.
carcinoma of the thyroid.
The submucosal extension of tumors in the hypo- The optimal therapy for the extensive squa-
pharynx after radiation is more extensive than that
mous cell cancers arising from this region is rad-
of those without radiotherapy. Most of these sub-
mucosal extensions are not visible macroscopically, ical surgery followed by radiotherapy. Concur-
thus a wider margin of resection is essential for rent chemoradiation aiming to preserve the lar-
salvage surgery following radiotherapy. ynx can be applied in well-informed patients and
Branches of the thyrocervical trunk such as the in well-equipped institutions. For those patients
transverse cervical arteries are less frequently who developed recurrences after chemoradiation,
affected by radiation and atherosclerosis. They surgical salvage remains the logical option. The
should be used as the recipient vessels for micro- extent of resection depends on the extent of the
vascular free flaps.
primary tumor. Only after adequate resection is
the optimal reconstruction modality deter-

P I T F A L L S
mined.
When a pedicled myocutaneous flap is turned into
Practical Tips
a tube form for reconstruction of a circumferential
pharyngeal defect, the incidence of pharyngocuta- The high propensity of submucosal extension of
neous fistula is not negligible and this is particularly squamous cell carcinoma arising from the laryn-
so in female patients. gopharynx necessitates a wider resection margin,
The procedure of gastric pull-up is associated with especially when surgery is carried out as a salvage
some morbidity and hospital mortality and thus procedure [1]. The location and size of the tumor
should only be considered when the esophagus has in the hypopharynx determine the extent of re-
to be removed for tumor extirpation.
section and choice of reconstruction procedure
Following reconstruction, small leakage at the anas- [2]. For a small-sized tumor located in the upper
tomosis might lead to more significant dehiscence part of the hypopharynx, total laryngectomy and
of the anastomosis through contained infection.
Thus early release of the leaked saliva or construc-
partial pharyngectomy are adequate. Thus a strip
tion of a controlled pharyngostome will facilitate a of pharyngeal mucosa can be left behind to fa-
favorable outcome. cilitate reconstruction. For a similar small-sized
tumor in the lower part of the hypopharynx,

where the lumen is smaller and the circumference neck. This operation however, has a definite hos-
of the hypopharyngeal wall short, adequate re- pital mortality and morbidity as it is a major pro-
section with a clear margin would include total cedure and the surgical field involves the neck,
laryngectomy and circumferential pharyngecto- chest and abdomen [9].
my. For tumor that is located in the lower part of For those patients who had previous opera-
the hypopharynx or in the cervical esophagus, tions on the stomach, a pedicled right colon with
taking a clear resection margin inferiorly would a terminal ileum could be used to bridge the gap
mean total esophagectomy with the laryngophar- between the oropharynx and the stomach rem-
yngectomy. nant in the abdomen [10].
The optimal reconstruction modality should
have the following qualities. It should be carried
out at the same setting with the resection as a References
one-stage procedure. Hospital mortality and 1 Ho CM, Lam KH, Wei WI, Yuen PW, Lam LK: Squamous cell car-
cinoma of the hypopharynx analysis of treatment results. Head
morbidity should be low and there should be good
Neck 1993;15:405412.
return of swallowing function soon after the op- 2 Ho CM, Ng WF, Lam KH, Wei WI, Yuen AP: Radial clearance in
eration [3]. resection of hypopharyngeal cancer: an independent prognostic
factor. Head Neck 2002;24:181190.
For a partial pharyngeal defect, the pedicled 3 Wei WI: The dilemma of treating hypopharyngeal carcinoma:
myocutaneous flap offers a quick and reliable more or less: Hayes Martin Lecture. Arch Otolaryngol Head
method of reconstruction [4]. Sometimes, a mi- Neck Surg 2002;128:229232.
4 Spriano G, Pellini R, Roselli R: Pectoralis major myocutaneous
crovascular free cutaneous flap transfer, such as flap for hypopharyngeal reconstruction. Plast Reconstr Surg
the anterolateral thigh flap [5] or the rectus ab- 2002;110:14081413.
dominis flap, is used. The entire operation usu- 5 Yu P, Robb GL: Pharyngoesophageal reconstruction with the an-
terolateral thigh flap: a clinical and functional outcomes study.
ally takes longer and there is a small chance that Plast Reconstr Surg 2005;116:18451855.
the free flap might fail [6].
For a circumferential pharyngeal defect, the
6 Lam LK, Wei WI, Chan VS, Ng RW, Ho WK: Microvascular free
tissue reconstruction following extirpation of head and neck tu- 5
mour: experience towards an optimal outcome. J Laryngol Otol
optimal reconstructive option is the use of a mi- 2002;116:929936.
crovascular free jejunal graft [7]. To avoid going 7 Rosenthal E, Couch M, Farwell DG, Wax MK: Current concepts
in microvascular reconstruction. Otolaryngol Head Neck Surg
into the abdomen, a microvascular free flap such 2007;136:519524.
as the radial forearm flap or the anterolateral 8 Yu P, Lewin JS, Reece GP, Robb GL: Comparison of clinical and
thigh flap turning into a tube for the reconstruc- functional outcomes and hospital costs following pharyngo-
esophageal reconstruction with the anterolateral thigh free flap
tion of the circumferential defect has also been versus the jejunal flap. Plast Reconstr Surg 2006;117:968974.
used [8]. The stenosis at the mucocutaneous junc- 9 Wei WI, Lam LK, Yuen PW, Wong J: Current status of pharyngo-
laryngo-esophagectomy and pharyngogastric anastomosis.
tion is not negligible and affects swallowing
Head Neck 1998;20:240244.
Following total laryngopharyngectomy and 10 Sartoris A, Succo G, Mioli P, Merlino G: Reconstruction of the
esophagectomy, the extensive defect can be re- pharynx and cervical esophagus using ileocolic free autograft.
Am J Surg 1999;178:316322.
constructed by mobilizing the stomach into the
99
6.1 Indications for Surgical Treatment of

William I. Wei, Rockson Wei

P E A R L S In most regions, NPC is uncommon while the
incidence of NPC in Hong Kong, located in south-
Persistent or recurrent tumors that could be sal- ern China, was 2030/100,000 [1]. Even for those
vaged successfully are those that have not infiltrat- southern Chinese who have immigrated to other
ed the internal carotid artery or the skull base bone.
continents, the incidence of NPC remains high.
Evaluation of the status of tumor in the nasophar- Radiotherapy is the mainstay of treatment for lo-
ynx should be carried out by endoscopic examina-
coregionally confined NPC as the tumor is radio-
tion and biopsy together with imaging studies such
as computed tomography (CT) and magnetic reso- sensitive. The tumor tends to spread to paranaso-
nance imaging. pharyngeal and cervical lymph nodes, hence pro-
phylactic nodal treatment with radiation is
Surgical salvage is carried out when the disease is
mandatory. The outcome of patients who were
localized at the nasopharynx and/or in the neck.
Nasopharyngectomy and radical neck dissection treated with radiotherapy has improved signifi-
can be carried out in one session. cantly in the past 4 decades [2]. In recent years,
with the application of intensity-modulated ra-

P I T F A L L S diotherapy better tumor control with reduction
of late complications has been achieved [3]. For
Following radical resection of the disease, exposing locoregionally advanced NPC, concurrent che-
too much bone at the skull base might lead to the
moradiotherapy has emerged as the treatment of
development of osteoradionecrosis. A microvascu-
lar free muscle flap should be used to cover the choice, following the Intergroup 0099 random-
exposed bone. ized trial [4]. Despite these treatments, a small
number of patients still develop persistent or re-
After surgical salvage, follow-up examination of the
current disease where surgical salvage is indicat-
nasopharynx at regular intervals is essential to
monitor progress and to diagnose the development ed.
of a second primary tumor.
Practical Tips
After definitive treatment regular endoscopic ex-
amination of the nasopharynx should be per-
Introduction formed. Evaluation of the copies of Epstein-Barr
Nasopharyngeal carcinoma (NPC) is a squamous virus (EBV) DNA in the plasma should be carried
cell carcinoma with different degrees of differen- out to identify the submucosal tumors. The num-
tiation and has a high propensity to metastasize ber of copies of EBV DNA in the blood increases
to cervical lymph nodes. during radiotherapy, meaning that more viral

DNA is released after cell death [5]. Elevated lev- ynx, then the defect should be covered with a mi-
els of EBV DNA, however, were only detected in crovascular free muscle flap to promote healing
67% of patients with locoregional recurrence and prevent the development of osteoradionecro-
when the tumor size was small and still amenable sis. Nasopharyngectomy with a negative surgical
to salvage treatment [6]. margin provides a better chance of eradicating
The confirmation of persistent or recurrent the persistent or recurrent NPC when compared
NPC still depends on the biopsy. To plan the ap- to reirradiation or stereotactic radiation.
propriate salvage procedure, endoscopic exami-
nation of the nasopharynx evaluates the surface
extension of the tumor while the deep extension References
is best evaluated by imaging. 1 Parkin DM, Whelan SL, Ferlay J, Raymond L, Young J: Cancer
Incidence in Five Continents. Lyon, International Agency for Re-
Magnetic resonance imaging with its multi-
search on Cancer (IARC Publ No 43), 1997, vol 7, pp 814815.
planar capability gives a three-dimensional im- 2 Lee AW, Sze WM, Au JS, Leung SF, Leung TW, Chua DT, Zee BC,
pression of the tumor extension. It is also useful Law SC, Teo PM, Tung SY, Kwong DL, Lau WH: Treatment results
for nasopharyngeal carcinoma in the modern era: the Hong
in the detection of paranasopharyngeal and deep Kong experience. Int J Radiat Oncol Biol Phys 2005;61:1107
cervical nodal metastases [7]. CT should be per- 1116.
formed for the evaluation of tumor erosion of 3 Kwong DL, Pow EH, Sham JS, McMillan AS, Leung LH, Leung
WK, Chua DT, Cheng AC, Wu PM, Au GK: Intensity-modulated
bone at the skull base and perineural spread radiotherapy for early-stage nasopharyngeal carcinoma: a pro-
through the foramen ovale. Positron emission to- spective study on disease control and preservation of salivary
mography is more sensitive than CT and MR in function. Cancer 2004;101:15841593.
4 Al-Sarraf M, LeBlanc M, Giri PG, Fu KK, Cooper J, Vuong T, Fo-
the detection of persistent and recurrent tumors rastiere AA, Adams G, Sakr WA, Schuller DE, Ensley JF: Chemo-
in the nasopharynx. radiotherapy versus radiotherapy in patients with advanced na-
sopharyngeal cancer: phase III randomized intergroup study
For small and shallow tumor localized in the 0099. J Clin Oncol 1998;16:13101317.
nasopharynx, brachytherapy using radioactive 5 Lo YM, Leung SF, Chan LY, Chan AT, Lo KW, Johnson PJ, Huang
gold grains (198Au) as the radiation source can be DP: Kinetics of plasma Epstein-Barr virus DNA during radiation
therapy for nasopharyngeal carcinoma. Cancer Res 2000;60:
carried out either transnasally under endoscopic 23512355.
guidance [8] or using the split-palate approach 6 Wei WI, Yuen AP, Ng RW, Ho WK, Kwong DL, Sham JS: Quantita-
[9]. The procedure was not difficult and morbid- tive analysis of plasma cell-free Epstein-Barr virus DNA in naso-
pharyngeal carcinoma after salvage nasopharyngectomy: a pro-
ity was minimal. With this form of brachythera- spective study. Head Neck 2004;26:878883.
py employed for persistent and recurrent tumors, 7 Dillon WP, Mills CM, Kjos B, DeGroot J, Brant-Zawadzki M:
Magnetic resonance imaging of the nasopharynx. Radiology
6
the 5-year local tumor control rates were 87 and
1984;152:731738.
63%, respectively [10]. 8 Harrison LB, Weissberg JB: A technique for interstitial nasopha-
Brachytherapy, however, has its limitations in ryngeal brachytherapy. Int J Radiat Oncol Biol Phys 1987;13:
451453.
bulky or extensive tumor, when eustachian tube 9 Wei WI, Sham JS, Choy D, Ho CM, Lam KH: Split-palate ap-
cartilage is involved, and in tumor that has ex- proach for gold grain implantation in nasopharyngeal carcino-
tended to the paranasopharyngeal space; in these ma. Arch Otolaryngol Head Neck Surg 1990;116:578582.
10 Kwong DL, Wei WI, Cheng AC, Choy DT, Lo AT, Wu PM, Sham
cases surgical salvage is indicated. When skull JS: Long term results of radioactive gold grain implantation for
base bone or internal carotid artery was exposed the treatment of persistent and recurrent nasopharyngeal carci-
following resection of the tumor in the nasophar- noma. Cancer 2001;91:11051113.
101
6.2 Practical Tips to Perform a Maxillary

Swing Approach
William I. Wei, Raymond W.M. Ng

Anatomically, the nasopharynx is located in the
The holes for the screws on miniplates are drilled center of the head; it is difficult to get adequate
before the osteotomies; this ensures precise bony exposure to remove pathologies in the region. Pa-
reassembly on closure.
thologies in the nasopharynx may arise from its
The free mucosa graft harvests from the removed wall or from the vicinity extending into the naso-
inferior turbinate on the side of the swing should
pharynx. These include schwannoma, sarcoma
be thinned to facilitate the graft take over the
raw area in the nasopharynx after the maxillary and chordoma.
swing procedure. The antererolateral route, the maxillary swing
approach, gives good exposure of the nasophar-
The posterior portion of nasal septum is removed
ynx and central skull base for an oncological re-
to enable adequate visualization and resection of
the opposite nasopharynx. section. The most frequent application of this
The internal carotid artery lies outside the pharyn- procedure is for surgical salvage of persistent or
gobasilar fascia which might be quite thick after recurrent nasopharyngeal carcinoma after radio-
radiation. Palpation of the internal carotid artery therapy or concurrent chemoradiotherapy.
through this might be difficult. A small additional
neck incision will allow identification of the internal Practical Tips
carotid artery in the neck; this can be traced up-
wards and the finger in the neck will reach superi-
As the most persistent or recurrent nasopharyn-
orly to meet the finger in the nasopharynx, thus geal carcinomas are located on the lateral wall of
locating precisely the internal carotid artery. the nasopharynx, closely associated with the ori-
fice of the eustachian tube, a curative oncological

P I T F A L L S resection should always include these structures.
Step serial sectioning of nasopharyngectomy
The internal carotid artery might sometimes be specimens has shown that persistent or recurrent
completely exposed after nasopharyngectomy. nasopharyngeal carcinomas exhibit extensive
A microvascular free muscle flap should be em-
submucosal spread and a wide resection of the
ployed to cover the exposed internal carotid artery.
nasopharynx is mandatory for a favorable out-
The majority of patients develops some degree of come [1].
trismus after the maxillary swing procedure, partic-
ularly if they have been irradiated. It is important to
The facial incision is the Weber-Ferguson-
start passive stretching once wound healing has Longmire incision as for maxillectomy and this
been completed to reduce this morbidity. continues between the central incisor teeth onto
the hard palate. Initially, this incision on the pal-

ate continues in the midline and then turns later- For those patients with localized persistent
ally along the attachment of the soft palate to the or recurrent nasopharyngeal carcinoma after
hard palate [2]. Soft tissue over the anterior wall chemoradiation, surgical salvage offers the best
of the maxilla is lifted, just enough to expose a outcome [4]. The 5-year actuarial control of tu-
narrow strip of anterior bony wall of the maxilla mors in the nasopharynx has been reported to be
for osteotomy below the orbital floor. The hard 65% and the 5-year disease-free survival rate was
palate is divided in the midline and a curved os- around 54% [5, 6]. Some irradiated patients devel-
teotome is used to separate the maxillary tuberos- oped palatal fistula; however, with modification
ity from the pterygoid plates. The maxilla at- of the palatal incision, separating soft tissue inci-
tached to the cheek flap can be swung laterally as sion and the osteotomy, there was no more palatal
an osteocutaneous complex to expose the central fistula [7]. Nasopharyngectomy with this ap-
skull base including the nasopharynx and pa- proach also does not affect the quality of life [8].
ranasopharyngeal space. The pterygoid plates to-
gether with the pterygoid muscle can be removed
to improve exposure of the paranasopharyngeal References
space. Lesions in the nasopharynx and central 1 Wei WI: Carcinoma of the nasopharynx. Adv Otolaryngol Head
Neck Surg 1998;12:119132.
skull base can all be removed under direct vision
2 Wei WI, Lam KH, Sham JS: New approach to the nasopharynx:
[3]. The carotid artery lying external to the pha- the maxillary swing approach. Head Neck 1991;13:200207.
ryngobasilar fascia can also be dissected from the 3 Wei WI, Ho CM, Yuen PW, Fung CF, Sham JS, Lam KH: Maxil-
lary swing approach for resection of tumors in and around the
pathology under direct vision. nasopharynx. Arch Otolaryngol Head Neck Surg 1995;121:638
After extirpation of the lesion in the naso- 642.
pharynx, the maxilla attached to the anterior 4 Wei WI, Sham JS: Nasopharyngeal carcinoma. Lancet 2005;365:
20412054.
cheek flap can be returned and fixed to the rest 5 Wei WI: Nasopharyngeal cancer: current status of management.
of the facial skeleton using miniplates or micro- Arch Otolaryngol Head Neck Surg 2001;127:766769.
plates. A prefabricated dental plate is also used 6 Wei WI: Cancer of the nasopharynx: functional surgical salvage.
World J Surg 2003;27:844848.
to facilitate the precise return of the maxilla. 7 Ng RW, Wei WI: Elimination of palatal fistula after the maxillary
A nasal pack is frequently used for a few days swing procedure. Head Neck 2005;27:608612.
8 Ng RW, Wei WI: Quality of life of patients with recurrent naso-
and a nasogastric tube is inserted for 1 week for pharyngeal carcinoma treated with nasopharyngectomy using
feeding. the maxillary swing approach. Arch Otolaryngol Head Neck
Surg 2006;132:309316. 6
103
6.3 Management of Neck Metastases of

Nasopharyngeal Carcinoma
William I. Wei, W.K. Ho

Nasopharyngeal carcinoma has a high propensity
Over 50% of patients suffering from nasopharyn- to metastasize to cervical lymph nodes. In a ret-
geal carcinoma present with cervical lymph node rospective study reporting the clinical features of
metastasis and most of them respond to concurrent
chemoradiotherapy.
4,768 patients, enlarged neck nodes were seen in
74.5% of the patients [1].
When the lymph node metastases persist or recur
As nasopharyngeal carcinoma is chemoradio-
after the primary treatment, malignant cells are
found in multiple lymph nodes with extensive sensitive, the primary treatment modality of the
infiltration. metastatic lymph node is concurrent chemora-
diation. When the neck nodes persist or recur af-
For those extensive neck metastases which
ter the primary treatment, surgical salvage is in-
infiltrate the floor of the neck, brachytherapy in
addition to radical neck dissection enhances dicated. For those patients with extensive recur-
control of neck disease. rent disease in the neck, brachytherapy should be
employed in addition to radical neck dissection

P I T F A L L S to improve the local control.
Parallel McFee incisions are recommended for Practical Tips

necks which were irradiated. Raising the neck skin
The detection of cervical lymph node metastases
should be done precisely, as skin necrosis might
lead to significant morbidities. has improved with cross-sectional imaging stud-
ies and functional imaging, such as positron
Despite positive findings on clinical examination,
emission tomography. Confirmation of the pres-
imaging studies and other investigations, 7%
of radical neck dissection specimens showed no ence of malignancy in these lymph nodes can be
viable tumor cell. achieved through fine needle aspiration cytology.
In view of the high incidence of occult cervical
lymph node metastases, prophylactic neck radia-
tion is recommended for all patients and this has
shown that locoregional control has improved [2].
In recent years, with the application of intensity-
modulated radiotherapy, only 1 patient out of 83
developed failure in the regional lymph nodes at
a 3-year follow-up [3]. For patients with advanced
nodal disease, the incidence of failure in the neck

following concurrent chemoradiation was as high defect should be reconstructed with nonirradi-
as 33% [4]. ated skin such as a deltopectoral flap, lateral tho-
For patients with nasopharyngeal carcinoma, racic flap [9] or a pectoralis major myocutaneous
when their cervical lymph nodes do not regress flap. For those patients with extensive neck dis-
completely by 3 months after completion of con- ease, with this form of adjuvant therapy, the local
comitant chemotherapy and radiotherapy, it is tumor control rate has been reported to be com-
likely that there was residual disease in the parable to when radical neck dissection alone was
nodes. performed for less extensive neck disease [10].
Fine needle aspiration cytology of the node
frequently yields inconclusive results due to the
increased fibrosis and the specificity of diagnosis References
is around 75% [5]. Positron emission tomography 1 Lee AW, Foo W, Law SC, Poon YF, Sze WM, O SK, Tung SY, Lau
WH: Nasopharyngeal carcinoma: presenting symptoms and du-
has been shown to be able to detect regional re-
ration before diagnosis. Hong Kong Med J 1997;3:355361.
currence in over 90% of patients [6]. 2 Lee AW, Lau WH, Tung SY, Chua DT, Chappell R, Xu L, Siu L, Sze
The surgical procedure of salvage is radical WM, Leung TW, Sham JS, Ngan RK, Law SC, Yau TK, Au JS,
OSullivan B, Pang ES, O SK, Au GK, Lau JT; Hong Kong Naso-
neck dissection. The pathological behavior of pharyngeal Cancer Study Group: Preliminary results of a ran-
these nodal metastases in nasopharyngeal carci- domized study on therapeutic gain by concurrent chemotherapy
noma was reported through a step serial section- for regionally-advanced nasopharyngeal carcinoma: NPC-9901
Trial by the Hong Kong Nasopharyngeal Cancer Study Group. J
ing of 43 radical neck dissection specimens [7]. Clin Oncol 2005;23:69666975.
The findings showed that in over 70% of the spec- 3 Liu MT, Hsieh CY, Chang TH, Lin JP, Huang CC, Wang AY: Prog-
imens, there were more tumor-bearing lymph nostic factors affecting the outcome of nasopharyngeal carcino-
ma. Jpn J Clin Oncol 2003;33:501508.
nodes than anticipated. The distribution of the 4 Palazzi M, Guzzo M, Bossi P, Tomatis S, Cerrotta A, Cantu G,
nodes was in all five levels, although most of them Locati LD, Licitra L: Regionally advanced nasopharyngeal carci-
noma: long-term outcome after sequential chemotherapy and
were found in levels II and V. In over 60% of tu- radiotherapy. Tumori 2004;90:6065.
mor-bearing lymph nodes, there was extracapsu- 5 Toh ST, Yuen HW, Goh YH, Goh CHK: Evaluation of recurrent
lar spread and in 35%, tumor cells were seen nodal disease after definitive radiation therapy for nasopharyn-
geal carcinoma: diagnostic value of fine-needle aspiration cytol-
among the nonlymphatic tissue in the neck. In ogy and CT scan. Head Neck 2007;29:370377.
over 28% of the specimens the tumor-bearing 6 Yen TC, Chang YC, Chan SC, Chang JT, Hsu CH, Lin KJ, Lin WJ,
nodes were infiltrating or lying close to the spinal Fu YK, Ng SH: Are dual-phase 18F-FDG PET scans necessary in
accessory nerve. Thus the surgical salvage proce-

nasopharyngeal carcinoma to assess the primary tumour and
loco-regional nodes? Eur J Nucl Med Mol Imaging 2005;32:541 6
dure for the cervical lymph nodes after radiother- 548.
7 Wei WI, Ho CM, Wong MP, Ng WF, Lau SK, Lam KH: Pathologi-
apy or chemoradiation should be radical neck
cal basis of surgery in the management of postradiotherapy cer-
dissection [7]. The reported 5-year tumor control vical metastasis in nasopharyngeal carcinoma. Arch Otolaryn-
rate in the neck was 66% and the 5-year actuarial gol Head Neck Surg 1992;118:923929.
8 Wei WI, Lam KH, Ho CM, Sham JS, Lau SK: Efficacy of radical
survival was 38% [8]. neck dissection for the control of cervical metastasis after radio-
In patients with advanced neck disease, de- therapy for nasopharyngeal carcinoma. Am J Surg 1990;160:439
spite adequate radical neck dissection, micro- 442.
9 Yuen AP, Ng WM: Surgical techniques and results of lateral cu-
scopic tumor might still be left behind. After- taneous, myocutaneous, and conjoint flaps for head and neck
loading brachytherapy could be applied to the reconstruction. Laryngoscope 2007;117:288294.
surgical bed. The overlying skin, which was irra- 10 Wei WI, Ho WK, Cheng AC, Wu X, Li GK, Nicholls J, Yuen PW,
Sham JS: Management of extensive cervical nodal metastasis in
diated initially, might not be able to tolerate this nasopharyngeal carcinoma after radiotherapy: a clinicopatho-
additional brachytherapy. Thus the area of skin logical study. Arch Otolaryngol Head Neck Surg 2001;127:1457
1462.
over the brachytherapy source had to be removed
at the time of the neck dissection. This cutaneous
105
7.1 Practical Tips to Identify the Main Trunk

of the Facial Nerve
Fernando L. Diasa, b, Roberto A. Lima a, b, Jorge Pinho c
a Head
and Neck Surgery Department, Brazilian National Cancer Institute and
b Post-Graduation School of Medicine, Catholic University of Rio de Janeiro, Rio de Janeiro, and
c Memorial San Jose Hospital of Recife, Recife, Brazil

P E A R L S ular is the antegrade approach with the identifi-
cation of the main trunk first [2]. Facial nerve pa-
Identification of the anatomic landmarks is para- resis or paralysis can occur as an early complica-
mount. tion following surgical procedures involving the
The pointer of the tragal cartilage indicates the parotid gland and the CN VII. Temporary paral-
position of CN VII trunk. ysis occurs in 1030% of superficial parotidecto-
In reoperations or when the identification is ob- mies, while permanent CN VII paralysis occurs
scured (by the tumor), try the retrograde approach. in less than 1% [3].

P I T F A L L S Practical Tips
It is important to keep in mind that the anatomic
Avoid going directly to the CN VII trunk area before landmarks in the operative identification of the
identifying the anatomic landmarks.
CN VII (posterior belly of the digastric muscle,
The styloid process is not a good landmark to mastoid process, timpanic bone and esternal au-
retrieve the CN VII.
ditory canal cartilage) should always be exposed
prior to any attempt at identifying the nerve, and
that the parotid parenchyma should not be in-
cised without first locating and following the CN
Introduction VII.
The facial nerve (CN VII) exits the skull base Superficial or total parotidectomy is performed
through the stylomastoid foramen, located slight- under general anesthesia. Long-term paralytic
ly posterolateral to the styloid process and antero- agents should be avoided to allow for CN VII
medial to the mastoid process. The main trunk of monitoring when indicated [25].
the CN VII passes through the parotid gland and, The nerve lies approximately 1.01.5 cm deep
at the pes anserinus (Latin: gooses foot), divides and slightly anterior and inferior to the tip of the
into the temporofacial and cervicofacial divisions external canal cartilage (also called pointer)
approximately 1.3 cm from the stylomastoid fora- [25].
men [1]. The nerve lies approximately 1.0 cm deep to
Although there are several ways to develop the medial attachment of the posterior belly of the
surgical access to the CN VII (and the surgeon digastric muscle to the digastric groove of the
must be familiar with all of them), the most pop- mastoid bone [25].

The tympanomastoid fissure, located between Conclusion
the mastoid and the tympanic bones, begins just Operative identification of the main trunk of the
distal to the suprameatal spine. The CN VII lies CN VII is a step-by-step procedure in which pre-
68 mm distal to the end point of this fissure vious identification of the anatomic landmarks
[25]. described above is highly advisable. The opening
The CN VII usually courses superficial to the of the preauricular space allows the exposure of
facial vein and division of this structure (as well the tragal cartilage pointer which is the last and
as the division of the external jugular vein) can most important landmark for the identification
contribute to increasing venous bleeding during of the main trunk of the CN VII.
dissection of the gland [3].
The stylomandibular artery, which lies just su-
perficial to the nerve as it enters the gland, may References
provoke troublesome bleeding if not ligated and 1 Holsinger FC, Bui DT: Anatomy, function, and evaluation of the
salivary glands; in Myers EN, Ferris RL (eds): Salivary Gland
divided [2].
Disorders. Berlin, Springer, 2007, pp 116.
If the proximal segment of the CN VII is ob- 2 Granick MS, Hanna DC 3rd: Surgical management of salivary
scured, retrograde dissection of one or more of gland disease; in Grannick MS, Hanna DC 3rd (eds): Manage-
ment of Salivary Gland Lesions. Baltimore, Williams & Wilkins,
the peripheral CN VII branches may be necessary 1992, pp 145174.
to identify the main trunk [2, 3, 5]. 3 Wang SJ, Eisele DW: Superficial parotidectomy; in Myers EN,
When necessary, the CN VII can be identified Ferris RL (eds): Salivary Gland Disorders. Berlin, Springer, 2007,
pp 247246.
in the mastoid bone by mastoidectomy and fol- 4 Mihelke A: Surgery of the salivary glands and the extratemporal
lowed peripherally. This approach is usually re- portion of the facial nerve; in Nauman HH (ed): Head and Neck
served for unusual recurrences, intratympanic or Surgery: Indications, Techniques, and Pitfalls. Philadelphia,
Saunders, 1980, pp 421465.
large tumors [2, 3]. 5 Shah JP, Patel SG: Salivary glands; in Shah JP, Patel SG (eds):
The use of wide-angled surgical loupes with Head and Neck Surgery and Oncology, ed 3. Edinburgh, Mosby,
2003, pp 439474.
2.53.5 magnifying lenses and facial nerve mon-
itoring may facilitate the identification of the
nerve, particularly in reoperations or in situa-
tions where the anatomy is not clear [25].
Although recommended by some, the styloid
process should not be used as a landmark for
finding the trunk of the CN VII since this in-
creases the risk of damaging the nerve [4].
107
7.2 Retrograde Approach to Facial Nerve:

Indications and Technique
Flavio C. Hojaij, Caio Plopper, Claudio R. Cernea

P E A R L S into a superficial and a deep lobe. Most common-
ly, the trunk of the facial nerve divides into two
Useful technique for peripheral tumors or for main branches: temporofacial and cervicofacial
difficult identification of the facial nerve. divisions. However, on rare occasions it can
Avoid wide dissections of the facial nerve in emerge from the stylomastoid foramen already in
peripheral tumors. two branches. A wide variety of branches can
Use magnifying lenses and electrical neural emerge through these main divisions. Due to
stimulation. these variations, the terminal divisions of the fa-
cial nerve are better named after their anatomical

P I T F A L L S distribution into temporal, zygomatic, buccal,
marginal mandibular and cervical nerves.
It should not be used for tumors involving many Usually, the most comfortable approach to the
branches of the facial nerve.
facial nerve in parotid gland operations is to find
Lack of constant anatomical landmarks for identifi- its main trunk. It is a larger anatomical structure,
cation of the terminal branches, except for the
its anatomical landmarks are more constant, and
mandibular marginal nerve.
dissection from the trunk to smaller branches is
often safer. However, in some situations, a retro-
grade dissection can become necessary or prefer-
able [2].
Introduction Practical Tips

Surgical procedures on the parotid gland are Indications
challenging for head and neck surgeons for a Peripheral parotid lesion, localized near one or
number of reasons. About 80% of parotid gland two terminal branches of the facial nerve, and
tumors are benign, and the importance of pres- with a small margin of normal salivary tissue.
ervation of the facial nerve in these operations Parotid lesion whose localization is so periph-
cannot be overemphasized. Therefore, thorough eral that long dissection from the main trunk of
knowledge of the anatomy of the facial nerve and the facial nerve is considered too morbid [3].
its branches is absolutely necessary [1]. Conditions that preclude safe identification of
Usually, the facial nerve, whose primary func- the facial nerve (such as fibrosis due to reopera-
tion is facial mobility, emerges through the stylo- tions and infections, or tumors adjacent to the
mastoid foramen, and its plane divides the gland mastoid process).

Technique The nerve branches become wider as retro-
The terminal branch of the facial nerve with few- grade dissection progresses and other terminal
er anatomical variations and determined ana- branches can join the dissected one; therefore,
tomical landmarks is the marginal mandibular salivary tissue division must be done more care-
nerve. Peripheral identification of the other ter- fully to avoid nerve injury.
minal branches lacks constant anatomical land-
marks and depends on careful dissection in the
midst of facial muscles and fascia, medial to the References
parotid gland (whose limits are also not well de- 1 Fee WE, Tran LE: Evaluation of a patient with a parotid tumor.
Arch Otolaryngol Head Neck Surg 2003;129:937938.
fined, making that task even more troublesome).
2 Myssiorek D: Removal of the inferior half of the superficial lobe
Some tips can be of help in those situations: is sufficient to treat pleomorphic adenoma in the tail of the pa-
Use of surgical magnification lenses. rotid gland. Arch Otolaryngol Head Neck Surg 1999;125:1164
Use of intraoperative electrical stimulation of 1165.
3 Lpez M, Quer M, Len X, Ors C, Recher K, Vergs J: Usefulness
the branches of the facial nerve (which can be of facial nerve monitoring during parotidectomy. Acta Otorrino-
monitored visually or, more effectively, with elec- laringol Esp 2001;52:418421.
4 Bhattacharyya N, Richardson ME, Gugino LD: An objective as-
tromyography) [4]. sessment of the advantages of retrograde parotidectomy. Otolar-
Identification of the marginal mandibular yngol Head Neck Surg 2004;131:392396.
nerve with the following anatomical landmarks:
Angle of the mandible.
Retromandibular vein (largest branch of the
external jugular vein); the nerves usually
cross the vein anteriorly.
109
7.3 Intraoperative Decisions for Sacrificing

the Facial Nerve in Parotid Surgery
Randal S. Weber, F. Christopher Holsinger
Department of Head and Neck Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Tex., USA

P E A R L S for evaluating salivary gland tumors but do not
provide consistent information for differentiating
In patients with a parotid neoplasms and normal benign from malignant disease [1]. Fine needle
facial function, facial nerve (FN) preservation aspiration (FNA) biopsy will correctly identify
should always be attempted.
neoplasia in over 85% of patients but differentiat-
When the tumor abuts the FN, a subepineural plane ing benign from malignant disease is more dif-
of dissection is possible: the tumor may be peeled
ficult and has lower accuracy. The potential for a
off of the FN.
false-positive diagnosis of malignancy by FNA
For microscopic residual disease, postoperative and frozen section exists in 2530% of patients
radiotherapy is effective for achieving local control
with preservation of FN function.
and these studies should not dictate sacrifice of
the FN. Ultrasound-guided core-needle biopsy
When the nerve is encased or preoperative facial
and open incisional biopsy are useful adjuncts in
paralysis is present, resect all involved branches or
the main trunk as necessary. the diagnostic armamentarium. A preoperative
definitive diagnosis obtained can identify malig-
nancy or lymphoma, thus altering either manage-

P I T F A L L S
ment or allowing the surgeon to better prepare
FN preservation where gross disease remains the patient for FN sacrifice.
increases the risk for local recurrence. The most common primary malignancies of
Parotid lymphoma may be confused with a primary the parotid gland are mucoepidermoid carcino-
parotid neoplasm and sacrifice of the FN is inappro- ma followed by adenoid cystic carcinoma, carci-
priate for this disease. noma ex pleomorphic adenoma, and acinic cell
carcinoma. Metastasis to the parotid from a pri-
mary cutaneous tumor is also a consideration.
Many tumors arising within or metastatic to the
parotid gland can invade the FN by direct exten-
Introduction sion or through neurotropic spread along the
Malignant tumors account for 20% of neoplasms nerve. Although many tumors can display peri-
arising within the parotid gland. Signs of malig- neural invasion, adenoid cystic carcinoma is the
nancy are pain, extension to the skin, fixation to most common tumor associated with this phe-
surrounding structures, FN paresis or paralysis nomenon. In one review, half of the patients
and lymph node metastasis. Computed tomogra- (79/160) presented with perineural invasion. Ma-
phy and magnetic resonance imaging are helpful jor named nerves were involved in 50% of pa-

tients; the remainder had small caliber nerve in- Conclusion
volvement [2]. Major nerve involvement is associ- FN preservation for patients with malignant pa-
ated with both increased locoregional failure and rotid tumors is an accepted contemporary man-
diminished survival [2]. agement paradigm. When the nerve is encased by
tumor or is not functioning preoperatively, it
Practical Tips should be sacrificed. An acceptable surgical tech-
Surgery with wide excision of the tumor is usu- nique is to sharply dissect the tumor off of the
ally chosen as the primary treatment. Superficial nerve in the subepineural plane. If microscopic
parotidectomy usually provides total tumor exci- disease remains, postoperative radiation therapy
sion unless the tumor arises within the deep lobe is indicated. Local regional control is excellent
or there is direct extension from the superficial and the patients quality of life is improved
lobe to the deep lobe. through preservation of FN function.
When normal FN function is present preop-
eratively, every effort should be made to preserve
the nerve during surgery. Occasionally, salivary References
tumors must be sharply dissected from the FN, 1 Koyuncu M, Seen T, Akan H, et al: Comparison of computed
tomography and magnetic resonance imaging in the diagnosis of
potentially leaving microscopic disease behind
parotid tumors. Otolaryngol Head Neck Surg 2003;129:726
[3]. Every attempt should be made not to leave 732.
gross tumor. If microscopic residual tumor is sus- 2 Fordice J, Kershaw C, El-Naggar A, Goepfert H: Adenoid cystic
carcinoma of the head and neck: predictors of morbidity and
pected, postoperative radiation therapy to the pa- mortality. Arch Otolaryngol Head Neck Surg 1999;125:149152.
rotid bed is indicated [46]. Occasionally, in ad- 3 Guillamondegui OM, Byers RM, Luna MA, et al: Aggressive sur-
vanced tumors, nerve encasement necessitates gery in treatment for parotid cancer: the role of adjunctive post-
operative radiotherapy. Am J Roentgenol Radium Ther Nucl Med
resection of the FN and adjacent structures as in- 1975;123:4954.
dicated by the extent of the tumor. The proximal 4 Garden AS, el-Naggar AK, Morrison WH, et al: Postoperative
and distal nerve segments should be examined by radiotherapy for malignant tumors of the parotid gland. Int J
Radiat Oncol Biol Phys 1997;37:7985.
frozen section to insure complete tumor eradica- 5 Armstrong JG, Harrison LB, Spiro RH, et al: Malignant tumors
tion. A mastoidectomy is occasionally necessary of major salivary gland origin. A matched-pair analysis of the
role of combined surgery and postoperative radiotherapy. Arch
to achieve negative margins on the proximal Otolaryngol Head Neck Surg 1990;116:290293.
stump of the FN. 6 Garden AS, Weber RS, Morrison WH, et al: The influence of pos-
Excellent local control (90%) for patients with itive margins and nerve invasion in adenoid cystic carcinoma of
the head and neck treated with surgery and radiation. Int J Ra-
parotid cancers treated with surgery and ipsilat- diat Oncol Biol Phys 1995;32:619626.
eral postoperative radiation, based on the M.D.
Anderson Cancer Center experience [6]. A post-
operative dose of 60 Gy in 30 fractions to the op-
erative bed is recommended. When a major,
named nerve is invaded, the path of the nerve is
7
treated electively to the central nervous system or
ganglion.
111
7.4 When and How to Reconstruct the

Resected Facial Nerve in Parotid Surgery
Peter C. Neligan
University of Washington Medical Center, Seattle, Wash., USA

P E A R L S are complications particularly following proxi-
mal repairs. Direct tension-free repair is opti-
Reconstruct immediately in case of intraoperative mal.
damage. Nerve Grafting. If a gap exists in the nerve, a
Tension-free repair. graft should be considered. Donor nerve selection
Consider graft if gap exists. depends on gap length and how many cables are
required. For short gaps, the greater auricular
Consider static sling to hold position while awaiting
nerve or the ansa cervicalis are good donors. The
nerve recovery.
sural nerve is best for larger defects. Success is
Static/dynamic reconstruction for established palsy.
multifactorial. The possibility of achieving tone
makes grafting worthwhile since the donor mor-

P I T F A L L S
bidity associated with sural nerve harvest is low
and significant function may be regained.
Proximal injury is more likely to result in synkinesis.
Nerve Transfer. When the proximal nerve
Long nerve grafts are likely to yield inferior results.
stump is not available, alternative donor nerves
Postoperative radiation may result in poor nerve may be used including the glossopharyngeal, ac-
recovery.
cessory, phrenic and hypoglossal nerves. Control
of facial muscles reinnervated in this way can be
unnatural, uncoordinated and synkinetic. The
hypoglossal nerve, the advantages and disadvan-
tages of which have been widely reported [2], is
Introduction commonly used. Tongue atrophy and associated
Management of facial nerve problems related to difficulty with mastication, speech and swallow-
parotid surgery falls under 4 headings: (1) direct ing are known complications [3]. More recently,
repair, (2) nerve graft, (3) static slings and (4) dy- the masseter motor nerve has been successfully
namic reconstruction. used as a transfer. Donor morbidity is minimal.
Nerve transfers are also used to baby-sit the
Practical Tips facial muscles and maintain their motor end
Direct Repair. If the nerve is cut during paroti- plates until a cross-facial nerve graft can be
dectomy it is best repaired directly under magni- brought over from the normal side.
fication. Recovery depends on multiple factors Static Slings. Static procedures to improve fa-
[1]. Synkinesis, facial spasm, and mass movement cial symmetry utilize slings of plantaris, palmar-

is longus or second or third toe extensor tendon, Spring devices are also available but placement
fascia lata or Gore-Tex that are anchored between and tension adjustment can be difficult and com-
key points in the upper lip and modiolus and the plications more common. Tarsorrhaphy may aid
fascia overlying the zygoma or temporalis. Over- eye closure but the visual field is compromised
correction is frequently required in anticipation and eye appearance can be unsatisfactory.
of stretching of the sling and relaxation of the fa- Temporalis muscle transfer can provide dy-
cial tissues. A static sling can improve function namic eyelid closure. A strip of temporalis muscle
by correcting the commissural droop that may is extended with fascia or tendon, passed through
cause drooling particularly with liquids. It can the upper and lower eyelid, and fastened to the
also improve speech by holding the cheek in a medial canthal ligament [7]. Complications in-
better position. clude a slit-like palpebral aperture with lateral
Dynamic Reconstruction. Dynamic recon- movement and skin wrinkling of the lateral lid on
struction can be achieved using a regional muscle closure. There may be a muscle bulge over the lat-
such as the masseter or temporalis or a free mus- eral orbital margin as well as some synkinetic
cle such as the gracilis or pectoralis minor. The eyelid movement when chewing. However, force-
excursion produced by regional muscles is disap- ful and full eyelid closure can result.
pointing. Furthermore, transfer of these muscles
can produce significant morbidity, e.g. temporal
hollowing following temporalis transfer. A more References
reliable result can be obtained using a function- 1 Eaton DA, Hirsch BE, Mansour OI: Recovery of facial nerve func-
tion after repair or grafting: our experience with 24 patients. Am
ing muscle transfer such as the gracilis [4] either
J Otolaryngol 2007;28:3741.
driven by a cross-facial nerve graft from the con- 2 Yamamoto Y, Sekido M, Furukawa H, et al: Surgical rehabilita-
tralateral side in a 2-stage procedure, or by the tion of reversible facial palsy: facial-hypoglossal network system
based on neural signal augmentation/neural supercharge con-
masseter motor [5] nerve from the same side in a cept. J Plast Reconstr Aesthet Surg 2007;60:223231.
single stage procedure. 3 Malik TH, Kelly G, Ahmed A, et al: A comparison of surgical
Management of the Eye. Inability of eye closure techniques used in dynamic reanimation of the paralyzed face.
Otol Neurotol 2005;26:284291.
and loss of the blink reflex render the cornea 4 Harii K: Microneurovascular free muscle transplantation for re-
prone to injury, and may lead to blindness. The animation of facial paralysis. Clin Plast Surg 1979;6:361375.
ectropic lower eyelid interferes with tear trans- 5 Manktelow RT, Tomat LR, Zuker RM, et al: Smile reconstruction
in adults with free muscle transfer innervated by the masseter
port, resulting in epiphora. The most common motor nerve: effectiveness and cerebral adaptation. Plast Recon-
procedure involves gold weight placement in the str Surg 2006;118:885899.
6 Manktelow RT: Use of the gold weight for lagophthalmos. Oper
upper eyelid, anterior to and secured to the tarsal Tech Plast Reconstr Surg 1999;6:157.
plate [6]. Complications include under or over- 7 Salimbeni G: Eyelid reanimation in facial paralysis by tempora-
correction, a visible bulge, infection and implant lis muscle transfer. Oper Tech Plast Reconstr Surg 1999;6:159.
extrusion.
7
113
7.5 Approaches to Deep Lobe

Parotid Tumors
Richard V. Smith
Department of Otorhinolaryngology Head and Neck Surgery, Albert Einstein College of Medicine,
Bronx, N.Y., USA

Accurate identification that a mass is from the
Evaluate the position of the posterior facial vein on deep parotid lobe is the most important aspect of
preoperative imaging to confirm suspicion of a its surgery. The deep lobe is defined as the pa-
deep lobe tumor.
rotid tissue medial to the facial nerve, and its tu-
The fat pad deep to the superior constrictor muscle mors may present externally, as a parotid mass, or
will be medial to a deep lobe parotid parapharyn-
be a radiographic finding of a parapharyngeal
geal mass.
space mass. The distinction between the two is
Most parapharyngeal parotid tumors can be the primary factor in choosing the appropriate
removed through a transcervical approach without
exposing the facial nerve or performing a mandi-
approach, and relies upon imaging.
bulotomy. Either CT or MRI scans can be used to iden-
tify a deep lobe mass [1], and the choice of which
Malignant parapharyngeal parotid tumors require
to use depends upon the location of the lesion. For
mandibulotomy for resection.
palpable lesions, a CT is often obtained in con-
junction with a fine needle aspiration. A dumb-

P I T F A L L S
bell deep lobe tumor occupies the spaces medial
Adequate counseling of a patient with a deep lobe and lateral to the posterior border of the man-
parotid mass is essential; discuss facial nerve resec- dibular ramus. Otherwise, the radiographic posi-
tion and grafting. tion of the posterior facial vein, better defined on
Obtain preoperative needle biopsy, if possible, to CT imaging, is used to classify the mass, as this
facilitate discussion and decision on approach. vein will be lateral to any deep lobe mass. MRI,
Facial nerve tolerance to manipulation is capricious, on the other hand, can provide more information
so avoid unnecessary dissection of the nerve or on the parapharyngeal deep lobe parotid tumor
traction on the nerve with parotid retraction. [2]. These tumors exist in the prestyloid parapha-
ryngeal space, and their identification is aided by
both the signal characteristics of the mass and the
position of the fat pad deep to the superior con-
strictor muscle, an important landmark. A para-
pharyngeal deep lobe parotid tumor will thin and
medialize that fat pad, but will rarely obliterate it
or render it unobservable on MRI scans.

Practical Tips Conclusions
Lateral or Dumbbell Tumors Deep lobe parotid tumors must be characterized
These are removed through a standard super- as either lateral or parapharyngeal to determine
ficial parotidectomy approach using a preauricu- the appropriate surgical approach for excision. A
lar incision with a cervical or rhytidectomy ex- transparotid approach should be used for lateral
tension. or dumbbell tumors, reflecting the normal super-
Adequate exposure requires mobilization, or ficial lobe and replacing it to its normal anatom-
removal, of the superficial lobe, exposing the per- ic position at the completion of the surgery. A
tinent branches of the facial nerve. transcervical approach should be employed for
Preserve as much of the superficial lobe as pos- the majority of parapharyngeal deep lobe parotid
sible to minimize the cosmetic defect, the inci- tumors, with malignant tumors necessitating a
dence of facial weakness, and gustatory sweating. wider approach through a paramedian mandibu-
The superficial lobe may be reflected anteriorly, lotomy and mandibular swing. The surgeon
away from the deep lobe mass, and can be re- must be aware of the pros and cons of the various
placed following removal of the tumor [35]. approaches to minimize unnecessary complica-
Mobilize the facial nerve sharply off the under- tions.
lying mass, then dissect the tumor from the sur-
rounding tissues through the spaces between the
facial nerve branches. References
Carefully retract the nerve during the dissec- 1 Divi V, Fatt MA, Teknos TN, Mukherji SK: Use of cross-sectional
imaging in predicting surgical location of parotid neoplasms.
tion, taking care to avoid significant stretch, or
J Comput Assist Tomogr 2005;29:315319.
desiccation, of the nerve. 2 Som PM, Sacher M, Stollman AL, Biller HF, Lawson W: Common
Dumbbell tumors often require division of the tumors of the parapharyngeal space: refined imaging diagnosis.
Radiology 1988;169:8185.
stylomandibular ligament to allow excision. 3 Avery CME, Fleming K, Siegmund CJ: Preservation of the super-
ficial lobe with tumours of the deep-lobe of the parotid. Br J Oral
Parapharyngeal Parotid Tumors Maxillofac Surg 2007;45:247248.
4 Colella G, Giudice A, Rambaldi PF, Cuccurullo V: Parotid func-
Rarely approached directly through the parot-
tion after selective deep lobe parotidectomy. Br J Oral Maxillofac
id gland. Surg 2007;45:108111.
Although not visualized, the facial nerve is 5 Hussain A, Murray DP: Preservation of the superficial lobe for
deep-lobe parotid tumors: a better aesthetic outcome. Ear Nose
rarely injured, but is vulnerable. Throat J 2005;84:518, 520524.
The transcervical approach is adequate for the
majority of these, mobilizing the submandibular
gland anteriorly, dividing the stylomandibular
ligament, and dissecting from below.
Even extremely large tumors can be removed
transcervically.
7
Any suggestion of an invasive malignancy, by
needle biopsy or imaging, should prompt a para-
median mandibulotomy approach, sparing the
neurovascular bundle of the mandible.
115
7.6 Recurrent Parotid Pleomorphic Adenoma

Bruce J. Davidson
Department of Otolaryngology Head and Neck Surgery, Georgetown University Medical Center,
Washington, D.C., USA

P E A R L S from the initial surgery was 15 years with a range
of 250 years [2]. This long period of time might
Recurrent parotid pleomorphic adenoma (RPPA) influence the observation that the mean age at
presents, on average, 15 years after the initial sur- initial operation for patients later developing re-
gery and 3/4 of cases have a multifocal recurrence.
current adenoma, 34 years, is about 10 years low-
Previous operative notes and pathology as well as er than of those who do not show evidence of re-
current imaging studies should be reviewed.
currence [2]. Incomplete capsule, penetration of
The use of intraoperative facial nerve (FN) monitor- the tumor capsule by tumor cells, pseudopodia
ing is associated with shorter surgical times, and satellite nodules may contribute to recur-
less severe immediate paresis and shorter nerve
recovery times.
rence. Zbren and Stauffer [1] showed that one of
these features was present in over 70% of pleo-
Radiotherapy (RT) is more commonly utilized after
morphic adenoma specimens. Usually, the pa-
second recurrences.
tient with RPPA presents with multiple masses in
the parotid bed [3]. Rarely, facial weakness may

P I T F A L L S
be present at RPPAs, but it should raise concern
for a carcinoma ex-pleomorphic adenoma. While
The number (one to hundreds) and size (some
multifocality (MF) is rare in PPAs, it is present in
<1 mm) of tumor foci can impair complete resec-
tion of recurrent disease (RD). 73% of RPPAs [2]. The number of tumor nodules
Immediate FN paresis occurs in over 50% after ranges from 220 in one series [2] and 1266
surgery for RPPA. (mean 26) in another [4]. Many of these nodules
may be <1 mm, making a comprehensive resec-
Second recurrences of PPA are seen in about 50% of
tion of RD difficult. The local control rate after
cases at 10 years and 75% of cases at 15 years.
surgery for RPPA ranges from 6585% [5]. Series
that report using surgery with adjuvant RT in all
cases report local control rates of 7995% [5].
Certainly after a second recurrence, most would
Introduction advocate the addition of adjuvant RT.
When PPA were treated by enucleation, tumor re-
currence rate was 1045% [1]. With adoption of Practical Tips
superficial parotidectomy (SP), it has dropped to Preoperative workup: It should include both
25% [1]. RD typically presents many years after imaging and biopsy. MRI is preferred, particu-
the initial surgery [1]. In a report, the mean time larly with concern for subtle multifocal disease.

Biopsy can be performed by FNA if the nodules 56% [4] to 100% [7]. Others have reported a 16%
are large or as open incision in small nodules. [7] to 21% [2] rate of permanent facial paresis. Use
Surgical planning: Previous operative notes of intraoperative FN monitoring does not replace
and pathology should be reviewed to determine the need for meticulous dissection, but some add-
the following: initial tumor MF, extent of the pre- ed statistical benefit was reported [7]; it is there-
vious surgery, eventual rupture of the tumor cap- fore recommended in surgery for RPPA.
sule and positive margins. Imaging evaluates Magnification: 2.5 magnification is suggest-
present MF, amount of residual parotid tissue and ed, but greater power may be helpful, particularly
its relationship with the subcutaneous tissue, the if nerve repair is required. The surgical micro-
FN, the deep parotid lobe, and the parapharyn- scope may also be employed, particularly to man-
geal space. age the FN branches within fibrosed tissue.
Surgical treatment: If the initial surgery was
less than an SP, the surgery for recurrence will be
a revision SP or total parotidectomy (TP) with FN References
dissection and preservation. If a standard SP was 1 Zbren P, Stauffer E: Pleomorphic adenoma of the parotid gland:
histopathologic analysis of the capsular characteristics of 218 tu-
performed previously, and there is a single focus
mors. Head Neck 2007;29:751757.
of RPPA, surgery will be limited to local resec- 2 Zbren P, Tschumi I, Nuyens M, Stauffer E: Recurrent pleomor-
tion. If the recurrence is multifocal, a TP should phic adenoma of the parotid gland. Am J Surg 2005;189:203
207.
be performed. The previous scar is usually ex- 3 Leonetti JP, Marzo SJ, Petruzzelli GJ, Herr B: Recurrent pleomor-
cised. phic adenoma of the parotid gland. Otolaryngol Head Neck Surg
FN management: It should be preserved unless 2005;133:319322.
4 Wittekindt C, Streubel K, Arnold G, Stennert E, Guntinas-Lichi-
there is documentation of malignant infiltrating us O: Recurrent pleomorphic adenoma of the parotid gland:
disease. Preoperative facial weakness may be a analysis of 108 consecutive patients. Head Neck 2007;29:822
clue, but occasionally infiltration may be seen in 828.
5 Chen AM, Garcia J, Bucci MK, Quivey JM, Eisele DM: Recurrent
a case with normal FN function. Benign tumors pleomorphic adenoma of the parotid gland: long-term outcome
may be dissected away from the nerve in the vast of patients treated with radiation therapy. Int J Radiat Oncol Biol
Phys 2006;66:10311035.
majority of cases, although the dissection is made 6 Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E:
considerably more difficult by scarring from pri- Parotidectomy for benign parotid disease at a University Teach-
or operations. The rate of permanent FN weak- ing Hospital: outcome of 963 operations. Laryngoscope
2006;116:534540.
ness after parotidectomy for primary disease has 7 Makeieff M, Venail F, Cartier C, Garrel R, Crampette L, Guerrier
been reported to be 6%, and involving all branch- B: Continuous facial nerve monitoring during pleomorphic ad-
es of the FN is under 1% [6]. Surgery for RPPA is enoma recurrence surgery. Laryngoscope 2005;115:13101314.
associated with a rate of immediate FN paresis of
117
7.7 How to Overcome Limitations of

Fine Needle Aspiration and Frozen Section
Biopsy during Operations for
Alfio Jos Tincani, Sanford Dubner
State University of Campinas UNICAMP, Campinas, Brazil

P E A R L S be helpful in the management of salivary tumors,
as the therapeutic strategy can sometimes be
The great majority of salivary gland tumors can changed preoperatively as well as during surgery.
be diagnosed by fine needle aspiration (FNA) and The FNA can be performed in an office setting,
confirmed by frozen section (FS).
offering a rapid diagnosis. The advantages of the
The use of ultrasound to guide the FNA increases method are that it is minimally invasive, well-tol-
the methods accuracy.
erated by patients, has few complications, a low
possibility of seeding tumors and minimal costs

P I T F A L L S
[1, 9]. The false-negative or false-positive result
rates may vary, depending upon the pathologists
When there is clinical suspicion of malignancy, not
experience as much as on the material of the col-
confirmed by FNA, FS must be performed.
lected sample. Sensitivity and specificity may
Extremely cellular tumors, inconclusive samples
vary around 73 and 91%, respectively [7]. Accu-
or tumors in which there is inadequate material
submitted to FNA indicate that FS must be racy may be enhanced with the use of ultrasound
performed. to guide the FNA. Introperative FS often offers
the first pathological diagnosis with high sensi-
tivity, confirming or not confirming the diagno-
sis of the FNA, and adds information about mar-
gin status and about nerve or vessel invasion [9].
Introduction Although the FNA has a better role in the diag-
Salivary gland tumors are rare neoplasms, usu- nosis of salivary tumors, the FS may offer better
ally benign (especially those in the parotid gland). microscopic invasion parameters, the tumors ar-
Sometimes, they present a challenge for diagnosis chitecture and circumscription. Diagnostic di-
and management. The role of FNA and FS in pre- lemmas of the FNA occur mainly in extremely
operative diagnosis and intraoperative manage- cellular tumors, such as pleomorphic and mono-
ment is often controversial. Many authors [19] morphic adenomas, when differential diagnosis
describe the advantages of other methods for the with low-grade adenoid cystic carcinoma [5, 6, 9]
differentiation of benign, malignant and inflam- may be difficult; the distinction between cystic
matory lesions. The use of FNA as well as FS can inflammatory diseases and low-grade mucoepi-

dermoid carcinoma may also be difficult. The FS References
can improve the decision-making process in 1 Batsakis JG, Sneige N, el-Naggar AK: Fine-needle aspiration of
salivary glands: its utility and tissue effects. Ann Otol Rhinol
those situations [9].
Laryngol 1992;101:185188.
2 Heller KS, Attie JN, Dubner S: Accuracy of frozen section in the
Practical Tips evaluation of salivary tumors. Am J Surg 1993;166:424427.
The history, physical exam and imaging stud- 3 Heller KS, Dubner S, Chess Q, Attie JN: Value of fine needle aspi-
ration biopsy of salivary gland masses in clinical decision-mak-
ies often contribute to the diagnosis [5, 6, 9]. ing. Am J Surg 1992;164:667670.
The presence of a motor deficit, especially of 4 Tincani AJ, Martins AS, Altemani A, Scanavini RC Jr, Barreto G,
Lage HT, Valerio JB, Molina G: Parapharyngeal space tumors:
the facial nerve, is highly suggestive of the pres- considerations in 26 cases. Sao Paulo Med J 1999;117:3437.
ence of malignancy [1, 5]. 5 Tincani AJ, Del Negro A, Araujo PP, Akashi HK, Martins AS, Al-
When the result of the FNA is uncertain, the temani AM, Barreto G: Management of salivary gland adenoid
cystic carcinoma: institutional experience of a case series. Sao
FS can often demonstrate the tissues architecture Paulo Med J 2006;124:2630.
and help to diagnose lymphoma and low-grade 6 Tincani AJ, Altemani A, Martins AS, Barreto G, Valrio JB, Del
Negro A, Arajo PP: Polymorphous low-grade adenocarcinoma
and high-grade tumors [8, 9]. at the base of the tongue: an unusual location. Ear Nose Throat J
The use of ultrasound to guide the FNA may 2005;84:794795, 799.
improve the exams accuracy [5]. 7 Hughes JH, Volk EE, Wilbur DC; Cytopathology Resource Com-
mittee, College of American Pathologists: Pitfalls in salivary
gland fine-needle aspiration cytology: lessons from the College
Conclusion of American Pathologists Interlaboratory Comparison Program
FNA is more sensitive whereas FS is more spe- in Nongynecologic Cytology. Arch Pathol Lab Med 2005;129:26
31.
cific. In fact, these methods are complementary. 8 Arabi Mianroodi AA, Sigston EA, Vallance NA: Frozen section
FS can be useful to determine the extent of the for parotid surgery: should it become routine? ANZ J Surg 2006;
76:736739.
surgery and to establish the diagnosis of cancer,
9 Seethala RR, LiVolsi VA, Baloch ZW: Relative accuracy of fine-
when FNA is uncertain. needle aspiration and frozen section in the diagnosis of lesions
of the parotid gland. Head Neck 2005;27:217223.
119
7.8 Practical Tips to Spare the Great Auricular

Nerve in Parotidectomy
Randall P. Morton
Counties-Manukau DHB and Auckland University, Auckland, New Zealand

P E A R L S auditory canal [2]. Some sketch a line from the
mastoid process to the angle of the mandible, and
The posterior branches of the great auricular then drop a perpendicular line at the midpoint.
nerve (GAN) can be preserved in more than 60% of The great auricular point is where this line inter-
parotidectomies.
sects with the posterior border of the SCM [3].
Surgical morbidity is reduced by preserving the From the great auricular point, the GAN heads
posterior branches of the GAN.
for the angle of the mandible. After crossing the
Burying the stump of a transected GAN avoids a anterior border of the SCM, the GAN forms an-
tender amputation neuroma. terior branches and a posterior division. The an-
terior branches have a variable distribution to the

P I T F A L L S parotid gland and cheek and in over 50% of cases
the GAN does not enter the gland at all [4]. These
The GAN becomes more superficial as it ascends,
anterior branches are divided in parotid surgery
and the posterior branches lie subcutaneously
inferior to the point of attachment of the ear lobe. because the ramifications to the cheek skin would
It is here that they are at the highest risk of inad- inevitably be severed during skin flap elevation.
vertent injury. There are 2 or 3 branches of the posterior divi-
In 510% of patients in whom the GAN has been sion of the GAN [5]; these supply the inferior por-
sacrificed an exquisitely sensitive subcutaneous tion of the pinna [6]. They pass directly towards
amputation neuroma may develop [1]. Less com- the anterior attachment of the ear lobe, and lie
monly neuropathic excoriation of the pinna may subcutaneously just inferior to the attachment of
occur.
the lobe.
The GAN posterior branches can be preserved
in at least 6570% of cases [5, 7]. Whilst postop-
eratively there is auricular hypoesthesia and an-
Introduction esthesia irrespective of whether or not the GAN
The GAN is a sensory nerve arising from the 2nd is divided, there is better long-term (12-month)
and 3rd cervical rami. It emerges from the poste- light touch and pain perception [6, 8, 9] and ther-
rior margin of the sternocleidomastoid (SCM) mal sensitivity [6] if the posterior branches are
muscle at the great auricular point (also known preserved than if the GAN is sacrificed. One year
as McKinneys point [2] and sometimes incor- is widely recognized as being a time limit for sen-
rectly Erbs point [3]), 6.5 cm below the external sory recovery of the facial region [6].

If the posterior branches of the GAN are pre- Conclusion
served, generally long-term sensory sequelae on This chapter highlights the significance of pres-
the pinna may only occur in about 15% of patients ervation of the posterior branches of the GAN in
compared with more than 50% where the GAN is the course of parotid surgery. The sensory bene-
sacrificed [5]. Preservation of the GAN posterior fits of this technique are not immediately evident,
branches adds very little to the surgical time in but the advantages are well documented at 12
my experience; others also report that it adds only months. Not only is sensation in the pinna pre-
510 min [7, 10]. served, but potential complications (neuropathic
Once the GAN has been sacrificed, patients excoriation [7, 10], amputation neuroma [1]) are
often forego wearing earrings and give up ski- avoided.
ing because of intolerance to cold temperatures
[7, 8].
References
Practical Tips 1 Moss CE, Johnston CJ, Whear NM: Amputation neuroma of the
Preservation of the GAN must not compro- great auricular nerve after operations on the parotid gland. Br J
Oral Maxillofac Surg 2000;38:537538.
mise oncological surgical principles. 2 Brown JS, Ord RA: Preserving the great auricular nerve in pa-
Make the initial skin incision through dermis rotid surgery. Br J Oral Maxillofac Surg 1989;27:459466.
3 Leung MKS, Dieu T, Cleland H: Surgical approach to the acces-
but not deeper. sory nerve in the posterior triangle of the neck. Plastic Reconstr
Dissect over the SCM, and identify the trunk Surg 2004;6:20672070.
of the GAN in the inferior part of the parotidec- 4 Zohar Y, Siegal A, Siegal G, Halpern M, Levy B, Gal R: The great
auricular nerve; does it penetrate the parotid gland? An anatom-
tomy incision before raising skin flaps in the re- ical and microscopical study. J Craniomaxillofac Surg 2002;30:
gion of the pinna. 318321.
Follow the GAN superiorly as you would fol- 5 Christensen NR, Jacobsen SD: Parotidectomy. Preserving the
posterior branch of the great auricular nerve. J Laryngol Otol
low the trunk of the facial nerve, raising the an- 1997;111:556559.
terior skin flap as you go. 6 Biglioli F, DOrto O, Bozzetti A, Brusati R: Function of the great
Divide the anterior branches of the GAN, but auricular nerve following surgery for benign parotid disorders.
J Craniomaxillofac Surg 2002;30:308317.
free the posterior branches of their attachments, 7 Hui Y, Wong DSY, Ho W-K, Wei WI: A prospective controlled
and reflect them posteriorly. double-blind trial of great auricular nerve preservation at pa-
rotidectomy. Am J Surg 2003;185:574579.
One of the posterior branches may pass deep
8 Suen DTK, Chow T-L, Lam CYW, Wong ESW, Lam S-H: Sensa-
and anterior to the lobule [10]. tion recovery improved by great auricular nerve preservation in
The parotid gland can now be separated from parotidectomy: a prospective double-blind study. ANZ J Surg
2007;77:374376.
the pinna and the SCM in the normal manner. 9 Porter MJ, Wood SJ: Preservation of the great auricular nerve
during parotidectomy. Clin Otolaryngol 1997;22:251253.
10 Vieira MBM, Maia AF, Ribiero JC: Great auricular nerve preser-
vation in parotidectomy. Arch Otolaryngol Head Neck Surg
2002;128:11911195.
7
121
7.9 Indications for Elective Neck Dissection in

Parotid Cancers
Roberto A. Lima, Fernando L. Dias
Head and Neck Service, Brazilian National Cancer Institute/INCA and Head and Neck Surgery,

P E A R L S elective neck dissection. Additionally, 10 patients
had periglandular positive nodal disease. Neck
In malignant parotid tumors, consider to stage the lymph node metastasis from salivary cancer is
neck by dissecting level II and III. Keep in mind that not common, nevertheless it has a poor progno-
most of the neck metastases that occur in these
levels are easily dissected through the same classi-
sis. Our institution [6] reported reductions in 10-
cal incision [1]. year survival rates from 77 to 34% for parotid
cancer.
Presence of facial dysfunction along with parotid
The characteristics that influence the risk of
mass indicates aggressive tumors. In this case
consider to electively dissect the neck [2]. occult metastasis in salivary cancer are worth re-
viewing in any discussion of elective surgical

P I T F A L L S treatment of the neck.
Spiro et al. [2] at the Memorial Sloan-Ketter-
Rates of complete agreement between the diagno- ing Cancer Center recommended an elective neck
sis based on intraoperative frozen sections and final dissection in patients with undifferentiated or
permanent sections can be as low as 36% and squamous carcinoma due to the high rate of de-
depend of the pathologists experience [3].
veloping nodal metastasis, and suggested that for
If lymph node metastasis is identified on frozen other high-grade tumors a staging supraomohy-
sections, consider to perform a modified radical
oid neck dissection is an appropriate adjunctive
neck dissection, levels IV.
therapy.
There are no randomized prospective studies con- Armstrong et al. [1] reported that high-grade
firming the reliability of radiotherapy in controlling
neck metastasis in salivary cancer.
tumors demonstrate increased occult lymph node
metastasis in comparison with low-grade tumors,
49 versus 2%.
According to Regis et al. [7], the significant
risk factors for neck metastasis in parotid carci-
Introduction noma are histological type, T stage and severe
The incidence of lymph node metastases in desmoplasia. Additional characteristics predic-
parotid carcinomas at the time of initial presenta- tive of a higher incidence of occult nodal metas-
tion varies from 12 to 24 [2, 46]. Armstrong tasis include advanced T stage (T3, T4), tumor
et al. [1] reported a rate of 38% of occult neck size 3 cm or more, and the presence of facial pa-
metastasis in 90 patients who had undergone ralysis at presentation [5].

Practical Tips References
Tumors classified as T3/T4 have a higher risk 1 Armstrong JG, Harrison LB, Thaler HT, et al: The indications for
elective treatment of the neck in cancer of the major salivary
of neck metastasis [8].
glands. Cancer 1992;69:615619.
Patients who present with facial nerve dys- 2 Spiro RH, Armstrong JG, Harrison LB, et al: Carcinoma of major
function on diagnosis have a higher risk of neck salivary glands recent trends. Arch Otolaryngol Head Neck
Surg 1989;115:316321.
metastasis [8]. Consider that facial dysfunction is 3 Zbren P, Schupbach J, Nuyens M, et al: Elective neck dissection
easy to identify when associated with parotid tu- versus observation in primary parotid carcinoma. Otolaryngol
mors. Head Neck Surg 2005;132:387391.
4 Spiro RH: Salivary neoplasms: overview of a 35-year experience
Tumor grade is difficult to establish with fro-
with 2807 patients. Head Neck 1986;8:177184.
zen sections [3]. However, it has been observed 5 Frankenthaler RA, Byers RM, Luna MA, et al: Predicting occult
that there is a relationship between histopathol- lymph node metastasis in parotid cancer. Arch Otolaryngol
Head Neck Surg 1993;119:517520.
ogy and grade [9]. Primary squamous cell carci- 6 Lima RA, Tavares MR, Dias FL, et al: Clinical prognostic factors
noma, high-grade mucoepidermoid carcinoma, in malignant parotid gland tumors. Otolaryngol Head Neck Surg
2005;133:702708.
salivary duct carcinoma, undifferentiated carci- 7 Regis De Brito Santos I, Kowalski LP, Cavalcante De Araujo V, et
noma, and adenocarcinoma have a higher risk of al: Multivariate analysis of risk factors for neck metastases in
harboring occult neck metastasis [7]. surgically treated parotid carcinomas. Arch Otolaryngol Head
Neck Surg 2001;127:5660.
Selective neck dissection (levels IB, IIA, IIB,
8 Medina JE: Neck dissection in the treatment of cancer of the ma-
III) is appropriate surgery for patients who are at jor salivary glands. Otolaryngol Clin North Am 1998;31:815
risk of neck metastasis. Upper neck areas (levels 822.
9 Godballe C, Schultz JH, Krogdahl A, et al: Parotid carcinoma:
I, II, III) are easily resected through a small exten- impact of clinical factors on prognosis in a histologically revised
sion of the parotidectomy incision [10]. series. Laryngoscope 2003;113:14111417.
10 McGuirt WF: Controversies regarding therapy of tumors of the
parotid gland; in Thawley SE, Panje WR, Batsakis JG, Lindberg
RD (eds): Comprehensive Management of Head and Neck Tu-
mors. Philadelphia, Saunders, 1999, pp 12111219.
123
7.10 Indications for Tactical Parotidectomy in

Nonsalivary Lesions
Caio Plopper, Claudio R. Cernea

P E A R L S The parotid gland is home to part of the lym-
phatic network of the head and neck, in continu-
Parotid gland tissue or intraglandular lymph nodes ity with upper level II lymph nodes. These lymph
can be compromised by malignant tumors of the nodes are usually located in the superficial lobe
anterior face and scalp.
of the parotid gland, and are an important basin
In these cases, superficial parotidectomy with pres- of lymphatic drainage of the anterior face and
ervation of the facial nerve is usually sufficient.
scalp [2]. Thus, primary tumors arising from
these locations with a histological high propen-

P I T F A L L S
sity for lymphatic metastases or with clinical met-
astatic disease to the parotid gland should also
Large skin tumors usually preclude identification of
require a formal parotidectomy as part of their
the main trunk of the facial nerve, making retro-
grade dissection a safer and easier tactic. surgical treatment [3, 4].
Practical Tips
Either when indicated for direct invasion of the
parotid gland or for lymph node dissection, pa-
Introduction rotid gland resection with preservation of the fa-
Parotid gland resections can be necessary for ad- cial nerve and all its branches should be attempt-
equate treatment of nonsalivary tumors, usually ed. However, some form of nerve sacrifice can be
for one of two reasons: tumors that either direct- necessary when the facial nerve is found to be
ly invade or are very close to the gland, or for compromised by primary or metastatic disease.
lymph node resection. A parotidectomy should be indicated whenev-
Most often, tumors that directly invade the er a primary skin tumor invades deep to the pa-
parotid gland are of cutaneous origin, namely rotid fascia. This can be necessary for facial nerve
basal cell and squamous cell carcinomas; how- identification and preservation, as well as for tu-
ever, melanomas and other rare tumors, such as mor resection with adequate margins [5].
desmoid tumors, dermatofibrosarcoma, or ec- Identification of the main trunk of the facial
crine carcinomas, can also mandate some kind of nerve is usually easier and safer; however, when a
parotid gland resection for their appropriate large tumor arising from the skin of the parotid
treatment [1]. region or the auditory canal precludes the identi-

fication of the main trunk of the facial nerve, a When indicated for elective or therapeutic in-
retrograde parotidectomy can be of use. traglandular lymph node dissection, parotid
Use of surgical magnification lenses and intra- lymph nodes should be viewed as contiguous to
operative nerve monitoring can be very impor- upper level II lymph nodes [1]. Hence, en bloc for-
tant for facial nerve identification and for docu- mal selective or comprehensive neck dissection
menting its preservation, especially for large tu- should be considered.
mors and when retrograde facial nerve dissection
When direct invasion of the parotid gland by a
is necessary. malignant disease or compromised parotid lymph
Some tumors that may clinically mimic pri- nodes are present, adjuvant radiation therapy can
mary parotid nodes, such as lymphomas or nerve be considered for improved local control [7].
sheath tumors, can arise in the parotid gland, and
a formal parotidectomy may be too extensive and
morbid for these patients [6]. In these instances, References
preoperative fine needle aspiration biopsies are 1 Plopper C, Cernea CR, Ferraz AR, Medina dos Santos LR, Regis
AB: Parotidectomy for primary nonparotid diseases. Otolaryn-
very useful and recommended for surgical plan-
ning. 2 McKean ME, Lee K, McGregor IA: The distribution of lymph
The vast majority of parotid lymph nodes are nodes in and around the parotid gland: an anatomical study. Br
J Plast Surg 1985;38:15.
located in the superficial lobe, lateral to the facial 3 Yarington CT Jr: Metastatic malignant disease to the parotid
nerve. Thus, whenever indicated for lymph node gland. Laryngoscope 1981;91:517519.
dissection, a superficial parotidectomy is suffi- 4 Nichols RD, Pinnock LA, Szymanowski RT: Metastases to pa-
rotid nodes. Laryngoscope 1980;90:13241328.
cient. 5 Lai SY, Weinstein GS, Chalian AA, Rosenthal DI, Weber RS: Pa-
For cutaneous melanoma of the anterior scalp rotidectomy in the treatment of aggressive cutaneous malignan-
and face, parotid lymphatic mapping and sentinel cies. Arch Otolaryngol Head Neck Surg 2002;128: 521526.
6 Loggins JP, Urquhart A: Preoperative distinction of parotid lym-
lymph node resection are still controversial. How- phomas. J Am Coll Surg 2004;199:5861.
ever, the importance of facial nerve preservation 7 Kraus DH, Carew JF, Harrison LB: Regional lymph node metas-
tasis from cutaneous squamous cell carcinoma. Arch Otolaryn-
in these cases cannot be overemphasized. gol Head Neck Surg 1998;124:582587.
125
7.11 When Not to Operate on a Parotid Tumor

Jeffrey D. Spiroa, Ronald H. Spiro b, c
a Universityof Connecticut School of Medicine, Farmington, Conn.,
b Head and Neck Surgery Service, Memorial Sloan-Kettering Cancer Center and
c Cornell University Medical College, New York, N.Y., USA

P E A R L S largement of lymph nodes located adjacent to, or
within, the parotid capsule. Given that more than
Not all parotid masses are actually neoplastic. 80% of neoplasms arising in the gland will prove
At least 80% of parotid neoplasms are benign. to be benign, the indications for resection are
Fine needle aspiration biopsy (FNABx) is usually usually: (a) confirmation of a pathologic diagno-
capable of distinguishing neoplastic from non- sis, (b) concern about appearance, and (c) the pos-
neoplastic lesions and benign from malignant sibility of malignant transformation of a preexist-
neoplasms. ing benign PA.
FNABx can be very useful when deciding

P I T F A L L S whether to proceed with parotid surgery. The ac-
curacy of FNABx in distinguishing a neoplastic
FNABx is not infallible, and therefore is not a substi- from a nonneoplastic process, and in distinguish-
tute for clinical judgment.
ing benign from malignant neoplasms, is gener-
Malignant transformation of a preexisting pleo- ally quite high, with an overall accuracy of 84
morphic adenoma (PA) is rare, but needs to be
98% [15]. An aspirate that is unequivocally neg-
considered in the decision to perform surgery.
ative for malignant cells in a patient with a
clinically benign parotid mass provides addition-
al reassurance in those cases when the patient
would prefer to defer surgery. When a lymphoid
Introduction aspirate suggests lymphoma, a core biopsy can
The patient who presents with a mass in the pa- provide enough tissue to establish a diagnosis
rotid area usually has a primary neoplastic pro- without a PTx. Clearly FNABx is not infallible,
cess arising in the parotid gland (PG). In general, and the clinical judgment of the surgeon must
clinicians will recommend a parotidectomy (PTx) take priority when the results of FNABx are in-
in this setting. There are, however, several con- consistent with the clinical presentation.
siderations that may impact on the decision to PTx may be the only way to reassure the anx-
proceed directly with surgery. ious patient even when a tumor is small and al-
most certainly benign. When a tumor is large and
Practical Tips unsightly, surgeons and patients alike will usu-
Not all masses arising in the PG are neoplastic ally favor intervention. It is worth recalling that
in origin. Other possibilities include benign cysts PA, the most common neoplasm encountered in
or inflammatory changes and hyperplastic en- the PG, usually enlarges slowly and steadily. In

our experience, however, some patients have tu- biopsy, thus avoiding surgery. In cases where a PA
mors that show no significant growth during is either suspected clinically, or diagnosed on
years of observation. For this reason, watchful FNABx, the risks and benefits of PTx must be dis-
waiting can be a reasonable alternative in certain cussed with the patient, assuring that only com-
patients, especially those who are older or who plete extirpation can guarantee accurate patho-
have significant medical problems. logic analysis, and that there is a small risk of ma-
Another often cited indication for PTx is the lignant transformation of benign tumors over
risk of malignant transformation of a preexisting time. If after such a discussion the patient prefers
PA. The actual incidence of such a transforma- to avoid surgery, it is reasonable to follow him or
tion is uncertain; however, it appears to be rare. her clinically. In the authors experience, some
Although this possibility needs to be discussed PAs may exhibit little or no significant growth
with the patient as part of the process of informed when observed over extended periods of time,
consent, we feel that it is not a compelling indica- thus making observation a reasonable option in
tion for surgery in patients with clinically benign carefully selected, properly informed patients.
parotid tumors.
There are obviously other considerations that
can influence a decision to proceed with parotid References
surgery. Patients whose overall health precludes 1 Seethala RR, LiVolsi VA, Baloch ZW: Relative accuracy of fine-
needle aspiration and frozen section in the diagnosis of lesions
general anesthesia are not candidates for surgery.
of the parotid gland. Head Neck 2005;27:217223.
Some patients with neglected or high-grade can- 2 Cohen EG, Patel SG, Lin O, et al: Fine-needle aspiration biopsy of
cers may have disease that is so locally extensive salivary gland lesions in a selected patient population. Arch Oto-
laryngol Head Neck Surg 2004;30:773778.
that it is deemed unresectable. As previously not- 3 Boccato P, Altavilla G, Blandamura S: Fine needle aspiration bi-
ed, the patients level of concern will clearly be an opsy of salivary gland lesions. A reappraisal of pitfalls and prob-
important factor in the decision to proceed with lems. Acta Cytol 1998;42:888898.
4 Al-Khafaji BM, Nestok BR, Katz RL: Fine-needle aspiration of
surgery. 154 parotid masses with histologic correlation: ten year experi-
ence at the University of Texas M.D. Anderson Cancer Center.
Conclusion Cancer 1998;84:153159.
5 Atula T, Greenman R, Laippala P, Klemi PJ: Fine-needle aspira-
While surgical excision is usually indicated for a tion biopsy in the diagnosis of parotid gland lesions: evaluation
mass arising in the PG, there are circumstances of 438 biopsies. Diagn Cytopathol 1996;15:185190.
when PTx may be deferred. A nonneoplastic pro-
cess may be diagnosed by FNABx or core needle
127
7.12 Practical Tips on Excision of the

Submandibular Gland
Kwang Hyun Kim
Department of Otolaryngology Head and Neck Surgery, Seoul National University College of Medicine,
Seoul, Korea

Excision of the SMG has been frequently associ-
The most important thing in submandibular gland ated with neurological complications after sur-
(SMG) resection is to avoid injury of the marginal gery, such as damage to the MMN (7.7%), hypo-
mandibular branch of the facial nerve (MMN).
glossal (2.9%), and lingual (1.4%) nerves [1]. The
The standard technique of avoiding injury to MMN standard technique of avoiding injury to MMN is
is to place the incision at least 3 cm below the lower
to place the horizontal limb of the neck dissection
margin of the mandible.
incision at least 3 cm below the lower margin of
Retrograde dissection of the cervical branch the mandible, ligating and dividing the common
upwards leads to the MMN.
facial vein deep to the fascia, lifting the vessel
Transient pseudoparalysis of the MMN due to along with the upper skin flap [2]. It is very easy
cervical branch injury can be distinguished from
to find the thick facial artery entering the SMG
MMN injury.
from behind. If the artery passes through the
Intraoral excision of the SMG causes no external gland, it should be cut and ligated securely; oth-
scar, no injury to the MMN or to the hypoglossal
nerve, and no residual Whartons duct inflamma-
erwise, it can be saved. The lingual nerve is con-
tion. nected with the SMG by the submaxillary gan-
glion, which must be carefully cut in order to
avoid nerve damage. The hypoglossal nerve is

P I T F A L L S
deep to the digastric muscle, thus being relatively
Facial nerve stimulators can be used, but their protected during dissection. The facial vessels
safety and reliability are not absolute. should be ligated and cut carefully at the upper
Intraoral excision of the SMG should not be indicat- border of the SMG. The last step is to ligate and
ed for patients with malignant or huge salivary cut the Whartons duct. The duct should be care-
gland tumors or when there is limitation in mouth fully palpated before cutting to confirm stone in
opening or floor of mouth exposure. the resected specimen.
Alternative surgical approaches have been de-
veloped to avoid visible scarring in the upper neck
and to reduce neurological risks, like intraoral
removal of the SMG [3] and minimally invasive
endoscopic and endo-robotic methods of SMG
resection.

Practical Tips function has been a common observation in pa-
A safe way of identifying the MMN is the in- tients undergoing neck dissection with platysma
traoperative use of facial nerve-monitoring de- excision. Transient pseudoparalysis of the MMN
vices, but a slightly time-consuming preoperative due to cervical branch injury could be distin-
setup is necessary. Both disposable intraoperative guished from MMN injury by the fact that those
facial nerve stimulators and plexus block nerve patients could still evert the lower lip because of
stimulators are available, but there is some con- a functioning mentalis muscle [7].
cern about their safety and reliability. The stan-
dard pulse current intensity recommended for Conclusion
stimulation is 1.00 mA delivered at a frequency of For a better cosmetic result after excision of SMG
1 Hz [4]. without neurologic deficit, especially of MMN,
Just below the superficial layer of deep cervical the reader should be aware of various available
fascia, the cervical branch of the facial nerve is surgical options, in order to choose the most ap-
identified, descending 510 mm anterior and propriate one.
parallel to the anterior border of the sternocleido-
mastoid muscle [5]. Retrograde dissection of this
cervical branch upwards with a fine mosquito References
forceps leads to MMN. 1 Berini-Aytes L, Gay-Escoda C: Morbidity associated with remov-
The major advantages of the intraoral ap- al of the submandibular gland. J Craniomaxillofac Surg 1992;20:
216219.
proach are no external scar, no injury to the 2 Martin H, Del Valle B, Ehrlich H, Cahan W: Neck dissection.
MMN or to the hypoglossal nerve and no residu- Cancer 1951;4:441499.
3 Hong KH, Kim YK: Intraoral removal of the submandibular
al Whartons duct inflammation [3]. The major gland: a new surgical approach. Otolaryngol Head Neck Surg
drawback is its technical difficulty with a signifi- 2000;122:798802.
cant learning curve, especially when the endo- 4 Sadoughi B, Hans S, de Mons E, Brasnu DF: Preservation of the
marginal mandibular branch of the facial nerve using a plexus
scope is used for magnification. This approach block nerve stimulator. Laryngoscope 2006;116:17131716.
has limited indications [6]. 5 Shuaib Zaidi SM: A simple nerve dissecting technique for iden-
The platysma muscle co-functions with de- tification of marginal mandibular nerve in radical neck dissec-
tion. J Surg Oncol 2007;96:7172.
pressor anguli oris muscle as a lip depressor. In- 6 Weber SM, Wax MK, Kim JH: Transoral excision of the subman-
jury to the cervical branch in these patients re- dibular gland. Otolaryngol Head Neck Surg 2007;137:343345.
7 Daane SP, Owsley JQ: Incidence of cervical branch injury with
sults in loss of depressor function to the affected marginal mandibular nerve pseudo-paralysis in patients un-
corner of the mouth. Transient lip depressor dys- dergoing face lift. Plast Reconstr Surg 2003;111:24142418.
129
Skull Base Tumors
8.1 Practical Tips to Perform the Subcranial

Approach
Ziv Gil, Dan M. Fliss
Department of Otolaryngology Head and Neck Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

The concept of a broad subcranial approach to the
The subcranial approach is a multidisciplinary team entire anterior skull base was first introduced as
effort. an alternative to the traditional craniofacial ap-
Use broad-spectrum antibiotic treatment perioper- proach. The subcranial approach has several ma-
atively to reduce complications. jor advantages. (1) It affords a broad exposure of
Insert a lumbar drain after administering anesthesia the anterior skull base from below rather than
to facilitate frontal lobe retraction and to reduce through the transfrontal route. (2) It provides an
the risk of postoperative cerebrospinal fluid leak. excellent access to the medial orbital walls and to
Improve patient satisfaction by performing surgery the sphenoethmoidal, nasal and paranasal cavi-
without facial incisions, tracheostomy and shaving ties. (3) It allows simultaneous intradural and ex-
the hair.
tradural tumor removal and safe reconstruction
In cases of massive involvement of the palate, the of dural defects. (4) It does not require facial inci-
pterygomaxillary fossa or the orbital apex, use com- sions. (5) It is performed with minimal frontal
bined approaches.
lobe manipulation.
Whenever possible, preserve one or both sides of
the olfactory filaments.
Practical Tips
Preoperative Evaluation and Anesthesia. All

P I T F A L L S
patients scheduled for surgery should be evalu-
ated preoperatively by a multidisciplinary surgi-
Avoid impairment of nasal breathing by preserving
cal team. Radiological evaluation should include
the distal third of the nasal bone.
computed tomography (CT) and magnetic reso-
Confirm a tight dural seal in order to prevent cere-
nance imaging. Positron emission tomography-
brospinal fluid leak.
CT is also recommended [1]. Broad-spectrum
Immediate extubation is required to allow continu-
antibiotics consisting of a combination of cefu-
ous neurological monitoring.
roxime, vancomycin and metronidazole are insti-
Never ventilate a patient with a positive pressure tuted perioperatively. No tracheostomy is re-
after extubation in order to avoid life-threatening
tension pneumocephalus.
quired unless free flap reconstruction is per-
formed [2]. A lumbar spine catheter is inserted for
Admit the patient to an intensive care unit for 24 h
cerebrospinal fluid drainage after administering
after surgery.
anesthesia.

The Surgical Technique of the Subcranial Ap- Postsurgical Treatment. After surgery, the pa-
proach. The skin is incised above the hairline and tient is extubated and transferred to the critical
a coronal flap is created in a supraperiosteal plane care unit for 24 h. Stool softeners are adminis-
[2]. The flap is elevated anteriorly beyond the su- tered to reduce the risk of Valsalva-induced in-
praorbital ridges. The pericranial flap is elevated creased intracranial pressure. The lumbar drain
up to the periorbits, and the supraorbital nerves is removed 35 days later and the nasal packing 7
and vessels are carefully separated from the su- days postoperatively. Routine CT is performed at
praorbital notch. The lateral and medial walls of the end of the procedure and again 1 week later.
the orbits are exposed, and the anterior ethmoid-
al arteries are clipped. Titanium mini-plates are Conclusions
applied to the frontal bones and removed before The subcranial approach is routinely used for ex-
performing the osteotomies to ensure the exact tirpation of tumors involving the anterior skull
repositioning of the bony segments. An osteoto- base, allowing wide exposure, minimal brain re-
my of the anterior and posterior frontal sinus traction and no facial incisions. Detailed preop-
walls, together with the nasal bony frame, part of erative imaging, appropriate reconstruction, in-
the medial wall of the orbit, and a segment of the tensive postoperative care, and the cooperation of
superoposterior nasal septum is performed [3]. multidisciplinary teams are crucial to assure suc-
Part of the nasal bone is preserved in order to sup- cessful tumor resection and improved quality of
port the nasal valve. The tumor is extirpated at life [5].
this stage and the dura or brain parenchyma is
resected if involved by tumor. A unilateral or bi-
lateral medial maxillectomy is performed from References
above if indicated, allowing direct visualization 1 Gil Z, Even-Sapir E, Margalit N, Fliss DM: Integrated PET/CT
system for staging and surveillance of skull base tumors. Head
of the maxillary sinus [4]. By means of this ap-
Neck 2007;29:537545.
proach, it is possible to safely and reliably access 2 Gil Z, Cohen JT, Spektor S, et al: Anterior skull base surgery with-
tumors involving the medial or superior walls of out prophylactic airway diversion procedures. Otolaryngol Head
Neck Surg 2003;128:681685.
the maxilla. Multilayer fascia lata flaps are rou- 3 Raveh J, Laedrach K, Speiser M, et al: The subcranial approach
tinely used for reconstruction of the dura and for fronto-orbital and anteroposterior skull base tumor. Arch
skull. A centripetal compression method is used Otolaryngol Head Neck Surg 1993;119:385393.
5 Gil Z, Abergel A, Spektor S, et al: Quality of life following surgery
to reduce the telecanthus, and stenting of the na- for anterior skull base tumors. Arch Otolaryngol Head Neck Surg
solacrimal duct is performed. 2003;129:13031309.
6 Gil Z, Cohen JT, Spektor S, et al: The role of hair shaving in skull-
base surgery. Otolaryngol Head Neck Surg 2003;128:4347.
131
Skull Base Tumors
8.2 Facial Translocation Approach

Fernando Walder
Federal University of So Paulo UNIFESP, So Paulo, Brazil

P E A R L S base (CB) is essential. Numerous approaches have
been described for lesions of this region [1]. The
Facial anatomy presents optimal lines of separation approach of this region of CB utilizes facial trans-
of facial units (FU) for a surgical approach, permit- locations (FT) for exposure of anterior and mid-
ting the least traumatic displacement.
dle CB as well as related structures [2]. This pro-
The primary blood supply to the FUs ensures their cedure utilizes the principle of vascularized facial
individual viability, when mobilized.
composite units that allow rapid access, generous
The middle face contains multiple hollow anatom- working space at the CB, and expedient recon-
ic spaces that facilitate the relative ease of surgical struction. Because of its modular design, it per-
access to the central skull base (SB).
mits great versatility and accommodates the sur-
Offers much greater tolerance to postoperative gical needs for limited as well as complex proce-
surgical swelling, as opposed to similar displace-
dures at the SB. Maximum preservation and
ment of the content of the neurocranium.
functional/esthetic reconstruction of craniofacial
Reestablishment of the normal anatomy is accom- anatomy are emphasized [3]. The current under-
plished with repositioning of the FUs during the
reconstruction phase.
lying principle of SB approaches is to minimize
brain retraction while maximizing SB visualiza-
tion. This concept facilitates 3D tumor resection,

P I T F A L L S
tumor margin verification, and functional recon-
Contamination of the surgical wound with oropha- struction with appropriate esthetic concerns.
ryngeal bacteria flora. Transfacial approaches create potential risks for
the function and esthetics of the following struc-
The need of facial incisions with subsequent scar
tures: skin, dentition, maxillofacial skeleton, mu-
development.
cosal lining of the upper airway, paranasal sinus,
Emotional considerations related to surgical facial
eustachian tubes, superior pharyngeal constric-
disassembly.
tor muscle, soft and hard palate, and tongue [4].
Practical Tips
Perform a cheek flap based on the facial and a la-
Introduction bial vascular pedicle that includes the entire cheek
Adequate exposure is the key to successful en bloc soft tissue, lower lid, facial nerve, and parotid
resection in any region. Due to the proximity to gland.
crucial anatomic structures, wide surgical expo- The ipsilateral facial skin is displaced laterally
sure of the nasopharyngeal region of the cranial and inferiorly to include upper lip split.

Superior incision continues from the nose to Bilateral FT exposes both infratemporal fos-
the inferior fornix of the lower eyelid, through the sae, the central SB, and the entire paracentral SB.
lateral canthus horizontally to the preauricular The palatal split permits a reach to the level of
area. C23. If further inferior extension is needed, a
Identify the frontal branches of the facial nerve mandibular split can be added so that a vertical
with nerve stimulator if needed. Place them in reach to C34 is accomplished [4].
silicone tubes; then they can be transected. Dur-
ing the reconstruction, they are reconnected, and Conclusions
their continuity is reestablished. The anatomic basis for this direct approach to the
The infraorbital nerve is electively sectioned SB region offers solid surgical principles. By uti-
along the floor of the orbit, tagged, and repaired lizing facial soft tissue translocation and cranio-
at the end of the procedure. facial osteotomies, the FT approach and its many
Rigid fixation is achieved with mini- and mi- extensions create a wide surgical field to the SB
croplates. access. The FT approach offers previously un-
Medially extended FT can expose the ipsilat- available wide and direct exposure with a poten-
eral infratemporal fossa and central and paracen- tial for immediate reconstruction of this complex
tral SB bilaterally. The entire clivus, optic nerves, region. The modifications available with this ap-
both precavernous internal carotid arteries, and proach add an element of versatility necessary to
the nasopharynx become accessible. tailor the surgical approach to a specific lesion.
Medially and inferiorly extended FT adds sig-
nificant inferior as well as upper cervical surgical
access. References
Posteriorly extended FT incorporates the ear, 1 Maran AG: Surgical approaches to the nasopharynx. Clin Oto-
laryngol 1983;8:417429.
temporal bone, and posterior fossa into its surgi-
2 Biller HF, Shugar JM, Krespi VP: A new technique for wide-field
cal access. This provides access to both the ante- exposure of the base of skull. Arch Otolaryngol 1981;107:698
rior and posterior aspect of the temporal bone 702.
3 Fish U: Infratemporal fossa approach to tumors of the temporal
with control of the key neurovascular struc- bone and base of the skull. J Laryngol Otol 1978;92:949967.
tures. 4 Janecka IP, Sen C, Sekhar L, et al: Facial translocation. A new ap-
proach to the cranial base. Otolaryngol Head Neck Surg 1990;
103:413419.
133
Skull Base Tumors
8.3 How to Manage Large Dural Defects in

Skull Base Surgery
Eduardo Vellutini, Marcos Q.T. Gomes
DFV Servios de Neurologia e Neurocirurgia, So Paulo, Brazil

P E A R L S of separating the paranasal sinuses-nasopharyn-
geal cavity and the intracranial cavity [1, 4].
Think about skull base reconstruction before skin The pericranium technique proposed by Van
incision. Buren et al. [5] in 1968 employs vascularized tis-
First step (dural reconstruction): autologous tissue sue and remains the most commonly used to date,
(temporalis fascia, fascia lata) and watertight suture probably due to ease of execution and manipula-
before facial approach.
tion, proving the most efficacious way of reduc-
Second step (nasal and cranial cavity separation): ing the risk of CSF fistula [2].
always vascularized tissue (pericranium, temporalis If covering the pericranium is not possible,
muscle, microvascular free flaps) and tissue
sealants.
particularly in cases of reoperation, surgeons
must look for other alternatives such as bilateral
temporalis muscle graft or microvascular grafts

P I T F A L L S
of the rectus abdominalis or radialis, provided a
Avoid postoperative lumbar drainage: risk of microsurgical reconstruction team is available.
pneumoencephalus.
Practical Tips
Do not let the pericranium flap get dried during the
The reconstruction should take into account tu-
surgical procedure.
mor origin and volume, extent of intracranial in-
vasion, primary surgery or reoperation and the
possibility of microsurgical reconstruction.
Reconstitution of the meningeal lining must
Introduction be performed immediately after removal of the
The possibility of reconstruction of extensive du- infiltrated dura mater and/or intradural compo-
ral defects following tumor resection at the skull nent of the tumor, prior to facial approach. Mini-
base decreased the rates of serious complications mizing contact between the nasal cavity and sub-
such as CSF fistula and meningitis with conse- dural space reduces the risk of intraoperative con-
quent reduction in treatment morbimortality tamination. Closure is carried out using free
[13]. nonvascularized patient-derived grafts, such as
Such reconstruction must be planned with a temporalis fascia muscle or fascia lata, and con-
wider objective than simple reconstruction of the tinuous suture with mononylon 5.0. Synthetic du-
dural lining proper. It should also entail reduc- ral analogs should be used only if a suitable dural
tion of dead space along with an effective method edge is not available for suture.

Separation of the cranial and nasal cavities is In lateral approaches, the temporalis muscle
performed after total removal of the tumor and can be used to fill and separate the infratemporal
should be based on vascularized grafts [1]. In an- fossa from the maxillary and/or nasal cavity. Care
terior approaches, the best choice is the pericra- should be taken to preserve the wide-based mus-
nium with its vascular pedicle through supraor- cular flap so as not to compromise its vascular-
bital arteries. Dissection is performed through a ization by the deep temporal artery. The muscle
bicoronal incision 2 cm behind the hair line up to can be attached to the bone edge of the resection
the level of the aponeurotic galea, followed by an- or to the maxillary sinus mucus.
terior and posterior detachment of the scalp flap. External lumbar drainage is not routinely used
Detaching the pericranium gives enough tissue to as prophylaxis for CSF fistula, in order to avoid
recover the entire anterior fossa floor, from the frequent complications such as pneumoencepha-
posterior wall of the frontal sinus up to the sellar lus and meningitis.
tubercle. During the procedure, the tissue must
be kept moist to prevent retraction. Conclusion
The fixation of the graft following tumor re- Extensive dural defects should be reconstructed
moval can be achieved using mononylon 5.0 in two stages: closure of the dura mater prior to
stitches through small drill holes in the bone edge beginning the facial approach and, following tu-
of the resection, either along the sphenoid plane mor removal, separation of the paranasal and
or orbital wall, according to the extent of bone cranial cavities using vascularized tissue.
removal.
This step is complemented with fibrin glue ap-
plied between the pericranial flap and previously References
reconstructed dura mater. 1 Thurnher D, Novak CB, Neligan PC, Gullane PJ: Reconstruction
of lateral skull base defects after tumor ablation. Skull Base
Except in rare instances, rigid structures such
2007;17:7988.
as bone or titanium plates are not required to sus- 2 Gil Z, Abergel A, Leider-Trejo L, Khafif A, Margalit N, Amir A,
tain the cerebral parenchyma [6]. Gur E, Fliss DM: A comprehensive algorithm for anterior skull
base reconstruction after oncological resections. Skull Base
Under circumstances precluding the use of 2007;17:2537.
pericranium (reoperation or tumor infiltration), 3 Imola MJ, Sciarretta V, Schramm VL: Skull base reconstruction.
alternatives available for vascularized patient-de- Curr Opin Otolaryngol Head Neck Surg 2003;11:282290.
4 Liu JK, Niazi Z, Couldwell WT: Reconstruction of the skull base
rived grafts include the two temporalis muscles, after tumor resection: an overview of methods. Neurosurg Focus
which can be shifted and stitched in order to re- 2002;12:e9.
cover the whole anterior fossa, and microvascular 5 Van Buren JM, Ommaya AK, Ketcham AS: Ten years experience
with radical combined craniofacial resection of malignant tu-
grafts such as abdominal rectus or radialis, re- mors of the paranasal sinuses. J Neurosurg 1968;28:341350.
quiring a reconstructive plastic microsurgical 6 Laedrach K, Lukes A, Raveh J: Reconstruction of skull base and
fronto-orbital defects following tumor resection. Skull Base
team. 2007;17:5972.
135
Skull Base Tumors
8.4 Which Is the Best Choice to Seal the

Craniofacial Diaphragm?

Resection of ASB tumors may create extensive de-
Resection of tumors in the anterior skull base (ASB) fects that result in a free conduit between the
may create defects in the craniofacial diaphragm. paranasal sinuses and the intracranial compart-
To accomplish a tight seal reconstruction, tailor
your reconstruction technique according to specific
ments. Reconstruction of such defects requires
anatomical requirements. precise and durable reconstruction [1]. The goals
of ASB reconstruction are (1) to form a watertight
The fascia lata (FL) offers a versatile, inexpensive
dural seal, (2) to provide a barrier between the
and reliable method of dural reconstruction using a
live biological tissue graft. Its neovascularization contaminated sinonasal space and the sterile sub-
provides long-term viability of the flap, without the dural compartment, (3) to prevent airflow into
need of an overlying vascularized flap. the intracranial space, (4) to maintain a function-
Use combinations of methods, including temporalis al sinonasal system, and (5) to provide a good cos-
muscle (TM) or free flap (FF), to reconstruct exten- metic outcome.
sive skull base (SB) defects in cases of orbital exen- A variety of approaches have been developed
teration (OE) or total maxillectomy.
to accomplish these goals, including viable, non-
viable and synthetic materials [2]. However, they

P I T F A L L S
can induce chronic inflammation, carrying a
high risk of infection, and are inferior to biologi-
Be aware that failure to create adequate reconstruc-
cal sources in terms of strength and sealing qual-
tion harbors significant complications, among them
cerebrospinal leak, meningitis and tension pneu- ity. On the other hand, local flaps are often inad-
mocephalus. equate, due to their limited size and their inabil-
Previous surgery or perioperative radiotherapy ity to produce a tight seal of the SB defect. FF is
significantly delays wound healing. In such cases, an excellent option for ASB reconstruction, but it
use viable biological reconstruction material as is relatively complex and its bulk may mask local
much as possible. recurrence. This chapter describes a reliable and
Wrap the bone segment with the pericranial flap reproducible method for cranial base reconstruc-
to prevent osteoradionecrosis of the frontal bone tion based on a multilayer FL allograft [3]. The FL
segment. flap already shows signs of vascularized fibrous
Treat infection promptly by using broad-spectrum tissue within a few weeks after surgery, eventu-
antibiotics. ally providing long-term graft viability without
an overlying vascularized flap [4].

The reconstruction technique is tailored to the The dray horse for dural reconstruction is the
type and size of the cranial defect, based on ra- double layer FL, which provides a simple, inex-
diological and intraoperative assessment. pensive and versatile means of SB reconstruction
Primary closure of the dura is performed after resection of advanced tumors. Other recon-
whenever possible using tight continuous prolene struction methods may be used according to the
sutures. A temporal fascia graft suffices if the de- SB defect. When reconstructed properly, the inci-
fect is small. dence and severity of perioperative complica-
If tumor resection results in an extensive SB tions, such as cerebrospinal fluid leak, intracra-
defect, a large FL sheath will be needed, fitted nial infection and tension pneumocephalus, are
precisely to the dimensions of the dural defect. less than 5%.
The dural repair is then covered with a second
layer of fascia that is applied against the entire
undersurface of the ethmoidal roof, the sella and References
the sphenoidal area. Fibrin glue is used to provide 1 Raveh J, Turk JB, Ladrach K, et al: Extended anterior subcranial
approach for skull base tumors: long-term results. J Neurosurg
additional protection against cerebrospinal fluid
1995;82:10021010.
leak. Vaseline gauze is then applied below the 2 Fliss DM, Zucker G, Cohen A, et al: Early outcome and complica-
dura and into the paranasal cavity for additional tions of the extended subcranial approach to the anterior skull
base. Laryngoscope 1999;109:153160.
support against pulsation of the brain [5]. 3 Amir A, Gatot A, Zucker G, et al: Harvesting of fascia lata sheaths:
When adjuvant radiation therapy is planned, a rational approach. Skull Base Surg 2000;10:2934.
it is advisable to wrap the frontal bone segment 4 Gil Z, Abergel A, Leider-Trejo L, et al: A comprehensive algo-
rithm for anterior skull base reconstruction after oncological re-
with a pericranial flap, in order to prevent osteo- sections. Skull Base Surg 2007;17:2538.
radionecrosis [6]. The frontal sinus bone is crani- 5 Fliss DM, Gil Z, Spektor S, et al: The double-layered fascia: a sim-
alized and the bone segment is returned to its ple skull base reconstruction method for anterior subcranial re-
section. Neurosurg Focus 2002;12:17.
original anatomical position. 6 Gil Z, Fliss DM: Pericranial wrapping of the frontal bone after
A TM flap and a split-thickness skin graft are anterior skull base tumor resection. Plast Reconstr Surg 2005;
116:395398.
used after extensive orbital wall resections, if OE
is performed.
After a radical maxillectomy, with or without
OE, a lateral thigh or a rectus abdominis FF is
used to obliterate the large resultant defect.
A dacryorhinocystostomy is performed to pre-
vent epiphora in all patients undergoing orbital
wall resection or medial maxillectomy.
137
Skull Base Tumors
8.5 Contraindications for Resection of

Skull Base Tumors
Fernando L. Dias, Roberto A. Lima
Head and Neck Surgery Department, Brazilian National Cancer Institute and Post-Graduation School of
Medicine, Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil

P E A R L S myocardial infarction: 33.3%, and cerebral in-
farction: 33.3%) of cases [3].
Be sure that the tumor is curable and that surgery
will extend survival. Practical Tips
Be sure that tumor histology and extent merit Current limitations and contraindications for SB
surgery. surgery are related to three areas (table 1): (1) an-
Be sure that there is an appropriate team backing atomical, (2) biological and (3) patient factors.
you up. a) Distant metastases from and to SB tumors
are definitive contraindications. An exception

P I T F A L L S may be adenoid cystic carcinoma in which pallia-
tive resection of primary SB tumor, mainly for
Resectability does not mean that the patient will pain, may be considered [2].
be able to tolerate and benefit from surgery.
b) Unilateral cavernous sinus (CS) or internal
Do not neglect the possibility of skull base (SB) carotid artery (ICA) invasion is not an unani-
metastases from an undiscovered or previously
mous contraindication for SB surgery but, even in
treated malignant tumor.
early cases, occult invasion of the opposite CS or
ICA may exist. A staging procedure with sinus
endoscopy (preferably) is advisable to establish
the confinement of the disease to one sphenoid
Introduction sinus [4]. Although ICA is most often encased and
Except for situations in which debulking surgery not invaded, en bloc resection requiring artery
is advocated, the main purpose of SB surgery is to resection is rarely performed for cancer [2, 4].
achieve en bloc removal of the tumor with ade- c) Tumors involving the superior sagittal sinus
quate margins of normal tissue [13]. (SSS) can usually be resected as long as its inner-
Death rates associated with SB surgery range most layer is left undisturbed. It is usually safe to
from 0 to 7.7% (average 4.4%). Major local com- ligate the SSS up to the level of the coronal suture
plications were the main cause of death in 73% of (when it rapidly increases in size). Interruption of
cases (intracranial sepsis: 55.5%, and intracrani- venous flow posterior to that level usually results
al bleeding/hematoma: 25.9%). Major systemic in quadroplegia or death [4].
complications also played an important role in d) There are multiple bridging veins from the
mortality rates with an incidence of 27% (acute convexity of the frontal lobes to the SSS. A few of

Table 1. Anatomic limitations/contraindications to extended procedures for paranasal sinus/SB tumors [13]
No longer contraindications Relative contraindications 1 Definitive contraindications

Pterygoid plate invasion Dural invasion Distant metastases
Infratemporal fossa invasion Minimal brain invasion Metastases to SB
Orbital invasion, unilateral Sphenoid sinus invasion Bilateral ICA invasion
Nasopharynx invasion Cavernous sinus invasion Bilateral cavernous sinus invasion
Regional metastases Clivus invasion SSS invasion
Unilateral ICA invasion Vital brain bridging vein invasion Massive brain (cortex) invasion
1
Often contraindications with high-grade tumors.
these can be sacrificed, but ligation of more than Conclusion

a few can also result in the patients death. Re- Tumors amenable to total excision with minimal
member that the vein of Labbe may be the only (acceptable) morbidity should be excised regard-
intact drainage venous system from the ipsilat- less of histology. For larger tumors close to or in-
eral cerebral hemisphere. Its sacrifice could result vading important neurological or vascular struc-
in a fatal outcome [4]. tures, tumor histology will help to determine the
e) Any evidence of lower cranial deficits plus advisability of surgery [2].
radiological evidence of proximity of tumor to
the brain stem usually means that the patient is
inoperable. Removal of vital portions of the cor- References
tex associated with a high risk of death or result- 1 Shah JP, Patel SG: The skull base; in Shah JP, Patel SG (eds): Head
and Neck Surgery and Oncology, ed 3. Edinburgh, Mosby, 2003,
ing in severe altered function (unacceptable to the
pp 93148.
patient) is also a contraindication. Although com- 2 Lavertu P: An overview of indications and contraindications of
plete removal of optic chiasm can be safely extended procedures for cancer of the paranasal sinuses. Pro-
ceedings of the 4th International Conference on Head and Neck
achieved and is not an absolute contraindication, Cancer, Toronto, 1996, pp 10331039.
most patients will decline surgery if they are to be 3 Dias FL, S GM, Kligerman J, et al: Complications of anterior
rendered blind [2, 4]. craniofacial resection. Head Neck 1999;21:1220.
4 Donald PJ: Skull base surgery for malignancy: when not to oper-
Attention to tumor histology. Aggressive tu-
ate. Eur Arch Otolaryngol 2007;264:713717.
mors such as malignant melanoma, high-grade 5 Cernea CR, Teixeira GV, Dos Santos LRM, et al: Indications for,
sarcomas and squamous carcinomas are ominous contraindications to, and interruption of craniofacial proce-
dures. Ann Otol Rhinol Laryngol 1997;106:927933.
findings. Even basal cell carcinomas may acquire
virulent behavior, particularly after several thera-
peutic attempts by means of surgery, RT and CT
[15].
Good general (clinical) health is paramount.
Common intercurrent diseases (between the age
of 50 and 70) such as diabetes, renal, gastrointes-
tinal, and heart diseases must be optimally con- 8
trolled. Chronological age is not as important as
physiological/clinical age. Patients commitment
is essential [15].
139
Skull Base Tumors
8.6 Practical Tips about Orbital Preservation

and Exenteration
Ehab Hanna
Department of Head and Neck Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Tex., USA

OE carries with it a significant emotional burden
Detailed neuro-ophthalmologic examination is essential. on patients and their families, deterring some pa-
High-resolution CT and MRI provide critical information tients from pursuing treatment, or making them
regarding the extent of orbital bony and soft tissue
involvement, respectively.
chose a less effective therapy regardless of the
chances for cure. Lately, the indications for OP
The decision to preserve or sacrifice the eye is sometimes
have evolved and are more clearly defined [1].
made intraoperatively. Clearly discuss this with the
patient and family, and obtain proper informed consent. Most studies have shown that if orbital invasion
Orbital preservation (OP) is feasible unless there is signifi- is limited to the bony orbit or the periorbita, OP
cant invasion of the orbital fat, muscles, nerves, or apex.
is possible without compromising oncologic out-
Invasion of the bony orbit or periorbita per se is not an
come [26]. OE is usually indicated when there is
indication for orbital exenteration (OE).
gross invasion of the periocular fat, extraocular
Meticulous reconstruction of the medial canthal ligament,
muscles, or optic nerve.
lacrimal system, and orbital floor and rim will maximize
functional results.
Practical Tips

P I T F A L L S Despite better definition of the indications for
OP, the preoperative decision as to whether the
Orbital invasion by perineural spread rather than direct orbit should be preserved or sacrificed is some-
extension may be missed unless careful examination of
the cranial nerves, especially V1 and V2, and accurate
times difficult. The presence of proptosis or dip-
assessment of even subtle enhancement or thickening of lopia may be due to displacement rather than in-
orbital nerves on MRI are done. vasion of the intraorbital contents. Decreased vi-
Perineural spread may extend proximally beyond the sual acuity or visual fields, or the presence of an
orbital apex and even to the cavernous sinus compromis-
ing local disease control.
afferent pupillary defect usually indicates gross
invasion of the orbit.
Bilateral orbital apex or optic chiasm involvement,
In the absence of any ocular signs or symp-
especially in central skull base lesions, is usually a contra-
indication for surgical resection. toms, evaluation of the extent of orbital involve-
Attempts at OP leaving gross residual disease usually ment relies mainly on imaging. CT is best for
result in poor disease control and ultimate loss of orbital
evaluating bony involvement of the orbital walls
function.
and MRI to evaluate the extent of soft tissue inva-
If OE is contemplated, always make sure that the patient
sion beyond the periorbita. MRI is also useful in
has useful vision in the contralateral eye.
detecting perineural spread proximally beyond
the orbital apex and into the cavernous sinus [7].

The accuracy of imaging in detecting invasion of Conclusions
the periorbita is not completely reliable [5] and Every effort should be made to preserve the eye
frequently, the definitive assessment of the extent as long as preservation does not compromise the
of orbital invasion and decision about eye preser- adequacy of oncologic resection. Careful plan-
vation has to be made intraoperatively. ning of surgical incisions and meticulous orbital
Perform the extended lateral rhinotomy in- reconstruction will enhance the functional out-
stead of the classic Weber-Fergusson incision, for come of the preserved orbit. Precise radiation do-
total maxillectomy with OP [8]. Avoiding a sub- simetry and proper shielding of the eye will min-
ciliary incision minimizes lower eyelid complica- imize ocular complications.
tions, particularly ectropion and prolonged eyelid
edema, and avoiding trifurcation of the incision
reduces the risk of skin breakdown at the medial References
canthal area. 1 Hanna EY, Westfall CT: Cancer of the nasal cavity, paranasal si-
Meticulous orbital reconstruction after OP is nuses, and orbit; in Myers EN, Suen JY, Myers JN, Hanna EY
(eds): Cancer of the Head and Neck. Philadelphia, Saunders,
imperative for good function [1, 9]. Careful re- 2003, pp 155206.
attachment of the medial canthal ligament will 2 Andersen PE, Kraus DH, Arbit E, Shah JP: Management of the
orbit during anterior fossa craniofacial resection. Arch Otolar-
prevent telecanthus. If the lacrimal apparatus is yngol Head Neck Surg 1996;122:13051307.
transected, a dacryocystorhinostomy prevents 3 McCary WS, Levine PA, Cantrell RW: Preservation of the eye in
postoperative epiphora. If the orbital rim or a sig- the treatment of sinonasal malignant neoplasms with orbital in-
volvement. A confirmation of the original treatise. Arch Otolar-
nificant portion (more than one third) of the or- yngol Head Neck Surg 1996;122:657659.
bital floor is removed, particularly if the perior- 4 Carrau RL, Segas J, Nuss DW, et al: Squamous cell carcinoma of
bita is resected, bony support is essential. Bone the sinonasal tract invading the orbit. Laryngoscope 1999;
109:230235.
reconstruction is best done using vascularized 5 Tiwari R, van der Wal J, van der Wal I, Snow G: Studies of the
bone flaps. If nonvascularized bone grafts or al- anatomy and pathology of the orbit in carcinoma of the maxil-
lary sinus and their impact on preservation of the eye in maxil-
loplastic implants are used, they should be ade- lectomy. Head Neck 1998;20:193196.
quately covered with well-vascularized soft tissue 6 Essig GF, Newman SA, Levine PA: Sparing the eye in craniofacial
to minimize infection and extrusion. surgery for superior nasal vault malignant neoplasms: analysis
of benefit. Arch Facial Plast Surg 2007;9:406411.
The function of the preserved eye will also be
7 Hanna E, Vural E, Prokopakis E, Carrau R, Snyderman C, Weiss-
greatly influenced by precise dosimetry of post- man J: The sensitivity and specificity of high-resolution imaging
operative radiation [10]. The use of 3-D confor- in evaluating perineural spread of adenoid cystic carcinoma to
the skull base. Arch Otolaryngol Head Neck Surg 2007;133:541
mal radiation therapy or intensity-modulated ra- 545.
diation therapy is particularly helpful in deliver- 8 Vural E, Hanna E: Extended lateral rhinotomy incision for total
maxillectomy. Otolaryngol Head Neck Surg 2000;123:512513.
ing effective radiation doses to the tumor bed
9 DeMonte F, Tabrizi P, Culpepper SA, Abi-Said D, Soparkar CN,
while sparing ocular contents. Patrinely JR: Ophthalmological outcome following orbital resec-
tion in anterior and anterolateral skull base surgery. Neurosurg
Focus 2001;10:E4.
10 Sheng K, Molloy JA, Larner JM, Read PW: A dosimetric com-
parison of non-coplanar IMRT versus helical tomotherapy for
nasal cavity and paranasal sinus cancer. Radiother Oncol
2007;82:174178.
141
Skull Base Tumors
8.7 Practical Tips to Approach the

Cavernous Sinus
Marcos Q.T. Gomes a, b, Eduardo Vellutini b
a Hospital das Clinicas, So Paulo University,
b DFV Servios de Neurologia e Neurocirurgia, So Paulo, Brazil

P E A R L S along V1 via the SOF or the optic nerve through
the optic canal.
Extradural approach peeling of the cavernous In this type of invasion, the CS tends to be af-
sinus (CS). fected when intracranial invasion occurs, ham-
Try to start peeling at the superior orbital fissure pering oncologic removal, where this must be ex-
(SOF). posed to achieve an oncologically free margin.
Fibrin glue injection into CS before opening. The most frequent clinical picture of invasion
of the CS is facial pain or numbness due to com-

P I T F A L L S promise of the trigeminal branch. If the invasion
is massive, symptoms of ocular paralysis may be
Always perform an MRI to assess the carotid associated.
involvement.
Practical Tips
Approach for tumors invading the CS must be
elected on a case-by-case basis. In the event of
Introduction ICA compromise, oncologic removal with mar-
The CS is a venous structure of walls formed by gins cannot take place without sacrificing this
dura mater containing inner neurovascular struc- vessel [2].
tures. The oculomotor (III), trochlear (IV), abdu- An MRI study must always be performed to
cens (VI) nerves and the two first branches of the assess the extent of invasion of the CS and in-
trigeminal nerve (V1 and V2) traverse the CS, volvement of the ICA. If it shows signs of tumor
while the third branch (V3) lies at its posterior around ICA, removal of this vessel should be con-
border [1]. The internal carotid artery (ICA) pass- sidered.
es through the CS where it continues a sinuous The CS nerves, with the exception of the VI,
path to exit at the roof of the sinus. pass through the lateral wall of the CS [1]. If only
Tumors of the paranasal sinuses and infratem- the portion lateral or anterior to the ICA is af-
poral fossa generally invade the CS due to its neu- fected, then removal without sacrificing the ICA
rotropism, infiltrating the trigeminal branches can be attempted.
(V2 and V3, respectively) and then expanding The dura mater of the lateral wall of the CS has
centripetally to the intracranial cavity reaching two layers: the inner one houses the nerves out-
the CS. Intraorbital tumors may invade the skull lined above, whereas the external one follows the

dura of the temporal convexity. This may be ment, precludes a free oncologic margin without
peeled away, leaving a thin continuous internal sacrificing the vessel. Exenteration of the CS with
layer, allowing the nerves to be seen by transpar- ICA must then be considered, involving ICA by-
ency, a procedure referred to as CS peeling. De- pass and the placing of a vascularized flap to re-
scribed by Dolenc [1] as the extradural access construct the cranial base [2, 4].
pathway to CS pathologies, this approach mini-
Bleeding of the CS is generally profuse, except
mizes damage to the nervous tissue, prevents the in cases where it is filled by tumor. It can often be
occurrence of liquor fistula and allows better controlled using Surgicel . Fibrin glue is extreme-
identification and saving of the nerves when pos- ly useful, being injected into the CS before open-
sible. ing, filling some of its compartments, thereby
The peeling is done by cutting the dural band minimizing blood loss.
at the lateral edge of the SOF, together with the
meningo-orbital artery. Pulling away the outer Conclusion
layer will detach it from the inner layer. The edge The extradural approach to the CS is the best way
is more strongly attached and needs to be cut, to reach the CS with minimum complications. If
particularly near V2 and V3 [1, 3]. the ICA wall has not been invaded, a partial re-
Although difficult, it is also possible to per- section of the CS can be performed. If the tumor
form the peeling following V2, and cutting the has reached the ICA, exenteration of the CS must
edges superiorly and posteriorly. This is particu- be considered, together with an arterial bypass.
larly useful in tumors that invade the skull
through the foramen rotundum or ovale, where
the nerve has to be sacrificed to achieve a free on- References
cologic margin. 1 Yasuda A, Campero A, Martins C, Rhoton AL, Oliveira E, Ribas
The peeling technique allows partial resection GC: Microsurgical anatomy and approaches to the cavernous si-
nus. Neurosurgery 2005;56(1 suppl):427.
of the CS without lesion to the oculomotor 2 George B, Ferrario CA, Blanquet A, Kolb F: Cavernous sinus ex-
nerves. enteration for invasive cranial base tumors. Neurosurgery
The ICA is the main limitation in removal of 2003;52:772782.
3 Dolenc VV: Transcranial epidural approach to pituitary tumors
tumors invading the CS. Its sinuous pathway extending beyond the sella. Neurosurgery 1997;41:542552.
within the CS often obscures the perceived pa- 4 Sekhar LN, Sen CN, Jho HD: Saphenous vein graft bypass of the
cavernous internal carotid artery. J Neurosurg 1990;72:3541.
thology extension. In malignant neoplasms, the
invasion of the ICA wall, even without encase-
143
Skull Base Tumors
8.8 How to Reconstruct Large

Cranial Base Defects
Patrick J. Gullane a, Christine B. Novak b, Kristen J. Otto a,
Peter C. Neliganc
a Department of Otolaryngology Head and Neck Surgery, University of Toronto and
b Wharton Head and Neck Centre, University Health Network, Toronto, Ont., Canada;
c Division of Plastic Surgery, University of Washington Medical Center, Seattle, Wash., USA

P E A R L S provide soft tissue coverage and structural sup-
port that is functional and esthetically accept-
Consider patient comorbidities in the selection of able. It is necessary to obtain a watertight dural
type of reconstruction. seal, to obliterate dead space, to support neural
A free flap (FF) provides ample well-vascularized structures and to ensure coverage with well-vas-
tissue to encompass the dead space in a complex cularized tissue. Previously, pedicled muscle
3-D defect [1].
flaps (e.g., the pectoralis) were used for recon-
Create a watertight barrier (dural seal) between struction of large defects. However, more recent-
intracranial and extracranial contents. ly, the advancement of microsurgery has relegat-
Secure dural repair with suspension sutures to the ed the pedicled flap to a less desirable option for
surrounding bone. LCBDs in favor of the FF in the appropriately se-
lected patient [1, 35]. It provides an ample sup-

P I T F A L L S ply of vascularized soft tissue and it can be de-
signed based upon the unique requirements of
Avoid the use of nonvascularized bone and soft
the reconstruction. An FF also provides the op-
tissue.
portunity for two surgical teams to work simul-
Entry into the orbit can lead to postoperative taneously, for the tumor ablation and the harvest
complications such as diplopia, optic neuropathy,
ectropion and enophthalmos [2].
of the free tissue transfer.
The tumor type, location of the tumor and
need for postoperative radiation will guide the
selection of the optimal surgical approach [6].
Following tumor ablation, the reconstruction will
depend on the size and position of the lesion and
if the dura has been breached. Patient comorbid-
Introduction ities, such as age greater than 75, diabetes, sig-
Management of large cranial base defects nificant vascular disease or immunosuppression,
(LCBDs) presents a reconstructive challenge due may preclude the use of a free tissue transfer, but
to the anatomic location and the complex recon- the consideration of individual patient factors is
struction that is required. The main goals are to necessary.

Practical Tips Orbital Reconstruction. If the orbit is violated
Soft Tissue Repair. Our choice of FF includes during the resection, controversy exists as to
the rectus abdominis muscle, the latissimus dorsi whether orbital reconstruction is necessary. A
muscle and the anterolateral thigh flap. In the good rule of thumb is that reconstruction should
skull base, the donor vessels from the neck are be pursued when more than 2/3 of the orbital
commonly used and vein grafts are rarely needed. floor is removed. Bony repair (bone grafting or
Postoperative external monitoring of pedicle pa- titanium mesh implants) as well as soft tissue re-
tency is performed using a venous Doppler and in construction (repair of the periorbita) are recom-
cases where there is no external skin paddle, an mended [2].
implantable venous Doppler may be used to mon-
itor the flap. Conclusion
Bony Reconstruction. Following tumor extir- Reconstruction of LCBD is complex and these re-
pation and reconstruction, many patients with pairs require a watertight dural seal, obliteration
skull base tumors may require adjuvant radio- of the dead space and coverage with vascularized
therapy, precluding the use of nonvascularized soft tissue. Advances in diagnostic pathology, im-
bone for reconstruction. In most patients, soft tis- aging and surgical technique for tumor extirpa-
sue will be adequate for the repair; however, when tion and reconstruction have improved the treat-
more bony support is required, vascularized bone ment of these patients, minimized postoperative
grafts or alloplastic materials (i.e. titanium mesh) complications and maximized patient outcome
should be used. Our FF preferences are the scapu- and health-related quality of life.
lar osseocutaneous (SFF) and the iliac crest
(ICFF), but they have weaknesses. To harvest the
SFF, the patient must be repositioned, which pre- References
cludes the use of two surgical teams, increasing 1 Weber SM, Kim JH, Wax MK: Role of free tissue transfer in skull
base reconstruction. Otolaryngol Head Neck Surg 2007;136:914
operative time. The ICFF is associated with in-
919.
creased postoperative patient morbidity and dis- 2 DeMonte F, Tabrizi P, Culpepper S, Suki D, Soparker CN, Patrine-
comfort. ly JR: Ophthalmological outcome after orbital entry during an-
Dural Seal. When the dura has been breached, terior and anterolateral skull base surgery. J Neurosurg 2002;
97:851856.
a watertight seal must be established to minimize 3 Jones NF, Schramm VL, Sekhar LN: Reconstruction of the cra-
the risk of CSF fistula. Due to the unique ana- nial base following tumour resection. Br J Plast Surg 1987;40:155
162.
tomic position of the cranial base, there is a down- 4 Neligan PC, Boyd JB: Reconstruction of the cranial base defect.
ward gravitational strain on any dural repair, Clin Plast Surg 1995;22:7177.
posing a difficult problem to maintain the dural 5 Neligan PC, Mulholland RS, Irish J, Gullane PJ, Boyd JB, Gentili
F, Brown D, Freeman J: Flap selection in cranial base reconstruc-
seal and creating more dead space. We use sus- tion. Plast Reconstr Surg 1996;98:11591166.
pension sutures to secure the flap to the sur- 6 Irish J, Gullane PJ, Gentili F, Freeman J, Boyd JB, Brown D, Rutka
J: Tumors of the skull base: outcome and survival analysis of 77
rounding bone, placing them in the tendinous in- cases. Head Neck 1994;16:310.
tersection of the FF to provide a more reliable at-
tachment. Fibrin glue may be used to further
secure the seal.
145
Skull Base Tumors
8.9 Surgical Management of Recurrent Skull

Base Tumors
Claudio R. Cerneaa, Ehab Hanna b
a Department of Head and Neck Surgery, University of So Paulo Medical School, So Paulo, Brazil;
b Department of Head and Neck Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Tex., USA

The treatment of RSBT represents a formidable
Try to preoperatively assess operability of a recur- challenge. Early detection of tumor relapse may
rent skull base tumor (RSBT) with accurate imaging be very difficult, due to distortion of anatomical
studies. High resolution CT and MRI are complimen-
tary and allow accurate planning of surgical access
landmarks and presence of fibrosis/gliosis, as well
and extent of resection. as reconstructive flaps used at the previous op-
Discuss extensively with the patient and his/her eration [1, 2]. Recurrence may involve vital areas
family the potential surgical morbidity, as well as of the central nervous system, precluding radical
the possibility to interrupt the procedure, if neces- resection with a reasonable chance of cure, while
sary. preserving life quality at a functional level [3, 4].
Taylor the incision according to the features of the On the other hand, significant long-term pallia-
recurrent lesion, mainly when treating recurrent
tion may be obtained, especially with slow-grow-
skin cancers.
ing tumors.
Use microvascular reconstructive techniques,
especially if a wide communication between the
cranium and the paranasal sinuses and/or skin was Practical Tips
created. Try to obtain data from the previous surgical
Meticulous watertight dural repair is imperative to procedure, as well as from the previous adjuvant
avoid CSF fistulas. treatment.
Consider placing metal clips to orient eventual tar- Imaging studies should include high resolu-
geted adjuvant radiotherapy.
tion CT and MRI for accurate assessment of the
bony and soft tissue extent of disease, respective-

P I T F A L L S
ly. The use of PET/CT is helpful in distinguishing
posttreatment effects from active tumor, and in
Be very careful when indicating a reoperation in
ruling out systemic disease.
the following instances: very aggressive histologic
types, extensive involvement of the cavernous Interventional radiology is indicated to perform
sinus (CS), of the intracranial internal carotid artery preoperative embolization of highly vascularized
(ICA), and of vital parts of the brain or of optic tumors, mainly in the lateral skull base [5]. Ca-
chiasm. rotid angiography may also be helpful in mapping
Do not hesitate to intraoperatively abort a redo out the cerebral circulation, and balloon test oc-
craniofacial resection, if an unexpectedly aggres-
sive invasion is observed.
clusion may guide the need for cerebral revascu-
larization in case of injury or sacrifice of the ICA.

Keep in mind that the treatment of skull base Conclusion
tumors requires multidisciplinary input; there- In this chapter, the reader was exposed to some
fore, surgical strategy must be extensively planned considerations about the management of RSBT. It
by all involved teams. The feasibility of pre- or is important to emphasize that the surgical indi-
postoperative adjuvant therapy may be a critical cations must be carefully debated in the scenario
determinant of the decision to pursue surgical re- of a multispecialty team approach and frankly
section. discussed with the patient and his/her family, due
Frequently, the surgical approach involves to the prognostic implications, the surgical risk
atypical incisions, mandated by the extension of and quality of life deterioration that may occur.
the recurrent lesion, especially if there is skin in-
volvement [6].
Usually, combined craniofacial resections start References
with the craniotomy. When dealing with recur- 1 Glenn LW: Innovations in neuroimaging of skull base pathology.
Otolaryngol Clin North Am 2005;38:613629.
rent tumors, do not hesitate to interrupt the pro-
2 Wallace RC, Dean BL, Beals SP, Spetzler RF: Posttreatment imag-
cedure at this point, provided an unexpectedly ing of the skull base. Semin Ultrasound CT MR 2003;24:164
extensive invasion of vital structures is noted 181.
3 Dos Santos LR, Cernea CR, Brandao LG, Siqueira MG, et al: Re-
(ICA, CS, optic chiasm, among others), especially sults and prognostic factors in skull base surgery. Am J Surg
with very aggressive histologic types [7]. Pay spe- 1994;168:481484.
cial attention to preserve the integrity of the cra- 4 Cant G, Solero CL, Mariani L, Mattavelli F, et al: A new classi-
fication for malignant tumors involving the anterior skull base.
nial nerves involved with the CS, especially if the Arch Otolaryngol Head Neck Surg 1999;125:12521257.
ipsilateral eye is still functional. Dural invasion is 5 Turowski B, Zanella FE: Interventional neuroradiology of the
not a contraindication per se, unless the remain- head and neck. Neuroimaging Clin N Am 2003;13:619645.
6 Cernea CR, Dias FL, Lima RA, Farias T, et al: Atypical facial ac-
ing defect is too basal, precluding adequate expo- cess: an unusually high prevalence of use among patients with
sure for reconstruction. Similarly, brain invasion skull base tumors treated at 2 centers. Arch Otolaryngol Head
Neck Surg 2007;133:816819.
may be adequately managed, except if vital areas, 7 Cernea CR, Teixeira GV, Medina dos Santos LR, Vellutini EA, et
like the dominant precentral gyrus, are invaded. al: Indications for, contraindications to, and interruption of cra-
Always perform a watertight dural closure, us- niofacial procedures. Ann Otol Rhinol Laryngol 1997;106:927
933.
ing grafts if necessary. In our experience, fascia 8 Chang DW, Langstein HN, Gupta A, De Monte F, et al: Recon-
lata is an excellent alternative. structive management of cranial base defects after tumor abla-
Do not hesitate to use microvascular flap re- tion. Plast Reconstr Surg 2001;107:13461355.
construction [8].
147
Skull Base Tumors
8.10 Management of Extensive Fibro-Osseous

Lesions of the Skull Base
Claudio R. Cerneaa, Bert W. OMalley, Jr.b
a Department of Head and Neck Surgery, University of So Paulo Medical School, So Paulo, Brazil;
b Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pa., USA

Fibro-osseous lesions of the head and neck com-
It is important to define the rationale for recom- prise a wide clinicopathological spectrum of dis-
mending surgery for any fibro-osseous lesion of the eases, ranging from monostotic fibrous dysplasia
skull base.
to Pagets disease and even Albrights syndrome,
Indications for the surgical treatment of extensive
which includes polyostotic fibrous dysplasia as-
fibro-osseous lesions of the skull base must be
objectively based on factors like compression of sociated with cutaneous pigmentation and preco-
vital structures (optic nerve), diplopia, facial dis- cious sexual development [1]. Some authors con-
figurement and rapid growth. sider other diseases, like ossifying fibroma, as
Most surgical approaches can be performed extra- part of this group, making diagnostic distinction
durally. Aggressive lesions may require a more sometimes rather difficult [1]. Fibro-osseous le-
extensive surgical resection that must be counter- sions of the skull base usually affect children and
balanced with the associated risk to cranial nerves
young adults, presenting as a slowly growing mass
and major vessels.
involving the mandible, the maxilla or the eth-
Less aggressive lesions may warrant no intervention
moid [2]. However, local expansion may occa-
and only observation.
sionally cause severe deformities as well as func-
Postoperative functional rehabilitation may be sur-
tional consequences, especially when there is
prisingly good, particularly in very young children.
compression of cranial nerves [3], which may lead
to diplopia or visual loss, dysphagia or dysphonia,

P I T F A L L S
pain or paresthesias if left untreated [4]. The ra-
Excessive drilling at the foramina or compartments diological diagnosis is of paramount importance,
which hold the cranial nerves, carotid artery, and not only to adequately establish the extent of the
brain and orbital soft tissues. disease but also to facilitate the surgical approach
Using aggressive rongeuring to remove the bony and requirements for reconstruction [5]. For en-
lesion at the cranial nerve foramina, near the supe- larging lesions or compressive lesions, surgical
rior and inferior orbital fissures, along the carotid treatment is the best option for intervention.
canal, and at the optic canal.
However, the indications for surgery must be
Excessive resection of bony craniofacial structures carefully balanced against the intraoperative
may lead to unsatisfactory cosmetic results.
risks and postoperative morbidity [6, 7].
Not obtaining CT or MRI imaging and clinical
follow-up on patients who receive a recommenda-
tion for observation.

Listen carefully to the clinical history, with In this chapter, the reader was exposed to some
special attention to the duration, intensity and considerations about the management of fibro-
progression of symptoms. osseous lesions of the skull base. It is important
Imaging studies should include CT and MRI to emphasize that the surgical treatment must be
to evaluate intracranial extension, orbital dis- carefully tailored to each case and to the aggres-
placement and, especially, optic nerve or other sive or slow-growing nature of each independent
cranial nerve compression. lesion. In some instances the intraoperative risks
If the lesion has been stable for years and no and postoperative morbidity may be significant
major symptoms are present, observation with and should be weighed according to the surgeons
clinical and radiological monitoring may be pre- recommendations and the patients desire for sur-
ferred instead of an extensive and potentially gery.
morbid operation.
Three-dimensional CT is very useful for re-
construction planning. References
In many cases, resection may be performed 1 Barnes L, Verbin RS, Appel BN, Peel RL: Diseases of the bones
and joints; in Barnes L (ed): Surgical Pathology of the Head and
extradurally via a transfacial or subcranial ap-
Neck. New York, Marcel Dekker, 2001, pp 10491232.
proach. 2 Lustig LR, Holliday MJ, McCarthy EF, Nager GT: Fibrous dyspla-
Another viable option would be endoscopic re- sia involving the skull base and temporal bone. Arch Otolaryngol
Head Neck Surg 2001;127:12391247.
section of the fibro-osseous lesion, particularly if 3 Katz BJ, Nerad JA: Ophthalmic manifestations of fibrous dyspla-
it is within the ethmoid, maxillary, or sphenoid sia: a disease of children and adults. Ophthalmology 1998;105:
sinuses, the frontal recess, or the medial orbital 22072215.
4 Michael CB, Lee AG, Patrinely JR, Stal S, Blacklock JB: Visual loss
wall or apex [8]. associated with fibrous dysplasia of the anterior skull base. Case
The most critical aspect in the management of report and review of the literature. J Neurosurg 2000;92:350
fibro-osseous lesions of the skull base is the care- 354.
5 Panda NK, Parida PK, Sharma R, Jain A, Bapuraj JR: A clinicora-
ful approach to decompression of critical struc- diologic analysis of symptomatic craniofacial fibro-osseous le-
tures such as the optic nerve or carotid artery [9]. sions. Otolaryngol Head Neck Surg 2007;136:928933.
6 Becelli R, Perugini M, Cerulli G, Carboni A, Renzi G: Surgical
It is very important to avoid excessive drilling or treatment of fibrous dysplasia of the cranio-maxillo-facial area.
aggressive rongeuring close to these structures in Review of the literature and personal experience from 1984 to
order to avoid inadvertent damage. Also, careful 1999. Minerva Stomatol 2002;51:293300.
7 Chen YR, Noordhoff MS: Treatment of craniomaxillofacial fi-
attention should be paid to the repositioning or brous dysplasia: how early and how extensive? Plast Reconstr
reconstruction of the bony or soft tissues of the Surg 1990;86:835842.
orbit in order to avoid diplopia, exophthalmos, or 8 Samaha M, Metson R: Image-guided resection of fibro-osseous
lesions of the skull base. Am J Rhinol 2003;17:115118.
enophthalmos. 9 Papay FA, Morales L, Flaharty P, et al: Optic nerve decompres-
sion in cranial base fibrous dysplasia. J Craniofac Surg 1995;6:
510.
149
Vascular Tumors
9.1 Practical Tips to Manage Extensive

Arteriovenous Malformations
Gresham T. Richter, James Y. Suen
Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences,
Arkansas Childrens Hospital, Little Rock, Ark., USA

P E A R L S latation, recruitment, and collateralization of
contributing arteries and veins. The result is a
Surgical resection complimented by preoperative progressively expanding high-flow vascular le-
embolization leads to best chance for cure. sion with devastating functional and cosmetic
Supraselective embolization of the nidus without consequences. Intervention is necessary to pre-
incorporating the major arterial supply should be vent progression, life-threatening bleeding, and
performed if embolization is the primary treatment
high-output cardiac failure [1, 2]. However, man-
of arteriovenous malformations (AVM).
agement decisions are met with the challenge of
Free tissue transfers should occur only when anas- high recurrence rates from inadequate excision
tomoses to vessels far distal to the resected AVM
can be performed. Otherwise, local flaps (with prior
and severe deficits from radical extirpation [3, 4].
expansion) or pedicle flaps should be used. Superficial lesions are often considered just the
tip of the iceberg.
Complete surgical extirpation is essential for cure.
Rapid growth of AVM frequently occurs at the
onset of puberty and during pregnancy. Contin-

P I T F A L L S
ued expansion can lead to significant destruction
of involved tissue and can grow to invade adjacent
AVM are frequently misdiagnosed as hemangiomas.
structures similar to malignancies. Partial exci-
Embolization alone or partial resection of AVM will
sion or embolization may lead to dramatic expan-
lead to rapid progression of residual disease with
recruitment of adjacent soft tissue vasculature. sion of previously unappreciated contributions to
the AVM. Embolization followed by radical re-
Ligation of contributing vessels without addressing
section and reconstruction has shown promising
the central lesion causes progressive growth and
neoformation of collateral blood vessels, making results and is commonly employed by those who
further management difficult. deal with complex AVM [47].
Practical Tips
A multidisciplinary team (interventional radi-
Introduction ologist, otolaryngologist, and reconstructive sur-
AVM are rare congenital anomalies of vascular geon) is essential for managing extensive head
development thought to arise from persistent and neck AVM.
arteriovenous channels of early fetal life. These A thorough understanding of vascular anato-
lesions are present at birth but may remain clin- my is critical to managing large head and neck
ically quiescent for many years until rapid di- AVM as aberrant vessels often make it difficult to

map the entire area involved by the lesion. This Conclusions
appreciation should be met by complex radio-
graphic imaging including MRI, MRA, and arte-
Extensive AVM of the head and neck are complex
and debilitating lesions. Embolization is effective
9
riograms [4, 8]. if followed with immediate (15 days) resection
Preoperative embolization should be per- of all or near total disease. Respect for vital struc-
formed on AVM 14 days prior to undergoing tures and functional outcome is weighed by the
surgical resection [1, 4]. Further delay can lead to need for complete extirpation to achieve clinical
rapid recruitment and collateralization of new cure. Early management of residual disease logi-
vessels. cally leads to improved long-term outcomes.
The operative surgeon should be present dur-
ing embolization to help identify feeding vessels
and prevent inadvertent occlusion of uninvolved References
tissue. 1 Erdmann MW, Jackson JE, Davies DM, Allison DJ: Multidisci-
Total resection of small and focal AVM has a plinary approach to the management of head and neck arterio-
venous malformations. Ann R Coll Surg Engl 1995;77:5359.
higher likelihood of cure [7, 9]. 2 Sugrue M, McCollum P, ODriscoll K, Feeley M, Shanik DG,
Incomplete resection of large AVM to avoid Moore DJ: Congenital arteriovenous malformation of the scalp
with high output cardiac failure: a case report. Ann Vasc Surg
cosmetic and functional deficits may be indicated 1989;3:387388.
with the understanding that recurrence is com- 3 Kane WJ, Morris S, Jackson IT, Woods JE: Significant hemangio-
mon and repeat intervention necessary [5]. mas and vascular malformations of the head and neck: clinical
management and treatment outcomes. Ann Plast Surg 1995;35:
Urgent management of ulcerative or bleeding
133143.
lesions is vital to preventing significant patient 4 Seccia A, Salgarello M, Farallo E, Falappa PG: Combined radio-
morbidity and mortality. These patients may be logical and surgical treatment of arteriovenous malformations
of the head and neck. Ann Plast Surg 1999;43:359366.
treated with palliative embolization or preopera- 5 Bradley JP, Zide BM, Berenstein A, Longaker MT: Large arterio-
tive embolization prior to complete extirpation. venous malformations of the face: aesthetic results with recur-
Surgeons should be prepared for complete re- rence control. Plast Reconstr Surg 1999;103:351361.
6 Jeong HS, Baek CH, Son YI, Kim TW, Lee BB, Byun HS: Treat-
section at the initial procedure with expectation ment for extracranial arteriovenous malformations of the head
of long operative time, significant intraoperative and neck. Acta Otolaryngol 2006;126:295300.
7 Kohout MP, Hansen M, Pribaz JJ, Mulliken JB: Arteriovenous
bleeding, and need for reconstruction [10]. Resec- malformations of the head and neck: natural history and man-
tion should proceed with preservation of vital agement. Plast Reconstr Surg 1998;102:643654.
structures and respect for cosmetic and function- 8 Cure JK: Imaging of vascular lesions of the head and neck. Facial
Plast Surg Clin North Am 2001;9:525549.
al concerns. 9 Richter GT, Suen J, North PE, James CA, Waner M, Buckmiller
Nonstick bipolar electrocautery is essential to LM: Arteriovenous malformations of the tongue: a spectrum of
disease. Laryngoscope 2007;117:328335.
control significant blood loss encountered when
10 Buckmiller LM, Richter GT, Waner M, Suen JY: Use of recombi-
removing AVM. nant factor VIIa during excision of vascular anomalies. Laryn-
Margins of AVM are extremely difficult to de- goscope 2007;117:604609.
fine at surgery due to increased blood flow of col-
lateral vessels. Bleeding patterns, such as diffuse
bleeding, can be helpful in defining surgical mar-
gins.
151
Vascular Tumors
9.2 How to Manage Extensive Lymphatic

Malformations
James Y. Suen, Gresham T. Richter
Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences,
Arkansas Childrens Hospital, Little Rock, Ark., USA

P E A R L S infancy. They can cause upper airway obstruc-
tion and often require tracheotomy for airway
Rapid growth of a lymphatic malformation (LM) control [1]. Obvious enlarged cystic components
may occur with any local infection and should be can be treated with either surgery or sclerothera-
managed initially with antibiotics and steroids for
710 days.
py. The face, tongue and other mucosal surfaces
more frequently harbor microcystic or mixed dis-
An MRI is very helpful to determine if an LM is
ease whereby sclerotherapy is not as useful [2].
microcystic, macrocystic, or mixed.
Tongue and floor of mouth involvement may re-
On MRI, a fluid-fluid level on T2 is usually diagnostic sult in protrusion of the tongue out of the mouth.
of LM.
If treatment with antibiotics and steroids does not
Sclerotherapy using OK-432, alcohol, doxycycline or improve this condition, the child may require
bleomycin can be very effective for macrocystic LM.
surgical reduction. If surgery is elected, primary
resection should be along the medial tip and mid-

P I T F A L L S
line substance of the tongue to preserve vascular
supply, innervation, and function of the tongue.
If surgery is used to resect an LM, avoid early
A second stage reduction may be necessary in
removal of drains because it will usually result in
lymph fluid collections. some patients.
Avoid sclerotherapy for microcystic forms of LM.
Practical Tips
Never remove the entire oral tongue for massive With extensive LM the goal is to control the
LM enlargement.
disease and not necessarily cure, except when pri-
marily macrocystic disease is present. The family
and patient need to understand that this often
means multiple treatments throughout life.
Introduction Mucosal lesions may be extensive and can be
Extensive LM are usually easy to diagnose. They treated with the scanning device of a CO2 laser [1,
typically present as painless enlargement of the 3]. Lasering should be performed through the
face, neck and/or tongue. They often contain cys- mucosal layer. The deep components of LM are
tic components with lymph fluid collections. Sur- better treated with Nd:Yag laser that can ablate
face vesicles are usually apparent when mucosa is deeper channels of the mucosal lesions [4]. The
involved, some of which contain blood. Extensive Nd:Yag laser setting ideal is at 2030 W at 0.5 s in
LM of the head and neck can grow rapidly during the noncontact mode.

Many LM have a significant venous malforma- After treatment of any kind, the patient should
tion component, so that surgical resection may
encounter many large vascular channels.
be placed on steroids and antibiotics for 12
weeks.
9
There is frequently a significant fibrofatty Dental caries is common with LM and dentists
component to LM that does not respond to lipo- should be involved early after diagnosis [5].
suction.
It is common to have hypertrophy of the adja- Conclusion
cent bones, such as the mandible and zygoma that Extensive LM are rare and a major challenge. It is
may also require surgical reduction. The mandi- better to refer these patients to a center that has
ble will often elongate and can result in a signifi- experience in treating these malformations.
cant deformity. Reshaping the mandible is com-
monly necessary [5].
In macrocystic lesions undergoing sclerother- References
apy, two or more treatments may be necessary to 1 Edwards PD, Rahbar R, Ferraro NF, Burrows PE, Mulliken JB:
Lymphatic malformation of the lingual base and oral floor. Plast
obtain the desired result [6].
Reconstr Surg 2005;115:19061915.
Protection of the facial nerve branches and the 2 Peters DA, Courtemanche DJ, Heran MK, Ludemann JP, Prendi-
muscles to which they innervate is critical when ville JS: Treatment of cystic lymphatic vascular malformations
with OK-432 sclerotherapy. Plast Reconstr Surg 2006;118:1441
resecting LM that involve the face and parotid. 1446.
Following surgical resection, it is important to 3 April MM, Rebeiz EE, Friedman EM, Healy GB, Shapshay SM:
place a suction drain and leave it for a week or Laser therapy for lymphatic malformations of the upper aerodi-
gestive tract. An evolving experience. Arch Otolaryngol Head
more. Neck Surg 1992;118:205208.
Wound dehiscence is common. 4 Bradley PF: A review of the use of the neodymium YAG laser in
With extensive LM, the surgical goal is pri- oral and maxillofacial surgery. Br J Oral Maxillofac Surg 1997;
35:2635.
marily to debulk the lesion and to do no harm. 5 Padwa BL, Hayward PG, Ferraro NF, Mulliken JB: Cervicofacial
LM involving the larynx usually infiltrates the lymphatic malformation: clinical course, surgical intervention,
and pathogenesis of skeletal hypertrophy. Plast Reconstr Surg
mucosa and CO2 laser is the treatment of choice 1995;95:951960.
[7]. 6 Alomari AI, Karian VE, Lord DJ, Padua HM, Burrows PE: Percu-
Sclerotherapy can be employed with cysts 2 cm taneous sclerotherapy for lymphatic malformations: a retrospec-
tive analysis of patient-evaluated improvement. J Vasc Interv Ra-
or greater [2, 6]. diol 2006;17:16391648.
Ultrasound is best to identify and treat cysts 7 Chan J, Younes A, Koltai PJ: Occult supraglottic lymphatic mal-
with sclerotherapy [2]. formation presenting as obstructive sleep apnea. Int J Pediatr
Otorhinolaryngol 2003;67:293296.
153
Vascular Tumors
9.3 How to Deal with Emergency Bleeding

Episodes in Arteriovenous Malformations
Eduardo Noda Kihara, Mario Sergio Duarte Andrioli,
Eduardo Noda Kihara Filho
Interventional Neuroradiology Department, Hospital Albert Einstein, So Paulo, Brazil

P E A R L S Prior angiographic evaluation of the AVM is
indicated before surgical access to look for the
Endovascular embolization of deep seated neck multiple afferent arteries, presence of nidus, ni-
and cranial arteriovenous malformations (AVM) is a dus size and draining veins.
feasible way to stop bleeding.
Percutaneous embolization by drainage vein com- Practical Tips
pression is the best treatment option for superficial Deep seated AVM or fistulas can be embolized
AVM.
with Onyx (ethylene vinyl alcohol) or NBCA (N-
butyl cyanoacrylate) placed at the nidus or at the

P I T F A L L S
fistula site, completely occluding the malforma-
tion.
Previous proximal artery AVM ligature make the
High-flow fistulas can also be treated by mi-
nidus and fistula inaccessible to embolization.
crocatheter embolization with external compres-
Surgical drainage vein clamping increases intra-
sion or by balloon catheter inflation, placed at the
nidal pressure and risk of bleeding.
proximal artery to reduce the flow. Ivalon (poly-
vinyl alcohol foam) or Gelfoam pledges are tran-
sitory occlusive particulate materials and should
not be used. Coils and fibered coils are used in
Introduction specific situations, when we are faced with very
Craniofacial and neck vascular AVM are infre- high-flow conditions and where we need to re-
quent entities. There are different types: nidus duce flow velocities.
AVM, arteriovenous fistulas, venous malforma- Superficial AVM and venous malformations
tions and cavernous hemangiomas. Bleeding due can be treated by percutaneous puncture and oc-
to AVM can occur after trauma, biopsy or during clusion with NBCA 50% or absolute alcohol (eth-
resection for curative or esthetic surgery. anol) during external compression using rubber
Modern technology based on high resolution bands or devices to increase the local effect and
fluoroscopy, small microcatheters and the new results. All these procedures are risky and must
embolizing materials can increase the possibility be used under high resolution fluoroscopy and
to reach the nidus of AVM or the arteriovenous extremely careful injection, avoiding pulmonary
fistula site, to treat the AVM or as a preoperative embolization or intracranial migration by dan-
adjuvant therapy. gerous anastomoses between the vertebral artery

and the external carotid artery branches and the References
intracranial circulation.
Complete digital angiographic study of an
1 Numan F, Omeroglu A, Kara B, et al: Embolization of peripheral
vascular malformations with ethylene vinyl alcohol copolymer 9
(Onyx). J Vasc Interv Radiol 2004;15:939946.
AVM followed by embolization in a high-flow le- 2 Kohout MP, Hansen M, Pribaz JJ, et al: Arteriovenous malforma-
sion precludes a dangerous situation, as a bleed- tions of the head and neck: natural history and management.
Plast Reconstr Surg 1998;102:643654.
ing condition, during a biopsy or a resection. It 3 Berenguer B, Burrows PE, Zurakowski D, et al: Sclerotherapy of
reduces blood loss and abbreviates both surgery craniofacial venous malformations: complications and results.
and recovery time. As stated above, care must be Plast Reconstr Surg 1999;104:111.
4 Persky MS, Yoo HJ, Berenstein A: Management of vascular mal-
taken with dangerous anastomoses between the formations of the mandible and maxilla. Laryngoscope 2003;113:
external carotid artery branches, vertebral artery 18851892.
branches and intracranial circulation. 5 Whiteside OJ, Monksfield P, Steventon NB, et al: Endovascular
embolization of a traumatic arteriovenous fistula of the superfi-
Passage of the embolizing material to the jugu- cial temporal artery. J Laryngol Otol 2005;119:322324.
lar vein or other large draining veins can cause 6 Ahn HS, Kerber CW, Deeb ZL: Extra- to intracranial arterial
anastomoses in therapeutic embolization: recognition and role.
pulmonary embolism. Ulcerations, skin necrosis AJNR Am J Neuroradiol 1980;1:7175.
and skin color changes can occur, usually related 7 Duncan IC, Fourie PA: Circumferential flow reduction during
to the material and volume used. percutaneous embolotherapy of extracranial vascular malfor-
mations: the cookie-cutter technique. AJNR Am J Neuroradiol
2003;24:14531455.
Conclusion
AVM are complex diseases and should be studied
by a multidisciplinary team before any surgical
attempt. It is feasible and safe for a well-trained
interventional team to carry out endovascular
and percutaneous treatment of AVM lesions. New
materials, tools and devices for vascular and ni-
dus occlusions can improve the final results ex-
cluding AVM and reducing time, bleeding and
surgical risk.
155
Congenital Tumors
10.1 Practical Tips to Manage Branchial Cleft

Cysts and Fistulas
Marcelo D. Durazzo, Gilberto de Britto e Silva Filho
Head and Neck Service, Hospital das Clnicas, Faculty of Medicine, University of So Paulo, So Paulo, Brazil

P E A R L S tract from the remnant of the cervical sinus to the
skin and/or to the mucosa of the upper aerodiges-
Branchial cleft (BrC) cysts may initially appear in tive tract, a fistula appears.
adulthood despite their presence since birth. Cysts BrCA are treated surgically. Surgery is ideally
may become evident after infection.
indicated in the absence of infection. A mass
Avoid surgical approach (drainage or resection) if a (cyst) or a cutaneous opening (fistula) may be
cyst is infected. Try to manage the infection with
evident at the level of the anterior border of the
antibiotics.
sternomastoid muscle. Cysts and fistulas in the
preauricular region arise from the first BrC.

P I T F A L L S
Infection is the main complication. It may be
present in one third of the cases in the pediatric
Consider performing a facial nerve (FN) dissection
population [3].
when treating a first branchial cleft anomaly (BrCA).
Dissection of the duct (or tract) must be carried out
Practical Tips
cranially when resecting a second or third BrCA.
Regarding first BrCA, the tract must be dissected
Recurrence is associated with incomplete resection
until it reaches the external auditory canal. The
of cysts and fistula ducts.
FN may be superficial to the tract, and it may be
dissected if necessary [4, 5].
The following tips refer to the treatment of
second BrCA. They are also useful for treating the
very rare third and fourth BrCA.
Avoid drainage as much as possible. Avoid a
surgical approach when the cyst is infected. Treat
Introduction the infection with antibiotics and wait until the
BrC fistulas are diagnosed at birth in the major- inflammatory signs disappear [1].
ity of cases. BrC cysts are usually seen only after Under general anesthesia, proceed to a lateral
infectious processes. They may also be seen in incision in the neck at the level of the anterior
adults despite their presence since birth [1, 2]. border of the sternomastoid muscle. It may be
Both conditions are congenital and result from done above or below depending on the level of the
the nonobliteration of the cervical sinus (formed cyst or fistula. When a cutaneous orifice is pres-
by the second, third and fourth BrCs during the ent in the neck, it must be completely circum-
embryo development). When there is a patent scribed by the incision [1, 2].

Proceed to blunt dissection of the cyst followed Conclusion
by a cranial isolation of the tract (or duct). Fistu- The management of BrC cysts and fistulas in-
las must have the external orifice included in the volves delicate dissection of cervical structures. It
skin resected followed by tract dissection cepha- must preferably be carried out by experienced sur-
lad. geons. Most complications are associated with in-
Follow the tract superiorly. In its upper por- jury of the following structures: hypoglossal
tion, the tract passes between the internal and ex- nerve, glossopharyngeal nerve, superior laryngeal
ternal carotid arteries. After that, it crosses the nerve, FN and carotid arteries. Recurrence can 10
superior laryngeal, the XII and the IX cranial only be avoided with complete excision of the fis-
nerves, and finally reaches its opening into the tula or cyst and its tract. Definitive surgical treat-
pharynx at the level of the tonsil. As the tract is ment is much more difficult when there is an as-
slightly lateral to these structures, it is not neces- sociated infection. In these cases, surgery should
sary to actively dissect them in order to have their be postponed until the infection has been treat-
control. In the deeper plane of the dissection they ed.
may be seen and preserved [1, 2].
After isolating the BrCA and its tract, proceed
to the duct ligation at the level of the tonsil. Use References
of a drain is recommended [1]. 1 Lor JM: An Atlas of Head and Neck Surgery. Philadelphia, Saun-
Third BrCAs may have their tracts opening to ders, 1988, pp 686693.
2 Peyngre R, Rugina MD, Ducroz V: Chirurgie des kystes et fis-
the larynx, to the trachea or to the pharynx. The tules du cou. Techniques chirurgicales Tte et cou, 46-480. En-
tracts reach these regions of the upper aerodiges- cycl Md Chir. Paris, Elsevier, 1995, p 12.
3 Schroeder JW Jr, Mohyuddin N, Maddalozzo J: Branchial anom-
tive tract after perforating the thyrohyoid mem- alies in the pediatric population. Otolaryngol Head Neck Surg
brane. They are rare and cysts may be confused 2007;137:289295.
with laryngocele [1, 2]. 4 Triglia JM, Nicollas R, Ducroz V, Koltai PJ, Garabedian EN: First
branchial cleft anomalies: a study of 39 cases and a review of the
Fourth BrC cysts and fistulas are extremely
literature. Arch Otolaryngol Head Neck Surg 1998;124:291295.
rare. The internal opening is located in the pyri- 5 Martinez Del Pero M, Majumdar S, Bateman N, Bull PD: Presen-
form sinus. They are clinically evident usually at tation of first branchial cleft anomalies: the Sheffield experience.
J Laryngol Otol 2007;121:455459.
the left side of the neck [6]. 6 Shrime M, Kacker A, Bent J, Ward RF: Fourth branchial complex
anomalies: a case series. Int J Pediatr Otorhinolaryngol 2003;
67:12271233.
157
Congenital Tumors
10.2 How to Avoid Surprises in the

Management of the Thyroglossal
Duct Cyst
Nilton T. Herter
FAHNS, Brazilian HNSS, Argentinian HNS, Chilean HNS, Peruvian HNS, LATS Head and Neck Service,
Hospital Santa Rita, Porto Alegre, Brazil

P E A R L S nant till the base of the tongue. Damage of the
lingual artery or the hypoglossal nerves must be
Keep in mind that thyroglossal duct cyst (TGDC) avoided with careful dissection. Surgical drain-
may be associated with other anatomical and age of the operative field is recommended, since
functional abnormalities of the thyroid gland.
postoperative hematoma may be dangerous.
Do not operate on a patient with TGDC without Associated with TGDC, we can find subclini-
previous anatomic and functional evaluation of the
cal hypothyroidism and other abnormalities of
thyroid gland.
the development of the thyroid gland, such as lin-
Carcinoma arising in TGDC may be found in adults, gual thyroid, ectopic gland, agenesis or hemi-
so preoperative cytological evaluation is recom-
mended in suspicious cases.
agenesis as well as rare cases of carcinoma.
Practical Tips

P I T F A L L S
Although it is usually easy to diagnose a TGDC
Risk of resection of the only thyroid tissue of the and to perform the Sistrunk procedure, associ-
patient. ated disorganogenetic, dishormonogenetic or
carcinogenetic changes may be found and lead to
Risk of hypothyroidism, either clinical or subclinical.
some surprises for the surgeon, jeopardizing the
Risk of finding a carcinoma in the pathologic report
patients health. It is important to keep in mind
after surgery.
some hazardous situations.
Consider the association between TGDC and
subclinical hypothyroidism and ask for blood
Introduction tests including TSH and thyroxine.
TGDC is the main abnormality of development Consider the association between TGDC and
in the neck. Most of the patients are children or other abnormalities of the embryologic develop-
young adults and complain of a single nodule in ment of the thyroid gland and ask for neck ultra-
the midline, at the level of hyoid bone. Clinical sound and scintiscan of the thyroid gland.
diagnosis is safe and easy [24]. The golden stan- Consider that in 23% of the TGDC we can
dard treatment is the Sistrunk procedure [1] find a carcinoma; so, ask for FNBA and cytolog-
which involves resection of the cyst, the central ical examination when the cyst is greater than
part of the hyoid bone and the embryologic rem- 3 cm, when it occurs in adults [5], when there is a

solid component in the cyst, when there is rapid References
growth, or in the presence of local invasive signs 1 Chandra RK, Madalozzo J, Kovarik P: Histological characteriza-
tion of the thyroglossal tract: Implications for surgical manage-
or of a clinically evident cervical lymph node.
ment. Laryngoscope 2001;111:1002.
Classical Sistrunk operation is the golden stan- 2 Herter NT, Silva GS: Carcinoma de cisto tireoglosso; relato de um
dard procedure for treatment of most TGDC. caso e reviso da literatura. Rev Brs Cir Cab Pesc 1989;13:21
Enlarged Sistrunk procedure is recommended 24.
3 Herter NT: Cistos, fstulas e neoplasias do ducto tireoglosso; in
for TGD carcinomas as well as supraomohyoid Kowalski LP (ed): Afeces Cirrgicas do Pescoo. Col Brs Cir.
neck dissection. So Paulo, Atheneu, 2005, vol VII, pp 105114.
4 Livosi VA: Surgical Pathology of Thyroid. Philadelphia, Saun-
10
Subclinical hypothyroidism must be evaluated
ders, 1990, p 156.
and treated. 5 Yadranko D: Thyroglossal duct cysts in the elderly population.
Am J Otolaryngol 2002;23:17.
Conclusion
In this chapter, the reader was exposed to a fre-
quently overlooked complication of surgical
treatment of the TGDC. TGDC may often be as-
sociated with subclinical hypothyroidism and
other anatomic abnormalities of the thyroid
gland, as well as with carcinoma, generally in
adults. Functional, anatomical and pathologic
evaluation of the cyst is recommended to prevent
further complications.
159
11.1 How to Manage Extensive Carotid

Body Tumors
Nadir Ahmad, James L. Netterville
Department of Otolaryngology Head and Neck, Vanderbilt University Medical Center, Nashville, Tenn., USA

CBT are paragangliomas arising from the carotid
Options include surgery, observation or radiation body (CB), a chemoreceptor located at the carotid
therapy (RDT). Decisive factors are tumor size, bifurcation. The CB is attached to the bifurcation
patient age and comorbidities, among others.
by the ligament of Mayer and is innervated by the
Resection of unilateral carotid body tumors (CBT) is glossopharyngeal (IX) nerve via its nerve of Her-
safe, with limited morbidity in tumors <5 cm.
ing branch. It is responsive to changes in PaO2,
Although not necessary for smaller CBT, preopera- PaCO2, pH and blood flow by regulating ventila-
tive embolization decreases blood loss, especially tion.
in larger CBT.
These tumors are predominantly benign and
Surgical resection involves a team approach, and a slow-growing. The typical patient presents in the
vascular surgeon should be alerted to the need for
5th decade with a painless upper neck mass; 10%
intraoperative carotid artery (CA) resection and
bypass if required. of these cases have bilateral tumors and even mul-
tiple other head and neck paragangliomas. Famil-
Keys to low surgical morbidity: high cervical expo-
ial cases are rare (2550% are multifocal) [1, 2].
sure, meticulous dissection and identification of
regional cranial nerves (CN), with proximal and Apart from careful history and physical exam fo-
distal control of carotid system (CS). cusing on CN assessment, the initial workup
should include either a contrast CT scan or MRI.

P I T F A L L S The characteristic finding is lyre sign or splay-
ing of the external and internal CAs. This is seen
Avoid dissection into the media layer of the CA. classically on angiography, which can be used for
Supraadventitial dissection is often sufficient for preoperative embolization. Malignant CBT are
CBT removal, but occasionally, subadventitial rare and are usually diagnosed through the find-
dissection is required and often fraught with ing of a lymph node metastasis.
bleeding; meticulous dissection and liberal use of Surgery is the optimal treatment [2, 3]. RDT is
bipolar cautery are recommended.
another option and should be considered in pa-
CN injury is the most common sequela, and must tients that cannot tolerate surgery or the potential
be discussed with the patient before surgery in
CN deficits. In our experience, RDT leads to re-
anticipation of rehabilitating possible deficits.
gression of the tumor size, to arrest in growth,
First-bite syndrome (FBS) and baroreceptor failure and to continued growth, respectively, in 1/3 of
(BF) are overlooked complications of CBT resection.
cases, each. Observation is a reasonable option in
select cases, as these are slow-growing tumors (1

1.5 mm/year). Complications include injury to Dissect along lateral surface of internal CA,
various regional CNs, as well as FBS, which is the rolling the tumor toward the bifurcation.
development of pain in the parotid region after Final removal often requires ligation of as-
the first bite of every meal [3, 4]. The cause of this cending pharyngeal artery and dissection of su-
complication is unknown but is thought to be due perior laryngeal nerve.
to interruption of regional sympathetic nerve
fibers. BF can occur after unilateral or bilateral Conclusion
resections, and the result is lability of blood pres- CBT are rare head and neck tumors that must be
sure and heart rate. considered in the differential diagnosis of neck
and parapharyngeal space masses. Surgery is the
Practical Tips primary treatment; RDT and observation are re-
High cervical incision that passes medially served for select cases. Preoperative embolization
over the region of hyoid bone.
Perform limited selective neck dissection to
is useful, mainly in large tumors. A vascular sur-
geon should be available. CN injury is uncom-
11
sample regional nodes for metastasis and to ex- mon. FBS and BF are less known complications
pose the regional CNs and carotid sheath struc- of CBT surgery.
tures.
Gain proximal and distal control of the CS.
Dissection starts along external CA to free its References
branches from the tumor. It can be sacrificed if 1 Cohen SM, Burkey BB, Netterville JL: Surgical management of
parapharyngeal space masses. Head Neck 2005;27:669675.
necessary.
2 Pellitteri PK, Rinaldo A, Myssiorek D, et al: Paragangliomas of
Plane of dissection can be supra or subadven- the head and neck. Oral Oncol 2004;40:563575.
titial depending on tumor invasion. Bipolar cau- 3 Sniezek JC, Sabri AN, Netterville JL: Paraganglioma surgery:
complications and treatment. Otolaryngol Clin North Am 2001;
tery is used liberally. 34:9931006.
Great care is taken to avoid dissection into the 4 Netterville JL, Reilly KM, Robertson D, et al: Carotid body tu-
media layer, resulting in an unsafe artery. Eventu- mors: a review of 30 patients with 46 tumors. Laryngoscope
1995;105:115126.
ally, vessel resection and bypass are performed by
a vascular surgeon.
161
11.2 How to Manage Extensive Neurogenic

Tumors

NTs of the head and neck represent a group of
Perform a detailed imaging workup, including con- uncommon lesions of benign or malignant ori-
trast computerized tomography and magnetic reso- gin. A variety of surgical approaches have been
nance imaging. Magnetic resonance angiography is
occasionally added to differentiate schwannomas
described for the management of extensive NTs
from paragangliomas. [1]. Although the cervical approach permits com-
plete tumor resection in the majority of cases,
Most of the benign neurogenic tumors (NTs) are
there are still situations in which the superior or
extirpated via cervical approach.
inferior aspects of the tumor are not adequately
For extensive tumors with multicompartment
accessed via conventional neck incision. For ex-
involvement, use combined approaches to allow
adequate exposure and safe resection. ample, these tumors may infiltrate superiorly
along the parapharyngeal space and invade the
paranasal sinuses, orbit, pterygopalatine fossa or

P I T F A L L S
the infratemporal fossa. They may also grow cau-
Always discuss with the patients the potential com- dally and invade the superior mediastinum.
plications of surgery, which may include multiple These latter cases require alternative approaches
cranial nerve palsies, bleeding, stroke and death. or a combination of several approaches to allow
Tracheostomy should be used in patients undergo- proper exposure and safe tumor resection [2].
ing the transmandibular approach and when the
resection requires bulky reconstruction, and in all Practical Tips
patients with expected airway impairment. The selected surgical approach should be safe
The surgical resection of extensive NTs should and should allow complete tumor resection when-
always start with proximal and distal control of the
ever possible, while minimizing functional and
great vessels of the neck and with identification,
exposure and protection of all neighboring cranial cosmetic morbidity.
nerves. In most patients, inferior NTs are excised via
the cervical approach with no need for any major
Appropriate reconstruction should be carried out
reconstructive procedures [1].
after dural, pharyngeal or extensive skin resection-
ing to prevent significant complications, for The transmandibular approach is suitable for
cosmesis and to provide good functional outcome. patients with extremely large tumors that involve
Consider immediate vocal cord medialization for the parapharyngeal space. Once the mandible is
patients with vagal schwannoma. split, the two segments of the mandible are sepa-
rated for exposing the tumor which is then re-

Table 1. Surgical approaches (single or combined) used for excision of extensive neurogenic skull base tumors
Tumor extension Surgical approach

Anterior skull base, frontal/ethmoidal/sphenoidal sinuses, Subcranial (not requiring facial incisions)
sphenoid clivus, planum sphenoidale
Malignant tumors involving the inferior/anterior/lateral Craniofacial or transfacial
maxillary walls
Extension to the lateral skull base, cavernous sinus, Orbitozygomatic, pterional or
middle fossa infratemporal fossa
Extension to the orbit Transorbital
Parapharyngeal space tumors extending to the middle fossa Cervical-orbitozygomatic, maxillary swing
moved under direct visualization of the sur- Large defects require reconstruction with re-
11
rounding structures. gional flaps (pectoralis major myocutaneous flap,
Pterional or orbitozygomatic approaches with temporalis muscle flap) or free flaps (a radial
or without the cervical approach are used for NTs forearm fasciocutaneous flap or a scapular flap).
involving in the trigeminal ganglion, cavernous
sinus and clivus with considerable skull base in- Conclusions
volvement [2]. Knowledge of the differential diagnosis and a de-
The middle fossa approach type A may be tailed presurgical workup allow careful, well
used in selected cases for surgical treatment of thought-out planning of the surgical approach
schwannomas and neurofibromas involving the and a safe tumor resection. Surgery of NTs may
jugular foramen [3]. be performed in most patients via the cervical ap-
Malignant NTs (e.g., esthesioneuroblastoma, proach. In a small number of patients with ex-
malignant peripheral nerve sheath tumor) fre- tremely large NTs extending to the skull base or
quently have multicompartmental invasion, re- mediastinum, and for invasive malignancies,
quiring a multifaceted approach to the anterior combined approaches are used to assure safe and
skull base. Both the craniofacial or subcranial ap- efficacious extirpation.
proaches can be used to access the anterior skull
base, while more extensive tumors can be reached
via a combined approach, based on the exact ana- References
tomical localization of the tumor (table 1) [2]. 1 Khafif A, Segev Y, Kaplan DM, Gil Z, Fliss DM: Surgical manage-
Median sternotomy is required for NTs with ment of parapharyngeal space tumors: a 10-year review. Otolar-
yngol Head Neck Surg 2005;132:401406.
the following indications: (1) recurrent intratho- 2 Fliss DM, Abergel A, Cavel O, Margalit O, Gil Z: Combined sub-
racic tumors, (2) previous mediastinal or cardio- cranial approaches for excision of complex anterior skull base
tumors. Arch Otol Head Neck Surg 2007;133:888896.
thoracic surgery, (3) previous radiation to the 3 Shahinian H, Dornier C, Fisch U: Parapharyngeal space tumors:
neck or mediastinum,(4) malignant NTs abutting the infratemporal fossa approach. Skull Base Surg 1995;5:73
the great vessels, (5) isolated intrathoracic tu- 81.
4 Ladas G, Rhys-Evans PH, Goldstraw P: Anterior cervical-trans-
mors, and (6) tumors invading below the level of sternal approach for resection of benign tumors at the thoracic
the carina [4]. inlet. Ann Thorac Surg 1999;67:785789.
163
11.3 How to Choose a Surgical Approach to a

Parapharyngeal Space Mass
Kerry D. Olsen
Mayo Clinic Rochester, Rochester, Minn., USA

P E A R L S sures complete tumor removal without rupture of
the tumor capsule and preservation of the sur-
The cervical parotid approach can be used to safely rounding nerves and vessels.
remove the majority of lesions encountered in the
parapharyngeal space.
Practical Tips
Division of the stylomandibular ligament is essen- The cervical parotid approach can be used to re-
tial to opening the parapharyngeal space.
move the majority of deep lobe parotid and extra-
Most deep lobe parotid tumors that involve the parotid salivary gland tumors [1, 2, 3]. This ap-
parapharyngeal space begin in the retromandibular proach is also used to remove most neurogenic
portion of the deep lobe. Widely surrounding this
portion of gland can be done without having to
tumors and small paragangliomas.
remove the superficial portion of the gland. The inferior division of the facial nerve is first
isolated and followed out to the level of the sub-
mandibular gland.

P I T F A L L S
The upper jugular nodes are removed to allow
Failure to identify the facial nerve can lead to inad- for exposure of the great vessels and cranial
vertent injury when the tumor extends superior to nerves X, XI and XII.
the position of the main trunk of the facial nerve. The stylomandibular fascia between the parot-
Failure to obtain maximum exposure by a mandibu- id and in the submandibular gland is divided and
lotomy in cases of skull base or carotid artery the gland retracted medially.
involvement by malignant tumors or vascular neo- The posterior belly of the digastric muscle and
plasms can lead to incomplete tumor removal or
significant morbidity.
stylohyoid muscles are divided near the mastoid
tip and reflected medially.
The dense stylomandibular ligament is next
divided as is the external carotid artery as it en-
Introduction ters the deep parotid tissue at the level of the sty-
The parapharyngeal space is involved by a wide loglossus muscle.
variety of benign and malignant neoplasms. The If the tumor is extending around the styloid
majority of cases (80%) are benign and arise from process, it is best to remove this bone to avoid in-
the deep lobe of the parotid gland or from nerves advertent tumor capsule rupture.
or paraganglia in the retrostyloid portion of the The medial extent of the tumor can be freed
parapharynx. The goal of surgery should be to from the superior constrictor muscles and the me-
provide adequate tumor visualization that in- dial pterygoid muscle by blunt finger dissection.

The tumor can then be removed under direct A transoral approach is rarely done and re-
vision with care to include a portion of the deep served for isolated, small, benign extraparotid
lobe if the tumor originates or involves a portion salivary tumors.
of the parotid gland.
Carefully look for any venous bleeding and re- Conclusion
tain a Hemovac drain for a minimum of 2 days to Surgery in the parapharyngeal space can be done
reduce the risk of dead space bleeding or infec- safely and with good tumor exposure. The cervi-
tion. cal parotid approach (90%) and cervical parotid
If there is no loose areolar plane surrounding approach with a parasymphyseal mandibulotomy
a prestyloid tumor, the lesion is either malignant (10%) are effective for complete tumor removal,
or has been previously biopsied transorally with control of bleeding, preservation of surrounding
subsequent scarring along the constrictor mus- nerves, and low morbidity.
cle.
The cervical parotid approach can be extended
11
posteriorly to perform a suboccipital craniotomy References
for tumors that extend intracranially via the ret- 1 Olsen KD: Tumors and surgery of the parapharyngeal space. La-
ryngoscope 1994;104(5 Suppl 63):128.
rostyloid space.
2 Stell PM, Mansfield AO, Stoney PJ: Surgical approaches to tu-
The use of a parasymphyseal mandibulotomy mors of the parapharyngeal space. Am J Otolaryngology 1985;
in combination with a cervical parotid approach 6:9297.
3 Olsen KD: Parapharyngeal space tumors; in Gates GA (eds): Cur-
is used in approximately 10% of cases. rent Therapy in Otolaryngology Head and Neck Surgery, ed 5.
The mandibulotomy approach is helpful for St Louis, Mosby, 1994, pp 243247.
vascular tumors that involve the carotid artery or
superior parapharyngeal space or for malignant
tumors that invade surrounding bone or the great
vessels.
165
12.1 Practical Tips to Approach a

Deep Neck Abscess
Flvio C. Hojaij, Caio Plopper
Federal Medical School of So Paulo, Department of Otorhinolaryngology and Head and Neck Surgery,
So Paulo, Brazil

P E A R L S ally caused by dental or upper airway infection
[15]. These abscesses can also be related to infec-
Detect and treat the primary cause of the infection. tions of salivary glands, congenital malformation
When necessary, surgical treatment should not be or trauma. In more than 25% of patients with
delayed. DNA, a clear etiology cannot be identified [15].
Contrast-enhanced computed tomography (CECT) The parapharyngeal space is the most com-
is the best exam to evaluate a deep neck abscess mon site; unfortunately abscesses in this region
and to plan surgical intervention. are more dangerous [14, 6, 7]. DNAs secondary
to dental infections frequently lead to sepsis or

P I T F A L L S necrotizing fasciitis [8, 9].
Remember that older patients with underlying Practical Tips

diseases are more likely to have complications.
In clinical practice, it is very important to listen
Keep in mind that necrotizing fasciitis does not to patients complaints. Cervical or oropharyn-
present with radiological signs of pus collection,
geal pain associated with fever must raise the sus-
but may be associated with gas formation
within deep fascial planes. picion of a possible deep neck infection. A good
physical examination can easily distinguish be-
Deep neck infections may progress toward exten-
tween deep and superficial infections. Some prac-
sive tissue necrosis and mediastinitis with high
mortality rates. tical tips are important in order to enable prompt
and successful treatment:
Always keep in mind that you need to look for
and to treat the primary cause of the abscess (for
Introduction example dental infection, upper airway infec-
It is very important to distinguish between super- tion).
ficial and deep neck infection. The former is very CECT is a useful tool to detect and to establish
common and easily treated uneventfully. In con- the treatment of neck abscesses, and should be
trast, the latter is more hazardous and can be life- done still in the early stage of the disease [17].
threatening. Broad-spectrum antibiotic therapy and surgi-
Deep neck abscesses (DNAs) are pus collec- cal drainage are the treatment of choice for the
tions that develop within deep cervical spaces, majority of cases [17].
separated by layers of deep cervical fascia, usu-

For selected cases (clinically stable patients It is very important to collect material for cul-
with only one cervical space abscess smaller than ture and antibiogram.
3 cm), a trial of intravenous antibiotics can be Seriously consider intensive care support and
made before immediate surgical drainage. In hyperbaric oxygen therapy.
these instances, a 48-hour wait-and-watch policy,
with a control CECT, will determine if surgical
intervention is needed [10]. References
Older age, diabetes mellitus, underlying sys- 1 Huang TT, Liu TC, Chen PR, Tseng FY, Yeh TH, Chen YS: Deep
neck infection: analysis of 185 cases. Head Neck 2004;26:854
temic disease and multiple-space involvement re-
860.
quire careful consideration about potential com- 2 Lee JK, Kim HD, Lim SC: Predisposing factors of complicated
plications [13, 7]. deep neck infection: an analysis of 158 cases. Yonsei Med J 2007;
Spotted gas images and edema are common 48:5562.
3 Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto
findings in patients with necrotizing fasciitis. MC: Deep neck infections: a constant challenge. ORL J Otorhino-
These patients should be treated with intravenous laryngol Relat Spec 2006;68:259265.
4 Parhiscar A, Har-El G: Deep neck abscess: a retrospective review
antibiotics and early surgical debridement [8, 9]. of 210 cases. Ann Otol Rhinol Laryngol 2001;110:10511054.
Dyspnea, dysphagia and hoarseness are poor 5 Sethi DS, Stanley RE: Deep neck abscesses changing trends.
prognostic signs, indicating the need for aggres- J Laryngol Otol 1994;108:138143.
6 Oh JH, Kim Y, Kim CH: Parapharyngeal abscess: comprehensive
sive surgical intervention. management protocol. ORL J Otorhinolaryngol Relat Spec 2007;
At operation, always under general anesthesia, 69:3742.
7 Mazita A, Hazim MY, Megat Shiraz MA, Primuharsa Putra SH:
12
large incisions are generally necessary. Neck abscess: five year retrospective review of Hospital Univer-
Do not delay a new surgical intervention if sity Kebangsaan Malaysia experience. Med J Malaysia 2006; 61:
there is no clinical improvement or if a new CECT 151156.
8 Edwards JD, Sadeghi N, Najam F, Margolis M: Craniocervical
still shows necrosis or pus collection. necrotizing fasciitis of odontogenic origin with mediastinal
Intraoral drainage, when possible, can be safe, extension. Ear Nose Throat J 2004;83:579582.
especially in the pediatric population. 9 Balbierz JM, Ellis K: Streptococcal infection and necrotizing fas-
ciitis implications for rehabilitation: a report of 5 cases and
Be aware that oral intubation can be difficult review of the literature. Arch Phys Med Rehabil 2004;85:1205
if the patient presents with trismus. Endoscopic- 1209.
10 Boscolo-Rizzo P, Marchiori C, Zanetti F, Vaglia A, Da Mosto MC:
assisted intubation or tracheostomy under local
Conservative management of deep neck abscesses in adults: the
anesthesia should be considered, in order to pre- importance of CECT findings. Otolaryngol Head Neck Surg
vent urgent surgical airway intervention. 2006;135:894899.
Special attention should be paid to mediasti-
num and pleura; do not hesitate to perform tho-
racotomy and/or chest drainage, if necessary.
167
12.2 Management of Necrotizing Fasciitis

Dorival De Carlucci, Jr.
Cerqueira Csar, So Paulo, Brazil

P E A R L S with loss of superficial and deep tissue. The term
NF was first used by Wilson [3] in 1952 to de-
Keep in mind that necrotizing fasciitis (NF) is a rare scribe cases with staphylococcal infection.
but aggressive soft tissue infection. NF can develop in patients of all ages with no
It is commonly associated with other debilitating predilection for sex or race [4]. A history of op-
conditions. eration, minor trauma or dental procedures rep-
The clinical manifestations and physical findings resents common causes of infection. Other asso-
are not specific but are often typical. ciated antecedent events included skin biopsy,
tracheostomy wound, and even fish bone inges-

P I T F A L L S tion. However, in many cases, not even a tiny
trauma inlet could be identified.
The management of cervical NF needs a multiple The predisposing factors include diabetes mel-
approach:
litus, arteriosclerosis, alcoholism, chronic renal
Local aggressive radical debridement. failure, malignancy and intravenous drug abuse.
Systemic-level broad-spectrum antibiotics. Most patients showed at least one debilitating
Intensive supportive care, such as hyperbaric condition [5].
oxygen. The exact mechanism of this rapidly spread-
ing gangrenous infection has not been estab-
lished. The releases of enzymes, such as hyal-
uronidase, and proteolytic portions of cell mem-
branes have been shown to be contributing factors
in the necrosis. The relative lack of vascularity of
Introduction the relevant fascial planes has also been hypoth-
One of the most dangerous complications of deep esized as a contributing factor [6].
abscesses of the head and neck is NF, which is a Polymicrobial infections are reported in most
relatively uncommon but aggressive soft tissue recent series. Causative organisms include mixed
infection characterized by progressive destruc- aerobes and anaerobes, most commonly Strepto-
tion of fascia and adipose tissue that may not in- coccus spp., Staphylococcus spp., Bacteroides
volve the skin [1]. spp., Fusobacterium spp. and Peptostreptococcus
NF was first observed during the American spp. [5].
Civil War in 1871 by Joseph Jones [2], a Confeder-
ate Army surgeon, who described hospital cases
of gangrene characterized by skin discoloration

Early recognition and management are essen- NF of the head and neck is a rare but aggressive
tial to a better prognosis [6]. soft tissue infection, commonly associated with
A number of signs and symptoms should alert other debilitating conditions.
clinicians, such as shortness of breath, dysphagia, The clinical manifestations and physical find-
and odynophagia. At the time of presentation, ings are not specific but are often typical. A high
most patients are toxic with high fever. In case index of suspicion for NF should be maintained.
shock, organ dysfunction, or gas in tissue (radi- CT is helpful for an early diagnosis and for
ography or palpation) are present, immediate sur- planning therapy.
gery is indicated [7]. The key to successful treatment is early diag-
Complications include pneumonia, lung ab- nosis combined with aggressive surgical treat-
scess, internal jugular vein thrombosis, meningi- ment and administration of parenteral antibiot-
tis, mediastinitis, arterial erosion and mandible ics.
necrosis. Recent reports suggested that the mor- Hyperbaric oxygen is an adjunctive therapy to
tality rate ranged from 16.5 to 20% [8, 9]. surgery and antibiotics.
Computed tomography (CT) is the imaging There is still a high mortality rate (25%) despite
modality of choice, providing information on the aggressive management.
localization and extension of the disease. It con-
firms the presence or absence of gas and provides 12
detailed anatomic information. Magnetic reso- References
nance imaging can also be helpful in delineating 1 Sellers BJ, Woods ML, Morris SE, Saffle JR: Necrotizing group A
streptococcal infections associated with streptococcal toxic
the extent of intramuscular or subcutaneous ab-
shock syndrome. Am J Surg 1996;172:523528.
scesses [5]. 2 Jones J: Investigation upon the nature, causes and treatment of
The key to successful treatment is early diagno- hospital gangrene as it prevailed in the Confederate Armies
18611865; in Hamilton FH (ed): Surgical Memoirs of the War of
sis, which, when combined with aggressive treat- Rebellion. New York, Riverside, 1871, pp 146170.
ment, can substantially improve the outcome. An 3 Wilson B: Necrotizing fasciitis. Am Surg 1952;18:416431.
extensive excision, debridement and drainage of 4 Reed JM, Vinod KA: Odontogenic cervical necrotizing fasciitis
with intrathoracic extension. Otolaryngol Head Neck Surg
the involved necrotic skin, fascia and muscle are 1992;107:596600.
the most important aspects of therapy. 5 Skitarelic N, Mladina R, Morovic M, Skitarelic N: Cervical nec-
Parenteral antibiotics should be instituted rotizing fasciitis: sources and outcomes. Infection 2003;31:39
44.
without delay. As the infection always exhibits a 6 Greinwald JH, Wilson JF, Haggerty PG: Peritonsillar abscess: an
fulminant course, it is not advisable to wait for unlikely cause of necrotizing fasciitis. Ann Otol Rhinol Laryngol
1995;104:133137.
culture results. Empirical initial coverage should 7 Lin C, Yeh FL, Lin JT, Ma H, Hwang CH, Shen BH, Fang RH: Nec-
include broad-spectrum antibiotics. The treat- rotizing fasciitis of the head and neck: an analysis of 47 cases.
ment generally includes penicillinase-resistant Plast Reconstr Surg 2001;107:16841693.
8 Haywood CT, McGeer A, Low DE: Clinical experience with 20
penicillins plus additional coverage for anaerobic cases of group A Streptococcus necrotizing fasciitis and myone-
organisms. crosis: 1995 to 1997. Plast Reconstr Surg 1999;103:15671573.
Hyperbaric oxygen is considered an adjunctive 9 Marty-An CH, Berthet JP, Alric P, Pegis JD, Rouvire P, Mary H:
Management of descending necrotizing mediastinitis: an ag-
therapy. It inhibits anaerobes and helps break the gressive treatment for an aggressive disease. Ann Thorac Surg
vicious synergistic cycle between anaerobes and 1999;68:212217.
10 Kirby SD, Deschler DG: Hyperbaric oxygen therapy: application
aerobes and limits the debridement by demarcat-
in diseases of the head and neck. Gen Otolaryngol 1999;7:137.
ing the border between devitalized and healthy
tissue [10].
169
Tracheotomy
13.1 Minimizing Complications in Tracheotomy

Eugene N. Myers

Once the incision is made, dissecting in the
Most complications of tracheotomy are prevent- midline will prevent bleeding from structures
able. such as the anterior jugular veins, carotid arter-
Securing the airway is fundamental to the success ies, aberrant innominate arteries or thyroid isth-
of the procedure and preventing complications. mus.
Meticulous surgical technique is the key feature in Keeping dissection in the midline will also
preventing complications. minimize the possibility of pneumomediastinum
or pneumothorax or injury to the recurrent la-

P I T F A L L S ryngeal nerves [2].
A false passage between the trachea and the
Failure to insert the tracheotomy cannula under sternum can be avoided by inserting the trache-
direct vision can lead to a false passage between
the anterior wall of the trachea and the sternum
otomy tube into the trachea under direct vision
which will result in death if not recognized. using retractors and good illumination [3].
Subcutaneous emphysema can be prevented by
Bleeding or injury to vital structures may occur if
securing the airway prior to the tracheotomy with
dissection is not limited to the midline.
an endotracheal tube, avoiding excess dissection
An unrepaired laceration of the posterior wall of the
of the paratracheal tissues and not closing the
trachea may result in a tracheoesophageal fistula.
skin incision tightly or packing the wound.
A displaced tracheotomy tube is a potentially
lethal problem [4]. Prevention includes the use of
traction sutures in the trachea and sewing the
neck plate of the tracheotomy tube to the peristo-
Introduction mal skin. Tube size and configuration is also im-
Tracheotomy may be one of the easiest or one of portant since an ill-fitting tube may be associated
the most difficult, dangerous, and frustrating of with increased morbidity and death [5].
surgical procedures. The highest priority before Tracheal stenosis is usually related to the cuff
performing a tracheotomy is securing the airway of an endotracheal tube. The use of high volume,
[1] since the risk factors for complications in- low pressure cuffs has greatly decreased the prob-
crease when the procedure is performed under lem. Avoiding injury to the cricoid cartilage by
less than ideal circumstances. Prevention of com- keeping the tracheotomy at the level of the 2nd to
plications is much easier than their manage- 3rd tracheal ring helps to prevent stenosis.
ment.

Conclusions References
Most complications of tracheotomy are prevent- 1 Walkevekar R, Myers EN: Techniques and Complications in Tra-
cheostomy in Adults. San Diego, Plural Publishing, 2007.
able. Securing the airway prior to tracheotomy is
2 Rabuzzi DD, Reed GF: Intrathoracic complications following tra-
the highest priority. Meticulous attention to the cheotomy in children. Laryngoscope 1971;81:939946.
details of the surgery is of paramount impor- 3 Durbin CG Jr: Early complications of tracheostomy. Respir Care
2005;50:511515.
tance. Complications such as a displaced trache- 4 Parnes SM, Myers EN: Traction sutures in a tracheostomy using
otomy tube are potentially fatal and require im- a ligature passer. Trans Am Acad Ophthalmol Otolaryngol 1976;
mediate attention. 82:479485.
5 Grillo HC: Management of non-neoplastic diseases of the tra-
chea; in Shields TW, LoCicero J 3rd, Ponn RB (eds): General Tho-
racic Surgery, ed 5. Philadelphia, Lippincott Williams & Wilkins,
2000, vol 1, pp 885897.
13
171
Tracheotomy
13.2 Emergency Upper Airway Obstruction:

Cricothyroidotomy or Tracheotomy?
Carlos N. Lehn
Head and Neck Surgery Service, Hospital Helipolis, So Paulo, Brazil

P E A R L S a few require open techniques. Today tracheoto-
my is not and should not be an emergency proce-
Orotracheal intubation should be attempted first in dure owing to the huge complication and mortal-
patients with upper airway obstruction; only a few ity rate of emergency tracheotomy and the exis-
patients will require tracheotomy or cricothyroi-
dotomy.
tence of alternative routes to obtain immediate
airway control in the acutely obstructed upper
Try to establish the cause of obstruction: edema,
airway [2, 3].
trauma, foreign body, infection or tumor.
The complication rates for emergency crico-
In cancer patients and in trauma with suspected thyroidotomy and tracheotomy are similar (20
laryngotracheal disjunction a tracheotomy is
preferred.
and 21%). Inpatients requiring an emergency sur-
gical airway had a higher complication rate (32 vs.
0%) but better overall survival (91 vs. 46%) than

P I T F A L L S
patients treated in the emergency department.
Performing a cricothyroidotomy in a larynx cancer Some authors describe a complication rate of 32%
patient may be disastrous: you will disrupt the in emergency cricothyroidotomy [4, 5].
tumor and may start a bleeding.
Cricothyroidotomy in acute laryngeal disease does Practical Tips
not provide adequate ventilation. Most patients with emergency upper airway
obstruction can be managed with orotracheal in-
tubation or rapid sequence intubation techniques
and only a few will require tracheotomy or crico-
thyroidotomy [3, 6].
Introduction Try to establish the cause of airway obstruc-
The management of emergency upper airway ob- tion: the approach may be different depending on
struction depends on its cause. Edema, trauma, whether the patient has a larynx tumor or a for-
foreign body, infection and tumor can lead to this eign body [1].
condition [1]. In head and neck surgery specifi- Remember that the hyoid bone is higher in
cally the presence of a growing tumor may lead to children than in adults.
this condition but it can be expected and prevent- In larynx cancer patients tracheotomy is the
ed with elective tracheotomy. method of choice.
In most trauma patients airway problems can In trauma patients, if laryngotracheal disjunc-
be managed with orotracheal intubation and only tion is suspected avoid cricothyroidotomy [7].

The conversion of a cricothyroidotomy into a References
tracheotomy can be performed if the patient is 1 Linscott MS, Horton WC: Management of upper airway obstruc-
tion. Otolaryngol Clin North Am 1979;12:351373.
not in a life-threatening condition. Some authors
2 Goldenberg D, Golz A, Netzer A, Joachims HZ: Tracheotomy:
do not agree that all cricothyroidotomies should changing indications and a review of 1,130 cases. J Otolaryngol
be converted [4]. 2002;31:211215.
Subglottic stenosis does not occur in all cases 3 Bair AE, Panacek EA, Wisner DH, Bales R, Sakles JC: Cricothy-
rotomy: a 5-year experience at one institution. J Emerg Med
of cricothyroidotomy. 2003;24:151156.
4 Gillespie MB, Eisele DW: Outcomes of emergency surgical air-
way procedures in a hospital-wide setting. Laryngoscope 1999;
Conclusion 109:17661769.
In this chapter we discussed the indications for 5 McGill J, Clinton JE, Ruiz E: Cricothyrotomy in the emergency
tracheotomy and cricothyroidotomy in emergen- department. Ann Emerg Med 1982;11:361364.
6 Bair AE, Filbin MR, Kulkarni RG, Walls RM: The failed intuba-
cy airway obstruction. It is important to state that tion attempt in the emergency department: analysis of preva-
in these cases we can expect a high rate of com- lence, rescue techniques, and personnel. J Emerg Med 2002;23:
131140.
plications but an even higher rate of survival of a 7 Weissler MC, Couch ME: Tracheotomy and intubation; in Bailey
life-threatening condition. The ability to differ- BJ, Johnson JT, Newlands SD (eds): Head and Neck Surgery and
entiate individual cases (tumor, trauma, infec- Otolaryngology. Philadelphia, Lippincott Williams & Wilkins,
2006.
tion, foreign body and edema) and the skill to
perform one or other technique of airway assess-
ment are crucial. The main goal of these tips is to
guide the reader how to evaluate the best option
for each patient, depending on the primary cause
of the airway impairment.
13
173
Tracheotomy
13.3 Avoidance of Complications in

Conventional Tracheotomy and
Percutaneous Dilatational Tracheotomy
David W. Eisele
Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, Calif., USA

P E A R L S patients and relate to the specific patient popula-
tion, indication, surgical technique and emergen-
Avoid a high tracheotomy through or near the cricoid cy setting [35]. The most common complica-
cartilage.
tions include hemorrhage, tube obstruction, and
Carefully select patients and use endoscopic guidance
accidental decannulation. PT, airway stenosis,
for percutaneous dilatational tracheotomy (PDT).
and tracheoesophageal fistula are uncommon
Carefully secure the tracheotomy tube (TT) and exer-
complications. Some complications are life-
cise precautions to avoid accidental decannulation.
threatening, thus requiring prompt recognition

P I T F A L L S and proper management.
Inadequate safety precautions can result in a surgical Practical Tips for Open Tracheotomy
fire. The surgeon must communicate with the an-
A small, sutured, or packed tracheotomy incision can esthesiologist and other members of the operat-
result in subcutaneous emphysema or pneumothorax
(PT).
ing team prior to the procedure.
The patient should be properly identified and
Hemorrhage from a tracheoinnominate artery
fistula can be fatal. positioned.
Prevent a surgical fire. Wait to drape until all
flammable prep solutions have dried [6]. Stop
Introduction supplemental oxygen for 1 min prior to use of
Conventional tracheotomy (CT) is indicated for electrocautery if possible. Be cognizant of possi-
emergency airway control and is the standard ble oxygen enrichment under the drapes.
method for elective tracheotomy. Either a vertical or horizontal neck incision,
Recently, PDT has become a widely accepted adequately sized, works well.
and efficient method of tracheotomy for select pa- Carefully divide the thyroid isthmus with elec-
tients who require prolonged intubation and me- trocautery [7]. Ligatures are used as needed.
chanical ventilation. Contraindications include Avoid a high tracheotomy near or through the
emergency airway access, children, obscuration cricoid cartilage.
of anatomic landmarks, tracheal deformity, high Never use electrocautery to enter the trachea
ventilation pressures, and uncorrectable coagu- [8].
lopathy [1]. Creation of a circular or square tracheal win-
CT became standardized by Chevalier Jackson dow or a Bjork flap facilitates TT reinsertion
[2] and others. Complications occur in 540% of should accidental decannulation occur.

Have the endotracheal tube (ET) withdrawn to Avoid puncture of the membranous trachea. Con-
just above the tracheal opening for TT placement. firm proper needle placement endoscopically.
If there is difficulty in placing the TT, the ET can Pass the guide wire, dilators, and TT under en-
be advanced into the distal trachea for ventila- doscopic inspection.
tion.
Never force the dilators or TT.
Select the proper TT based on the patients Confirm proper tube placement with FB.
characteristics. For obese patients, perform sub- Confirm that the tracheotomy cuff has not
cutaneous fat excision. been damaged.
Do not suture or pack the tracheotomy wound The TT should not be removed until matura-
to avoid subcutaneous emphysema or PT. tion of the tract has occurred [1]. For accidental
Carefully secure the TT by suturing the tube decannulation within 1 week of the procedure,
flange to the skin, with snugly secured ties, and orotracheal intubation may be preferred because
with cuff inflation to avoid accidental decannula- of potential difficulty with TT reinsertion [3].
tion.
A routine postoperative (PO) chest radiograph Conclusion
is not indicated [9]. Complications of CT and PDT should be care-
Postoperatively administer humidified air. fully avoided. Proper patient selection, broncho-
Monitor TT cuff pressures and keep the cuff scopic guidance and proper technique, and ad-
pressure less that 25 mm Hg to prevent tracheal herence to postprocedure principles increase the
mucosa injury. safety of PDT.
Keep a spare TT and instruments necessary for
tube replacement at the bedside postoperatively.
All instances of PO hemorrhage must be care- References
fully evaluated and managed. A tracheoinnomi-
nate artery fistula must be excluded to avoid fatal
1 Bhatti N, Tatlipinar A, Mirski M, et al: Percutaneous dilational
tracheotomy in intensive care unit patients. Otolaryngol Head 13
Neck Surg 2007;136:938941.
hemorrhage. 2 Jackson C: High tracheotomy and other errors: the chief causes
of chronic laryngeal stenosis. Surg Gynecol Obstet 1923;32:392
398.
Practical Tips for PDT 3 Kost KM: Endoscopic percutaneous dilatational tracheotomy: a
If PDT is performed, an endoscopist uses the prospective evaluation of 500 consecutive cases. Laryngoscope
flexible bronchoscope (FB) for endoscopic guid- 2005;115:130.
4 Goldenberg D, Gov-Ari E, Golz A, et al: Tracheotomy complica-
ance and general anesthesia is administered. tions: a retrospective study of 1130 cases. Otolaryngol Head Neck
Have all instruments and kit components. Surg 2000;123:495500.
Have a standard tracheotomy tray available. 5 Gillespie MB, Eisele DW: Outcomes of emergency surgical proce-
dures in a hospital-wide setting. Laryngoscope 1999;109:1766
Make the neck incision the same length as used 1769.
for open tracheotomy. 6 Weber SM, Hargunani CA, Wax MK: Duraprep and the risk of
Dissect bluntly to the trachea. fire during tracheostomy. Head Neck 2006;28:649652.
7 Calhoun KH, Weiss RL, Scott B, et al: Management of the thyroid
Visualize the trachea with the FB after the tip isthmus in tracheostomy: a prospective and retrospective study.
of the ET is withdrawn to the proximal trachea. Otolaryngol Head Neck Surg 1994;111:450452.
8 Tykocinski M, Thomson P, Hooper R: Airway fire during trache-
Be wary of oxygen desaturation with use of the
otomy. ANZ J Surg 2006;76:195197.
bronchoscope. 9 Hamburger MD, Wolf JS, Berry JA, Molter D: Appropriateness of
Use transillumination and palpation of ana- routine chest radiography after tracheotomy. Arch Otolaryngol
Head Neck Surg 2000;126:649651.
tomic landmarks to place the needle through the 10 Swanson GJ, Meleca RJ, Bander J, Stackler RJ: The utility of chest
anterior tracheal wall. Avoid the thyroid isthmus. radiography following percutaneous dilational tracheotomy.
Arch Otolaryngol Head Neck Surg 2002;128:12531254.
175
Reconstruction
14.1 Practical Tips to Perform a Microvascular

Anterolateral Thigh Flap
Luiz Carlos Ishida, Luis Henrique Ishida
Plastic Surgery Division, Faculty of Medicine, University of So Paulo, So Paulo, Brazil

P E A R L S The ALT flap is based on the perforator vessels
of the descending branch of the lateral circumflex
Very versatile thin flap with a large amount of skin femoral artery (DBLCFA). There are up to 4 per-
available. forators per thigh, all in a 6-cm radius from the
Low donor site morbidity, both esthetically and midpoint between the anterosuperior iliac spine
functionally. (ASIS) and the lateral border of the patella (LBP).
Long vascular pedicle that allows microvascular The average pedicle length is about 12 cm. The
anastomosis far from the defect site. artery and vein diameter at the origin of the
DBLCFA is about 2.5 mm, which is very suitable

P I T F A L L S for microanastomosis. The perforator pedicles
are musculocutaneous in 75% of the thighs and
There is a small chance (1%) of an absence of perfo- septocutaneous in 25%. Among the musculocu-
rator vessels originating from the descending
branch of the lateral circumflex artery.
taneous pedicles, 87% have direct and 13% indi-
rect intramuscular trajectory [35]. The unique
Overweight and female patients may have thicker
characteristics of the ALT flap increase the reli-
subcutaneous tissue in the anterolateral thigh area.
ability of this flap and reduce surgical time.
Practical Tips
Usually the dissection of perforator flaps is more
difficult than of traditional flaps. The ALT flap is
not different, and the tiny perforators and the
Introduction intramuscular dissection may increase surgical
Since its first description [1], the anterolateral time. About 35% of the thighs have septocutane-
thigh (ALT) flap has become a very important ous or direct musculocutaneous perforators and
resource in head and neck reconstructions and a 65% have indirect musculocutaneous ones [3].
workhorse for soft tissue reconstructions [2]. This Only the former impose some additional difficul-
flap has very interesting characteristics for the re- ties during flap dissection, whereas with the first
constructive surgery, such as one of the greatest two types dissection is no different from any oth-
extensions of skin, one of the longest pedicles, er fasciocutaneous flap. On the other hand, the
and one of the lowest morbidities at the donor site advantages of this flap, such as the donor site [6],
when compared to the traditionally used micro- easily surpass possible intraoperatory difficul-
surgical flaps [3]. ties.

The perforator vessels to the ALT flap are the most reliable ones with a well-known and pre-
found in an area of 6 cm of diameter around the dictable anatomy. It can provide a thin cutaneous
middle point between the ASIS and the LBP [3, flap on a very long pedicle with a relatively low
5]. morbidity at the donor site.
The exact perforator locations can be plotted
with a 5.3-MHz Doppler ultrasound; even though
it is not necessary for ALT flap raising, it may re- References
duce the dissection time. 1 Song YG, Chen GZ, Song YL: The free thigh flap: a new flap con-
The dissection should start by finding the cept based on the septocutaneous artery. Br J Plast Surg 1984;
37:149159.
DBLCFA between the rectus femoralis and the 2 Wei FC, Vivek J, Celik N, Chen HC, Chuang DCC, Lin CH: Have
vastus lateralis muscles. In this way, the perfora- we found an ideal soft-tissue flap? An experience with 672 an-
terolateral thigh flaps. Plast Reconstr Surg 2002;109:2219
tor vessel locations are easily found distally. 2226.
The fascia lata can be raised along with the cu- 3 Ishida LC, Ishida LH, Munhoz AM, Martins DS, Besteiro JM,
taneous flap, providing a vascularized fascial tis- Cernea CR, Ferreira MC: Utilizao do retalho perfurante an-
terolateral da coxa na reconstruo de cabea e pescoo: estudo
sue and facilitating the perforator dissection. anatmico e aplicaes clnicas. Rev Bras Cir Cab Pesc 2002;27:
When necessary, muscular flaps can be raised 716.
along on the same pedicle of the ALT flap, spe- 4 Ishida LH, Ishida LC, Munhoz AM, Morais J: Retalhos perfuran-
tes em cirurgia de cabea e pescoo; in Mlega JM (ed): Cirurgia
cially the vastus lateralis (chimeric flaps) [7]. plstica fundamentos e arte: cirurgia reparadora de cabea e
More than one cutaneous flap can be raised pescoo. Medsi, Rio de Janeiro, 2002, pp 10461050.
5 Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, Gao JH:
separately depending on the number and location Applied anatomy of the anterolateral femoral flap. Plast Reconstr
of the perforator vessels [7]. Surg 1988;82:305310.
Overweight and female patients tend to have 6 Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakat-
suka T, Harii K: Anterolateral thigh flap donor-site complica-
thicker subcutaneous tissue in the ALT area. The tions and morbidity. Plast Reconstr Surg 2000;106:584589.
ALT flap can be thinned on its deeper subcutane- 7 Koshima I, Yamamoto H, Hosoda M, et al: Free combined com-
ous portion as the main vascularization is through posite flaps using the lateral circumflex femoral system for re-
pair of massive defects of the head and neck regions: an introduc-
the subdermal plexus [8]. tion to the chimeric flap principle. Plast Reconstr Surg 1993;
In case of an absence of perforator vessels from 92:411.
8 Nojima K, Brown SA, Acikel G, Arbique G, Ozturk S, Chao J,
the DBLCFA, which may occur in 1% of the pa-
Kurihara K, Rohrich RJ: Defining vascular supply and territory
tients, the surgeon can use on the same donor site of thinned perforator flaps. I. Anterolateral thigh perforator
perforator flaps based on the transverse branch flap. Plast Reconstr Surg 2005;116:182193.
9 Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K: Ana-
14
of the lateral circumflex artery or direct branches tomic variations and technical problems of the anterolateral
from the femoral artery [9, 10]. thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102:
The perforator branches are extremely delicate 15171523.

10 Kawai K, Imanishi N, Nakajima H, Aiso S, Kakibuchi N, Hoso-
and sensitive to torsions; the surgeon must avoid kawa K: Vascular anatomy of the anterolateral thigh flap. Plast
cauterizing nearby vessels, always preferring me- Reconstr Surg 2004;114:11081117.
chanical hemostasis.
Conclusion
Perforator flaps offer a whole new perspective in
reconstructive surgery. They allow the recon-
structive surgeon to transfer almost any tissue in
the human body. Any segment of the skin can be
transferred nowadays as a perforator flap, and
among all the skin flaps, the ALT flap is one of
177
Reconstruction
14.2 Practical Tips to Perform a

Deltopectoral Flap
Roberto A. Limaa, b, Fernando L. Dias a, b, Jorge Pinho Filho c
a Head
and Neck Service, Brazilian National Cancer Institute/INCA and,
b Catholic
University of Rio de Janeiro, Rio de Janeiro,
c Memorial San Jose Hospital of Recife, Brazil

P E A R L S The majority of complex head and neck recon-
structions required more than one flap. The pec-
Separate the fascia of the pectoral muscles in the toralis major flap is most often combined with
subfascial plane, sparing the thin musculature the deltopectoral flap in this setting. When used
investing the fascia to preserve the fine vascular
network that supplies the random portion of
simultaneously, these two flaps are complemen-
the flap. tary.
Limited extension of the inferior incision does not
Practical Tips
compromise the length of the flap and assures the
blood supply. Two nearly parallel lines running laterally
from a parasternal base that spans the first four

P I T F A L L S intercostals spaces mark the borders of the pecto-
ral portion. The first is at the level of the inferior
Good fixation prevents the flap from collapsing, border of the clavicle and the second at the level
compromising the suture on the recipient area. of the apex of the anterior axillary fold. Continu-
Tracheotomy fixation tape that is too tight compro- ing from these two lines the outline of the deltoid
mises the blood supply. portion ends with a rounded linear margin that
extends to the anterolateral, lateral or posterolat-
eral line of the shoulder.
The elevation of the flap should be done care-
fully, separating the fascia of the pectoral muscles
Introduction sparing the thin musculature investing the fas-
Bakamjian [1] introduced the deltopectoral skin cia.
flap in 1965, and thereafter it was used extensive- Elevate the flap in the subfascial plane from
ly for reconstructive surgery of the head and neck. lateral to medial. As the dissection proceeds into
Flap failure rates amount to 1025% [25], and the parasternal region take care to not injure the
can exceed 50% in cases of pharyngoesophageal perforating vessels of the internal mammary ar-
or oral cavity reconstruction [5]. Nevertheless, tery that supply the flap. The inferior incision is
the deltopectoral flap remains a versatile and reli- usually described as extending medially to the
able tissue source that can be used simultaneous- parasternal region to provide a maximal arc of
ly with the pectoralis major myocutaneous flap rotation and length. Kingdom and Singer [6] re-
for a complex head and neck reconstruction. ported that this is not necessary and can compro-

mise the integrity of the third and fourth perfora- Suture the inferior-medial incision pivot point
tors. Hamaker [7] suggested that the extension of and the superior cervical skin. This maneuver ex-
the inferior incision no further than the level of tends the arc of rotation, counteracts gravitation-
the nipple does not compromise the arc of rota- al pull, and decreases the donor site defect [6].
tion and length of the flap and blood supply is
In cases of peritracheostomal reconstruction,
consistently preserved. avoid fenestrating the flap [8]. It is preferable to
Provide postoperative care to avoid kinking or rotate the distal end of the flap into the tracheal
compression of the flap by dressings, drain tubes, stump. In this setting, several centimeters of
or tape of the tracheotomy. length can be provided and up to 360 of the tra-
If the flap is to be passed beneath cervical flaps, cheostoma reconstructed. Besides, this technique
the lower cervical incision must be horizontal avoids the limited extensibility that occurs in the
and should be the same incision as the superior flap fenestration [6].
flap incision.
In cases of longer flaps, consider to autono-
mize the flap before the final reconstruction, also References
in the presence of arteriosclerosis, diabetes, or se- 1 Bakamjian VY: A two-stage method for pharyngoesophageal re-
construction with a primary pectoral skin flap. Plast Reconstr
vere malnutrition. Some authors [5] suggested au-
Surg 1965;36:173184.
tonomizing the flap in cases of previous radio- 2 Bakamjian VY, Long M, Rigg B: Experience with the medially
therapy in the recipient area, reporting 49% of based deltopectoral flap in reconstructive surgery of the head
and neck. Br J Plast Surg 1971;24:174183.
failures. We agree with the report of Bakamjian 3 Mendelson BC, Woods JE, Masson JK: Experience with the del-
[2] that previous radiotherapy to the recipient site topectoral flap. Plast Reconstr Surg 1977;59:360365.
does not affect the flap viability. Kingdom and 4 Tiwari RM, Gorter H, Snow GB: Experiences with the deltopec-
toral flap in reconstructive surgery of the head and neck. Head
Singer [6] reported an 88% of successful recon- Neck Surg 1981;3:379383.
struction with deltopectoral flap in previously ir- 5 Kirkby B, Krag C, Siemssen OJ: Experience with the deltopec-
radiated areas. toral flap. Scand J Plast Reconstr Surg 1980;14:151157.
6 Kingdom TT, Singer MI: Enhanced reliability and renewed ap-
Use a larger flap base, usually with 4 perforat- plications of the deltopectoral flap in head and neck reconstruc-
ing arteries, branches of the internal mammary tion. Laryngoscope 1996;106:12301233.
7 Hamaker RC: Four chest flaps. Arch Otolaryngol 1978;104:437
artery, if the flap needs to reach the face and/or 438.
upper neck. This provides better blood supply. 8 East CA, Flemming AF, Brough MD: Tracheostomal reconstruc-
tion using a fenestrated deltopectoral skin flap. J Laryngol Otol
1988;102:282283.
14
179
Reconstruction
14.3 Practical Tips for Performing a Pectoralis

Major Flap
Jos Magrim, Joo Gonalves Filho
Head and Neck Surgery and Otorhinolaryngology Department, Hospital AC Camargo, So Paulo, Brazil

P E A R L S head and neck region, ranging from skin defects
through to large reconstructions of the oral cav-
Design your flap in the donor area of the pectoralis ity and pharyngeal-esophageal tissues [13]. The
at the beginning of the surgery; however, it should main complications arising from its use, fistulas,
only be performed after resection.
dehiscence of the flap, partial or total ischemia of
Use the maximum amount of muscle possible for the skin and necrosis, have been described as oc-
providing a better supply to the skin.
curring in 3357% of cases [2, 46]. On the other
hand, a major complication, such as the need for

P I T F A L L S
a new flap due to complete necrosis, occurs in
13% of cases [2, 4, 7].
Always start performing the flap by incising the skin
of the inferior and lateral part.
Practical Tips
Avoid excessively manipulating the flap with your
Design your flap in the donor area of the pec-
hands.
toralis at the beginning of the surgery; however,
Dissect the subclavicular tunnel between the
it should only be performed after resection and
clavicle and its posterior periosteum.
assessment of the extent of the receptor area, un-
less you are certain of the size of the resected area.
When planning, it is important to observe the
flap rotation arch, the dimensions and the loca-
tion of the main vascular bundle.
Introduction Use the maximum amount of muscle possible,
Since it was described by Ariyan [1] in 1979, the because the larger the muscular volume, the safer
pectoralis major myocutaneous flap (PMMF) has the flap, providing a better supply to the skin and
been one of the main methods of reconstruction avoiding ischemia.
in oncological surgery of the head and neck. The Always start performing the flap by incising
anatomical proximity of the donor area for per- the skin of the inferior and lateral part (or distal
forming the flap surgery to the resection location, extremity), avoiding the superior part of the ped-
the simplicity of the technique, its versatility and icle. Its anterior face is then released at the supra-
presence of a rich vascular pedicle have made the facial level of the skin and subcutaneous tissue;
PMMF one of the most frequently used tech- the posterior face is lifted from the thoracic wall,
niques in reconstruction of the head and neck. the entire course of main vascular pedicle being
The PMMF is widely used to repair surgical visualized, and the flap is raised in the inferior-
defects following treatment for tumors in the superior direction. The vascular pedicle is dis-

sected between the clavipectoral fascia and the Conclusion
clavicular part of the pectoralis major muscle The present technical modifications that preserve
[4, 8]. parts of the pectoralis major muscle are impor-
We use a technical modification in which the tant, because they foresee functional deficits in
clavicular bundle from the second to the third the arm and are useful for manual laborers. The
intercostal bundle and the lateral edge of the pec- infraclavicular tunnel also provides an increase
toralis major are preserved. of around 23 cm to the flap rotation arch and it
Avoid excessively manipulating the flap with is important for alleviating the traction on the
your hands; place two stitches at the inferior ex- vascular pedicle.
tremity to lift it, preserving the integrity of the
microcirculation.
After harvesting the flap and ligaturing collat- References
eral vessels of the pedicle, transfer it to the cervi- 1 Ariyan S: The pectoralis major myocutaneous flap. Plast Recon-
str Surg 1979;63:7381.
cal region by the infraclavicular or supraclavicu-
2 Milenovic A, Virag M, Uglesic V, Aljinovic-Ratkovic N: The pec-
lar route [8, 9]. toralis major flap in head and neck reconstruction: first 500 pa-
The subclavicular tunnel (ST) is performed by tients. J Craniomaxillofac Surg 2006;34:340343.
3 Magrin J, Kowalski LP, Saboia M, Saboia RP: Major glossectomy:
dissecting the muscle down to the insertion and end results of 106 cases. Eur J Cancer B Oral Oncol 1996;32B:879
the inferior border of the subclavius muscle fas- 884.
cia. The neurovascular structure leading to the 4 Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J,
Kowalski LP: Pectoralis major and other myofacial/myocutane-
proximal portion of the pectoralis major muscle ous flaps in head and neck cancer reconstruction: experience
is identified and preserved. The ST is dissected with 437 cases at a single institution. Head Neck 2004;26:1018
between the clavicle and its posterior periosteum. 1023.
5 Chepeha DB, Annich G, Pynnonen MA, Beck J, Wolf GT, Teknos
During this maneuver, the subclavius muscle is TN, Bradford CR,Carroll WR, Esclamado RM: Pectoralis major
deflected off the fascia and sectioned together myocutaneous flap vs revascularized free tissue transfer: com-
plications, gastrostomy tube dependence, and hospitalization.
with the posterior periosteum of the clavicle. By Arch Otolaryngol Head Neck Surg 2004;130:181186.
finger dissection, the tunnel is enlarged to ac- 6 Mariani PB, Kowalski LP, Magrin J: Reconstruction of large de-
commodate passage of the flap. In difficult cases, fects postmandibulectomy for oral cancer using plates and myo-
cutaneous flaps: a long-term follow-up. Int J Oral Maxillofac
such as in patients with bulky flaps, sterile liquid Surg 2006;35:427432.
vaseline is used to lubricate the flap and the ipsi- 7 Shah JP, Haribhakti V, Loree TR, Sutaria P: Complications of the
lateral shoulder is raised to facilitate passage. pectoralis major myocutaneous flap in head and neck recon-
struction. Am J Surg 1990;160:352356.
14
During the procedure, a vasodilator substance 8 Azevedo JF: Modified pectoralis major myocutaneous flap with
(papaverine or lidocaine) is instilled over the flap partial preservation of the muscle: a study of 55 cases. Head Neck
Surg 1986;8:327331.
pedicle.
9 Kerawala CJ, Sun J, Zhang ZY, Guoyu Z: The pectoralis major
myocutaneous flap: is the subclavicular route safe? Head Neck
2001;23:879884.
181
Reconstruction
14.4 Practical Tips to Perform

a Trapezius Flap
Richard E. Hayden
Mayo Clinic Arizona, Scottsdale, Ariz., USA

Trapezius musculocutaneous flaps are infre-
The superior trapezius flap is the most reliable but quently used in this era of advanced free flap re-
the least versatile. It is unaffected by previous neck construction. However, they can provide simple
surgery and damage to the transverse cervical
vessels.
and sometimes the best option for certain de-
fects.
The lower trapezius flap is the only pedicled muscu-
The flat trapezius muscle and overlying skin
locutaneous flap with an arc of rotation sufficient to
reach the vertex or the frontal region. have three zones and three possible flaps with a
very confusing vascular anatomy. The superior is
There is almost perfect reliability with the harvest
supplied by the occipital and paraspinous perfo-
of the lower trapezius flap if, instead of a distal skin
island, the skin is maintained axially over the entire rating arteries. The middle is supplied by the su-
vertical extent of the flap. This allows flaps to be perficial cervical artery (SCA; superficial branch
up to 8 38 cm. These skin paddles can extend up of the transverse cervical artery). This artery
to 13 cm caudal to the trapezius muscle though leaves the lower posterior triangle of the neck to
sometimes requiring a second procedure to section
run under the trapezius usually near the acces-
the pedicle.
sory nerve. It runs over the levator scapulae and
rhomboid vessels. The lower is supplied by the

P I T F A L L S
dorsal scapular artery (DSA; deep branch of the
transverse cervical artery). The DSA leaves the
Intraoperative lateral decubitus positioning is
lower posterior triangle by running deep to the
required.
levator and rhomboid muscles. It sends a nutrient
Previous or contiguous neck surgery, especially
branch through the space between rhomboid ma-
radical neck dissection, may compromise the
vascular pedicles of the lateral and lower flaps. jor and minor to supply the caudal or lower por-
tion of the muscle.
Preoperative Doppler is recommended, but even if
The confusion stems mainly from the extreme
the arterial supply is noted, the venous drainage is
difficult to assess. variability of the origins of the vessels in the neck.
Seroma formation is common. The DSA can be a separate branch of the subcla-
vian or costocervical trunk (45%) or form a com-
Donor site skin grafts are unreliable.
mon trunk with the SCA (33%), with the subscap-
ular (3%) or with both (19%). The trunk formed
by the DCA and the SCA is called the transverse
cervical artery and in the 33% of cases where it is

found, it originates from the subclavian in 19% Conclusions
and the thyrocervical trunk in 14%. Trapezius flaps demand a thorough understand-
The lateral island flap from the middle zone ing of a variable anatomy. Avoid the lateral trape-
which can carry the spine of the scapula is the zius flap in patients with previously operated
least reliable flap. It is based on the SCA and SCV necks. Consider the superior flap for posterolat-
which drains into the external jugular vein in eral neck defects after radical surgery. Consider
80% of cases. the extended vertical (lower) flaps for large scalp
defects and maximize the vertical length of the
Practical Tips skin paddle to increase reliability.
Consider superior flap for patients with large
skin defect in the neck, when the muscle is al-
ready paralyzed after radical neck dissection. References
Extend caudad flap incision medially across 1 Conley J: Use of composite flaps containing bone for major re-
pairs in the head and neck. Plast Reconstr Surg 1972;49:522.
the midline with a cephalad backcut to increase
2 Demergasso F: The Lateral Trapezius Flap. Third International
the arc of rotation. Symposium of Plastic and Reconstructive Surgery, New Orleans,
Consider extended lower flap for large scalp 1979.
3 Panje WR: The Island (Lateral) Trapezius Flap. Third Interna-
defects vertex to frontal. tional Symposium of Plastic and Reconstructive Surgery, New
Line from acromion to T12 outlines the lower Orleans, 1979.
muscle border. 4 Gregor RT, Davidge-Pitts KJ: Trapezius osteomyocutaneous flap
for mandibular reconstruction. Arch Otolaryngol 1985;111:198
8-cm-wide skin paddle vertically oriented be-
203.
tween spine and medial border scapula extends 5 Baek SM, Biller HF, Krespi YP, Lawson W: The lower trapezius
from level of scapular spine to 1015 cm caudal island myocutaneous flap. Ann Plast Surg 1980;5:108114.
6 Netterville JL, Wood D: The lower trapezius flap: vascular anat-
to trapezius. omy and surgical technique. Arch Otolaryngol Head Neck Surg
Dissect distal to proximal superficial to rhom- 1991;117:73.
7 Urgurlu K, Ozcelik D, Huthut I, Yildiz K, Kiminc L, Bas L: Ex-
boids. tended vertical trapezius myocutaneous flap in head and neck
Once visualized, temporarily occlude DSA reconstruction as a salvage procedure. Plast Reconstr Surg 2004;
with a vascular clip. 114:339350.
8 Haas F, Weiglein A, Schwarzl F, Scharnagl E: The lower trapezius
If distal skin bleeding is unchanged, section
musculocutaneous flap from pedicled to free flap: anatomical
DSA and pedicle flap on SCA for maximal arc of basis and clinical applications based on the dorsal scapular ar-
rotation. tery. Plast Reconstr Surg 2004;113:15801590. 14
If distal skin is compromised, keep DSA as ad-

ditional pedicle, section its caudal continuation
deep to rhomboid major and section rhomboid
minor to increase the arc of rotation.
Divide upper trapezius only if necessary for
adequate arc of rotation.
Close donor site primarily.
183
Reconstruction
14.5 Latissimus Dorsi Myocutaneous Flap for

Head and Neck Reconstruction
Gady Har-El a, b, Michael Singerb
a Department of Otolaryngology Head and Neck Surgery, Lenox Hill Hospital, New York, N.Y., and
b Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, N.Y., USA

P E A R L S One factor that has limited the popularity of
the LDMF is the repositioning of the patient.
The latissimus dorsi myocutaneous flap (LDMF) is a However, repositioning is usually not required.
versatile flap that can be used to reconstruct large The patient can be placed in the supine position
defects in the head, neck and scalp.
for the ablative segment of the surgery and then
Repositioning of the patient to inset the flap after rotated into the lateral position for flap harvest-
harvest can be avoided in most cases.
ing. Flap inset can often be accomplished with the
Maintaining the orientation of the flap is vital to patient remaining in the lateral position [10].
prevent torsion of the vascular pedicle.
Practical Tips

P I T F A L L S Due to the branching nature of the thoracodor-
sal artery within the muscle, the cutaneous por-
The exposed pedicle, which is not protected by a
tion of the flap can be harvested as one or two
cuff of muscle, may be easily traumatized or com-
pressed. skin paddles [1]. The more distal skin paddle has
decreased viability due to fewer cutaneous perfo-
Transferring the muscle through a narrow subcuta-
rators.
neous tunnel may expose the flap and pedicle to
risk of obstruction and congestion. Division of the latissimus dorsi tendon in-
creases the arc of rotation.
The skin paddle is stabilized by anchoring its
dermal layer to surrounding muscle fascia with
fine absorbable sutures.
Introduction Tagging the medial and lateral aspects of the
The LDMF is a reliable option for surgical recon- LDMF with different sutures helps with orienta-
struction of virtually any region of the head, neck tion of the flap during transfer.
and scalp [24, 6, 9]. It is particularly useful for Flap elevation begins at the anterolateral mus-
secondary reconstruction or cephalad defects. cle edge. Only after identifying the thoracodorsal
This is due to its large surface area, its long vas- vessels is medial and inferior elevation of the
cular pedicle which permits an extensive arc of muscle performed.
rotation, its ease of dissection, and minimal do- Ligation and transection of the vascular
nor site morbidity [8]. The vascular pedicle can branches to the serratus anterior muscle allow a
extend 810 cm on average. greater arc of rotation.

Preservation of the circumflex scapular artery The vascular supply of the LDMF allows it to
assists in maintaining flap orientation, but it can be harvested in a patient who has undergone a
be divided to achieve greater pedicle length [7]. neck dissection. These patients are, however, at
After transection of the tendon of the latissi- greater risk of shoulder dysfunction.
mus dorsi, the pedicle remains exposed without
any muscular protection; then, it must be handled Conclusion
with extreme care. Excessively skeletonizing the The LDMF is a dependable flap that should be
vessels puts them at increased risk of vasospasm considered when reconstructing defects in the
[5]. head and neck. This flap can be easily elevated,
Care for the elevated muscle and skin flap has a large surface and long pedicle, and causes
should include wrapping them in warm, moist limited donor site morbidity.
laparotomy pads.
Infiltration of the soft tissues around the ped-
icle with 2% lidocaine will prevent vasospasm. References
Brachial plexus injury can be prevented by 1 Bartlett SP, May JW Jr, Yaremchuk MJ: The latissimus dorsi mus-
cle: a fresh cadaver study of the primary neurovascular pedicle.
avoiding hyperabducting or overrotating the
arm. 2 Barton FE, Spicer TE, Byrd HS: Head and neck reconstruction
In order not to jeopardize flap viability the with the latissimus dorsi myocutaneous flap. Anatomic observa-
tions and report of 60 cases. Plast Reconstr Surg 1983;71:199
tunnel created for passing the LDMF is widened 204.
to at least 57 cm. 3 Maves MD, Panje WR, Sjagets FW: Extended latissimus dorsi
Most flaps are easily passed between the skin myocutaneous flap reconstruction of major head and neck de-
fects. Otolaryngol Head Neck Surg 1986;92:551558.
and clavicle. In some patients clavicular protru- 4 Maxwell G, McGibbon B, Hoopes J: Experience with thirteen la-
sion may result in an excessively tight tunnel. In tissimus dorsi myocutaneous free flaps. Plast Reconstr Surg
these cases a subclavicular tunnel can be dissect- 1979;64:17.
5 Har-El G, Bhaya M, Sundaram K: Latissimus dorsi myocutane-
ed and utilized. ous flap for secondary head and neck reconstruction. Am J Oto-
The flap should not be rotated more than laryngol 1999;20:287293.
6 Haughey BV, Fredrickson JM: The latissimus dorsi donor site
180. current use in head and neck reconstruction. Arch Otolaryngol
After surgery, the arm is kept flexed across the Head Neck Surg 1991;117:11291134.
chest for 5 days. 7 Hayden RE, Kirby SD, Deschler DG: Technical modifications of
Postoperatively, avoid ipsilateral flexion of the the latissimus dorsi pedicled flap to increase versatility and vi-
ability. Laryngoscope 2000;110:352357. 14
neck, which can cause kinking of the pedicle. 8 Olivari N: Use of thirty latissimus dorsi flaps. Plast Reconstr
Postoperatively, check the flap viability and Surg 1979;64:654661.
9 Quillen CG, Shearin JC, Georgiade NG: Use of the latissimus dor-
capillary refill, and with Doppler ultrasound. si myocutaneous island flap for reconstruction in the head and
Rarely, the subcutaneous tunnel through neck area. Plast Reconstr Surg 1978;62:113117.
10 Urken ML, Sullivan MJ: Latissimus dorsi; in Urken ML, Cheney
which the flap passes can become swollen, risking
ML, Sullivan MJ, et al (eds): Atlas of Regional and Free Flaps for
flap viability. In this instance, the skin layer over- Head and Neck Reconstruction. New York, Raven Press, 1995, pp
lying the clavicle can be opened to allow for ap- 237259.
propriate pedicle blood flow.
185
Reconstruction
14.6 Transverse Rectus Abdominis Flap

Julio Morais Besteiro
So Paulo University Medical School, So Paulo, Brazil

P E A R L S Large transverse or oblique previous abdomi-
nal scars are a relative contraindication for the
One of the best and safest flaps for treatment of ex- TRAM. Previous abdominoplasty or extensive li-
tensive soft tissue defects. posuction is an absolute contraindication for
Very versatile donor area. both TRAM and muscle-sparing flap [1].
Constant and reliable pedicle. The flap elevation should begin on the lateral
border of the skin island, where the lateral row of
Hidden donor area scars specially in transverse rec-
perforators is encountered above the rectus fas-
tus abdominis (TRAM) flap and muscle flap.
cia. As the medial perforators are identified, the
rectus fascia is incised along its length and the

P I T F A L L S
dissection proceeds from medial to lateral until
Risk of hernia or bulging in the lower abdomen. the medial row of perforators is reached again.
Another vertical incision in the fascia, medial to
Risk of umbilicus deviation.
the perforators, creates a thin strip of fascia that
Reduction of the muscular strength.
is included in the flap to preserve the perforator
Bulky flap in obese patients. vessels. This strip should be thin enough to
Be aware of previous scars in the abdomen. achieve direct closure of the anterior sheet of the
aponeurosis without tension.
The lower part of the muscle is usually severed
Introduction at the level of the arcuate line where the pedicle
The TRAM is among the most used free flaps for enters into the muscle. This preserves a distal
extensive soft tissue defects. The pedicle is con- stalk of muscle to be inserted in the arcuate line
stant, long and has a large diameter. The skin is and to reconstruct the posterior sheet of the rec-
supplied through a series of musculocutaneous tus fascia when closing the donor area.
perforators that are arranged in two parallel rows Functionally, the closure of the aponeurotic
along the muscle. The distribution of the perfora- layer is the main step in the donor area. A tight
tors permits different designs of the flap and a closure without excessive tension is mandatory.
variety of patterns of the skin paddle. The position of the umbilicus is important. As
the harvesting of the muscle and aponeurosis is
Tips and Technical Details unilateral, the umbilicus will be displaced toward
Main perforators to the skin are around the um- the donor site. It may be centered again through
bilical area, so the design of the flap should in- a row of stitches over the contralateral rectus fas-
clude these vessels if a long flap is planned. cia symmetric to the one on the donor site, or it

may be rerouted through a stab wound adjacent the perforators. Secondary defatting with lipo-
to the vertical incision. suction or sharp dissection is usually done and is
safe [5, 6].
Potential Donor Site Complications The muscular component of the flap can be
Previous abdominal transverse incisions or reduced to a small cuff around the pedicle and the
oblique incisions may cut the rectus muscle or the medial row of perforators.
main perforator vessels. Even an extended appen-
dectomy incision can sometimes cut the inferior Conclusion
epigastric pedicle. Extensive previous liposuction This donor site provides a large amount of tissue
can also damage the perforator vessels. in different types of design with an acceptable es-
The main drawback is the lower abdominal thetic result in the donor area, allowing simulta-
weakness and the development of hernias or ab- neous dissection in donor and receptor areas. The
dominal bulging. For weak or lax fascia, Marlex long vascular pedicle with large-diameter vessels
mesh or other synthetic material should be used enables an easy and safe transfer. Variability of
to reinforce the lower abdomen. Also, the small- flap thickness must be considered.
est strip of fascia should be performed, to pre-
serve the perforators when harvesting the flap.
Even partial resection of the muscle reduces References
the abdominus muscle strength, representing a 1 Granzow JW, Levine JL, Chiu ES, Allen RJ: Breast reconstruction
with the deep inferior epigastric perforator flap. J Plast Reconstr
problem in young and physically active patients
Aesthet Surg 2006;59:571579.
[2, 3]. 2 Feller AM: Free TRAM. Results and abdominal wall function.
Clin Plast Surg 1994;21:223232.
3 Futter CM, Webster MH, Hagen S, Mitchell SL: A retrospective
Reducing the Bulkiness comparison of abdominus muscle strength following breast re-
Patients have a different distribution of abdomi- construction with a free TRAM or DIEP flap. Br J Plast Surg
nal fat. Usually the oblique flap (the main axis of 2000;53:578582.
4 Taylor GI, Corlett R, Boyd JB: The extended inferior epigastric
the skin paddle is from the umbilicus to the tip of flap: a clinical technique. Plast Reconstr Surg 1983;72:751764.
the scapula) is thinner than other designs [4]. 5 Hallock GG: Defatting of flaps by means of suction-assisted
Defatting this flap is safe if done under the su- lipectomy. Plast Reconstr Surg 1985;76:948952.
6 Taylor GI, Corlett RJ, Boyd JB: The versatile deep inferior epigas-
perficial fascia in the cutaneous portion. Some fat tric (inferior rectus abdominis) flap. Br J Plast Surg 1984; 37:330
can also be removed with extreme care around 350. 14
187
Reconstruction
14.7 Practical Tips to Perform a

Microvascular Forearm Flap
Adam S. Jacobson, Mark L. Urken
Beth Israel Medical Center, New York, N.Y., USA

P E A R L S superficial system has larger caliber vessels which
have thicker walls, permitting an easier anasto-
Thin, soft, pliable, and easy to harvest. mosis. The blood supply to the thumb and index
Two-team approach can be utilized. finger are most at risk following interruption of
the radial artery if the superficial palmar arch is
Harvest with or without an extended subcutaneous
incomplete and there is a lack of communication
component for added bulk.
between the superficial and deep arches. The co-
Can be harvested with 79 cm of radius bone.
existence of these two anomalies occurred in less
Can be harvested with nerve for sensate flap
than 12% of the specimens reported by Coleman
reconstruction.
and Anson [2].
The flap can be designed in a variety of geo-

P I T F A L L S
metric configurations and it can be harvested
with vascularized bone (radius), vascularized
Usually requires a split-thickness skin graft for
tendon (palmaris longus), the brachioradialis
closure of donor site.
muscle, and vascularized sensory nerves (medial
If ulnar blood supply to hand is not adequate
and lateral antebrachial cutaneous nerves) [3].
ischemia may result.
Extremity requires splint for 7 days.
Practical Tips
Exposed tendon. The Allen test is the most important preoperative
Sensory loss over thumb and first finger due to test, to assess the adequacy of circulation to the
injury to the superficial branch of radial nerve. hand through the ulnar artery. A more objective
Pressure ulceration from splint. test is based on pulse oximeter readings.
The harvest is performed with a tourniquet for
temporary occlusion of the radial artery.
We routinely perform an intraoperative as-
Introduction sessment of the capillary refill of the thumb and
The radial forearm fasciocutaneous free flap index finger after interruption of the radial ar-
(RFF) was reported in the Chinese literature by tery, following release of the tourniquet. Occa-
Yang et al. [1] in 1981. It is a thin, pliable, highly sionally, when a patient has a questionable preop-
reliable soft tissue flap. erative Allen test we have elected to proceed with
This free flap is based on the radial artery and the harvest and performed intraoperative assess-
either the deep or superficial venous system. The ment of the ulnar circulation. In this scenario, the

distal incision is made in order to allow access to The donor site must be regularly assessed for
the radial artery. The radial artery is isolated and adequate capillary refill. If the patient complains
a temporary microvascular clamp is placed on the of pain at the donor site that is out of proportion
artery and the capillary refill of the hand is reas- to what is anticipated, one must remove the splint
sessed. If the refill time is acceptable, we safely and assess the arm to rule out the possibility of
proceed with the harvest. pressure necrosis.
We most frequently design the skin paddle to
end distally at the flexor crease of the wrist, in- Conclusion
cluding the thinnest and the least hair-bearing The RFF is an excellent soft tissue flap which can
forearm skin. be used for a wide variety of defects, and is one of
A skin monitor to provide postoperative access the most utilized free flaps in head and neck re-
to buried flaps can be designed by creating a sep- construction today.
arate skin paddle over the proximal forearm [4].
A bilobed design can be utilized to reconstruct
the tongue and floor of mouth separately [5]. References
If additional bulk is required, an extended 1 Yang G, Chen B, Gao Y: Forearm free skin flap transplantation.
Natl Med J China 1981;61:139.
component of subcutaneous tissue is harvested in
2 Coleman SS, Anson BJ: Arterial patterns in the hand based upon
continuity with the intermuscular septum and a study of 650 specimens. Surg Gynecol Obstet 1961;113:409
folded under the skin paddle. 424.
3 Urken ML, Weinberg H, Vickery C, Biller HF: The neurofascio-
Generally, we close the proximal limb of the cutaneous radial forearm flap in head and neck reconstruction:
donor site incision line primarily, but the location a preliminary report. Laryngoscope 1990;100:161173.
where the skin paddle was harvested often re- 4 Urken ML, Futran N, Moscoso JF, Biller HF: A modified design
of the buried radial forearm free flap for use in oral cavity and
quires a split-thickness skin graft. Ulnar-based pharyngeal reconstruction. Arch Otolaryngol Head Neck Surg
flaps can often be rotated into the defect to avoid 1994;120:12331239.
a skin graft. 5 Urken ML, Biller HF: A new bilobed design for the sensate radial
forearm flap to preserve tongue mobility following significant
A volar splint is fashioned with meticulous at- glossectomy. Arch Otolaryngol Head Neck Surg 1994;120:26
tention paid to padding the hand and forearm to 31.
prevent pressure ulcerations.
Assess viability of a free flap with a 25-gauge
needle prick. If bright red blood egresses in a 14
timely fashion, one can feel comfortable that the
circulation is adequate. If there is a delayed egress
or the blood is too dark, one must quickly con-
sider the possibility of a vascular compromise.
189
Reconstruction
14.8 Mandible Reconstruction with Fibula

Microvascular Transfer

Since the first description of the fibular trans-
Carefully draw in the donor area the important ana- plant for mandible, it became the gold standard
tomical elements and the skin island if necessary. in all mandibular reconstructions [1, 2]. Although
On the upper part of the incision, identify and it is a well-established technique it is still a com-
protect the common peroneal nerve as it courses
plex surgery with many difficult steps.
around the neck of the fibula.
During the dissection, flex the leg in order to relax
Practical Tips
the muscle of the posterior compartment of the leg.
In the preoperative examination, check both
Excise a small piece of bone in the proximal osteot-
dorsalis pedis and posterior tibialis pulse. When
omy, in order to do a safer and easier dissection of
the vascular pedicle. in doubt, it is safer to perform a radiographic
evaluation of the vessels, because between 1 and
Spare 8 cm of the distal fibula to provide adequate
2% of the population has a single vessel in the leg
ankle stability. In children, fix the distal fibula to the
tibia with a lag screw, in order to prevent varus (congenital peroneal magna artery) [3, 4]. Other
deformity. aberrations can occur in up to 10% of the popula-
Carefully plan the osteotomies, the plate fixation tion.
and position of the recipient vessels. Two teams work simultaneously, one in the do-
nor area and the other in the recipient field.

P I T F A L L S The lateral approach is preferred, and a tour-
niquet is used in the thigh. If an osteocutaneous
The skin paddle of the osteocutaneous flap receives
flap is indicated, the dissection should begin by
its vascular supply from the intermuscular septum,
but sometimes the portion of the soleus or flexor the anterior border of the cutaneous island and
hallucis longus must be included in the flap. the intermuscular septal vessels identified usu-
Be aware of the absence of dorsalis pedis and ally between the medial and distal third of the
posterior tibialis artery pulse. In about 1% of the fibula [5]. The skin paddle has an unpredictable
patients, there is a single vessel in the leg and blood supply and may be lost in up to 510% of
the transfer cannot be done. patients.
Avoid extensive periosteal dissection when multi- Identify septal vessels and the common pero-
ple osteotomies are necessary. neal nerve. The bone is isolated with a thin cuff
Be aware of deep varicose veins in the donor area. of muscle all around. A small piece of bone should
Although this does not prevent the transplant, be excised in the proximal part and the peroneal
it will make the flap dissection difficult.
vessels isolated. The distal osteotomy is then per-

formed and the distal fibular vessels are ligated. Conclusion
Cut the interosseous membrane and expose the The fibular free flap can successfully restore mas-
vascular pedicle all along the fibula. Considerable tication, dental occlusion and maintain adequate
additional length of the pedicle can be gained by oral excursion. Good postoperative speech qual-
harvesting a more distal segment of bone. ity may be expected if no significant tongue re-
To fit the fibula to the mandible defect multiple section is required. There is no significant mor-
osteotomies usually are performed. Osteotomies bidity related to the donor site.
should be done opposite to the vessels, to avoid
the risk of injury by the screws of the fixation
plate. One single reconstruction titanium plate or References
several miniplates can be used. 1 Hidalgo DA: Fibula free flap: a new method of mandible recon-
Place the fibula in continuity with the inferior struction. Plast Reconstr Surg 1989;84:71.
2 Hidalgo DA, Pusic AL: Free-flap mandibular reconstruction: a
border of the remaining mandible to get a better 10-year follow-up study. Plast Reconstr Surg 2002;110:438.
contour result. If it is too thin and osseointegrat- 3 Kim D, Orron DE, Skillman JJ: Surgical significance of popliteal
arterial variants: a unified angiographic classification. Ann Surg
ed implants are anticipated, a bone graft or a dou- 1989;210:776.
ble-barrel fibula can be done in part of the hori- 4 Astarci P, Siciliano S, Verhelst R, et al: Intra-operative acute leg
zontal ramus of the neomandible. Osseointegrat- ischaemia after fibula flap harvest for mandible reconstruction.
Acta Chir Belg 2006;106:423426.
ed implant placement as a secondary procedure 5 Wei FC, Seah CS, Tsai YC, et al: Fibula osteoseptocutaneous flap
is a worthwhile procedure [6, 7]. for reconstruction of composite madibular defects. Plast Recon-
The mandible is maintained in occlusion and str Surg 1994;93:294306.
6 Gurlek A, Miller MJ, Jacob RF, Lively JA, Schusterman MA:
the defect is accurately measured. The fibula is Functional results of dental restoration with osseointegrated im-
then fixed in the defect, leaving enough space to plants after mandible reconstruction. Plast Reconstr Surg 1998;
101:650.
insert a prosthesis between the fibula and the 7 Weischer T, Mohr C: Ten-year experience in oral implant reha-
maxilla. Avoid inserting screws in the horizontal bilitation of cancer patients: treatment concept and proposed
portion of the neomandible where the osseointe- criteria for success. Int J Oral Maxillofac Implants 1999;14:521.
grated implants are supposed to be inserted.
Mandibular templates and measurements of
the surgical specimen are useful.
When a reconstruction plate is used or the

miniplates have a strong fixation, liquid or soft 14
meal may be allowed from the very first days till
the end of the third postoperative month. Usu-
ally, no intermaxillary fixation is used.
191
Reconstruction
14.9 Practical Tips to Perform

a Microvascular Iliac Crest Flap
Mario S.L. Galvao
Reconstructive Microsurgery Unit, National Cancer Institute, Rio de Janeiro, Brazil

P E A R L S Its normal curvature is ideal for hemiman-
dible defects, allowing a reconstruction without
Iliac crest offers excellent quality bone for mandib- fracturing the bone in order to obtain a normal
ular reconstruction allowing osseointegrated im- contour.
plants.
The bony structure is the best choice for os-
Reliable soft tissue paddle for oral reconstruction if seointegrated implants.
needed.
Compound graft has a reliable skin blood
supply for intraoral reconstruction.

P I T F A L L S
Secondary defect and scarring are easily hid-
den by clothes, and the resulting linear scar is
Injury to ilioinguinal nerve may lead to important
usually of good quality.
postoperative pain.
The deep circumflex iliac vessels are of good
This flap is contraindicated in obese or in very hairy
caliber and reasonably long pedicle to reach the
patients.
recipient vessels on the neck.
Hernia formation may be avoided by using mesh
To achieve the best results, the mandible must
sheath.
be reconstructed immediately following resec-
The compound flap (bone and skin) is contraindi- tion, as the procedures in later reconstruction are
cated in obese patients, however, the flap is
suitable for hairy patients as the skin overlying the
more difficult due to retraction, fibrosis and dis-
iliac bone is always hairless. placement of the remaining mandible.
Furthermore, immediate reconstruction al-
lows reattachment of the preserved masticatory
muscles to the transplanted graft, improving the
Introduction postoperative function.
Several techniques have been described to recon- The compound grafts (skin and bone) are in-
struct the mandible [1, 2], but the free iliac graft dicated for mandible and intraoral lining defects.
is undoubtedly the best one [35]. In some patients the defect involves the bone and
The main advantages to choose this bone are also the soft tissue surrounding it. In these pa-
as follows: tients, the skin of the compound graft can be de-
The thickness of the bone allows tridimen- epithelialized and used to fill defect contours,
sional reconstruction. thus improving the esthetic appearance.

Practical Tips The muscles are cut internally close to the ves-
Outlining the Flap sels and the bone is lifted on its pedicle.
The patient is operated on in the supine posi-
The same procedure is carried out for com-
tion with a cushion under his buttocks. pound grafts. In these procedures about 12 4 cm
The donor site must be ipsilateral. of skin is left overlying the bone.
The skin is outlined about 1 cm above and par- Hemimandible defects do not require osteoto-
allel to the inguinal ligament, and over the iliac mies. For central arch defects, miniplates are used
crest. following osteotomy.
Dissecting and Carving the Flap Repairing the Secondary Defect

The skin incision is made exposing the bone The muscles are approximated with nonab-
and the fascia above the inguinal ligament. sorbable stitches and a mesh graft is always used
About half way between the anterior superior to avoid herniation.
iliac spine and the pubis, the external and inter- A corset is worn for 3 months.
nal oblique muscle fibers are dissected and the
deep circumflex iliac vessels are found. Contraindications
A rubber band is passed around the vessels and The compound graft (bone and skin) is not
dissection is carried out medially as far as the suitable for obese and hairy patients but it can be
femoral vessels, and then, laterally close to the an- used in hairy patients as the skin overlying the
terior superior iliac spine. The ascending branch iliac crest is always hairless.
of the deep circumflex iliac vessels and its small
branches are ligated. These vessels must be pre-
served when dissecting compound flap. References
All muscles are detached from the outer border 1 Galvao MSL, Wance JR, Braga ACCR: A contribuio da micro-
cirurgia no tratamento do paciente oncolgico. Rev Brasil Can-
of the iliac crest, exposing the external part of the
cerol 1984;30:2934.
bone. 2 Galvao MSL, Sbalchiero J: Reconstruo mandibular. Cirurgia
The lateral cutaneous nerve of the thigh is Plstica: Fundamentos e Arte. Rio de Janeiro, Editora Medsi,
2002, pp 949962.
found and preserved just bellow the anterior su- 3 Sanders R, Mayou B: A new vascularized bone graft transferred
perior iliac spine. This is a very important guide by microvascular anastomosis as a free flap. Br J Surg 1979;66:
as this nerve will cross the deep circumflex iliac 787788.
4 Taylor GI, Townsend P, Corlett R: Superiority of the deep circum-
14
vessels internally, behind the anterior superior flex iliac vessels as the supply for free groin flaps. Experimental
iliac spine. work. Plast Reconstr Surg 1979;64:595604.
The amount of bone necessary to be used is 5 Taylor GI, Townsend P, Corlett R: Superiority of the deep circum-
flex iliac vessels and supply for free groin flaps. Clinical work.
now carved using chisel and saw. It is mandatory Plast Reconstr Surg 1979;64:745759.
to leave the anterior superior iliac spine intact in
place with the inguinal ligament attached to it.
The bone is fractured and dissection of the ves-
sels is accomplished laterally passing the lateral
nerve of the thigh.
193
Reconstruction
14.10 The Scapular Flap


P E A R L S At present, these characteristics limit the indi-
cations to moderate mandible defects associated
Indicated for complex three-dimensional defects of with extensive double-face tegumental defects or
the mandible or the maxilla. certain situations of maxilla reconstruction as-
sociated with extensive soft tissue defects

P I T F A L L S
Practical Tips
Two-team approach is difficult.
As in all complex reconstructions, careful preop-
Long lateral decubitus positioning is associated erative planning is mandatory. In this particular
with morbidity of the brachial plexus.
situation, the positioning of the patient must be
Possible decreased range of motion and weakness considered. In some situations as in posterolat-
of the shoulder. eral defects, most of the operation can be done in
lateral decubitus, although a simultaneous two-
team approach may be necessary. The patient is
positioned in a lateral or three-quarter lateral po-
Introduction sition, with the arm draped free with a stockinet,
The scapular donor area is unique in that it can in such a way that it can be mobilized during flap
provide a wide range of tissue types based in the dissection.
same vascular pedicle [1]. Advantages of all these The transverse and descending branches of
flaps include a long and constant pedicle (1014 the circumflex scapular artery can preoperative-
cm) with large-diameter vessels and abundant in- ly be identified with Doppler ultrasonography. If
dependent surface areas, which allows for free- Doppler is not available, the flaps are centered
dom in a three-dimensional insetting. Up to 10 over the triangular space of the lateral border of
cm of bone can be removed from the lateral as- the scapula and the dissection begins distally in
pect of the scapula. This bone is not always thick the cutaneous flap toward the triangular space,
enough to allow for osseointegrated implants right over the deep fascia [4]. The vessels can be
[2, 3]. seen on the undersurface of the flap, especially
The main disadvantage of this donor site is its with backward illumination.
positioning that may prevent a two-team ap- The dissection proceeds toward the identifica-
proach and increase operative time, that may pro- tion and isolation of the circumflex subscapular
voke brachial plexus compression and the poten- pedicle between the teres major and minor. The
tial compromise in the range and power of the branch of the circumflex scapular artery to the
motion of the shoulder. lateral border of the scapula is identified and the

dissection should preserve the connection be- Potential Complications and Drawbacks
tween this artery and the periosteal vessels. If a Functional recovery of the donor site is excep-
long segment of bone, including the tip of scapu- tionally good provided that the muscles are prop-
la, or some osteotomy is necessary, the branch to erly reinserted. Shoulder stiffness and decreased
the serratus muscle should also be included to as- mobility have been seen in a minority of patients.
sure the circulation of the tip of the scapula. The The principal complication is the loss of the distal
circumflex scapular artery can be traced to its or- part of the bone, when distal osteotomies are
igin in the triangular space at the subscapular ar- done.
tery by retracting the teres major and long head The extent of harvested bone is very limited
of the triceps [5]. The bone is cut with an oscillat- and the positioning of the patient usually pre-
ing saw parallel to the lateral border of the scap- vents the use of the two-team approach and in-
ula and this is completed with a transverse oste- creases operative time substantially.
otomy approximately 1 cm distal from the glen-
oid fossa. Some attachments of the serratus
muscle and other muscles must be sharply divid- References
ed to isolate the flap in the circumflex scapular 1 Rowsell AR, Davis DM, Eisenberg N, et al: The anatomy of the
subscapular-thoracodorsal arterial system: a study of 100 cadav-
pedicle [6].
er dissections. Br J Plast Surg 1984;37:574576.
To prevent complications each of the muscles 2 Frodel JL Jr, Funk GF, Capper DT, et al: Osseointegrated im-
that have been divided is reattached to the sur- plants: a comparative study of bone thickness in four vascular-
ized bone flaps. Plast Reconstr Surg 1993;92:449455.
rounding musculature using strong nonreab- 3 Roumanas ED, Markowitz BL, Lorant JA, et al: Reconstructed
sorbable sutures. If no secure sutures can be ob- mandibular defects: fibula free flaps and osseointegrated im-
tained with muscle-to-muscle sutures, the mus- plants. Plast Reconstr Surg 1997;99:356365.
4 Teot L, Bosse JP, Moufarrege R, et al: The scapular crest pedicled
cles should be strongly reattached to the scapula bone grafts. Int J Microsurg 1981;3:257262.
through drill holes. 5 Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous
In the postoperative period, shoulder exercises scapular flap for mandibular and maxillary reconstruction.
are begun under the supervision of a physical 6 Coleman JJ, Sultan MR: The bipedicle osteocutaneous scapula
therapist to restore shoulder elevation. flap: a new subscapular system free flap. Plast Reconstr Surg
1991;87:682692.
14
195
Reconstruction
14.11 Reconstruction of Pharyngoesophageal

Defects with the Jejunal Free Autograft
John J. Coleman, 3rd
Indiana University School of Medicine and Roudebush VAMC, Indianapolis, Ind., USA

The jejunal free autograft is a useful method of
Select a length of jejunum far enough away from pharyngoesophageal reconstruction [1] that has
the ligament of Treitz to allow for tube jejunostomy shown in many large series to be reliable and ver-
of the distal segment after anastomosis.
satile [24]. The bowel can be harvested by a sec-
Leave the graft in situ perfusing after jejunostomy ond team of reconstructive surgeons working in
until the neck is completely prepared for transfer of
the abdomen at the same time as the extirpative
the segment.
team works in the neck.
Perform the most difficult pharyngoenteric anasto-
mosis first, then the microvascular anastomosis,
then the second pharyngoenteric anastomosis to
Practical Tips
minimize ischemic time. Through an upper midline incision the liga-
ment of Treitz is identified. Moving distally along
the jejunum, a segment of bowel is chosen that,

P I T F A L L S
when resected, will allow the remaining reanas-
The mesenteric vessels particularly the vein are tomosed jejunum to reach without tension the ab-
thin-walled and delicate. Careful dissection at the dominal wall, thus creating a feeding jejunosto-
junction of the feeding branch to the superior my distal to the enteroenterostomy. When the ap-
mesenteric vessels and meticulous division of the
propriate segment has been identified, the branch
venovenous branches of the venae comitantes is
critical to avoiding damage to the vessels or mesen- of the superior mesenteric vessels that supplies
teric hematoma. This may be particularly difficult that segment is isolated by carefully incising the
in obese patients. serosa and separating the mesenteric fat from the
Positioning the segment and the donor and vessels. By careful dissection from proximal (near
recipient vessels in the neck must account for the the origin of the vessel from the superior mesen-
possibility of kinking the mesentery when the neck teric vessels) to distal (near the antimesenteric
turns and causing vessel thrombosis. The carotid, edge of the jejunum) the mesentery is divided
jugular and pharyngoesophagus are all near
proximal and distal and finally the bowel is di-
midline structures and there is a finite length to the
mesentery. vided with two lines of staples. It is important at
this point to observe the ends of the reconstruc-
tive segment and the ends of the bowel remaining
to assure that they are adequately perfused prior
to harvest or enteroenterostomy. If the ends of the
remaining bowel are viable enteroenterostomy is

performed and a tube jejunostomy placed distal but leaving it perfused and exteriorizing it, by im-
to the anastomosis. The segment to be harvested plantable Doppler or thermo probe, or by exter-
is left in site perfused until the neck has been pre- nally applied Doppler ultrasound. Continuity of
pared for transfer since the jejunum tolerates a the pharynx should be checked by contrast imag-
relatively short ischemia time. ing 10 days after surgery [5].
Preparation of the neck is critical. A branch of
the external carotid and jugular vein or the trans- Conclusion
verse cervical artery and vein should be prepared The jejunal free autograft is a reliable method for
under the microscope prior to dividing the mes- pharyngoesophageal reconstruction, provided
enteric vessels. When the jejunum is brought to that some basic technical principles are strictly
the neck the vessels must be arranged so that nei- followed during its harvesting and positioning in
ther the vessels nor the mesentery will kink when the neck; carefully performed free-tension micro-
the neck is turned. Usually it is best to perform vascular and visceral anastomoses are equally
the more difficult pharyngoenteric anastomosis important.
(usually the jejunum to base of tongue) first, then
the microvascular anastomosis, then the second
pharyngoenteric anastomosis. An ischemia time References
of less than 2 h is desirable. Injection of saline 1 Coleman JJ: Reconstruction of the pharynx after resection for
cancer: a comparison of methods. Ann Surg 1989;209:554561.
through the nose under pressure will demon-
2 Carlson GW, Coleman JJ, Jurkiewicz MJ: Reconstruction of the
strate possible sites of leak or potential fistula. hypopharynx and cervical esophagus. Curr Probl Surg 1993;30:
The bowel segment should be sewn into the defect 425480.
3 Reece GP, Shusterman MA, Miller MJ: Morbidity and functional
in an isoperistaltic orientation under slight ten- outcome of free jejunal transfer reconstruction for circumferen-
sion because on reperfusion the jejunum will tial defects of the pharynx and cervical esophagus. Plast Recon-
lengthen somewhat. Excessive graft length in the str Surg 1995;96:13071316.
4 Theile DR, Robinson DW, Theile DE, et al: Free jejunal interposi-
neck can result in swallowing difficulty. tion reconstruction after pharyngolaryngectomy: 201 consecu-
The flap can be monitored in a number of tive cases. Head Neck 1995;17:8388.
ways: by direct observation by leaving a small 5 Torres WE, Fibus TF, Coleman JJ, et al: The radiographic evalu-
ation of the free jejunal graft. Gastrointest Radiol 1987;12:226
part of the neck flap incision open to observe the 230.
bowel serosa or by taking an extra small segment
of jejunum separating it from the bowel conduit 14
197
Reconstruction
14.12 Practical Tips to Perform a Gastric Pull-Up

William I. Wei, Vivian Mok

The gastric pull-up operation is one option of re-
For adequate mobilization of the stomach to reach construction for the hypopharynx after tumor
higher in the neck, the duodenum should be kocher-
extirpation. It was used before the era of myocu-
ized to the medial side of the inferior vena cava.
The posterior wall of the oropharynx and nasopharynx taneous flaps and microvascular free tissue trans-
should also be separated from the prevertebral fer [1]. Recently, this operation has only been per-
muscle. formed when the tumor is located in the lower
The esophagus should be mobilized under direct portion of hypopharynx or in the cervical esoph-
vision through the assistance of the thoracoscope agus [2]. Removing the esophagus also eliminates
rather than transhiatally with blunt dissection.
the organ which might develop a second primary
The fundus of the stomach is the highest point where tumor [3].
it meets the oropharynx for pharyngogastric anasto-
mosis. The incisions on the anterior stomach wall
This operation is indicated for patients who
should be T-shaped, to allow the gastric wall to move have dysphagia due to a tumor in the laryngopha-
up laterally to reduce the tension there. The base of ryngeal region. The gastric pull-up operation, be-
the tongue moves inferiorly to meet the lowered ante- sides removing the tumor in a single operation,
rior wall of the stomach.
invariably relieves the disturbing dysphagia. The
procedure however is still associated with hospi-

P I T F A L L S
tal mortality and morbidity [4]. With technical
improvements and better perioperative support,
During the transposition of the stomach transhiatally
both morbidity and mortality rates have been re-
to the neck, the axis of the stomach tube should be
maintained; twisting of the stomach will lead to duced [5] and the associated long-term morbidi-
necrosis. ties are acceptable [6].
Pyloromyomectomy, removing a segment of the
muscle at the pylorus, helps stomach emptying. Practical Tips
A pyloroplasty, although equally effective, also short-
Preoperatively, patients should be given chest
ens the stomach.
physiotherapy and enteric feeding with nasogas-
For carcinoma of the cervical esophagus affecting the
tric tube or parenteral feeding to achieve a posi-
posterior tracheal wall the cuff of the tracheostomy
tube should be lowered during the separation of these tive nitrogen balance.
two walls to allow precise dissection. The patient is positioned in the right lateral
When the pharyngogastric anastomosis dehisced, position for thoracoscopic mobilization of the
there might not be significant signs to alert the esophagus. The sharp dissection under direct vi-
clinician. Whenever leakage at the anastomosis is sus- sion avoids damaging intrathoracic vessels and
pected, early drainage of the neck wound is essential
to prevent extension of infection to the mediastinum.
also reduces surgical trauma, and the patients in
general have a smoother recovery [7]. After mo-

bilizing the esophagus, the patient is then turned For a high anastomosis, a U-shaped incision
into the supine position; the neck and the abdo- can be made on the anterior stomach wall. Turn-
men are approached simultaneously by two surgi- ing this anterior gastric wall flap superiorly, it will
cal teams. reach the posterior pharyngeal wall and a myo-
In the neck, soft tissue at the intrathoracic in- cutaneous flap can be used to close the defect in
let is removed for the stomach to come up. When the anterior wall.
the posterior wall of the trachea is infiltrated by
tumor in the cervical esophagus, it should be
carefully dissected off the tumor. When the upper References
posterior tracheal wall is damaged, it can be re- 1 Lam KH, Wong J, Lim ST, Ong GB: Pharyngogastric anastomosis
following pharyngolaryngoesophagectomy. Analysis of 157 cas-
paired from the neck. If the injury is lower down,
es. World J Surg 1981;5:509516.
then thoracotomy is mandatory for direct closure 2 Lam KH, Choi TK, Wei WI, Lau WF, Wong J: Present status of
of the defect [8]. pharyngogastric anastomosis following pharyngolaryngo-oe-
sophagectomy. Br J Surg 1987;74:122125.
In the abdomen, the stomach is mobilized into 3 Martins AS: Multicentricity in pharyngoesophageal tumors: ar-
a tubular structure with the right and left gastric gument for total pharyngolaryngoesophagectomy and gastric
vessels running along lesser and greater curva- transposition. Head Neck 2000;22:156163.
4 Sasaki CT, Salzer SJ, Cahow E, Son Y, Ward B: Laryngopharyn-
tures. The adequately mobilized stomach should goesophagectomy for advanced hypopharyngeal and esophageal
reach the posterior pharyngeal wall at the level of squamous cell carcinoma: the Yale experience. Laryngoscope
the tonsils. When the stomach is transposed or- 1995;105:160163.
5 Wei WI, Lam LK, Yuen PW, Wong J: Current status of pharyngo-
thotopically to the neck, the fundus is the highest laryngo-esophagectomy and pharyngogastric anastomosis.
point to reach the posterior pharyngeal wall. A Head Neck 1998;20:240244.
6 Wei WI, Lam KH, Choi S, Wong J: Late problems after pharyngo-
T-shaped incision is made on the anterior gastric laryngoesophagectomy and pharyngogastric anastomosis for
wall, part of the anterior wall can be mobilized cancer of the larynx and hypopharynx. Am J Surg 1984;148:509
laterally to reduce the tension there and the base 513.
7 Cense HA, Law S, Wei W, Lam LK, Ng WM, Wong KH, Kwok KF,
of the tongue can be pulled down towards the an- Wong J: Pharyngolaryngoesophagectomy using the thoraco-
terior wall of the stomach to complete the pha- scopic approach. Surg Endosc 2007;21:879884.
ryngogastric anastomoses. 8 Wei WI, Lam KH, Lau WF, Choi TK, Wong J: Salvageable medi-
astinal problems in pharyngolaryngo-esophagectomy and pha-
ryngogastric anastomosis. Head Neck Surg 1988;10:S60S68.
14
199
Miscellaneous
15.1 Indications and Limitations of

Fine Needle Aspiration Biopsy of
Lateral Cervical Masses
Paulo Campos Carneiro, Luiz Fernando Ferraz da Silva
Department of Pathology, University of So Paulo School of Medicine, So Paulo, Brazil

P E A R L S malignant from benign processes, but also to de-
termine the nature of the disease, including or-
Fine needle aspiration biopsy (FNAB) is a powerful gan, microorganism and cell lineage identifica-
and accurate method to diagnose the majority of tion [2]. When the lymph node is accessed by
lateral cervical nodules.
FNAB, it can commonly distinguish among reac-
Imaging methods (IM) ultrasound, CT scans and tional lymphadenitis (acute, chronic and granu-
MRI are helpful to define lesion topography. The
lomatous infectious process), Hodgkin and non-
ultrasound must always be the method of choice to
guide FNAB. Hodgkin lymphoma, and metastases from differ-
ent sites, including occult thyroid neoplasm. Yet,
Immunocytochemistry of the FNAB sample increas-
FNAB hardly differentiates, only on a morpho-
es the diagnostic precision.
logical basis, among lymphoid proliferations, re-
actional lymphoid tissue or lymphoma. Immuno-

P I T F A L L S
cytochemical reactions are helpful tools in FNAB
Extensive representation is essential to avoid of lymph nodes [3].
scant cytological material and to increase lesion FNAB of salivary glands is usually conclusive
sampling. for acute and chronic inflammatory processes;
Carefully sample cystic, calcified and fibrotic benign neoplasm (pleomorphic adenoma, War-
lesions. thin tumor); malignant neoplasm (mucoepider-
moid, adenoid cystic, epidermoid, undifferenti-
ated carcinomas and adenocarcinomas), and
glandular ectopy in the low cervical region. Lim-
itations: Sometimes, it is hard to differentiate be-
Introduction tween the benign and malignant characteristics
FNAB is the method in which puncturing with a of lesions with well-differentiated epithelial cell
fine needle (2325 gauge) coupled to a syringe proliferation.
and a negative pressure device allows the assess- FNAB of cervical cysts, skin and its append-
ment of cytological samples for diagnoses. It was ages usually confirms the clinical-radiological
first described in 1930 by Martin and Ellis [1], and hypothesis of branchial cysts and thyroglossal
has been increasingly used and improved with duct cyst and defines skin and skin appendage
the help of IM. It is useful not only to differentiate neoplasms.

The identification of vascular structures with b) Immunocytochemical reactions: identifica-
imaging exams, such as aneurisms, contraindi- tion of cell lineages, primary sites of neoplasms,
cates FNAB. clonality, prognostic markers, and other differen-
tial diagnoses [1].
Practical Tips c) Culture: for necrotic material and/or signs
Knowledge of previous IM is essential. of infectious diseases.
When FNAB is not performed by the patholo- Other useful techniques include in situ hy-
gist guided by the radiologist, an interaction bridization and polymerase chain reaction.
among the patients clinician, the physician who The FNAB report should avoid simple classifi-
collects the sample and the pathologist may pro- cations such as positive, negative, suspect or in-
vide better results [4]. conclusive as this restricts the range of diagnos-
Adequate sampling of each lesion is pivotal. tic possibilities. When a single cytological diag-
Several strategies have been used to improve it, nosis is not possible, it is essential to explore all
such as: diagnostic possibilities, preferentially ordering
a) 24 biopsies from each region to be sam- them from the most to the least probable differ-
pled. ential diagnoses within the observed cytological
b) Smears on 58 slides per biopsy for different aspect.
stains (routinely, Papanicolaou and Giemsa
stains). Conclusions
c) Cell blocks with the remaining material in FNAB is a simple and easy method that can de-
the syringe and needle (if there is too little, it is fine the diagnosis in the majority of cervical lat-
possible to pool it; if there is a large amount avail- eral nodules. The knowledge of imaging methods
able, different cell blocks are preferred). is important to define the best approach and in-
Depending on the lesion characteristics, the terpretation of FNAB. Special techniques, partic-
FNAB method may be varied to ensure adequate ularly immunocytochemistry, may improve the
sampling: diagnostic potential of FNABs.
a) Partially cystic lesions: perform FNAB di-
rected to solid areas, avoiding cystic ones. If not
possible, drain the cystic content and then per- References
form a new FNAB to sample the solid compo- 1 Martin HE, Ellis EB: Biopsy by needle puncture and aspiration.
Ann Surg 1930;92:169181.
nent.
2 Koss LG: Koss Diagnostic Cytology and Its Histopathologic Bas-
b) Solid fibrotic/calcified lesions: increase the es, ed 5. New York, Lippincott Williams & Wilkins, 2005.
number of biopsies. 3 El Hag IA, Chiedozi LC, Al Reyess FA, Kollur SM: Fine needle
aspiration cytology of head and neck masses. Seven years expe-
c) Hypervascularized lesions: increase the rience in a secondary care hospital. Acta Cytol 2003;47:387
number of biopsies; use thinner needles (25
gauge); increase the needle movement speed, and
392.
4 Kocjan G, Feichter G, Hagmar B, Kapila K, Kardum-Skelin I, 15
Kloboves V, Kobayashi TK, Koutselini H, Majar B, Schenck U,
decrease the total time of the procedure. Schmitt F, Tani E, Totch M, Onal B, Vass L, Vielh P, Weynand B,
Use of special techniques increases the diag- Herbert A: Fine needle aspiration cytology: a survey of current
nostic specificity. The commonly used ones are: European practice. Cytopathology 2006;17:219226.
a) Cytochemical stainings: for microorganism

identification such as acid-fast bacilli, fungi, and
others.
201
Miscellaneous
15.2 When and How to Perform an Open Neck

Biopsy of a Lateral Cervical Mass
Pedro Michaluart, Jr., Srgio Samir Arap
Head and Neck Service, Hospital das Clnicas da Faculdade de Medicina, Universidade de So Paulo,
So Paulo, Brazil

Evaluation of neck masses is one of the most com-
In patients older than 40 years and a with a neck mon situations in the head and neck surgeons
mass, malignancy is the greatest concern. daily clinical practice. Inflammatory, congenital
Fine-needle aspiration (FNA) biopsy usually or neoplastic diseases may present with a neck
precedes an open biopsy.
mass and may affect neck organs other than
When a metastatic carcinoma is suspected, evalua-
lymph nodes (LN) [13]. It is crucial to have in
tion of the upper aerodigestive tract mucosa is
indicated. mind all the differential diagnoses while evaluat-
ing the patient. It is very important to obtain a
In case of suspicion of well-differentiated metastat-
careful clinical history and a complete physical
ic thyroid cancer, thyroglobulin should be put on
the FNA material. examination. Imaging studies should be used
Frozen-section examination during open biopsy when necessary. Ultrasound and CT scan are the
aims to confirm that the tissue sample is adequate. most helpful exams and can differentiate LN en-
Metastatic cancer in a supraclavicular mass should largements from other masses and show impor-
raise the suspicion of a thoracic or abdominal tant characteristics, for example, whether the
primary.
mass is within the parotid gland or not. To define
the etiology, a tumor sample is needed. In case of

P I T F A L L S
metastatic squamous cell carcinoma, the primary
tumor is often found within the upper aerodiges-
Do not substitute physical examination by image
tive tract mucosa and a biopsy can easily be done.
diagnosis.
Biopsies of neck masses should start routinely
Do not perform open biopsy before complete head
with cytology obtained by FNA. In most instanc-
and neck evaluation.
Open biopsy of neck mass as the first investigative es the cytology is able to confirm a diagnosis and
procedure is rarely recommended as it may inter- definitive treatment can be planned. Sometimes
fere with future treatment strategies. though, the diagnosis cannot be made on the ba-
Do not realize open biopsy within the parotid sis of cytology and an open biopsy is needed [15].
topography without being sure that the node is This is the case for lymphomas when routinely an
extraglandular.
LN should be evaluated for accurate diagnosis
The spinal accessory nerve (SAN) is superficial in the and treatment planning [1]. When cytology sug-
posterior triangle of the neck and its injury is the
most frequent complication of surgeries at this site.
gests metastatic carcinoma and an LN biopsy is
indicated, general anesthesia should be consid-

ered, so that a pan endoscopy can also be done at Frozen section of the LN should be performed
the same time. to make sure that there is enough material for the
diagnosis.
Practical Tips When there is a possibility of infectious dis-
Performing an LN Biopsy eases, material should be collected for cultures.
The first step is to determine a target node. It
is important to determine if the LN is superficial Conclusion
or deep to the sternocleidomastoid muscle. Although LN biopsy is usually considered a sim-
The target LN should be the most easily acces- ple procedure, complications may be disabling
sible with characteristics of disease involvement and should be prevented with careful preopera-
like enlargement, stiffness or necrotic center. tive evaluation and selection of the best anesthe-
Nodes may become less palpable after infiltra- sia for each case. The surgeon has to have pro-
tion of anesthesia so it is helpful to mark the skin found knowledge of the anatomy of the neck and
incision before. should be prepared to perform a bigger operation
Several factors should be considered for defini- if needed.
tion of the anesthesia. The size, location and mo-
bility of the node are important. Patients charac-
teristics are also relevant, for instance, age and References
capacity to collaborate. 1 Karen M, Close LG: Mass in the neck; in Close LG (ed): Essentials
Posterior superficial LNs may be of the SAN of Head and Neck Oncology. Stuttgart, Thieme, 1998, pp 243
251.
chain. Caution needs to be exercised with the in- 2 Frank DK, Sessions RB: Physical examination of the head and
cision and elevation of skin flaps in the posterior neck; in Harrison LB, Sessions RB, Hong WK, Kies MS, Medina
JE, Mendehall WM, Mukherji SK, OMalley BB, Wenig BM: Head
triangle because of the superficial course of the and Neck Cancer: A Multidisciplinary Approach, ed 2. Balti-
nerve and absence of the platysma. The incision more, Lippincott Williams & Wilkins, 2004, pp 410.
should allow for adequate exposure of the nerve 3 Schwetschenau E, Keley DJ: The adult neck mass. Am Fam Physi-
cian 2002;66:831838.
[6, 7]. 4 Gleeson M, Herbert A, Richards A: Regular review: management
Every effort should be made to excise the LN of lateral neck masses in adults. BMJ 2000;320:15211524.
without rupture of the capsule so that its archi- 5 Batthacharyya N: Predictive factors for neoplasia and malignan-
cy in neck mass. Arch Otolaryngol Head Neck Surg 1999;125:303
tecture is preserved. Grabbing the node with 307.
clamps should be avoided. For traction a nylon 6 Nason RW, Abdulrauf BM, Stranc MF: The anatomy of the acces-
sory nerve and cervical lymph node biopsy. Am J Surg 2000;180:
3-0 stitch that transfixes the node may be help- 241243.
ful. 7 Weisberger EC, Lingeman RE: Cable grafting of the spinal acces-
sory nerve for rehabilitation of shoulder function after radical
neck dissection. Laryngoscope 1987;97:915918.
15
203
Miscellaneous
15.3 Practical Tips in Managing Radiation-

Associated Sarcoma of the Head and Neck
Thomas D. Shellenberger a, b, Erich M. Sturgisc, d
a
Head and Neck Surgical Oncology, M.D. Anderson Cancer Center Orlando, Orlando, Fla.,
b
The University of Texas M.D. Anderson Cancer Center and Departments of c Head and Neck Surgery and
d
Epidemiology, The University of Texas M.D. Anderson Cancer Center, Houston, Tex., USA

P E A R L S more prolonged survival probabilities. The esti-
mated incidence of RAS ranges from 0.03 to 2.2%
Management of radiation-associated sarcoma (RAS) in those surviving more than 5 years after head
depends on prompt diagnosis/evaluation, defined and neck radiotherapy [1, 2]. The criteria for RAS
treatment goals, and multimodal therapy.
include: development of a sarcoma within the ra-
Despite the poor prognosis of RAS, the combina- diation field and at least 5-year latency between
tion of surgery, chemotherapy, and rarely additional
radiation and RAS diagnosis [3]. RAS appears to
radiotherapy can offer a chance for disease cure.
occur in a dose-dependent manner with the ma-
jority of cases occurring after therapeutic doses

P I T F A L L S
(median 50 Gy) [4, 5]. The histology is frequently
of high grade, including pleomorphic sarcoma
Failing to consider the possibility of RAS delays
(malignant fibrous histiocytoma or undifferenti-
diagnosis.
ated sarcoma) and osteosarcoma [2, 4].
RAS must be differentiated from more common
sarcoma to optimize treatment.
Practical Tips
The risk of RAS is low; therefore, RAS risk
should not have a major influence on treatment
decisions for patients with head and neck cancer
Introduction [6]. However, the incidence of RAS may increase
Sarcoma can arise as a rare secondary malignan- as improvements in head and neck cancer treat-
cy within radiation treatment fields, and the dou- ment and changing demographics result in pro-
ble-strand DNA damage induced by ionizing ra- longed survival.
diation appears to underlie RAS pathogenesis. New symptoms/signs or changes in the char-
The etiology of RAS may include the effects of acter of chronic symptoms, such as pain, should
other carcinogens such as chemotherapy alkylat- prompt investigation. Fine needle aspiration is
ing agents, genetic susceptibility, or other un- often adequate for initial diagnosis, but histolog-
known factors. Therefore, the terms RAS and ic typing will usually require core needle or open
postirradiation sarcoma may be more descriptive biopsy, which should be approached with further
than radiation-induced sarcomas. surgery in mind. All specimens from current and
RAS occurs in head and neck cancer patients previous biopsies, along with clinical and radio-
less frequently than in other cancer patients with graphic features, must be reviewed by a patholo-

gist with experience in sarcoma. Immunohisto- While further external beam radiotherapy is
chemical stains and cytogenetic studies can assist rarely possible, brachytherapy or intraoperative
pathologic subtyping. radiotherapy may be applied in selected cases.
Old records and dosimetry data may not be
available; nonetheless, evidence of the extent of Conclusion
the radiated field may come from tattoo marks, Detection of RAS at an early stage is paramount,
cutaneous radiation changes, and histologic find- and favorable outcomes depend on a high index
ings of radiation injury in tissues adjacent to the of suspicion in patients with a history of radiation
RAS. exposure. RAS presents unique challenges; none-
For RAS, 5-year overall survival ranges from theless, complete surgical resection offers the
10 to 30% [79]. Grade and tumor size are the only realistic chance for long-term survival.
most important prognostic factors. Prognosis for
RAS appears worse than that for sarcomas of a
similar stage arising de novo. Patel et al. [10] offer References
the following explanations: (1) delay in diagnosis 1 Patel SR: Radiation-induced sarcoma. Curr Treat Options Oncol
2000;1:258261.
caused by the unreliability of clinical examina-
2 Ko JY, Chen CL, Lui LT, Hsu MM: Radiation-induced malignant
tion due to postradiation induration and fibrosis, fibrous histiocytoma in patients with nasopharyngeal carcino-
(2) proximity of tumor to major neurovascular ma. Arch Otolaryngol Head Neck Surg 1996;122:535538.
3 Cahan WG, Woodward HQ, Higinbotham NL, Stewart SW, Coley
structures constraining surgical resection, (3) BL: Sarcoma arising in irradiated bone: report of eleven cases.
limited treatment options, (4) relatively poor che- Cancer 1948;1:329.
mosensitivity, (5) more aggressive biology, and (6) 4 Brady MS, Gaynor JJ, Brennan MF: Radiation-associated sarco-
ma of bone and soft tissue. Arch Surg 1992;127:13791385.
immunodepression caused by the first tumor 5 Kuttesch JF, Wexler LH, Marcus RB: Second malignancies after
and/or its treatment. Ewings sarcoma: radiation dose-dependency of secondary sar-
Surgical resection with adequate margins, in comas. J Clin Oncol 1996;14:27892795.
6 Mark RJ, Bailet JW, Poen J, Tran LM, Calcaterra TC, Abemayor
combination with neoadjuvant or adjuvant che- E: Postirradiation sarcoma of the head and neck. Cancer 1993;
motherapy, provides the best chance for RAS cure 72:887893.
7 Robinson E, Neugut AI, Wylie P: Clinical aspects of postradia-
in the absence of metastatic disease (and for pal- tion sarcomas. J Natl Cancer Inst 1988;80:233240.
liation in selected cases). By the time of detection, 8 Davidson T, Westbury G, Harmer CL: Radiation induced soft-tis-
many tumors have extended beyond their local sue sarcoma. Br J Surg 1986;73:308309.
9 Wiklund TA, Blomqvist CP, Raty J, Elomaa I, Rissanen P, Miet-
confines limiting the probability of complete en tinen M: Postirradiation sarcoma: analysis of a nationwide can-
bloc resection. Moreover, tissue changes in the cer registry material. Cancer 1991;68:524531.
radiated field impose technical difficulties at sur- 10 Patel SG, See AC, Williamson PA, Archer DJ, Rhys Evans PH: Ra-
diation induced sarcoma of the head and neck. Head Neck 1999;
gery, challenge the pathologic analysis of mar- 21:346354.
gins, and affect wound healing.
High-grade tumors of borderline resectability
should be considered for neoadjuvant chemother-
15
apy followed by complete resection whenever pos-
sible. Resectable high-grade tumors and all low-
grade tumors should be treated surgically when-
ever possible followed by adjuvant chemotherapy
when a negative margin is difficult or impossible.
Because of the high risk for distant failure, adju-
vant chemotherapy should be considered even in
those completely resected high-grade tumors [1].
205
Miscellaneous
15.4 Practical Tips for Performing Transoral

Robotic Surgery
Gregory S. Weinstein, Bert W. OMalley, Jr.
Department of Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania,
Philadelphia, Pa., USA

P E A R L S robotic instruments via manipulators in the con-
sole. Our team has published numerous preclini-
Transoral robotic surgery (TORS) is performed via cal reports as well as reports from our TORS
mouth gags and never tubular laryngoscopes. patient study including the TORS approach to
supraglottic partial laryngectomy, tongue base

P I T F A L L S resections and radical tonsillectomy [48].
Attempting TORS without both general da Vinci

Practical Tips
robot certification as well as a standardized animal
and operating observational course specifically As in all oncologic surgery, patient selection is
focused on TORS is inadvisable. paramount. With some exceptions we recom-
mend preoperative assessment both in the outpa-
tient setting as well as at the time of preoperative
endoscopy under general anesthesia at which
time the patient may be triaged between nonsur-
gical treatment, open surgical resection, transoral
Introduction laser surgery, and TORS.
Intraoperative efficiency is significantly im-
The feasibility of TORS using the da Vinci Ro-
botic Surgical System (Intuitive Surgical, Sunny- proved if there is a dedicated team of operating
vale, Calif., USA) was first demonstrated, by our room personnel trained in robotic and operating
surgical team at the University of Pennsylvania, room setup for TORS.
in mannequin, cadaver and canine models [13]. Since with rare exceptions the same set of ro-
TORS utilizes a readily available robotic system botic instruments and nonrobotic instruments
in which there is a bedside robotic cart which has are needed for TORS cases, the room setup and
a minimum of three arms that can be inserted via instrument setup should be standardized and the
a variety of mouth gags to perform the transoral same for every case which yields improved effi-
surgery. The robotic arms are under the control ciency and decreased operative times.
of the surgeon who sits at a console and sees a Never attempt to do TORS via a tubular laryn-
three-dimensional video view of the operative goscope. Mouth gags must be used to provide ac-
field. In TORS two instrument arms are utilized cess for instruments and the most commonly
as well as the central double video endoscope. The used is the Davis-Crow mouth gag (tongue base
surgeon has full control of the miniaturized and tonsil) and FK-Laryngo-Pharyngoscope sys-

tem (Feyh-Kastenbauer retractor) from Gyrus Conclusion
ACMI (www.gyrus-ent.com)/Explorent GmbH, In this chapter the reader was exposed to the key
Tuttlingen, Germany (www.explorent.de; larynx points for successfully performing TORS. Our
and hypopharynx). experience with over 150 TORS procedures has
The bedside assistant plays key roles in TORS allowed us to not only describe reproducible sur-
including retraction, suctioning and applying gical approaches but also summarize the com-
clips to blood vessels for hemostasis. mon features of all TORS cases that if followed
The 5-mm spatula tip electrocautery instru- will improve the chance for excellent outcomes
ment is the most common cutting tool and works [58].
very well in all anatomic locations.
All blood vessels with a lumen large enough to
visualize should have two to three clips applied to References
each end prior to transection. We have found it 1 Weinstein GS, OMalley BW Jr, Hockstein NG: Transoral robotic
surgery (TORS): supraglottic laryngectomy in the canine model.
more efficient to apply clips with the handheld
Laryngoscope 2005;115:13151319.
Storz Laryngeal clip applier (Karl Storz, Tuttlin- 2 Hockstein NG, OMalley BW Jr, Weinstein GS: Assessment of in-
gen, Germany). traoperative safety in transoral robotic surgery. Laryngoscope
If at the end of the case the surgeon is con- 2006;116:165168.
3 OMalley BW Jr, Weinstein GS, Hockstein NG: Transoral robotic
cerned about the potential for significant airway surgery (TORS): glottic microsurgery in a canine model. J Voice
edema then the patient should remain intubated 2006;20:263268.
4 OMalley BW Jr, Weinstein GS, Snyder W, Hockstein NG: Trans-
for a period of 2448 h with both intravenous ste- oral robotic surgery (TORS) for base of tongue neoplasms.
roids and antibiotics. Laryngoscope 2006;116:14651472.
Neck dissection, when it is indicated, is staged 5 Weinstein GS, OMalley BW Jr, Snyder W, Hockstein NG: Trans-
oral robotic surgery: supraglottic partial laryngectomy. Ann
and performed 13 weeks following TORS. The Otol Rhinol Laryngol 2007;116:1923.
rationale for staging the neck dissection has been 6 OMalley BW Jr, Weinstein GS: Robotic anterior and midline
skull base surgery: preclinical investigations. Int J Radiat Oncol
discussed elsewhere [7]. Biol Phys 2007;69(2 Suppl):S125S128.
In patients in whom aspiration is a possible 7 Weinstein GS, OMalley BW, Snyder W: Transoral robotic sur-
risk, a percutaneous gastrostomy is performed gery (TORS) radical tonsillectomy. Arch Otolaryngol Head Neck
Surg, in press.
preoperatively. 8 OMalley BW, Weinstein GS: Robotic skull base surgery: preclin-
ical investigations to human clinical application. Arch Otolaryn-
gol Head Neck Surg, in press.
15
207
Corresponding Authors by chapters
1.1 1.9 1.15

Dr. Orlo H. Clark, MD Dr. William B. Inabnet, MD, FACS Dr. Patrick Sheahan
UCSF/Mt. Zion Medical Center Chief, Section of Endocrine Surgery 125 Pier View Street, No. 109
Department of Surgery Co-Director of New York Thyroid Center Daniel Island
1600 Divisadero St., Box 1674 Associate Professor of Clin. Surgery Charleston 29492 SC, USA
Hellman Building, Room C-347 College of Physicians and E-Mail sheahan.patrick@gmail.com
San Francisco 94143-1674 CA, USA Surgeons of Columbia University
E-Mail clarko@surgery.ucsf.edu 161 Fort Washington Ave. 1.16
New York 10032 NY, USA Prof. Thomas V. McCaffrey, MD, PhD
1.2/7.2/7.10/8.9/8.10 E-Mail wbi2102@columbia.edu Professor and Chair
Prof. Claudio R. Cernea Department of Otolaryngology
Department of Head and Neck Surgery 1.10 Head and Neck Surgery
Univ. of So Paulo Medical School Prof. Keith S. Heller, MD, FACS University of South Florida
Alameda Franca, 267-cj 21 Professor and Chief of Endocrine Surgery 12902 Magnolia Drive
Jd. Paulista New York University, School of Medicine Suite 3057
01422-000 So Paulo, SP, Brazil 530 First Avuene, Suite 6H Tampa 33612-9497 FL, USA
E-Mail cerneamd@uol.com.br New York 10016 NY, USA E-Mail Thomas.McCaffrey@Moffitt.org
E-Mail keith.heller@med.nyu.edu
1.3 2.1
Dr. Gregory W. Randolph, MD 1.11 Dr. Michiel van den Brekel, MD, PhD
243 Charles Street Dr. Fbio Luiz de Menezes Montenegro, Netherlands Cancer Institute
Boston 02114 MA, USA MD Plesmanlaan 121
E-Mail Rua Apeninos, 1118 APT 62 1066 CX Amsterdam, The Netherlands
Gregory_Randolph@meei.harvard.edu Paraiso E-Mail m.vd.brekel@nki.nl
04104-021 So Paulo, SP, Brazil
1.4/1.6 E-Mail fabiomonte@uol.com.br 2.2
Prof. Ashok R. Shaha Dr. Yoav P. Talmi, MD, FACS
Head and Neck Service 1.12 Chief of Head and Neck Service
Memorial Sloan-Kettering Cancer Ctr. Dr. Alfred Simental, MD The Chaim Sheba Med. Center
Cornell Univ. Med. Center Chief Otolaryngology, Tel Hashomer, Israel 52621
1275 York Ave. Head and Neck Surgery E-Mail yoav.talmi@sheba.health.gov.il
New York 10021 N.Y., USA 11234 Anderson St. Suite 2584
E-Mail shahaa@mskcc.org Loma Linda 92354 CA, USA 2.3/7.1/7.9/8.5
E-Mail asimenta@ahs.llumc.edu Prof. Fernando L. Dias, MD, FACS
1.5 Chief, Head & Neck Surgery Dept.
Prof. Jean-Franois Henry, MD 1.13/8.1/8.4 Brazilian National Cancer Institute
University Hospital Marseille Dr. Dan M. Fliss, MD Professor of Surgery
Department of Endocrine Surgery Department of Otolaryngology Post Graduation School of Medicine
264, rue Saint-Pierre Head and Neck Surgery Av. Alexandre Ferreira, 190
Marseille 13385 Cedex 05, France Tel-Aviv Sourasky Medical Center Lagoa
E-Mail 6 Weizmann St. 2270220 Rio de Janeiro, SP, Brazil
jean-francois.henry@mail.ap-hm.fr Tel Aviv 64239, Israel E-Mail fdias@inca.gov.br
E-Mail fliss@tasmc.health.gov.il
1.7 2.4
Dr. Jeremy L. Freeman, MD, FRCSC, FACS 1.14 Prof. Francisco Civantos, MD, FACS
Mount Sinai Hospital Dr. Marcos R. Tavares, MD Co-Director, Head and Neck Surgery
600 University Avenue 401 Department of Head and Neck Surgery Associate Professor
Toronto M5G 1X5, Canada University of So Paulo Department of Otolaryngology
E-Mail jfreeman@mtsinai.on.ca Medical School University of Miami
Rua Joaquim Floriano, 101 Sylvester Comprehensive Cancer Ctr.
1.8 Conj. 601 1475 NW 12 Ave. No. 4027
Dr. Erivelto M. Volpi, MD 04534-010 So Paulo, SP, Brazil Miami 33136 FL, USA
R. das Figueiras, 551 E-Mail Tavares.mr@uol.com.br E-Mail FCivanto@med.miami.edu
09080-370 Santo Andre, SP, Brazil
E-Mail eriveltovolpi@hotmail.com
Corresponding Authors 209

2.5 2.11 3.5
Prof. Jesus E. Medina, MD Prof. Gary L. Clayman, DMD, MD Dr. Jacob Kligerman, MD
Department of Otorhinolaryngology Department of Head and Neck Surgery Av. Rui Barbosa 870 apto. 901
University of Oklahoma The University of Texas 22250-020 Rio de Janeiro-Flamengo,
Health Sciences Center M.D. Anderson Cancer Center SP, Brazil
P.O. Box 26901 1515 Holcombe Boulevard, Unit 441 E-Mail jkligerman@uol.com.br
Oklahoma City 73190 OK, USA Houston 77030 TX, USA
E-Mail jesus-medina@ouhsc.edu E-Mail gclayman@mdanderson.org 3.6
Dr. Sheng-Po Hao
2.6 2.12/4.10 14 F, No. 16, Alley 4, Lane 137
Dr. John C. OBrien, Jr., MD Dr. Bhuvanesh Singh MD, PhD, FACS Min-Sheng E. Road
Sammons Cancer Center Laboratory of Epithelial Cancer Biology Taipei, Taiwan (ROC)
Baylor University Medical Center Head and Neck Service E-Mail shengpo@adm.cgmh.org.tw
1004 North Washington Avenue Memorial Sloan-Kettering Cancer Ctr.
Dallas 75204-6416 TX, USA 1275 York Avenue 4.1
E-Mail job8223@aol.com New York 10065 NY, USA Dr. F. Christopher Holsinger, MD, FACS
E-Mail singhb@mskcc.org Department of Head and Neck Surgery
2.7 The University of Texas
Prof. K. Thomas Robbins, MD 3.1 M.D. Anderson Cancer Center
Simmons Cooper Cancer Institute Prof. Charles Ren Leemans, MD, PhD 1515 Holcombe Boulevard
at Southern Illinois University Professor and Chairman Box 441
P.O. Box 19677 Department of Otolaryngology Houston 77030-4009 TX, USA
Springfield 62794-9677 IL, USA Head and Neck Surgery E-Mail holsinger@mdanderson.org
E-Mail trobbins@siumed.edu VU University Medical Center (VUmc)
P.O. Box 7075 4.2
2.8 1007 MB Amsterdam, The Netherlands Dr. Steven M. Zeitels, MD, FACS
Dr. Jonas T. Johnson E-Mail chr.leemans@vumc.nl Director
Dept. of Otolaryngology Center for Laryngeal Surgery and
University of Pittsburgh 3.2 Voice Rehabilitation
Suite 500, 203 Lothrop Street Dr. Neal D. Futran, MD, DMD Massachusetts General Hospital
Pittsburgh 15213 PA, USA Department of Otolaryngology One Bowdoin Square
E-Mail johnsonjt@upmc.edu Head and Neck Surgery 11th floor
Uni. of Washington School of Medicine Boston 02114 MA, USA
2.9a 1959 NE Pacific Street, Room BB 1165 E-Mail steven@mgh.harvard.edu
Prof. James Cohen, MD, PhD Seattle 98195-6515 WA, USA
Department of Otolaryngology E-Mail nfutran@u.washington.edu 4.3
Head and Neck Surgery Dr. Onivaldo Cervantes
Oregon Health Sci. University 3.3 Rua Estela, 515.
3710 SW US Veterans Hospital Road Dr. Richard J. Wong, MD Bloco G cj. 81
Portland 97239 OR, USA Memorial Sloan-Kettering Cancer Center 04011-002 Viala Mariana
E-Mail James.Cohen2@VA.gov Head and Neck Service, C-1069 So Paulo, SP, Brazil
Department of Surgery E-Mail ocervantes@uol.com.br
2.9b/7.3 1275 York Avenue
Dr. Randal S. Weber, MD, FACS New York 10021 NY, USA 4.4/4.9/13.1
Department of Head and Neck Surgery E-Mail wongr@mskcc.org Dr. Eugene N. Myers
University of Texas Distinguished Prof. and Emeritus Chair
M.D. Anderson Cancer Center 3.4 Department of Otolaryngology
1515 Holcombe Boulevard Dr. Matthew M. Hanasono, MD University of Pittsburgh
Box 441 Department of Plastic Surgery School of Medicine
Houston 77030-4009 TX, USA The University of Texas The Eye & Ear Insitute, Suite 519
E-Mail rsweber@mdanderson.org M.D. Anderson Cancer Center 200 Lothrop Street
1515 Holcombe Boulevard, Unit 443 Pittsburgh 15213 PA, USA
2.10 Houston 77030 TX, USA E-Mail myersen@msx.upmc.edu
Dr. Rod P. Rezaee, MD, FACS E-Mail mhanasono@mdanderson.org
University Hospital 4.5/14.2
Case Medical Center Dr. med. Roberto A. Lima, MD
1110 Euclid Avenue Av. Armando Lombardi, 1000 Bloc2 107
4th Floor Lakeside Bldg. 22640-000 Rio de Janeiro, SP, Brazil
Cleveland 44106 OH, USA E-Mail rlimamd@uol.com.br
E-Mail rod.rezaee@uhhospitals.org

4.6/15.4 7.5 8.2
Prof. Gregory S. Weinstein, MD, FACS Dr. Richard V. Smith, MD, FACS Dr. Fernando Walder, MD
Professor and Vice Chair Department of Otorhinolaryngology Federal University of So Paulo
The Department of Otorhinolaryngology Head and Neck Surgery UNIFESP
Head and Neck Surgery 3400 Bainbridge Avenue Rua Joaquim Floriano, 397/3rd floor
The University of Pennsylvania Bronx 10467 NY, USA 04534-011 So Paulo, SP, Brazil
3400 Spruce Street E-Mail rsmith@montefiore.org E-Mail fernandowalder@terra.com.br
Philadelphia 19035 PA, USA
E-Mail 7.6 8.3
gregory.weinstein@uphs.upenn.edu Prof. Bruce J. Davidson, MD, FACS Dr. Eduardo Vellutini
Professor and Chairman Paa Amadeu Amaral 27/71
4.7 Department of Otolarynology 01327-010 So Paulo, SP, Brazil
Prof. Javier Gaviln, MD Head and Neck Surgery E-Mail evellu@terra.com.br
Servicio de ORL Georgetown University Medical Center
Hospital Unviersitario La Paz Washington 20007 DC, USA 8.6
Paseo de la Castellana, 261 E-Mail davidsob@georgetown.edu Prof. Ehab Hanna MD, FACS
28046 Madrid, Spain Professor and Vice Chairman
E-Mail jgavilan.hulp@salud.madrid.org 7.7 Director of Skull Base Surgery
Prof. Alfio Jos Tincani, MD Medical Director Head and Neck Ctr.
4.8/5.2 Professor of Head & Neck Surgery Department of Head and Neck Surgery
Prof. Dennis H. Kraus, MD State University of Campinas UNICAMP University of Texas
Memorial Sloan-Kettering Cancer Center Rua Geraldo Trefiglio 140 M.D. Anderson Cancer Center
Head and Neck Service 13083-793 Campinas, SP, Brazil 1515 Holcombe Boulevard, Unit 441
1275 York Avenue E-Mail alfio.jt@gmail.com Houston 77030-4009 TX, USA
New York 10065 NY, USA E-Mail eyhanna@mdanderson.org
E-Mail krausd@mskcc.org 7.8
Dr. Randall P. Morton, MB, BS, MSc, FRACS 8.7
5.1 Counties-Manukau DHB, and Dr. Marcos Q.T. Gomes
Dr. Abrao Rapoport Auckland University Praca Amadeu Amaral 27/71
Head and Neck Surgeon PO Box 98 743 01327-010 So Paulo, SP, Brazil
Hospital Heliopolis South Auckland Mail Centre E-Mail marcos@dfvneuro.com.br
Rua Congeo Xavier, 276 10 andar Manukau 2240
04231-030 So Paulo, SP, Brazil Auckland, New Zealand 8.8
E-Mail arapoport@terra.com.br E-Mail rpmorton@middlemore.co.nz Dr. Patrick J. Gullane, MB
Department of Otolaryngology
5.3 7.11 Head and Neck Surgery
Dr. Frans JM Hilgers, MD, PhD Dr. Jeffrey D. Spiro, MD 200 Elizabeth Street, 8N-800
Netherlands Cancer Institute Division of Otolaryngology/ Toronto M5G 2C4, Canada
Plesmanlaan 121 Head and Neck Surgery E-Mail Patrick.gullane@uhn.on.ca
1066 CX Amsterdam, The Netherlands University of Connecticut Health Ctr
E-Mail f.hilgers@nki.nl 263 Farmington Avenue MC-6228 9.1/9.2
Farmington 06030-6228 CT, USA Prof. James Y. Suen, MD
5.4/6.1/6.2/6.3/14.12 E-Mail spiro@nso.uchc.edu Professor and Chairman
Prof. William I. Wei Department of Otolaryngology
Li Shu Pui Professor of Surgery 7.12 Head and Neck Surgery
Chair in Otorhinolaryngology Dr. Kwang Hyun Kim, MD 4301 W. Markham St.
Department of Surgery Department of Otolaryngology Little Rock 72205 AR, USA
University of Hong Kong Med. Ctr. Head and Neck Surgery E-Mail suenjamesy@uams.edu and
Queen Mary Hospital Seoul National University suenjamesy@exchange.uams.edu
Hong Kong, Peoples Republic of China College of Medicine
E-Mail hrmswwi@hkucc.hku.hk 28, Yeongeon-dong, Jongno-gu 9.3
110-744 Korea, South Korea Dr. Eduardo Noda Kihara
7.4 E-Mail kimkwang@plaza.snu.ac.kr Hospital Albert Einstein
Prof. Peter C. Neligan, MB, FRCS Neuro Interventional Department
University of Washington Med. Ctr. Avenida Albert Einstein, 701
Division of Plastic Surgery Hemodinamica 4 andar
1959 NE Pacific St. 05651-091 So Paulo, SP, Brazil
Box 356410 E-Mail kihara@einstein.br
Seattle 98195-6410 WA, USA
E-Mail pneligan@uwashington.edu
Corresponding Authors 211

10.1 13.3 14.7
Dr. Marcelo D. Durazzo, MD Prof. David W. Eisele, MD, FACS Dr. Mark L. Urken, MD
Praa Amadeu Amaral 47, suite 41 Professor and Chairman Beth Israel Medical Center
01413-000 So Paulo, SP, Brazil 400 Parnassus Avenue 10 Union Square East, Suite 5B
E-Mail durazzo@attglobal.net Suite A-730 New York 10003 NY, USA
San Francisco 94143-0342 CA, USA E-Mail murken@chpnet.org
10.2 E-Mail deisele@ohns.ucsf.edu
Dr. Nilton T. Herter, MD 14.9
Av. Independncia 1211 Sala 201 14.1 Dr. Mario S.L. Galvao, MD
90035-075 Porto Alegre, SP, Brazil Dr. Luiz Carlos Ishida, MD Reconstructive Microsurgery Unit
E-Mail nherter@uol.com.br Plastic Surgery Division of the National Cancer Institute
Faculty of Medicine of the Rua Visconde Silva 52/suite 1006
11.1 University of So Paulo Botafogo, Rio de Janeiro, SP, Brazil
Dr. Nadir Ahmad Rua Itamiami, 35 E-Mail galvaorj@iis.com.br
Department of Otolaryngology Vila Mariana
Head and Neck 04120-100 So Paulo, SP, Brazil 14.11
Vanderbilt University Medical Center E-Mail lci@uol.com.br Prof. John J. Coleman, 3rd, MD
7209 Medical Center East, South Tower Professor of Surgery
1215 21st Avenue South 14.3 Chief of Plastic Surgery
Nashville 37232-8605 TN, USA Dr. Jos Magrim, MD, PhD Indiana University School of Med.
E-Mail nadirahmad@hotmail.com Head and Neck Surgery and Roudebush VAMC- Indianapolis
Otorhinolaryngology Department Indianapolis 46204 IN, USA
11.2 Hospital AC Camargo E-Mail jjcolema@iupui.edu
Dr. Ziv Gil, MD Rua Professor Antonio Prudente, 211
Department of Otolaryngology 01509-900 So Paulo, SP, Brazil 15.1
Head and Neck Surgery E-Mail jgon13@terra.com.br Dr. Paulo Campos Carneiro, MD, PhD
Tel-Aviv Sourasky Medical Center University of So Paulo
6 Weizmann Street 14.4 School of Medicine
64239 Tel-Aviv, Israel Prof. Richard E. Hayden, MD Department of Pathology
E-Mail ziv@baseofskull.org Professor and Chair Av. Rebouas 353 cj. 114
Department of Otolaryngology 05401-000 Cerqueira Cesar,
11.3 Head and Neck Surgery So Paulo, SP, Brazil
Dr. Kerry D. Olsen, MD 5777 East Mayo Boulevard E-Mail p.carneiro@saudetotal.com.br
Mayo Clinic Rochester Phoenix 85054 AZ, USA
200 First Street Southwest E-Mail hayden.richard@mayo.edu 15.2
Rochester 55905 MN, USA Dr. Pedro Michaluart, Jr., MD
E-Mail olsen.kerry@mayo.edu 14.5 Head and Neck Service
Prof. Gady Har-El, MD, FACS Hospital das Clinicas da Faculdade
12.1 Chairman, Dept. of Otolaryngology de Medicina da Universidade
Prof. Flvio C. Hojaij, MD Head and Neck Surgery de So Paulo
Rua Padre Joo Manuel 450, cj 18 Lenox Hill Hospital, New York R. Dr. Enas de Carvalho Aguiar, 255
01411-001 So Paulo, SP, Brazil Prof. of Otolaryngology & Neurosur. No. 8 andar, Sala 8074
E-Mail fchojaij@uol.com.br State University of New York 0540 3900 So Paulo, SP, Brazil
Downstate Medical Center E-Mail pemic@uol.com.br
12.2 Brooklyn 11201 NY, USA
Dr. Dorival De Carlucci, Jr., MD E-Mail gadyh@aol.com 15.3
Rua Padre Joo Manuel 45, room 18 Dr. Erich M. Sturgis, MD, MPH
Cerqueira Csar 14.6/14.8/14.10 Department of Head and Neck Surgery
01411-001 So Paulo, SP, Brazil Dr. Julio Morais, MD, PhD and Epidemiology
E-Mail decarlucci@uol.com.br Assistant Professor of Plastic Surgery The University of Texas
So Paulo University Medical School M.D. Anderson Cancer Center
13.2 Rua Baronesa de Bela Vista, 196 1515 Holcombe Boulevard, Unit 441
Dr. Carlos N. Lehn, MD 04612-000 So Paulo, SP, Brazil Houston 77030-4009 TX, USA
Chief of the Head and Neck Surgery E-Mail jmorais@br2001.com.br E-Mail esturgis@mdanderson.org
Service
Hospital Helipolis, So Paulo
Rua Joaquim Floriano 636 ap 22
04534-002 So Paulo, SP, Brazil
E-Mail cnlehn@terra.com.br

Subject Index
Abscess, deep neck abscess surgical planning 166, 167 Fibula microvascular transfer, mandible
Arteriovenous malformation (AVM) reconstruction 190, 191
bleeding emergency management 154, 155 Fine needle aspiration biopsy (FNAB)
management of extensive malformations 150, 151 lateral cervical masses 200, 201
AVM, see Arteriovenous malformation salivary gland tumors 118, 119, 126
FNAB, see Fine needle aspiration biopsy
Bilateral neck dissection (BND) 48, 49
BND, see Bilateral neck dissection GAN, see Great auricular nerve
Branchial cleft, cyst and fistula management 156, 157 Gastric pull-up, technique 198, 199
Glottis, reconstruction after partial vertical
Carotid body tumor (CBT), management 160, 161 laryngectomy 76, 77
Cavernous sinus, extradural approach in skull base Goiter, intrathoracic goiter surgery 12, 13
tumor surgery 142, 143 Great auricular nerve (GAN), sparing in parotid
CBT, see Carotid body tumor surgery 120, 121
Completion thyroidectomy (CT)
facilitation 10 Head and neck squamous cell carcinoma,
indications 10 preoperative workup 34, 35
technique 11 Hyperparathyroidism, secondary
Computed tomography (CT) hyperparathyroidism surgical management 22, 23
carotid body tumor 160 Hypoparathyroidism, management 9
chemoradiotherapy node-positive neck patients Hypopharyngeal cancer
55 N3 neck patient management 92, 93
deep neck abscess surgical planning 166, 167 reconstruction
laryngeal cancer 73 total laryngectomy/partial pharyngectomy
skull base tumors 130 defect 94, 95
Cricothyroidectomy, indications versus tracheotomy total pharyngolaryngectomy 98, 99
172, 173 voice rehabilitation after pharyngolaryngectomy
CT, see Completion thyroidectomy; Computed 96, 97
tomography
ILN, see Inferior laryngeal nerve
da Vinci Robotic Surgical System, transoral robotic Inferior laryngeal nerve (ILN)
surgery 206, 207 anatomy 2, 3
Deep neck abscess, surgical planning 166, 167 injury avoidance 2, 3
Deltopectoral flap, technique 178, 179 intrathoracic goiter surgery 12, 13
monitoring with NIM 2 system 6, 7
EBSLN, see External branch of superior laryngeal well-differentiated thyroid cancer management
nerve with recurrent nerve invasion 50, 51
External branch of superior laryngeal nerve (EBSLN), Intrathoracic goiter, surgery 12, 13
injury avoidance 4, 5 Invasive thyroid cancer, see Well-differentiated
thyroid cancer
Facial nerve
main trunk identification 106, 107 Jejunal free autograft, pharyngoesophageal defect
parotid surgery intraoperative decisions 110, 111 reconstruction 196, 197
reconstruction in parotid surgery 112, 113
retrograde approach indications and technique
108, 109
Subject Index 213

Laryngeal cancer, laser resection 72, 73 Nasopharyngeal cancer
Laryngectomy maxillary swing approach 102, 103
glottis reconstruction after partial vertical neck metastasis management 104, 105
laryngectomy 76, 77 surgical indications 100, 101
hypopharyngeal cancer Neck dissection
reconstruction bilateral neck dissection 48, 49
total laryngectomy/partial pharyngectomy chemoradiotherapy node-positive neck patients
defect 94, 95 54, 55
total pharyngolaryngectomy 98, 99 functional modified neck dissection 58, 59
voice rehabilitation after marginal mandibular nerve management 46, 47
pharyngolaryngectomy 96, 97 medullary thyroid cancer and lymph node
pharyngocutaneous fistula prevention management 28, 29
84, 85, 90, 91 oral cancer
supracricoid partial laryngectomy 82, 83 N0 neck
supraglottic laryngectomy and functional elective neck dissection 38, 39
outcome improvement 80, 81 sentinel lymph node biopsy 40, 41
total laryngectomy and functional outcome wait and watch policy 36, 37
improvement 84, 85 N+ neck dissection 42, 43
tracheostomal recurrence management 86, 87 paratracheal neck dissection 26, 27
tracheostomal stenosis prevention 88, 89 parotid cancers and elective neck dissections
Lateral cervical mass 122, 123
fine needle aspiration biopsy 200, 201 spinal accessory nerve management 44, 45
open biopsy 202, 203 Necrotizing fasciitis (NF), management 168, 169
Latissimus dorsi myocutaneous flap, technique Neurogenic tumor (NT), management of extensive
184, 185 tumors 162, 163
LM, see Lymphatic malformation NF, see Necrotizing fasciitis
Lymphatic malformation (LM), management of NIM 2, recurrent laryngeal nerve monitoring 6, 7
extensive malformations 152, 153 NT, see Neurogenic tumor
Magnetic resonance imaging (MRI) OE, see Orbital exenteration

carotid body tumor 160 Oral cancer
laryngeal cancer 73 mandibular resection surgical margins 64, 65
suprahyoid pharyngotomy planing 78 N0 neck
Mandibular osteoradionecrosis, management 70, 71 elective neck dissection 38, 39
Mandibular resection sentinel lymph node biopsy 40, 41
anterior mandibular reconstruction 66, 67 wait and watch policy 36, 37
reconstruction with fibula microvascular transfer N+ neck dissection 42, 43
190, 191 reconstructive surgery
surgical margins in oral cavity squamous cell large defects 62, 63
carcinoma 64, 65 small defects 60, 61
Marginal mandibular nerve (MMN), management in Orbital exenteration (OE), skull base tumor surgery
neck dissection 46, 47 140, 141
Maxillary swing approach, nasopharyngeal cancer Osteoradionecrosis, see Mandibular
102, 103 osteoradionecrosis
Medullary thyroid cancer (MTC), lymph node
management 28, 29 Parapharyngeal space tumor, surgical approach
Microvascular anterolateral thigh flap, technique selection 164, 165
176, 177 Parathyroid glands
Microvascular forearm flap, technique 188, 189 autotransplantation 9
Microvascular iliac crest flap, technique 192, 193 hypoparathyroidism management 9
MMN, see Marginal mandibular nerve limited parathyroidectomy 20, 21
MRI, see Magnetic resonance imaging preservation in thyroid surgery 8, 9
MTC, see Medullary thyroid cancer

reoperative parathyroidectomy 24, 25 pectoralis major flap 180, 181
secondary hyperparathyroidism surgical scapular flap 194, 195
management 22, 23 transverse rectus abdominis flap 186, 187
video-assisted parathyroidectomy 18, 19 trapezius flap 182, 183
Parathyroid hormone (PTH), intraoperative gastric pull-up 198, 199
measurement 20, 21, 25 glottis after partial vertical laryngectomy 76, 77
Paratracheal neck dissection (PTND) hypopharyngeal cancer
indications 26 total laryngectomy/partial pharyngectomy
tips 26, 27 defect 94, 95
Parotid surgery, see Salivary gland tumors total pharyngolaryngectomy 98, 99
Partial horizontal laryngectomy, functional outcome jejunal free autograft for pharyngoesophageal
improvement 80, 81 defect reconstruction 196, 197
Partial vertical laryngectomy (PVL), glottis mandible reconstruction with fibula microvascular
reconstruction 76, 77 transfer 190, 191
PCF, see Pharyngocutaneous fistula oral cancer surgery
PDT, see Percutaneous dilatational tracheotomy large defects 62, 63
Pectoralis major flap, technique 180, 181 small defects 60, 61
Percutaneous dilatational tracheotomy (PDT), Recurrent laryngeal nerve, see Inferior laryngeal
complication avoidance 174, 175 nerve
PET, see Positron emission tomography Retropharyngeal lymph node metastasis,
Pharyngectomy, hypopharyngeal cancer management in thyroid cancer
reconstruction transcervical approach 52, 53
total laryngectomy/partial pharyngectomy transoral approach 50, 51
defect 94, 95
total pharyngolaryngectomy 98, 99 Salivary gland tumors
voice rehabilitation after pharyngolaryngectomy deep lobe parotid tumor approaches 114, 115
96, 97 diagnosis 118, 119
Pharyngocutaneous fistula (PCF), prevention in total elective neck dissections in parotid cancers 122,
laryngectomy 84, 85, 90, 91 123
Positron emission tomography (PET) facial nerve
chemoradiotherapy node-positive neck patients main trunk identification 106, 107
55 parotid surgery intraoperative decisions 110, 111
skull base tumors 130 reconstruction in parotid surgery 112, 113
PTH, see Parathyroid hormone retrograde approach indications and technique
PTND, see Paratracheal neck dissection 108, 109
PVL, see Partial vertical laryngectomy great auricular nerve sparing in parotid surgery
120, 121
Radiation-associated sarcoma (RAS), management parotid tumor surgery indications 126, 127
204, 205 recurrent parotid pleomorphic adenoma
RAS, see Radiation-associated sarcoma management 116, 117
Reconstruction submandibular gland excision 126, 127
anterior mandibular 66, 67 tactical parotidectomy in nonsalivary lesions 124,
cranial base defect 144, 145 125
facial nerve in parotid surgery 112, 113 SAN, see Spinal accessory nerve
flaps Sarcoma, see Radiation-associated sarcoma
deltopectoral flap 178, 179 Scapular flap 194, 195
latissimus dorsi myocutaneous flap 184, 185 SCPL, see Supracricoid partial laryngectomy
microvascular anterolateral thigh flap 176, 177 Sentinel lymph node biopsy (SLNB), N0 oral cancer
microvascular forearm flap 188, 189 40, 41
microvascular iliac crest flap 192, 193
Subject Index 215

Skull base tumors Thyroidectomy
cavernous sinus and extradural approach 142, 143 completion thyroidectomy
contraindications for resection 138, 139 facilitation 10
cranial base defect reconstruction 144, 145 indications 10
craniofacial diaphragm sealing 136, 137 technique 11
facial translocation approach 132, 133 extent for benign disease 14, 15
fibro-osseous lesion management 148, 149 minimally invasive video-assisted surgery 16, 17
large dural defect management 134, 135 Tongue carcinoma
orbital preservation and exenteration 140, 141 resection margins 68, 69
recurrent tumor management 146, 147 suprahyoid pharyngotomy 78, 79
subcranial approach 130, 131 TORS, see Transoral robotic surgery
SLNB, see Sentinel lymph node biopsy Tracheoesophageal puncture (TEP), speech
SMG, see Submandibular gland rehabilitation after total laryngectomy 85
SP, see Suprahyoid pharyngotomy Tracheostomal recurrence, management after
Spinal accessory nerve (SAN), management in neck laryngectomy 86, 87
dissection 44, 45 Tracheostomal stenosis, prevention after
Squamous cell carcinoma, see Head and neck laryngectomy 88, 89
squamous cell carcinoma; Oral cancer Tracheotomy
Stoma, creation 85 complication minimization 170, 171, 174, 175
Submandibular gland (SMG), excision 126, 127 indications versus cricothyroidectomy 172, 173
Substernal goiter, see Goiter percutaneous dilatational tracheotomy 174, 175
Superior laryngeal nerve, see External branch of Transoral robotic surgery (TORS) 206, 207
superior laryngeal nerve Transverse rectus abdominis flap, technique 186, 187
Supracricoid partial laryngectomy (SCPL) 82, 83 Trapezius flap, technique 182, 183
Suprahyoid pharyngotomy (SP) 78, 79
Upper airway obstruction, see Cricothyroidectomy;
TD, see Thoracic duct Tracheotomy
TEP, see Tracheoesophageal puncture
TGDC, see Thyroglossal duct cyst Vocal fold, phonomicrosurgical treatment of benign
Thoracic duct (TD), injury avoidance in left level IV lesions 74, 75
lymph node resection 56 Voice rehabilitation, pharyngolaryngectomy 96, 97
Thyroglossal duct cyst (TGDC), management 158, 159
Thyroid cancer, see Medullary thyroid cancer; WDTC, see Well-differentiated thyroid cancer
Retropharyngeal lymph node metastasis; Well-differentiated thyroid cancer (WDTC)
Well-differentiated thyroid cancer invasive thyroid cancer management 32, 33
management with recurrent nerve invasion 50, 51

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Pearls and Pitfalls in

Basel Freiburg Paris London New York

Library of Congress Cataloging-in-Publication Data

Copyright 2008 by S. Karger AG, P.O. Box, CH4009 Basel (Switzerland)

Thyroid and Parathyroid Glands

VI Pearls and Pitfalls in Head and Neck Surgery

Salivary Gland Tumors

VIII Pearls and Pitfalls in Head and Neck Surgery

Skull Base Tumors

Parapharyngeal Space Tumors

Infections of Head and Neck

X Pearls and Pitfalls in Head and Neck Surgery

209 Corresponding Authors

1.1 How to Avoid Injury of Inferior Laryngeal

2 Pearls and Pitfalls in Head and Neck Surgery

1.2 How to Avoid Injury of the External

4 Pearls and Pitfalls in Head and Neck Surgery

1.3 Recurrent Laryngeal Nerve Monitoring

6 Pearls and Pitfalls in Head and Neck Surgery

1.4 How to Preserve the Parathyroid Glands

8 Pearls and Pitfalls in Head and Neck Surgery

1.5 Completion Thyroidectomy

10 Pearls and Pitfalls in Head and Neck Surgery

1.6 Surgery for Intrathoracic Goiters

12 Pearls and Pitfalls in Head and Neck Surgery

SS is seldom necessary, and can involve partial

1.7 How to Decide the Extent of

14 Pearls and Pitfalls in Head and Neck Surgery

Patient risk factors Tumor risk factors Imaging risk factors 1

1.8 Minimally Invasive Video-Assisted

16 Pearls and Pitfalls in Head and Neck Surgery

1.9 Video-Assisted Parathyroidectomy

18 Pearls and Pitfalls in Head and Neck Surgery

1.10 Limited Parathyroidectomy

20 Pearls and Pitfalls in Head and Neck Surgery

1.11 Practical Tips for the

22 Pearls and Pitfalls in Head and Neck Surgery

1.12 Reoperative Parathyroidectomy

24 Pearls and Pitfalls in Head and Neck Surgery

1.13 Paratracheal Neck Dissection:

26 Pearls and Pitfalls in Head and Neck Surgery

1.14 Management of Lymph Nodes in

28 Pearls and Pitfalls in Head and Neck Surgery

1.15 How to Manage a Well-Differentiated

30 Pearls and Pitfalls in Head and Neck Surgery

1.16 Management of Invasive Thyroid Cancer

32 Pearls and Pitfalls in Head and Neck Surgery

2.1 Preoperative Workup of the Neck in Head

34 Pearls and Pitfalls in Head and Neck Surgery

2.2 N0 Neck in Oral Cancer:

36 Pearls and Pitfalls in Head and Neck Surgery

2.3 N0 Neck in Oral Cancer:

38 Pearls and Pitfalls in Head and Neck Surgery

In N0 neck, levels IV and V LN are generally

2.4 Sentinel Node Biopsy in the Management

40 Pearls and Pitfalls in Head and Neck Surgery

2.5 Selective Neck Dissection in the

42 Pearls and Pitfalls in Head and Neck Surgery

2.6 How to Manage the XI Nerve in Neck

44 Pearls and Pitfalls in Head and Neck Surgery

2.7 Preservation of the Marginal Mandibular

46 Pearls and Pitfalls in Head and Neck Surgery

2.8 Bilateral Neck Dissections: